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Pensa AV, Zheng V, Davis L, Harap RW, Wilcox JE. Clinical Perspective of Myocardial Recovery and Improvement: Definitions, Prevalence, and Relevance. Methodist Debakey Cardiovasc J 2024; 20:6-15. [PMID: 39184164 PMCID: PMC11342833 DOI: 10.14797/mdcvj.1441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 08/27/2024] Open
Abstract
Partial or complete imaging resolution of left ventricular (LV) systolic dysfunction in patients with heart failure with reduced ejection fraction (HFrEF) has gone by many names in the past few decades, including LV recovery, remission, reverse remodeling, and, most recently, improvement. This phenomenon has been described in a variety of clinical scenarios, including removal of an acute myocardial insult, unloading with durable LV assist devices, and treatment with various devices as well as pharmacotherapies, termed guideline-directed medical therapy (GDMT). Irrespective of definition, systolic improvement is associated with improved clinical outcomes compared to persistent systolic dysfunction. In the past few years, systolic improvement has been distinguished from HFrEF as a new clinical entity referred to as HF with improved EF (HFimpEF). Given the relative novelty of this condition, there is a paucity of data with regard to the clinical trajectory and management of this population. In this review, we describe the history of myocardial improvement terminology and explore notable findings that have led to the delineation of HFimpEF. Additionally, we highlight the importance of understanding LV trajectory and the potential opportunity for new GDMT management for clinicians when treating patients with HFimpEF.
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Affiliation(s)
- Anthony V. Pensa
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, US
| | - Veronica Zheng
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, US
| | - Lucia Davis
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, US
| | - Rebecca W. Harap
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, US
| | - Jane E. Wilcox
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, US
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Cao TH, Tay WT, Jones DJL, Cleland JGF, Tromp J, Emmens JE, Teng THK, Chandramouli C, Slingsby OC, Anker SD, Dickstein K, Filippatos G, Lang CC, Metra M, Ponikowski P, Samani NJ, Van Veldhuisen DJ, Zannad F, Anand IS, Lam CSP, Voors AA, Ng LL. Heart failure with improved versus persistently reduced left ventricular ejection fraction: A comparison of the BIOSTAT-CHF (European) study with the ASIAN-HF registry. Eur J Heart Fail 2024. [PMID: 39119882 DOI: 10.1002/ejhf.3378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/24/2024] [Accepted: 06/24/2024] [Indexed: 08/10/2024] Open
Abstract
AIMS We investigated the prevalence, clinical characteristics, and prognosis of patients with heart failure (HF) with improved ejection fraction (HFimpEF). METHODS AND RESULTS We used data from BIOSTAT-CHF including patients with a left ventricular ejection fraction (LVEF) ≤40% at baseline who had LVEF re-assessed at 9 months. HFimpEF was defined as a LVEF >40% and a LVEF ≥10% increase from baseline at 9 months. We validated findings in the ASIAN-HF registry. The primary outcome was a composite of time to HF rehospitalization or all-cause mortality. In BIOSTAT-CHF, about 20% of patients developed HFimpEF, that was associated with a lower primary event rate of all-cause mortality (hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.28-0.97, p = 0.040) and the composite endpoint (HR 0.46, 95% CI 0.30-0.70, p < 0.001) compared with patients who remained in persistent HF with reduced ejection fraction (HFrEF). The findings were similar in the ASIAN-HF (HR 0.40, 95% CI 0.18-0.89, p = 0.024, and HR 0.29, 95% CI 0.17-0.48, p < 0.001). Five independently common predictors for HFimpEF in both BIOSTAT-CHF and ASIAN-HF were female sex, absence of ischaemic heart disease, higher LVEF, smaller left ventricular end-diastolic and end-systolic diameter at baseline. A predictive model combining only five predictors (absence of ischaemic heart disease and left bundle branch block, smaller left ventricular end-systolic and left atrial diameter, and higher platelet count) for HFimpEF in the BIOSTAT-CHF achieved an area under the curve of 0.772 and 0.688 in the ASIAN-HF (due to missing left atrial diameter and platelet count). CONCLUSIONS Approximately 20-30% of patients with HFrEF improved to HFimpEF within 1 year with better clinical outcomes. In addition, the predictive model with clinical predictors could more accurately predict HFimpEF in patients with HFrEF.
