Time to Reframe Ejection Fraction in Light of New Pathophysiological Insights Into Heart Failure

Peter P. Liu, MD; Mohammad Al-Khalaf, PHD; Alice Blet, MD, PHD


J Am Coll Cardiol. 2020;76(17):1995-1998. 

In This Article

Abstract and Introduction


In the management of patients with heart failure, ejection fraction (EF) has become sacrosanct in categorizing the patient's phenotype. Guideline recommendations for heart failure (HF) treatments are based on EF categories, whether HF with reduced ejection fraction (HFrEF) (i.e., EF <40%), or HF with preserved ejection fraction (HFpEF) (i.e., EF ≥50%), or the more recent HF with midrange ejection fraction (HFmrEF) (i.e., EF between 40% and 49%). The concept of different categories of heart failure patients based on EF is so entrenched that it influences how clinical trials are conducted, criteria for reimbursement of medications or devices, and even how HF clinics are set up.

Although EF has the advantage of being a simple and easily obtainable parameter based on the imaging tools with which cardiologists have become proficient, it was not designed to be the phenotyping criteria for all patients with HF. Previously, EF was used as a tool to enrich for event rates in HF trials. These and other authors have subsequently called to attention the neglected rising number of patients with HFpEF in the community and their associated adverse outcomes.[1]