Management of Heart Failure With Improved Ejection Fraction

Heart failure with improved ejection fraction (HFimpEF) is defined by improved left ventricular ejection fraction (LVEF) among patients who previously had reduced LVEF. HFimpEF is associated with improved prognosis, albeit with persistent risk of relapse and adverse events in some patients. Current guidelines thus recommend sustained and indefinite guideline-directed medical therapy (GDMT) for all patients with HFimpEF. Emerging clinical experience suggests that heart failure arising from acute etiologies that fully resolve along with complete LVEF recovery may have a favorable prognosis with lower risk of relapse. Indeed, cohort and case series studies have demonstrated the feasibility of safe de-escalation of GDMT in select patients with specific etiologies, with multiple small trials ongoing. Future studies should investigate whether advanced imaging or blood biomarkers could aid in risk stratifying patients with recovered LVEF, whether partial de-escalation of GDMT could be safe and feasible, and whether implantable cardioverter-defibrillator therapy can be safely discontinued.