Normal Left Ventricular Ejection Fraction
Normal LVEF ranges from 50% to 70%, with a midpoint of 60%, according to current American College of Cardiology/American Heart Association guidelines. 1
Established Reference Ranges
The definition of normal LVEF varies slightly depending on the measurement method and guideline source:
- ACC/AHA standard range: 50-70% (midpoint 60%) 1
- European Society of Cardiology range: 53-73% (mean 63 ± 5%) using the biplane method of disks, regardless of age, gender, or body size 1
- 2D Echocardiography (Biplane Simpson's): 53-73% with mean 63 ± 5% 1
- 3D Echocardiography: 52-72% for women with mean LVEF of 62 ± 5% 1
LVEF Classification Categories
Beyond the normal range, LVEF is systematically classified as follows:
- Hyperdynamic: Greater than 70% 1
- Normal: 50-70% 1
- Mildly reduced: 40-49% 1
- Moderately reduced: 30-39% 1
- Severely reduced: Less than 30% 1
Clinical Significance of "Low Normal" LVEF
The 50-55% range, while technically "normal," carries increased clinical risk. 2 In asymptomatic community-dwelling adults, those with LVEF 50-55% had a 3.64-fold increased risk of developing heart failure compared to those with LVEF ≥55%, though mortality risk was not significantly elevated. 2 This U-shaped relationship suggests that values at the lower end of normal warrant closer monitoring despite meeting technical criteria for "normal." 2
Important Measurement Considerations
Several factors affect LVEF interpretation:
- Load dependency: LVEF cannot distinguish between preload, afterload, and intrinsic contractility, meaning the same measurement may reflect different underlying cardiac states 1
- Measurement variability: LVEF varies between imaging modalities and interpreters, so a single measurement may be inadequate, particularly for borderline values (41-49%) 1
- Volume status: Hypovolemia or dehydration can artificially elevate LVEF 1
- Small ventricular cavity: May produce artificially high LVEF calculations (>70%) 1
When to Question "Normal" LVEF
Do not assume higher LVEF always means better cardiac function. 1 If clinical suspicion of dysfunction exists despite preserved LVEF, consider:
- Global longitudinal strain (GLS): Values < -16% indicate mild depression, < -10% severe reduction, and can detect subclinical dysfunction before EF impairment 1
- Diastolic parameters: Assess left atrial size and diastolic function if heart failure symptoms are present, as diastolic dysfunction can coexist with preserved systolic function 1
- Serial measurements: Use the same equipment and methodology for borderline values rather than relying on a single measurement 1