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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 ParameterCriteriaInitial LVEF< 40%Follow-up LVEF≥ 40%Evidence of HFCurrent or historical symptoms/signs of heart failureTime IntervalImprovement in LVEF over a period with stable medical therapy 2. Characteristics and Comparison with Other Heart Failure Types FeatureHFimpEFHFrEFHFpEFLVEFImproves from < 40% to ≥ 40%LVEF < 40%LVEF ≥ 50%Risk of HospitalizationReduced compared to HFrEF but remainsHighIntermediateMortalityLower than HFrEFHighLower but significantRemodelingReverse remodelingOften worsensMinimal to no remodelingMedical TherapySimilar to HFrEFEssentialVaries, 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 AspectRecommended ApproachMedication ContinuationContinue HFrEF therapy even after EF improvement due to risk of relapseMonitoringRegular follow-ups to monitor EF, symptoms, and biomarkersLifestyle ModificationSimilar to other HF types; includes dietary control, exercise, smoking cessationBiomarker TrackingRegular BNP/NT-proBNP testing to monitor heart failure statusDevice TherapyCRT/ICD in select cases; consider reassessment if significant EF improvement 5. Prognosis and Outcomes of HFimpEF Compared to Other Heart Failure Types OutcomeHFimpEFHFrEFHFpEFRisk of HF-related eventsLower than HFrEF but remainsHighLower than HFrEF, higher than generalRelapse to HFrEFPossible if therapy stoppedN/AN/AMortalityImproved mortality vs HFrEFHighLower than HFrEF 6. Medications Recommended for HFimpEF (Adapted from HFrEF Therapy) Medication ClassExamplesMechanismBeta-BlockersMetoprolol, CarvedilolReduces HR, decreases SNS activityACE Inhibitors/ARBs/ARNIsEnalapril, Valsartan, Sacubitril-ValsartanBlocks RAAS pathway, reduces remodelingMineralocorticoid Receptor AntagonistsSpironolactoneAnti-fibrotic effectsSGLT2 InhibitorsDapagliflozinEnhances natriuresis, reduces hospitalization 7. Prognostic Markers and Indicators of Relapse in HFimpEF Prognostic MarkerIndicator of OutcomeBNP/NT-proBNPHigher levels indicate increased relapse riskLVEF ReductionDecline in LVEF over time indicates risk of reversionSymptomatic StatusPersistence of symptoms linked with worse outcomesCardiac MRI for FibrosisPresence of myocardial fibrosis is a poor prognostic marker

Tag: dyspnea

Understanding Heart Failure with Improved Ejection Fraction (HFimpEF): A Path to Cardiac Recovery-Dr.Akif Baig

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