Supranormal LVEF

Left ventricular ejection fraction (LVEF) is the most commonly used metric to assess ventricular function, and lower values are associated with worse outcomes. Not much is known, however, regarding the clinical and prognostic implication of ejection fraction values above the normal range.

At #AHA21, we presented findings from our study analyzing the long-term cardiovascular (CV) outcomes associated with a “supranormal” LVEF by cardiac MRI. We used data from two large, community-based, ethnically diverse registries – the Dallas Heart Study (DHS) and the Multi-Ethnic Study of Atherosclerosis (MESA) – and compared the baseline and cardiac MRI characteristics of individuals without existing cardiovascular disease across increasing LVEF quartiles. We found that individuals with a higher ejection fraction by cardiac MRI were older, had more cardiovascular risk factors at baseline, and had smaller LV cavities.

After adjustment, we found that individuals with a higher ejection fraction have worse CV outcomes, defined as a composite of cardiovascular death, incident heart failure, myocardial infarction, stroke, and atrial fibrillation. Additionally, we found that left ventricular stroke volume modifies the association between supranormal LVEF and adverse CV outcomes, such that individuals with a lower indexed stroke volume and higher LVEF had worse outcomes. Taken together, our findings suggest that when it comes to ejection fraction, a “U-shaped” curve exists: Like individuals with low LVEF, those with a supranormal LVEF also appear to have worse CV outcomes than individuals with LVEF within the normal range.