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Affiliation(s)
- Thong Huy Cao
- Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- National Institute for Health and Care Research Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
- Leicester van Geest Multi-OMICS facility, University of Leicester, Leicester, UK
| | - Wan Ting Tay
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Donald J L Jones
- Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- Leicester van Geest Multi-OMICS facility, University of Leicester, Leicester, UK
- Leicester Cancer Research Centre, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, University of Leicester, Leicester, UK
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Jasper Tromp
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and the National University Health System, Singapore, Singapore
| | | | - Tiew-Hwa Katherine Teng
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Chanchal Chandramouli
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Oliver Charles Slingsby
- Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- National Institute for Health and Care Research Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
- Leicester van Geest Multi-OMICS facility, University of Leicester, Leicester, UK
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kenneth Dickstein
- University of Bergen, Stavanger University Hospital, Stavanger, Norway
| | - Gerasimos Filippatos
- Department of Cardiology, Heart Failure Unit, Athens University Hospital Attikon, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University and Cardiology Department, Military Hospital, Wroclaw, Poland
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- National Institute for Health and Care Research Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | | | - Faiez Zannad
- Inserm CIC 1433, Université de Lorrain, Nancy, France
| | - Inder S Anand
- Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis, MN, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, Groningen, The Netherlands
| | - Leong L Ng
- Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- National Institute for Health and Care Research Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
- Leicester van Geest Multi-OMICS facility, University of Leicester, Leicester, UK
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Segev A, Avrahamy B, Fardman A, Matetzky S, Freimark D, Regev O, Kuperstein R, Grupper A. Heart failure with improved ejection fraction: patient characteristics, clinical outcomes and predictors for improvement. Front Cardiovasc Med 2024; 11:1378955. [PMID: 39087071 PMCID: PMC11288926 DOI: 10.3389/fcvm.2024.1378955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 07/02/2024] [Indexed: 08/02/2024] Open
Abstract
Background Heart failure with improved ejection fraction (HFimpEF) is a recently recognized entity presenting a diagnostic and therapeutic challenge. Our aim was to characterize the profile of HFimpEF patients and evaluate predictors for EF lack of improvement among heart failure with reduced ejection fraction (HFrEF) patients. Methods We included ambulatory HFrEF patients (EF≤40%) between January 1, 2015, and September 1, 2022, with two consecutive echocardiography exams at least 6 months apart. HFimpEF was defined as improved EF from ≤40%->40% and by ≥10%. Results A total of 567 HFrEF patients (72% male, 54.3 ± 14.4 years old) were analyzed. Patients without EF improvement were more likely to be male, had more comorbidities, ischemic cardiomyopathy (ICMP), markers of adverse cardiac remodeling (lower EF and higher left and right ventricular diameters) and presence of late gadolinium enhancement (LGE) in MRI (P < 0.05 for all). In a multivariate analysis, male sex, ICMP, lower EF, larger ventricular size and LGE remained independent predictors for lack of EF improvement. A prediction model for lack of EF improvement including LVEF, LV diameter, diastolic blood pressure and ischemic etiology exhibited an area under the ROC curve of 0.77 (95% CI 0.73-0.81; P < 0.001). HFimpEF patients had better prognosis with lower hospitalizations and mortality rates. Guideline directed medical therapy (GDMT) were associated with improved outcomes in both groups regardless of EF improvement. Conclusions Lack of improvement in EF among HFrEF patients may be predicted by HF etiology and imaging parameters of adverse cardiac remodeling, and is associated with worse prognosis. GDMT were associated with improved outcomes in both HFimpEF and HFrEF patients.
