Beyond Static LVEF: A Proposed Decision-Centered Framework for Multimodality and Longitudinal Phenotyping in Heart Failure

Heart failure (HF) is a clinical syndrome whose severity cannot be inferred from left ventricular ejection fraction (LVEF) alone. Loading conditions, rhythm, comorbidities, congestion, and measurement variability can produce discordance between EF categories and clinical status. This narrative review proposes a decision-centered framework integrating clinical assessment and biomarkers with relatively stable traits, dynamic physiological states, and longitudinal treatment responses. A new focused PubMed search through 16 October 2026 retrieved 543 unique records; 91 were prioritized for an evidence map, supplemented by the original bibliography and targeted source checking. Application-specific judgments distinguish technical validity, diagnostic or prognostic information, clinical actionability, and demonstrated outcome benefit. Representative pathways address unexplained dyspnea, cardiomyopathic substrate, amyloidosis, right-sided dysfunction, and worsening HF. Conventional echocardiography, natriuretic peptides, clinical risk factors, and congestion assessment anchor these pathways; advanced testing is selected when results could change management. Illustrative scenarios show how positive, negative, and indeterminate findings affect the next step. The proposed framework has not been prospectively validated; its incremental value over guideline-based multimodality assessment, including effects on outcomes, efficiency, and cost, remains hypothetical. Its contribution is an explicit structure for choosing tests and planning reassessment, with evidence boundaries made visible.