Heart Failure with Recovered EF and Heart Failure with Mid-Range EF: Current Recommendations and Controversies
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Purpose of review
This review explores key features and potential management controversies in two emerging populations in heart failure: heart failure with recovered ejection fraction (HF-recovered EF) and heart failure with mid-range ejection fraction (HFmrEF).
While HF-recovered EF patients have better outcomes than heart failure with reduced ejection fraction (HFrEF), they continue to have symptoms, persistent biomarker elevations, and abnormal outcomes suggesting a continued disease process. HFmrEF patients appear to have features of HFrEF and heart failure with preserved ejection fraction (HFpEF), but have a high prevalence of ischemic heart disease and may represent a transitory phase between the HFrEF and HFpEF. Management strategies have insufficient data to warrant standardization at this time.
HF-recovered EF and HFmrEF represent new populations with unmet needs and expose the pitfalls of an EF basis for heart failure classification.
KeywordsHeart failure Recovered ejection fraction Mid-range ejection fraction
Compliance with Ethical Standards
Conflict of Interest
Peter Unkovic and Anupam Basuray each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Yancy C, Jessup M, Bozkurt B, Butler J, Casey D Jr, Drazner M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–327.CrossRefPubMedGoogle Scholar
- 2.• Punnoose L, Givertz M, Lewis E, Pratibhu P, Stevenson L, Desai A. Heart failure with recovered ejection fraction: a distinct clinical entity. J Card Fail. 2011;17(7):527–32. This paper was the first to describe HF-Recovered EF out of a group of patients who were labeled as HFpEF, suggesting that HFrEF patients who improve ejection fraction are a distinct population.CrossRefPubMedGoogle Scholar
- 3.• Basuray A, French B, Ky B, Vorovich E, Olt C, Sweitzer N, et al. Heart failure with recovered ejection fraction: clinical description, biomarkers and outcomes. Circulation. 2014;129(23):2380–7. This paper was the first to demonstrate that despite a normalized LVEF, patients with a recovered EF were not normal as demonstrated by clinical charactersitics, biomarkers, and outcomes.CrossRefPubMedPubMedCentralGoogle Scholar
- 4.Ponikowski P, Voors A, Anker S, Bueno H, Cleland J, Coats A, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J. 2016;37:2129–200.CrossRefPubMedGoogle Scholar
- 6.Merlo M, Stolfo D, Anzini M, Negri F, Pinamonti B, Barbati G, et al. Persistent recovery of normal left ventricular function and dimension in idiopathic dilated cardiomyopathy during long-term follow-up: does real healing exist? J Am Heart Assoc. 2015;4(1).Google Scholar
- 13.•• Mann D, Barger P, Burkhoff D. Myocardial recovery and the failing heart: myth, magic, or molecular target? J Am Coll Cardiol. 2012;60(24):2465–72. Excellent explanation of existing data and propositions for future studies on the mechanism of myocardial recovery. It is also a comprehensive review of the myocardial recovery literature.CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Felker G, Anstrom K, Adams K, Ezekowitz J, Fiuzat M, Houston-Miller N, et al. Effect of natriuretic peptide–guided therapy on hospitalization or cardiovascular mortality in high risk patients with heart failure and reduced ejection fraction: a randomized clinical trial. JAMA. 2017;318(8):713–20.CrossRefPubMedPubMedCentralGoogle Scholar
- 19.• Birks E, George R, Hedger M, Bahrami T, Wilton P, Bowles C, et al. Reversal of severe heart failure with a continuous-flow left ventricular assist device and pharmacological therapy: a prospective study. Circulation. 2011;123(4):381–90. LVAD data showing that myocardial recovery leading to LVAD explantation can be achieved with proper patient selection and intense medical management.CrossRefPubMedGoogle Scholar
- 22.•• Shah K, Xu H, Matsouaka R, Bhatt D, Heidenreich P, Hernandez A, et al. Heart failure with preserved, borderline, and reduced ejection fraction 5-year outcomes. J Am Coll Cardiol. 2017;70(20):2476–86. This article was pertinent because it used a large cohort to demonstrate that mortality after a HF hospitalization was uniformly associated with poor event-free survival regardless of EF.CrossRefPubMedGoogle Scholar
- 24.Chioncel O, Lainscak M, Seferovic P, Anker S, Crespo-Leiro M, Harjola V, et al. Epidemiology and one-year outcomes in patients with chronic heart failure and preserved, mid-range and reduced ejection fraction: an analysis of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2017;19:1574–85.CrossRefPubMedGoogle Scholar
- 25.Rickenbacher P, Kaufmann B, Maeder M, Bernheim A, Goetschalckx K, Pfister O, et al. Heart failure with mid-range ejection fraction: a distinct clinical entity? Insights from the Trial of Intensified versus standard medical therapy in elderly patients with congestive heart failure (TIME-CHF). Eur J Heart Fail. 2017;19:1586–96.CrossRefPubMedGoogle Scholar
- 26.Kapoor J, Kapoor R, Ju C, Heidenreich P, Eapen Z, Hernandez A, et al. Precipitating clinical factors, heart failure characterization, and outcomes in patients hospitalized with heart failure with reduced, borderline, and preserved ejection fraction. JACC Heart Fail. 2016;4(6):464–72.CrossRefPubMedGoogle Scholar
- 27.Sartipy U, Dahlström U, Fu M, Lund L. Atrial fibrillation in heart failure with preserved, mid-range, and reduced ejection fraction. JACC: Heart Fail. 2017;5:565–74.Google Scholar
- 29.• Nadruz W, West E, Santos M, Skali H, Groarke J, Forman D, et al. Heart failure and midrange ejection fraction implications of recovered ejection fraction for exercise tolerance and outcomes. Circ: Heart Fail. 2016;9(4):e002826. First study to suggest HFmrEF group is heterogeneous and that those who recovered from HFrEF have a more favorable phenotype.Google Scholar
- 30.Tromp J, Khan M, Mentz R, O’Connor C, Metra M, Dittrich H, et al. Biomarker profiles of acute heart failure patients with a mid-range ejection fraction. JACC: Heart Fail. 2017;5(7):507–17.Google Scholar
- 37.Hsu J, Boback Z, Fonarow G. Heart failure with mid-range (borderline) ejection fraction clinical implications and future directions. JACC: Heart Fail. 2017;5:763–71.Google Scholar
- 42.Savarese G, Donal E, Hage C, Oger E, Persson H, Daubert J, et al. Changes in natriuretic peptides after acute hospital presentation for heart failure with preserved ejection fraction: a feasible surrogate trial endpoint? A report from the prospective Karen study. Int J Cardiol. 2017;226:65–70.CrossRefPubMedGoogle Scholar
- 45.Packer M. Heart failure with a mid-range ejection fraction: a disorder that a psychiatrist would love. JACC: Heart Fail. 2017;5(11):805–7.Google Scholar