Heart Failure With Improved Ejection Fraction: Definitions, Epidemiology, and Management Journal of the American College of Cardiology (JACC), Volume 85, Issue 24, 2025.
Heart Failure With Improved Ejection Fraction: Definitions, Epidemiology, and Management
Journal of the American College of Cardiology (JACC), Volume 85, Issue 24, 2025.
Key Points:
1. What is HFimpEF?
• HFimpEF (Heart Failure with improved Ejection Fraction) is when a patient’s LVEF was once ≤40% and later improves to >40%, with at least a ≥10% absolute increase in LVEF.
• It is now recognized as a separate heart failure (HF) phenotype.
2. Why It Matters:
• Despite LVEF recovery, these patients still carry risks for adverse cardiovascular outcomes and require ongoing follow-up.
3. How Common Is It?
• Estimated prevalence is ~23% among HF patients over ~3.8 years of follow-up, based on a meta-analysis of 9 studies.
• Increased prevalence reflects broader use of guideline-directed medical therapy (GDMT) and standardized definitions.
4. Cardiac Remodeling (Reverse Remodeling):
• LVEF recovery is linked to structural and molecular improvement in the heart muscle and reversal of fibrosis.
• Reverse remodeling is key to prognosis, but does not mean full recovery.
5. Underlying Causes:
• Causes vary: ischemic heart disease, myocarditis, toxic cardiomyopathy, and idiopathic forms.
• Some causes are more likely to reverse, others (like genetic or infiltrative diseases) carry a higher relapse risk.
6. Imaging & Biomarkers:
• Advanced imaging (e.g., cardiac MRI) helps assess potential for recovery.
• Biomarkers such as NT-proBNP and troponin can aid in predicting reverse remodeling and managing treatment.
7. Medical Therapy in HFimpEF:
• GDMT remains critical even after recovery (ACEi/ARB/ARNI, beta-blockers, MRAs, SGLT2i).
• Stopping meds is not currently recommended due to relapse risk.
8. DELIVER and FINEARTS-HF Trials:
• These are the first RCTs to provide dedicated insights into treating HFimpEF.
• DELIVER post hoc analysis showed that 25% of patients with HFimpEF were undertreated (received ≤1 HF medication).
9. Special Populations:
• Ischemic HFimpEF: Needs revascularization + secondary prevention (statins, antiplatelets).
• Genetic Cardiomyopathies: Some mutations (e.g., LMNA, TTN, FLNC) are linked to arrhythmic risk despite LVEF recovery.
• ICD may still be warranted in some.
10. Role of Genetic Testing:
• Useful in familial or idiopathic cases.
• Helps in identifying patients at high risk of late deterioration or arrhythmias.
11. Ongoing Trials:
• PROSPER-HF: Sacubitril/valsartan vs. valsartan in HFimpEF.
• WEAN-HF: Evaluating when/if GDMT can be safely withdrawn.
• Other trials explore therapy tapering and personalized care pathways.
12. Unresolved Questions:
• What’s the best threshold for defining HFimpEF?
• Can therapy be withdrawn safely?
• How to stratify risk more accurately?
• What is the role of cardiac MRI vs. echo in follow-up?
13. Conclusions:
• HFimpEF is a dynamic condition: LVEF may improve, but patients remain vulnerable.
• Continued GDMT and surveillance are essential.
• New evidence is emerging, but many clinical decisions still rely on expert opinion and limited data.
