Heart Failure and Improved or Recovered Ejection Fraction

Study Questions:

What are the characteristics and outcomes of adult outpatients with heart failure and improved or recovered ejection fraction (HFrecEF)?


This was a retrospective cohort study (inception period, January 1, 2012, to April 30, 2012) with 3-year follow-up at cardiology clinics (including HF subspecialty) in an academic institution. The dates of the analysis were May 21, 2015, to August 10, 2015. Participants were all outpatients 18 years or older who received care for a verified diagnosis of HF not attributed to specific cardiomyopathies or other special causes during the inception period. Data on type of HF at baseline, classified as HF with reduced EF (HFrEF) (defined as current left ventricular EF [LVEF] ≤40%), HF with preserved EF (HFpEF) (defined as current and all previous LVEF reports >40%), and HF with recovered EF (HFrecEF) (defined as current LVEF >40%, but any previously documented LVEF ≤40%) were collected. The main outcome measures were mortality, hospitalization rates, and composite endpoints (death or first hospitalization for any cause, death or first hospitalization for cardiovascular causes, and death or first HF-related hospitalization), and hospitalization rates over the entire follow-up period (all-cause, cardiovascular, and HF-related hospitalizations).


The study cohort comprised 2,166 participants. Their median age was 65 years, 41.4% (896 of 2,166) were female, 48.7% (1,055 of 2,166) were white, and 45.2% (1,368 of 2,166) black, and 63.2% (1,368 of 2,166) had coronary artery disease. Preserved (>40%) LVEF at inception was present in 816 of 2,166 (37.7%) patients. Of these patients, 350 of 2,166 (16.2%) had previously reduced (≤40%) LVEF and were classified as having HFrecEF, whereas 466 of 2,166 (21.5%) had no previous reduced LVEF and were classified as having HFpEF. The remaining 1,350 (62.3%) patients were classified as having HFrEF. After 3 years, age- and sex-adjusted mortality was 16.3% in patients with HFrEF, 13.2% in patients with HFpEF, and 4.8% in patients with HFrecEF (p <0 .001 vs. HFrEF or HFpEF). Compared with patients with HFpEF and patients with HFrEF, patients with HFrecEF had fewer all-cause (adjusted rate ratio [RR] vs. HFpEF, 0.71; 95% confidence interval [CI], 0.55-0.91; p = 0.007), cardiovascular (RR, 0.50; 95% CI, 0.35-0.71; p < 0.001), and HF-related (RR, 0.48; 95% CI, 0.30-0.76; p = 0.002) hospitalizations and were less likely to experience composite endpoints commonly used in clinical trials (death or cardiovascular hospitalization and death or HF hospitalization).


The authors concluded that outpatients with HFrecEF have a different clinical course than patients with HFpEF and HFrEF, with lower mortality, less frequent hospitalizations, and fewer composite endpoints.


This retrospective study reports that patients with HFrecEF had distinctly better 3-year outcomes compared with patients with HFpEF or HFrEF, including lower mortality and fewer all-cause, cardiovascular, and HF-related hospitalizations. These data suggest that patients with HFrecEF should be investigated separately in future outcome studies and clinical trials as a distinct phenotype/entity. The retrospective design of this study does not provide insights into potential predictors of LVEF recovery, including clinical and genetic characteristics. Future studies should prospectively enroll patients with newly diagnosed HFrEF within a prespecified window of onset and regularly follow-up these patients with echocardiography for recovery after guideline-directed medical and device therapy, and would help inform on the natural history and outcomes of LVEF response groups.

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