Characteristics and outcomes of adult outpatients with heart failure and improved or recovered ejection fraction

Importance: Heart failure (HF) guidelines recognize that a subset of patients with HF and preserved left ventricular ejection fraction (LVEF) previously had reduced LVEF but experienced improvement or recovery in LVEF. However, data on these patients are limited. Objective: To investigate the characteristics and outcomes of adult outpatients with HF and improved or recovered ejection fraction (HFrecEF). Design, Setting, and Participants: Retrospective cohort study (inception period, January 1, 2012, to April 30, 2012) with 3-year follow-up at cardiology clinics (including HF subspecialty) in an academic institution. The dates of the analysis were May 21, 2015, to August 10, 2015. Participants were all outpatients 18 years or older who received care for a verified diagnosis of HF not attributed to specific cardiomyopathies or other special causes during the inception period. Exposures: Type of HF at baseline, classified as HF with reduced ejection fraction (HFrEF) (defined as current LVEF≤40%), HF with preserved ejection fraction (HFpEF) (defined as current and all previous LVEF reports >40%), and HF with recovered ejection fraction (HFrecEF) (defined as current LVEF >40% but any previously documented LVEF≤40%). Main Outcomes and Measures: Mortality, hospitalization rates, and composite end points. Results: The study cohort comprised 2166 participants. Their median age was 65 years, 41.4%(896 of 2166) were female, 48.7%(1055 of 2166) were white and 45.2%(1368 of 2166) black, and 63.2%(1368 of 2166) had coronary artery disease. Preserved (>40%) LVEF at inception was present in 816 of 2166 (37.7%) patients. Of these patients, 350 of 2166 (16.2%) had previously reduced (≤40%) LVEF and were classified as having HFrecEF, whereas 466 of 2166 (21.5%) had no previous reduced LVEF and were classified as having HFpEF. The remaining 1350 (62.3%) patients were classified as having HFrEF. After 3 years, age and sex-adjusted mortality was 16.3%in patients with HFrEF, 13.2%in patients with HFpEF, and 4.8%in patients with HFrecEF (P < .001 vs HFrEF or HFpEF). Compared with patients with HFpEF and patients with HFrEF, patients with HFrecEF had fewer all-cause (adjusted rate ratio [RR] vs HFpEF, 0.71; 95%CI, 0.55-0.91; P = .007), cardiovascular (RR, 0.50; 95%CI, 0.35-0.71; P < .001), and HF-related (RR, 0.48; 95%CI, 0.30-0.76; P = .002) hospitalizations and were less likely to experience composite end points commonly used in clinical trials (death or cardiovascular hospitalization and death or HF hospitalization). Conclusions and Relevance: Outpatients with HFrecEF have a different clinical course than patients with HFpEF and HFrEF, with lower mortality, less frequent hospitalizations, and fewer composite end points. These patients may need to be investigated separately in outcomes studies and clinical trials.