Heart Failure With Improved Ejection Fraction (HFimpEF) – Structured Summary
Heart Failure With Improved Ejection Fraction (HFimpEF) – Structured Summary
Published: August 14, 2025 | Source: Medscape Medical News (summary of JACC 2025 article by Riccardi et al.)
1. Definition
• HFimpEF is identified in patients whose LVEF was initially ≤ 40% and later improves to > 40%.
• The universal definition (2021) also includes a requirement of ≥ 10% absolute improvement in LVEF.
• While guidelines like ACC/AHA 2022 consider a rise above 40% sufficient, the universal definition is more precise.
• This condition represents a state of remission—not a full recovery.
2. LVEF Evolution
• Termed variously as LVEF Evolution, LVEF Progression, or EF Time Trend, all capture changes over time.
• Improvement commonly persists for up to 10 years, but many patients eventually experience a drop in LVEF.
• Those who relapse face higher risks of mortality, need for transplantation, or LVAD placement.
3. Outcomes Compared with Persistent HFrEF
• HFimpEF carries about a 60% lower risk of death or hospitalization than persistent HFrEF.
• Confirmed across major registries: MECKI, BIOSTAT-CHF, and ASIAN-HF.
• Risk of ventricular arrhythmia is reduced—but not eliminated, highlighting ongoing uncertainty around ICD/CRT decisions.
4. Outcomes Compared with HFpEF
• Generally better prognosis than HFpEF: fewer readmissions and lower mortality.
• However, the DELIVER trial found similar event rates to HFpEF; HFimpEF patients often required more intensive in-hospital care due to their higher baseline risk.
5. Pathophysiology & Remodeling
• Improvement results from reverse remodeling driven by GDMT, device therapy, revascularization, or resolution of reversible triggers (e.g., myocarditis, peripartum cardiomyopathy).
• Despite EF recovery, underlying molecular and structural changes persist—thus relapse remains possible.
6. Predictors of Recovery
• More likely in younger, female patients with non-ischemic cardiomyopathy, short disease duration, fewer comorbidities, and good therapy adherence.
• Less likely in ischemic or genetic heart disease.
• Genetic factors (e.g., TTN vs desmosomal mutations) affect both recovery chances and prognosis.
7. Management
• Continue GDMT indefinitely; withdrawal risks relapse (as shown by the TRED-HF trial).
• ICD/CRT decisions require careful individual evaluation—risk persists, and recovery is not total.
• Emerging treatments like SGLT2 inhibitors and finerenone show promise in symptomatic patients.
8. Role of Imaging & Biomarkers
• Echocardiography: GLS and left atrial strain give insight into risk of relapse.
• Cardiac MRI (CMR): Evaluates fibrosis, viability, and T1 mapping changes.
• Biomarkers:
• NT-proBNP decline signals favorable remodeling.
• ST2 (soluble suppression of tumorigenicity 2) is a fibrosis-related marker—persistent elevation predicts poorer outcomes despite EF recovery.
9. Reducing Communication Barriers
• Effective collaboration among clinicians is critical, yet often hindered by personal reluctance or hierarchical barriers.
• Establishing a confidential, case-based discussion platform—where specialists can consult on complex HFimpEF cases anonymously—can foster collaboration without embarrassment and improve patient management.
10. Key Takeaway
HFimpEF patients enjoy improved outcomes compared to those with HFrEF or HFpEF—but they are not cured. Long-term therapy, surveillance, and thoughtful decision-making are essential. Collaboration—especially via confidential peer discussions—can further bridge gaps in care and optimize recovery.
Proposal: Encourage confidential, blind case discussions among cardiologists. A neutral moderator presents the case (without revealing the sender), allowing open, respectful dialogue and exchange of expertise — free from personal sensitivities, strengthening collaboration and improving patient care.
