Is it time to leave diagnostics based on ejection fraction?

"At first glance, left ventricular (LV) function may seem easy to understand, and most physicians are familiar with frequently used parameters such as ejection fraction (EF), stroke volume, and cardiac output. Although well known, these measurements do not necessarily provide a comprehensive measurement of LV function." - Smiseth, Aalen and Skulstad write in "Heart failure and systolic function: time to leave diagnostics based on ejection fraction?". 

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The apparent discrepancy between global longitudinal strain (GLS) and ejection fraction (EF) is explained by EF being related predominantly to left ventricular (LV) circumferential shortening, whereas GLS measures longitudinal shortening. Since myofibres that account for longitudinal shortening are located mainly in the vulnerable subendocardium, reduction in GLS may precede reduction in LVEF. Furthermore, with concentric hypertrophy, which is common in HFpEF patients, there is typically a small LV cavity and therefore normal or supernormal EF even when stroke volume is reduced. A limitation of GLS, as well as of EF, is the marked afterload dependency. Additionally, reduced GLS is found in only ∼50% of HFpEF cases. Therefore, in a large fraction of HFpEF patients, GLS will not provide the information needed.

Read more in:

Heart failure and systolic function: time to leave diagnostics based on ejection fraction? 
European Heart Journal, Volume 42, Issue 7, 14 February 2021, Pages 786–788, https://doi.org/10.1093/eurheartj/ehaa979
17 January 2021