In following more than 1,100 patients with heart failure for up to 15 years, Spanish cardiologists found left ventricular ejection fraction (LVEF) followed an inverse U-shape: LVEF improved for the first year, then plateaued for the rest of the first decade and declined in the following years—especially before death.
The researchers followed European Society of Cardiology guidelines for optimal medical therapy and suggested drug initiation played a role in the early LVEF improvement after study enrollment.
All patients had heart failure and left ventricular ejection fraction (LVEF) of 49 percent or below at baseline. They received echocardiography at that point, one year later and then every two years thereafter for up to 15 years.
Patients with ejection fraction below 40 percent (HFrEF) showed an average LVEF increase of 9 percent in the first year. Those with midrange ejection fraction (HFmrEF)—EF between 40 and 49 percent—demonstrated a smaller initial increase of 3 percent but the groups eventually overlapped at 15 years.
“Our data support that LVEF improvement in most patients represents myocardial remission rather than true myocardial recovery indicative of myocardial cure, and the decision to discontinue maintenance HF therapy, namely, beta-blockers, angiotensin-converting enzyme inhibitors, and mineralocorticoid receptor antagonists, requires careful consideration,” wrote lead author Josep Lupon, MD, PhD, and colleagues in the Journal of the American Cardiology.
The authors found the early improvements of LVEF were most pronounced in women, who also had higher measurements at baseline, as well as in patients with heart failure of a nonischemic origin.
At the end of follow-up, 56 percent of patients who began the study with HFrEF remained in that category, while 21 percent and 23 percent advanced to HFmrEF and preserved ejection fraction (HFpEF), respectively. On the other hand, only 39 percent who began the observational period in the midrange category stayed there, with 25 percent falling to reduced EF.
“Our long-term data support the characterization of HFmrEF as just a snapshot on the way toward recovering or declining left ventricular systolic function rather than as a stable phenotype,” Lupon et al. noted. “At present, patients with HFmrEF receive inconsistent treatment, with some clinicians using HFrEF therapy (as we do) and others awaiting more evidence and guideline recommendations.”
In a related editorial, Leslie W. Miller, MD, with Texas Heart Institute, said it was an “important lesson” that a decline in LVEF over subsequent visits was predictive of impending mortality. Miller noted that greater absolute declines in LVEF between measurements signaled even higher risks of death.
“A decline in EF should alert clinicians who are following patients with HF to increase the frequency of follow-up visits for these patients and to consider referral to an HF center for evaluation of more advanced therapies when appropriate,” Miller wrote. “It also raises the question of the optimal frequency of determining EF over time to identify patients who may have a significant decline in EF with a modest change or even an absence of worsening symptoms.”
Miller pointed out this is the longest prospective study tracking LVEF trajectories, and said the dataset should inform treatment strategies and future heart failure studies.
“What separates this study from all previous trials is that the treating physicians were all HF cardiologists from a single university practice who committed to adhere to the published guidelines of international societies for HF management throughout the 15-year period of the study, regardless of changes in EF,” he wrote. “This protocol provided the best observation of the natural history of EF changes in patients receiving the best therapy available.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.