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Left ventricular ejection fraction (LVEF) that improves substantially with heart failure treatment should be considered as heart failure with recovered ejection fraction (HFrecEF) but still treated, according to the American College of Cardiology (ACC).

HFrecEF reflects complete (>50%) or partial normalization (40%-50%) of LVEF in patients who had heart failure with reduced ejection fraction (HFrEF), said a scientific expert panel led by Jane Wilcox, MD, of Northwestern University Feinberg School of Medicine in Chicago.

"Patients with HFrecEF represent a distinctly responsive subset of patients with HFrEF whose biological substrate for HF and clinical course are distinct from patients with HFrEF and HFpEF [heart failure with preserved ejection fraction]," the group proposed in recommendations published in the .

There have been no guidelines on how these patients should be followed up and managed.

Despite their apparent reverse LV remodeling, many HFrecEF patients will develop recurrent LV dysfunction accompanied by recurrent heart failure events. Any LVEF improvements "often represent myocardial 'remission' rather than a true cure of HF," Wilcox and colleagues said.

As such, patients should be closely followed and continue guideline-directed medical and device therapy "indefinitely until the biology and clinical epidemiology of HFrecEF is better understood," according to the ACC group.

"We have learned a great deal about the biology, epidemiology, clinical predictors, and outcomes of reverse LV remodeling and recovery of LV function over the past 2 decades. Unfortunately, far less is known about the biology, natural history, and the long-term clinical outcomes for HFrecEF patients," the authors wrote.

For example, it is unclear why some patients with recovered LV function remain free from heart failure events while others continue to suffer such events. Nevertheless, "the redevelopment of HF in patients with HFrecEF likely has more to do with our lack of understanding with respect to how to manage HFrecEF than to inadequate clinical care," the authors suggested.

Wilcox's team also highlighted the little research done on how to manage these patients. Only one small randomized controlled clinical trial has been performed studying the safety of weaning guideline-directed medical therapy in people with HFrecEF, they noted.

"We believe that future research in this area will benefit from improved phenotyping of HFrEF patients to guide care, developing inception cohorts of HFrecEF patients to better understand the natural history of HFrecEF and additional clinical trials to define which elements of clinical care are important for maintaining clinical remission, as well as basic studies to better define the biology of HFrecEF," the ACC group suggested.

"The goal is to develop new therapeutic targets that will enable patients with HFrecEF to experience a durable remission from HF," they added.

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