HEART FAILURE WITH IMPROVED EJECTION FRACTION

HEART FAILURE WITH IMPROVED EJECTION FRACTION

 

Heart Failure with Improved Ejection Fraction (HFimpEF)

Heart Failure with Improved Ejection Fraction (HFimpEF) refers to patients who were previously diagnosed with heart failure with reduced ejection fraction (HFrEF) but later demonstrate a significant improvement in their left ventricular ejection fraction (LVEF). This improvement is usually a result of optimal medical therapy or other interventions, leading to a recovery of heart function.

Definition

The term HFimpEF is typically used when a patient’s LVEF increases from a reduced level (usually <40%) to >40-50%, with or without reaching the normal range (LVEF ≥50%).

Key Characteristics

  1. Previous Diagnosis of HFrEF: Patients must have a documented history of heart failure with reduced ejection fraction (HFrEF), typically defined as LVEF <40%.
  2. Improvement in LVEF: The LVEF increases by at least 10 percentage points (e.g., from 30% to 40%) after the initiation of therapy.
  3. Symptomatic Improvement: Along with improved LVEF, patients often experience improvement in heart failure symptoms, such as reduced shortness of breath, less fatigue, and improved exercise tolerance.

Pathophysiology

The improvement in ejection fraction in patients with HFrEF is thought to occur due to a combination of:

  • Neurohormonal Blockade: Medications such as ACE inhibitors, ARBs, beta-blockers, and aldosterone antagonists help reverse the neurohormonal activation that worsens heart failure, leading to reverse remodeling of the heart.
  • Device Therapy: Cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillators (ICDs) can improve cardiac function in selected patients with heart failure.
  • Lifestyle Changes: Improved heart failure outcomes are often linked to lifestyle modifications such as better diet, exercise, and avoidance of substances like alcohol and tobacco.

Importance of HFimpEF

HFimpEF is clinically significant because it suggests that heart failure is a dynamic condition that can be partially reversible with appropriate treatment. However, the term is not synonymous with complete recovery, as many patients with HFimpEF still require continued treatment and close monitoring to prevent worsening of their heart function.

Treatment Considerations

Despite the improvement in LVEF, patients with HFimpEF continue to benefit from standard heart failure therapies to maintain their improved ejection fraction and prevent relapse. These include:

  • ACE inhibitors or ARBs: To prevent worsening heart failure and further improve cardiac function.
  • Beta-blockers: To reduce heart rate, improve cardiac efficiency, and prevent arrhythmias.
  • Mineralocorticoid receptor antagonists (e.g., spironolactone): To reduce fluid retention and further improve heart function.
  • SGLT2 inhibitors: Emerging evidence suggests these drugs can further improve outcomes in patients with heart failure.

Risk of Recurrence

Patients with HFimpEF remain at risk for heart failure recurrence. Even after LVEF has improved, discontinuation of heart failure medications or re-exposure to stressors such as ischemic events, infections, or arrhythmias can lead to a decline in heart function and a return to HFrEF.

Prognosis

  • Better than Persistent HFrEF: Patients with HFimpEF generally have a better prognosis than those with persistent HFrEF, including lower rates of hospitalization and death.
  • Not Equivalent to Normal Heart Function: Despite improvements, HFimpEF patients do not return to normal cardiac health. Ongoing heart failure therapy and lifestyle interventions remain essential to maintaining their improved status and preventing adverse outcomes.

Monitoring

Patients with HFimpEF require regular follow-up to monitor for:

  • LVEF Maintenance: Ensure that LVEF remains stable or continues to improve.
  • Symptom Recurrence: Watch for signs of worsening heart failure, including fluid retention, shortness of breath, and fatigue.
  • Ongoing Treatment: Reinforce the importance of adhering to medication regimens and lifestyle modifications to maintain heart function.

Conclusion

Heart failure with improved ejection fraction (HFimpEF) represents a positive response to heart failure therapy, but it requires ongoing management to maintain gains in heart function and prevent relapse. Patients with HFimpEF benefit from continuous heart failure treatment and monitoring, as they remain at risk for symptom recurrence and deterioration.

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