Supra-Normal Left Ventricular Function

•Supra-normal left ventricular ejection fraction is a new concept possibly associated with U-shaped prognosis.•Heart failure with supra-normal ejection fraction (HFsnEF) and Supra-normal left ventricular ejection fraction of definition, approach to pathophysiology, diagnostic strategy, and prognosis are reviewed.•The pathophysiology of HFsnEF is mainly microvascular dysfunction and its low stroke volume index.•Data on HFsnEF are still limited and further studies will be expected. Heart failure (HF) is often categorized by left ventricular (LV) ejection fraction (LVEF). A new category of HF characterized by supra-normal LVEF (>65%), named HF with supra-normal ejection fraction (HFsnEF), has been recently proposed. Some studies reported that patients with supra-normal LVEF might have an increased risk of long-term major adverse cardiovascular events and U-shaped mortality patterns. Currently, the prognosis of HFsnEF is not well established but seems to be associated with an increased risk of long-term major adverse cardiovascular events. It has been reported that HFsnEF is more prevalent in women and is associated with higher prevalence of nonischemic HF, higher blood urea nitrogen plasma levels, lower levels of natriuretic peptides, and to be less likely treated with β blockers. The pathophysiology of HFsnEF would be associated with microvascular dysfunction because of microvascular inflammation or reduced coronary flow reserve, and low stroke volume index with smaller cardiac chamber dimensions and concentric LV geometry. In this study, we systematically reviewed published data on patients with s supra-normal LV function and reported its definition, proposed pathophysiology, phenotypes, diagnostic strategy, and prognosis.