An ejection fraction of 79% does not mean a stronger heart
In short
On an echo report, a higher ejection fraction is not automatically a better heart. In this case a 72-year-old woman showed an ejection fraction of 79% with a markedly reduced end-systolic volume, which the authors read not as a strong heart but as a small, hyperdynamic left ventricle. Cardiac MRI in the same patient showed that the apparently thickened interventricular septum was not muscle but replacement fibrosis confirmed by focal late gadolinium enhancement — scar. The conclusion is single: ejection fraction should not be read alone, but together with end-systolic volume, which is what exposes a hyperdynamic state.
The case is a 72-year-old postmenopausal woman presenting with chest discomfort and electrocardiographic findings suggestive of myocardial ischemia. Acetylcholine provocation testing revealed spasm in both the epicardial coronary arteries and the microvasculature. The ischemia came not from a blocked vessel but from a constricting one — ischemia with nonobstructive coronary arteries.
Is a thick wall always muscle?
No. Cardiac MRI showed focal late gadolinium enhancement in the interventricular septum, meaning dead tissue replaced by fibrous tissue — replacement fibrosis, not thickened muscle. The imaging finding was mimicking hypertrophy. Measuring wall thickness on echo does not separate the two. It is the same class of trap as what ECG voltage criteria miss when calling left ventricular hypertrophy.
Why is a high ejection fraction a problem?
Because ejection fraction is a ratio. When the left ventricle gets smaller and end-systolic volume drops sharply, the ratio rises even though the absolute volume ejected has not. The 79% here did not mean better performance; it signalled that a small ventricle was contracting excessively. The authors state that recurrent coronary spasm is not benign and can lead to irreversible myocardial fibrosis and maladaptive hyperdynamic remodeling, raising the risk of diastolic dysfunction and heart failure. A heart that looks powerful in systole can be a heart that cannot relax.
What does this mean for a lifter?
People who handle heavy loads end up looking at echo reports. Thick walls and a high ejection fraction are easy to read as a sign that training worked, and this case shows the same numbers can point the other way. Two things are worth taking. First, do not read ejection fraction without end-systolic volume next to it. Second, if chest symptoms appear at rest or in the early morning rather than during exertion, vasospastic ischemia belongs on the list — the pattern differs from exertional angina. Read alongside the difference between a heart thickened by training and one thickened by disease and what imaging adds to risk prediction.
A single case report is not a basis for interpreting your own test results. If you have chest pain, fainting, or unusual symptoms during exercise, get a cardiologist's assessment before adjusting a training plan around it.
Frequently asked questions
Is a higher ejection fraction better?
Not always. Ejection fraction is a ratio against ventricular volume, so when the ventricle gets smaller and end-systolic volume falls sharply, the number rises even if the absolute volume ejected has not. The 79% in this case was interpreted as a small hyperdynamic ventricle.
Why does end-systolic volume have to be read with it?
Ejection fraction alone cannot distinguish a genuinely strong heart from a ventricle whose ratio rose because it shrank. The authors conclude that ejection fraction must be interpreted together with end-systolic volume to identify hyperdynamic states.
Does a thickened ventricular wall always mean hypertrophy?
No. In this case the septum that looked thickened was confirmed by focal late gadolinium enhancement on cardiac MRI to be replacement fibrosis — scar. It was mimicking hypertrophy, and wall thickness alone does not separate the two.
Is coronary spasm dangerous?
The authors argue recurrent spasm is not benign. They describe it as capable of producing irreversible myocardial fibrosis and maladaptive hyperdynamic remodeling, which raises the risk of diastolic dysfunction and heart failure.
Do chest symptoms at rest rather than during exercise matter?
Vasospastic ischemia can present with a different symptom pattern from exertional angina caused by a blocked artery. As in this case, acetylcholine provocation testing can reveal epicardial and microvascular spasm, so chest symptoms at rest are worth evaluating.
Source: PubMed