Recovered heart failure with reduced ejection fraction and outcomes: a prospective study

Abstract

Aims Significant recovery of left ventricular ejection fraction (LVEF) occurs in a proportion of patients with heart failure (HF) and reduced ejection fraction (HFrEF). We analysed outcomes, including mortality [all‐cause, cardiovascular (CV), HF‐related, and sudden death], and HF‐related hospitalizations in this HF‐recovered group. The primary endpoint was a composite of CV death or HF hospitalization. Methods and results LVEF was assessed at baseline and at 1 year in 1057 consecutive HF patients. Patients were classified into three groups: (i) HF‐recovered: LVEF <45% at baseline and ≥45% at 1 year (n = 233); (ii) HF with preserved EF (HFpEF): LVEF ≥45% throughout follow‐up (n = 117); and (iii) HFrEF: LVEF <45% throughout follow‐up (n = 707). Mean follow‐up was 5.6 ± 3.1 years. HF‐recovered patients differed from HFrEF and HFpEF groups in demographic and clinical characteristics. The mean LVEF increase was 21.1 ± 10 points in HF‐recovered patients. Using the HF‐recovered group as a reference, the risks for the primary composite endpoint (n = 376), with non‐CV death as competing risk, for HFpEF and HFrEF groups were: hazard ratio (HR) 2.33 [95% confidence interval (CI) 1.60–3.39], P < 0.001 and HR 1.99 (95% CI 1.50–2.65), P < 0.001, respectively. All‐cause (n = 429), CV (n = 245), HF‐related (n = 127), and sudden death (n = 60) were significantly lower in HF‐recovered subjects relative to HFrEF (all P < 0.01). HF‐recovered patients also experienced less recurrent HF hospitalizations (P < 0.001). Conclusion One in four treated patients with HFrEF showed recovery of systolic function. HF‐recovered patients had significantly improved mortality and morbidity relative to HFpEF and HFrEF subjects. Further research is needed to identify optimal medications and device indications for HF‐recovered patients.

What have we learned about heart failure with mid‐range ejection fraction one year after its introduction?

“…Hypertensive and ischaemic aetiologies for heart failure with reduced (HFrEF), mid‐range (HFmrEF), and preserved ejection fraction (HFpEF) in four recent studies …”

“…Testing bias might be introduced when the serial echocardiograms were not systematically performed, but their timing was dictated by the clinical status of the patient. The studies of Tsuji and Lupón had echos that were required by protocol at fixed times, whereas the studies of Rastogi and Vedin let the indication for echo at the discretion of the treating physician.…”

December 2017 at a glance: left ventricular ejection fraction, exercise capacity, peripartum cardiomyopathy

“…The impact of chronic kidney disease on outcomes was also larger in patients with HFrEF and HFmrEF than in those with HFpEF . The assessment of the temporal changes of LVEF shows that most patients with HFmrEF have recovered from a lower LVEF whereas the decline from HFpEF to HFmrEF is much less common . Thus, these studies show that the characteristics of HFmrEF patients are similar to those of HFrEF patients.…”

Peripartum cardiomyopathy

“…Although heart failure with recovered ejection fraction generally has a more favorable natural course than heart failure with reduced or preserved ejection fraction,156 patients retain some risk of recurrent heart failure and adverse outcomes 157. Further research is needed to identify appropriate drug withdrawal strategies and to elucidate the benefit, if any, of continued neurohormonal blockade after ejection fraction recovery, for patients with heart failure overall and specifically in PPCM 158. Finally, the genetic susceptibility identified in at least a proportion of women with PPCM raises several additional questions.…”