European Journal of Cardiovascular Medicine

Diagnosing and managing heart failure according to the left ventricle’s ejection fraction (LVEF) has become part of evidence-based medicine. Not surprisingly, LVEF - a powerful prognostic factor in heart failure - has caused a marked heterogeneity in the clinical benefit of various therapeutic interventions. From a pathophysiological point of view, however, many disease characteristics are shared among the entire heart failure spectrum (from low to high LVEF). The many functional and anatomical differences within the spectrum are merely quantitative, with an extensive overlap between the extremes of the spectrum and belonging to the same linear relation when plotted against LVEF. Therefore, although counter-intuitive from a clinical point of view, from a patho- physiological point of view heart failure seems to progress along a common disease trajectory independently of LVEF. In this review, we will scrutinize this apparent paradox, estimate how it relates to the recent biomarker-oriented (as opposed to a classic LVEF-oriented) approach to heart failure and discuss to what extent it may affect conceptual progress in chronic heart failure.