What is a normal left ventricular ejection fraction in healthy adults? A meta-analysis of population-based echocardiographic studies

TL;DR

This study determines normal left ventricular ejection fraction (LVEF) ranges in healthy adults, finding that an LVEF below 50% is unlikely to be normal.

Contribution

The study provides updated normal LVEF thresholds by sex and race/ethnicity using a meta-analysis of population-based echocardiographic data.

Findings

The pooled mean LVEF was 62.8% with lower normal limits of 51.8% and upper limits of 73.2%.

Women had higher LVEF (63.7%) than men (61.9%), with lower normal limits of 52.7% and 51.7%, respectively.

An LVEF below 50% is highly unlikely to be normal across all demographic subgroups.

Abstract

Transthoracic echocardiography derived left ventricular ejection fraction (LVEF) is a cornerstone in heart failure risk prevention. However, the lower limits of normal LVEF remains imprecisely defined. We aimed to define normal LVEF ranges by sex, age group, and self-reported race/ethnicity using data from population-based echocardiographic studies.

We systematically searched MEDLINE for studies published between January 1, 2000, and January 3, 2025, that reported the mean and standard deviation of LVEF measured by 2D or 3D echocardiography in healthy, community-based adult populations.

In 10 studies (n = 10,427; female sex, 48%), the pooled mean LVEF was 62.8% (95% confidence interval, 61.0%–64.7%), with estimated lower and upper normal limits of 51.8% and 73.2%, respectively. Women had higher mean LVEF (63.7%) than men (61.9%), with corresponding lower normal limits of 52.7% and 51.7%, respectively. LVEF was similar across age groups. Individuals of Asian origin had 2 to 3 percentage points higher LVEF than Black or White individuals, with lower normal limits of 54% for women and 53% for men. Fewer than 1% of women and approximately 1% of men would be expected to have an LVEF below 50%. Across all demographic subgroups, the probability that an LVEF < 50% is within the normal range was < 5%. There was significant heterogeneity of the included studies (e.g., τ2 = 8.82, I2 = 99.7% for overall analysis) that appeared unexplained by sex, age, or echocardiography modality (2D vs. 3D).

In healthy adults, the lower limit of normal LVEF is approximately 53% for women and 52% for men, with slightly higher thresholds among individuals of Asian origin. An LVEF < 50% is highly unlikely to reflect normal function, regardless of sex, age, or self-reported race/ethnicity. Given the high statistical heterogeneity, the results should be interpreted with caution.

The online version contains supplementary material available at 10.1186/s44348-025-00063-4.

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