Understanding Heart Failure with Improved Ejection Fraction (HFimpEF): A Path to Cardiac Recovery-Dr.Akif Baig
Heart Failure with Improved Ejection Fraction (HFimpEF) refers to a subset of heart failure in which patients have experienced an improvement in left ventricular ejection fraction (LVEF) from a reduced state to a higher value, typically above 40%. This category reflects clinical recovery or partial recovery in cardiac function, though patients may still experience heart failure symptoms or remain at risk for adverse outcomes.
1. Definition and Diagnostic Criteria for HFimpEF
Parameter
Criteria
Initial LVEF
< 40%
Follow-up LVEF
≥ 40%
Evidence of HF
Current or historical symptoms/signs of heart failure
Time Interval
Improvement in LVEF over a period with stable medical therapy
2. Characteristics and Comparison with Other Heart Failure Types
Feature
HFimpEF
HFrEF
HFpEF
LVEF
Improves from < 40% to ≥ 40%
LVEF < 40%
LVEF ≥ 50%
Risk of Hospitalization
Reduced compared to HFrEF but remains
High
Intermediate
Mortality
Lower than HFrEF
High
Lower but significant
Remodeling
Reverse remodeling
Often worsens
Minimal to no remodeling
Medical Therapy
Similar to HFrEF
Essential
Varies, evidence weaker
3. Pathophysiology of HFimpEF
Reverse remodeling: Improvement in LVEF due to beneficial changes in ventricular size, shape, and function, often influenced by medical therapy (e.g., beta-blockers, ACE inhibitors).
Neurohormonal Modulation: Downregulation of deleterious neurohormonal pathways (e.g., RAAS, SNS) contributes to improved cardiac function.
Reduction in Fibrosis: Anti-fibrotic effects of medications can help improve ventricular compliance and function.
4. Management Strategy in HFimpEF
Management Aspect
Recommended Approach
Medication Continuation
Continue HFrEF therapy even after EF improvement due to risk of relapse
Monitoring
Regular follow-ups to monitor EF, symptoms, and biomarkers
Lifestyle Modification
Similar to other HF types; includes dietary control, exercise, smoking cessation
Biomarker Tracking
Regular BNP/NT-proBNP testing to monitor heart failure status
Device Therapy
CRT/ICD in select cases; consider reassessment if significant EF improvement
5. Prognosis and Outcomes of HFimpEF Compared to Other Heart Failure Types
Outcome
HFimpEF
HFrEF
HFpEF
Risk of HF-related events
Lower than HFrEF but remains
High
Lower than HFrEF, higher than general
Relapse to HFrEF
Possible if therapy stopped
N/A
N/A
Mortality
Improved mortality vs HFrEF
High
Lower than HFrEF
6. Medications Recommended for HFimpEF (Adapted from HFrEF Therapy)
Medication Class
Examples
Mechanism
Beta-Blockers
Metoprolol, Carvedilol
Reduces HR, decreases SNS activity
ACE Inhibitors/ARBs/ARNIs
Enalapril, Valsartan, Sacubitril-Valsartan
Blocks RAAS pathway, reduces remodeling
Mineralocorticoid Receptor Antagonists
Spironolactone
Anti-fibrotic effects
SGLT2 Inhibitors
Dapagliflozin
Enhances natriuresis, reduces hospitalization
7. Prognostic Markers and Indicators of Relapse in HFimpEF
Prognostic Marker
Indicator of Outcome
BNP/NT-proBNP
Higher levels indicate increased relapse risk
LVEF Reduction
Decline in LVEF over time indicates risk of reversion
Symptomatic Status
Persistence of symptoms linked with worse outcomes
Cardiac MRI for Fibrosis
Presence of myocardial fibrosis is a poor prognostic marker
