Incidence, medical therapy, and outcomes in heart failure with improved ejection fraction across guideline definitions
A Agharahmanian, K H Min, A S Go, R V Parikh, A P Ambrosy, T C Tan, J Svetlichnaya, S D Solomon, R M Inciardi, M Vaduganathan, A T Sandhu, I A Ku, A S BhattAbstract
Introduction
With increasing adoption of guideline directed medical therapy (GDMT), more patients experience recovery of ejection fraction (EF). While heart failure with improved ejection fraction (HFimpEF) is increasingly recognized; professional societies have proposed varying definitions for HFimpEF, leading to challenges in patient classification, guidelines, and clinical trial programs.
Purpose
To assess the incidence of HFimpEF across three major guideline definitions (ACC/AHA, ESC, HFA/HFSA/JHFS) and to evaluate differences in guideline-directed medical therapy (GDMT) utilization and rates of worsening heart failure hospitalization (WHF) or death among patients meeting each defining criterion.
Methods
We identified patients with incident HFrEF between January 2013 and December 2023 within the Kaiser Permanente Northern California (KPNC) healthcare system. HFimpEF was defined with a follow-up LVEF that satisfied at least one of three guideline definitions: ACC/AHA (EF > 40%), HFA/HFSA/JHFS (EF > 40% with ≥10-point increase), and ESC (EF ≥ 50%). We assessed (1) HFimpEF incidence, (2) the one-year post-diagnosis mutually exclusive incidences of heart failure hospitalization or death, and (3) guideline-directed medical therapy (GDMT) use across each definition.
Results
Of 37,443 patients with newly diagnosed HFrEF, 15,030 (40.1%) were classified as HFimpEF based on the ACC/AHA definition, 13,253 (35.4%) based on the HFA/HFSA/JHFS definition, and 10,304 (27.5%) based on the ESC definition. Mutually exclusive cumulative incidences of HF hospitalization or death at 10 years after HFimpEF were similar across definitions (ACC/AHA: 59.5%, HFA/HFSA/JHFS: 58.4%, ESC: 57.2%, p < 0.0001).
Conclusion
Based on definition used, the prevalence of HFimpEF ranges widely from 28-40%. Irrespective of definition, patients with HFimpEF remain at substantial residual risk for clinical deterioration and share a similar prognosis despite improvement in ejection fraction. These data highlight the persistence of heart failure rather than true recovery; trials to optimize available and new HF treatments are warranted.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.