Heart failure and left ventricular ejection fraction: a necessary but imperfect partnership

The left ventricular ejection fraction (LVEF) is the most commonly used index to assess left ventricular systolic function and guide management in patients with heart failure (HF). This is largely due to the widespread availability of echocardiography, its practicality, rapid scan time, ease of measuring left ventricular (LV) volumes, and its extensive application in both clinical practice and research. Accordingly, a recent joint clinical consensus statement from the Heart Failure Association (HFA) and the Heart Failure Society of America (HFSA) recommends that LVEF be evaluated longitudinally to assess disease trajectory, natural history, and response to treatment in patients with heart failure (6). However, there is little, if any, evidence that serial LVEF assessment improves risk stratification or guides management in HF. Notably, LVEF may not accurately reflect overall cardiac function. While it is commonly used as a measure of systolic function, LVEF does not fully capture the status of the heart. Other parameters-such as diastolic function, ventricular size, valvular function, and right ventricular function-also play important roles in determining patient risk. This paper proposes an alternative strategy, shifting from serial LVEF evaluation to a more comprehensive approach that includes assessment of congestion, right ventricular function, and structural myocardial damage to provide more robust diagnostic and prognostic information.