Management of Heart Failure with Improved Ejection Fraction
Yes, patients with CHF still have heart failure and require continued management even if their ejection fraction improves. According to the 2022 AHA/ACC/HFSA Heart Failure Guidelines, improvement in LVEF does not mean full myocardial recovery or normalization of left ventricular function 1.
Understanding HF with Improved EF (HFimpEF)
The 2022 AHA/ACC/HFSA guidelines specifically define a category called "HF with improved EF" (HFimpEF) for patients who previously had an LVEF ≤40% and now have a follow-up measurement of LVEF >40% 1. This classification acknowledges that:
- Most patients with improved EF still have cardiac structural abnormalities
- LV chamber dilatation and ventricular systolic/diastolic dysfunction often persist
- Changes in LVEF may not be unidirectional (improvement can be followed by decline)
Why Continued Management is Essential
Risk of EF Deterioration: EF can decrease after withdrawal of pharmacological treatment in many patients who had improved EF to normal range with guideline-directed medical therapy (GDMT) 1.
Persistent Structural Abnormalities: Despite improved EF, most patients continue to have cardiac structural abnormalities that require ongoing management 1.
Medication Continuation Benefits: Continued use of renin-angiotensin-aldosterone system inhibitors is associated with maintaining the improved EF beyond the initial improvement phase 2.
Risk Factors for Relapse: Several factors are associated with EF decline after previous improvement, including:
- Male sex
- Atrial fibrillation/flutter
- Coronary artery disease
- History of myocardial infarction
- Presence of an implanted cardioverter-defibrillator
- Use of loop diuretics 2
Management Recommendations
Medication Management
- Continue GDMT indefinitely: The American College of Cardiology recommends continuing guideline-directed medical therapy indefinitely, even if LVEF improves to >40% 3.
- Maintain RAAS inhibitors: ACE inhibitors, ARBs, or ARNIs should be continued as they are associated with maintaining improved EF 2.
- Beta-blockers: Continue evidence-based beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) 3.
- SGLT2 inhibitors: Dapagliflozin or empagliflozin should be continued regardless of diabetes status 3.
Monitoring Protocol
- Regular Clinical Follow-up: Continue regular clinical assessment and echocardiographic follow-up 3.
- Short-term monitoring (2-4 weeks): Assess renal function, electrolytes, and blood pressure; evaluate medication tolerance and side effects 3.
- Medium-term monitoring (3 months): Reassess LVEF and symptoms; optimize GDMT to target doses 3.
Common Pitfalls to Avoid
Premature Discontinuation: Stopping GDMT when EF improves is a critical error that can lead to relapse 3, 1.
Inadequate Dose Titration: Failing to maintain optimal doses of medications can reduce treatment effectiveness 3.
Underutilization of Evidence-Based Therapies: Only 33% of eligible patients receive MRA therapy despite clear mortality benefits 3.
Failure to Recognize HFimpEF as a Distinct Entity: HFimpEF requires specific management approaches different from other HF categories 4.
Special Considerations
For patients whose heart failure arose from acute, fully resolved etiologies (such as alcoholic cardiomyopathy with complete abstinence), some studies suggest potentially favorable prognosis 5. However, the current guideline recommendation remains to continue GDMT indefinitely for all patients with HFimpEF 1, 3.
Remember that once a patient has been diagnosed with heart failure, they remain in Stage C heart failure even if symptoms resolve, and should be treated accordingly 1.