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Affiliation(s)
- Amitai Segev
- Cardiovascular Division, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Benny Avrahamy
- Cardiovascular Division, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Alexander Fardman
- Cardiovascular Division, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Shlomi Matetzky
- Cardiovascular Division, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Dov Freimark
- Cardiovascular Division, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Ohad Regev
- Faculty of Health Sciences, Joyce and Irving Goldman Medical School, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Rafael Kuperstein
- Cardiovascular Division, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
| | - Avishay Grupper
- Cardiovascular Division, Chaim Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
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Kodur N, Tang WHW. Myocardial Recovery and Relapse in Heart Failure With Improved Ejection Fraction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2024; 26:139-160. [PMID: 38993352 PMCID: PMC11238717 DOI: 10.1007/s11936-024-01038-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/13/2024]
Abstract
Purpose of review The purpose of this review is to discuss myocardial recovery in heart failure with reduced ejection fraction (HFrEF) and to summarize the contemporary insights regarding heart failure with improved ejection fraction (HFimpEF). Recent findings Improvement in left ventricular ejection fraction (LVEF ≥ 40%) with improved prognosis can be achieved in one out of three (10-40%) patients with HFrEF treated with guideline-directed medical therapy. Clinical predictors include non-ischemic etiology of HFrEF, less abnormal blood or imaging biomarkers, and lack of specific pathogenic genetic variants. However, a subset of patients may ultimately relapse, suggesting that many patients are merely in remission rather than having fully recovered. Summary Patients with HFimpEF have improved prognosis but nonetheless remain at risk of relapse and long-term adverse events. Future studies will hopefully chart the natural history of HFimpEF and identify clinical predictors such as blood or novel imaging biomarkers that distinguish subgroups of patients based on differential trajectory and prognosis.
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Affiliation(s)
- Nandan Kodur
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, US
| | - W. H. Wilson Tang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, US
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, US
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Samson R, Ennezat PV, Jemtel THL. Patient-Centered Heart Failure Therapy. Am J Med 2024; 137:23-29. [PMID: 37838238 DOI: 10.1016/j.amjmed.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/16/2023]
Abstract
Simultaneous initiation of quadruple therapy with angiotensin receptor-neprilysin inhibitor, beta-adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor aims at prompt improvement and prevention of readmission in patients hospitalized for heart failure with reduced ejection fraction. However, titration of quadruple therapy is time consuming. Lengthy up-titration of quadruple therapy may negate the benefit of early initiation. Quadruple therapy should start with a sodium glucose cotransporter 2 inhibition and a mineralocorticoid antagonist, as both enable safe decongestion and require minimal or no titration. Depending on the level of decongestion and clinical characteristics, patients receive an angiotensin receptor-neprilysin inhibitor or a beta-adrenergic receptor blocker to be titrated after hospital discharge. Outpatient addition of an angiotensin receptor-neprilysin inhibitor to a beta-adrenergic receptor blocker or vice versa completes the quadruple therapy scheme. By focusing on decongestion and matching intervention to patients' profile, the present therapeutic sequence allows rapid implementation of quadruple therapy at fully recommended doses.
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Affiliation(s)
- Rohan Samson
- Advanced Heart Failure Therapies Program, University of Louisville Health-Jewish Hospital, Ky
| | - Pierre V Ennezat
- Department of Cardiology, AP-HP Hopitaux Universitaires Henri Mondor, Créteil, France
| | - Thierry H Le Jemtel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, La.
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Pensa AV, Khan SS, Shah RV, Wilcox JE. Heart failure with improved ejection fraction: Beyond diagnosis to trajectory analysis. Prog Cardiovasc Dis 2024; 82:102-112. [PMID: 38244827 DOI: 10.1016/j.pcad.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
Left ventricular (LV) systolic dysfunction represents a highly treatable cause of heart failure (HF). A substantial proportion of patients with HF with reduced ejection fraction (EF;HFrEF) demonstrate improvement in LV systolic function (termed HF with improved EF [HFimpEF]), either spontaneously or when treated with guideline-directed medical therapy (GDMT). Although it is a relatively new HF classification, HFimpEF has emerged in recent years as an important and distinct clinical entity. Improvement in LVEF leads to decreased rates of mortality and adverse HF-related outcomes compared to patients with sustained LV systolic dysfunction (HFrEF). While numerous clinical and imaging factors have been associated with HFimpEF, identification of which patients do and do not improve requires further investigation. In addition, patients improve at different rates, and what determines the trajectory of HFimpEF patients after improvement is incompletely characterized. A proportion of patients maintain improvement in LV systolic function, while others experience a recrudescence of systolic dysfunction, especially with GDMT discontinuation. In this review we discuss the contemporary guideline-recommended classification definition of HFimpEF, the epidemiology of improvement in LV systolic function, and the clinical course of this unique patient population. We also offer evidence-based recommendations for the clinical management of HFimpEF and provide a roadmap for future directions in understanding and improving outcomes in the care of patients with HFimpEF.
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Affiliation(s)
- Anthony V Pensa
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Sadiya S Khan
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Ravi V Shah
- Department of Medicine, Division of Cardiology, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Jane E Wilcox
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
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