Heart Failure With Recovered LVEF: JACC Scientific Expert Panel

Wilcox JE, Fang JC, Margulies KB, Mann DL.
Heart Failure With Recovered Left Ventricular Ejection Fraction: JACC Scientific Expert Panel. J Am Coll Cardiol 2020;76:719-734.

Heart failure with recovered ejection fraction (HFrecEF) is a complex clinical entity in which biology and clinical management are addressed in this JACC Scientific Expert Panel article. The authors review the pathophysiology and epidemiology of HFrecEF and provide expert opinion–based recommendations surrounding its management. The following are 10 key points summarizing their insights and recommendations:

  1. Given the complexity and heterogeneity of patients with HFrecEF, there is no consensus on the definition, diagnosis, and management of this patient population.
  2. The expert panel provides the following working definition for HFrecEF: 1) documentation of a left ventricular ejection fraction (LVEF) <40% at baseline, combined with 2) a ≥10% absolute improvement in LVEF and 3) a second LVEF measurement >40%.
  3. The proportion of patients with HFrecEF varies widely (10-40%), depending on the patient population and definitions used.
  4. HFrecEF represents a clinical entity distinct from HF with reduced EF (HFrEF) and HF with preserved EF (HFpEF), characterized by a less pathological myocardial “steady state” associated with improved outcomes, while retaining many molecular features of the failing heart and a high risk of long-term recurrence of HF.
  5. Patients with HFrecEF have a 50% decrease in HF hospitalization and improved survival compared to HFpEF and HFrEF.
  6. The biology of HFrecEF is heterogeneous and depends on the underlying injurious process such as ischemia, cardiotoxic chemotherapy, alcohol-induced cardiomyopathy, stress-induced chemotherapy, and myocarditis, and competing reverse (beneficial) and forward (pathologic) remodeling of the LV.
  7. Female sex, nonischemic etiology, younger age, and shorter duration of HF are associated with higher rates of reverse LV remodeling and LVEF recovery.
  8. Discontinuation of medical therapy in HFrecEF is associated with high rates (>30%) of HF recurrence. The panel recommends not stopping goal-directed medical therapy in HFrecEF.
  9. Patients with HFrecEF should be followed every 6 months to 1 year, with imaging obtained every 3-5 years to monitor LV function.
  10. Whether a subset of HFrecEF continues to benefit from implantable cardioverter-defibrillator (ICD) therapy is unclear. The panel supports ICD generator change for most patients with HFrecEF, and recommends maintaining cardiac resynchronization therapy.

Clinical Topics: Arrhythmias and Clinical EP, Cardio-Oncology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure

Keywords: Cardiac Resynchronization Therapy, Cardiomyopathies, Cardiotoxicity, Defibrillators, Implantable, Diagnostic Imaging, Heart Failure, Myocardial Ischemia, Myocarditis, Myocardium, Stroke Volume, Ventricular Function, Left

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