Normal Left Ventricular Ejection Fraction
Normal left ventricular ejection fraction (LVEF) ranges from 50% to 70% with a midpoint of 60%, and the lower limit of normal is approximately 52-53%. 1, 2, 3
Established Reference Ranges
The most precise normal ranges based on current guidelines and population studies are:
- Overall normal range: 50-70% (ACC/AHA definition) 1, 2, 3
- European Society of Cardiology reference: 53-73% (mean 63 ± 5%) using biplane method of discs 2
- Recent meta-analysis of healthy populations: Lower limit 51.8% (pooled mean 62.8%) 4
Sex-Specific Differences
Women have slightly higher LVEF than men 2, 4:
Race/Ethnicity Considerations
Individuals of Asian origin demonstrate 2-3 percentage points higher LVEF compared to Black or White individuals 4:
Clinical Classification Categories
The 2022 ACC/AHA Heart Failure Guidelines define LVEF categories as follows 1, 2, 3:
- Hyperdynamic: >70% 2, 3
- Normal: 50-70% 1, 2, 3
- Mildly reduced (HFmrEF): 41-49% 1, 2
- Reduced (HFrEF): ≤40% 1, 2
- Moderately reduced: 30-39% 2, 3
- Severely reduced: <30% 2, 3
Critical Clinical Threshold
An LVEF <50% is highly unlikely to represent normal function across all demographic groups. 4 Population studies demonstrate that fewer than 1% of women and approximately 1% of men would be expected to have LVEF below 50%, with the probability that LVEF <50% represents normal function being less than 5% across all subgroups 4.
Measurement Method Considerations
Preferred Techniques
The biplane method of discs (modified Simpson's rule) from apical four-chamber and two-chamber views is the recommended measurement approach, particularly reliable in abnormally shaped ventricles 2. Three-dimensional echocardiography provides more accurate measurements when available, with normal ranges of 52-72% for women (mean 62 ± 5%) 2.
Important Measurement Caveats
LVEF measurement varies significantly between imaging modalities and interpreters, with potential differences of 5-7% between studies due to technical factors rather than actual cardiac function changes. 3, 5 In a multicenter study of patients with coronary artery disease, correlation between modalities was only moderate (r = 0.493-0.660), with only 43-54% of measurements falling within a 5% range between different imaging methods 5.
A single LVEF measurement at one time point may not be adequate, particularly for borderline values (41-49%). 1, 2 The trajectory of LVEF over time is clinically important, especially for patients in the mildly reduced category who may be improving from HFrEF or deteriorating toward it 1.
Common Pitfalls to Avoid
- Do not assume higher LVEF always means better cardiac function - LVEF is load-dependent and cannot distinguish between preload, afterload, and intrinsic contractility 2
- Avoid geometric assumptions - Linear measurements (Teichholz or Quinones methods) fail in abnormally shaped ventricles 2
- Consider volume status - Hypovolemia, dehydration, or small ventricular cavity can artificially elevate LVEF calculations (>70%) 2
- Specify imaging modality - Always document which imaging method was used, as each has different normal value ranges 3, 5
Clinical Significance of Low-Normal LVEF
LVEF in the 50-55% range (low-normal) carries prognostic significance despite being technically "normal." 6 In the Multiethnic Study of Atherosclerosis, asymptomatic adults with low-normal LVEF (50-55%) had a 3.64-fold increased risk of incident heart failure compared to those with LVEF ≥55%, though mortality risk was not significantly elevated 6. This demonstrates a gradient-response relationship between LVEF categories and future heart failure risk 6.
Advanced Assessment When LVEF Appears Preserved
When LVEF appears preserved but dysfunction is suspected, consider global longitudinal strain (GLS) 2:
- Normal GLS: Values more negative than -18% (though vendor-dependent) 1, 2
- Mild depression: -16% to -10% 2
- Severe reduction: Less negative than -10% 2
GLS detects subclinical LV dysfunction before EF impairment and has recognized prognostic value in heart failure with both reduced and preserved LVEF 1, 2.