The EchoNoRMAL (Echocardiographic Normal Ranges Meta-Analysis of the Left Heart) Collaboration. Ethnic-Specific Normative Reference Values for Echocardiographic LA and LV Size, LV Mass, and Systolic Function: The EchoNoRMAL Study

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OBJECTIVES This study sought to derive age-, sex-, and ethnic-appropriate adult reference values for left atrial (LA)
and left ventricular (LV) dimensions and volumes, LV mass, fractional shortening, and ejection fraction (EF) derived from
geographically diverse population studies.
BACKGROUND The current recommended reference values for measurements from echocardiography may not be
suitable to the diverse world population to which they are now applied.
METHODS Population-based datasets of echocardiographic measurements from 22,404 adults without clinical
cardiovascular or renal disease, hypertension, or diabetes were combined in an individual person data meta-analysis.
Quantile regression was used to derive reference values at the 95th percentile (upper reference value [URV]) and fifth
percentile (lower reference value [LRV]) of each measurement against age (treated as linear), separately within sex and
ethnic groups.
RESULTS The URVs for left ventricular end-diastolic volume (LVEDV), LV end-systolic volume, and LV stroke volume
(SV) were highest in Europeans and lowest in South Asians. Important sex and ethnic differences remained after
indexation by body surface area or height for these measurements, as well as for the LRV for SV. LVEDV and SV decreased
with increasing age for all groups. Importantly, the LRV for EF differed by ethnicity; there was a clear apparent difference
between Europeans and Asians. The URVs for LV end-diastolic diameter and LV end-systolic diameter were higher for
Europeans than those for East Asian, South Asian, and African people, particularly among men. Similarly, the URVs for LA
diameter and volume were highest for Europeans.
CONCLUSIONS Sex- and/or ethnic-appropriate echocardiographic reference values are indicated for many measurements
of LA and LV size, LV mass, and EF. Reference values for LV volumes and mass also differ across the age


Original languageEnglish
Pages (from-to)656
Number of pages665
JournalJACC: Cardiovascular Imaging
Issue number6
Publication statusPublished - 6 Jun 2015