Characteristics, outcomes and the necessity of continued guideline-directed medical therapy in patients with heart failure with improved ejection fraction

Much remains to be learned about patients with heart failure with improved ejection fraction (HFimpEF). This study sheds light on the characteristics and clinical outcomes of HFimpEF patients, including the consequences of halting guideline-directed medical therapy (GDMT). This retrospective study was conducted on patients diagnosed with heart failure with reduced ejection fraction (HFrEF) who underwent a second echocardiogram at least 6 months apart between January 2009 and February 2023. The primary outcomes were major adverse cardiovascular events (MACEs), including all-cause mortality and heart failure hospitalization. The second outcome was recurrent HFrEF. Of 4,560 HFrEF patients were included, 3,289 (72.1%) achieved HFimpEF within a median follow-up period of 3.4 years (IQR: 1.8 − 5.9 years). Among these HFimpEF patients, recurrent HFrEF was observed in 941 (28.6%) patients during a median follow-up period of 2.3 years (IQR: 0.8–4.6 years). The proportion of patients who halted GDMT was 70.4%, 53.2%, 59.8% and 63.8% for MRA, beta-blockers, ACEI/ARB/ARNI and SGLT-2 inhibitors. Multivariable Cox analysis revealed ischemic heart disease, chronic kidney disease, coronary heart disease, lower left ventricular ejection fraction, larger left ventricular diastolic dimension and non-use GDMT are associated with recurrent HFrEF. Individuals without GDMT use exhibited lower chances of persistently recovering ejection fraction and high risks of MACEs compared to those who continue use. HFimpEF is a common condition across all clinical follow-ups. Prevalent discontinuation of GDMT medications may contribute significantly to recurrent HFrEF, placing patients at a higher risk for poor prognosis.

目前对于射血分数改善型心力衰竭（heart failure with improved ejection fraction, HFimpEF）患者的认知仍存在诸多空白。本研究旨在阐明HFimpEF患者的临床特征与临床转归，包括停止指南指导的药物治疗（guideline-directed medical therapy, GDMT）所带来的相关结局。本回顾性研究纳入了2009年1月至2023年2月期间确诊为射血分数降低型心力衰竭（heart failure with reduced ejection fraction, HFrEF）、且间隔至少6个月接受二次超声心动图检查的患者。主要结局为主要不良心血管事件（major adverse cardiovascular events, MACEs），涵盖全因死亡率与心力衰竭住院事件；次要结局为复发性HFrEF。本研究共纳入4560例HFrEF患者，其中3289例（72.1%）在中位随访3.4年（四分位距：1.8~5.9年）内达到HFimpEF标准。在这些HFimpEF患者中，有941例（28.6%）在中位随访2.3年（四分位距：0.8~4.6年）期间出现复发性HFrEF。停止GDMT的患者比例在盐皮质激素受体拮抗剂（MRA）、β受体阻滞剂（beta-blockers）、血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂/血管紧张素受体脑啡肽酶抑制剂（ACEI/ARB/ARNI）以及钠-葡萄糖协同转运蛋白2抑制剂（SGLT-2 inhibitors）中分别为70.4%、53.2%、59.8%与63.8%。多变量Cox回归分析显示，缺血性心脏病、慢性肾脏病、冠心病、较低的左心室射血分数、较大的左心室舒张末期内径以及未使用GDMT均与复发性HFrEF显著相关。与持续使用GDMT的患者相比，未使用GDMT的患者持续维持射血分数改善状态的概率更低，且发生MACEs的风险更高。HFimpEF在所有临床随访队列中均较为常见。GDMT药物的普遍停用可能是复发性HFrEF的重要诱因，会使患者面临不良预后的更高风险。