Vol 25, No 3 (2018)
Original articles — Clinical cardiology
Published online: 2017-09-06

open access

Page views 3690
Article views/downloads 2595
Get Citation

Connect on Social Media

Connect on Social Media

Heart failure with recovered ejection fraction: Clinical characteristics, determinants and prognosis. CARDIOCHUS-CHOP registry

Rosa Agra Bermejo, Eva Gonzalez Babarro, J. Nicolás López Canoa, Alfonso Varela Román, Inés Gómez Otero, Marcos Oro Ayude, Pablo Parada Vazquez, Isabel Gómez Rodríguez, Oscar Díaz Castro, Jose Ramón González Juanatey
Pubmed: 28980289
Cardiol J 2018;25(3):353-362.


Background: The magnitude and the prognostic impact of recovering left ventricular ejection fraction (LVEF) in patients with heart failure (HF) and systolic dysfunction is unclear. The aim of this study was to evaluate the clinical characteristics and prognosis of patients with HFrecEF in an HF population.

Methods: 449 consecutive patients were selected with the diagnosis of HF and an evaluation of LVEF in the 6 months prior to selection who were referred to two HF units. Patients with systolic dysfunction were only considered if a second echocardiogram was performed during the follow-up.

Results: At the time of diagnosis, 207 patients had LVEF > 40% (HFpEF) and 242 had LVEF ≤ 40% (HFrEF). After 1 year, the LVEF was re-evaluated in all 242 patients with a LVEF ≤ 40%: in 126 (52%), the second LVEF was > 40% (HFrecEF), and the remaining 116 (48%) had LVEF ≤ 40% (HFrEF). After 1800 ± 900 days of follow-up patients with recovered LVEF had a significantly lower mortality rate (HFpEF vs. HFrecEF: hazard ratio [HR] = 2.286, 95% confidence interval [95% CI] 1.264–4.145, p = 0.019; HFrEF vs. HFrecEF: HR = 2.222, 95% CI 1.189–4.186, p < 0.001) and hospitalization rate (HFpEF vs. HFrecEF: HR = 1.411, 95% CI 1.046–1.903, p = 0.024; HFrEF vs. HFrecEF: HR = 1.388, 95% CI 1.002–1.924, p = 0.049). The following are predictors of LVEF recovery: younger age, lower functional class, treatment with renin–angiotensin–aldosterone system inhibitors and beta-blockers, absence of defibrillator use, and non-ischemic etiology.

Conclusions: Patients with HF and reduced LVEF who were re-evaluated after 1 year, had significant improvement in their LVEF and had a more favourable prognosis than HF with preserved and reduced ejection fraction.

Article available in PDF format

View PDF Download PDF file


  1. Butler J, Fonarow GC, Zile MR, et al. Developing therapies for heart failure with preserved ejection fraction: current state and future directions. JACC Heart Fail. 2014; 2(2): 97–112.
  2. McMurray JJV, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012; 33(14): 1787–1847.
  3. Yusuf S, Pfeffer MA, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet. 2003; 362(9386): 777–781.
  4. Ponikowski P, Voors A, Anker S, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for thediagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC).Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016; 37(27): 2129–2200.
  5. Gómez OI, Ferrero-Gregori A, Varela RA, et al. Mid-range ejection fraction does not permit risk stratification among patients hospitalized for heart failure. Rev Esp Card. .
  6. Varela Romén A, Grigorian Shamagian L, Bandin Diéguez MA, et al. Influence of sex on mortality in hospitalized patients with congestive heart failure and preserved or depressed systolic function. Revista Española de Cardiología (English Edition). 2005; 58(10): 1171–1180.
  7. Basuray A, French B, Ky B, et al. Heart failure with recovered ejection fraction: clinical description, biomarkers, and outcomes. Circulation. 2014; 129(23): 2380–2387.
  8. Stevenson LW. Heart failure with better ejection fraction: a modern diagnosis. Circulation. 2014; 129(23): 2364–2367.
  9. Mendez GF, Cowie MR. The epidemiological features of heart failure in developing countries: a review of the literature. Int J Cardiol. 2001; 80(2-3): 213–219.
  10. MacIntyre K, Capewell S, Stewart S, et al. Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995. Circulation. 2000; 102(10): 1126–1131.
  11. Kalogeropoulos AP, Fonarow GC, Georgiopoulou V, et al. Characteristics and Outcomes of Adult Outpatients With Heart Failure and Improved or Recovered Ejection Fraction. JAMA Cardiol. 2016; 1(5): 510–518.
  12. Florea VG, Rector TS, Anand IS, et al. Heart failure with improved ejection fraction: clinical characteristics, correlates of recovery, and survival: results from the valsartan heart failure trial. Circ Heart Fail. 2016; 9(7).
  13. Lupón J, Díez-López C, de Antonio M, et al. Recovered heart failure with reduced ejection fraction and outcomes: a prospective study. Eur J Heart Fail. 2017 [Epub ahead of print].
  14. Nadruz W, West E, Santos M, 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.
  15. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015; 28(1): 1–39.e14.
  16. Punnoose LR, Givertz MM, Lewis EF, et al. Heart failure with recovered ejection fraction: a distinct clinical entity. J Card Fail. 2011; 17(7): 527–532.
  17. Moon J, Ko YG, Chung N, et al. Recovery and recurrence of left ventricular systolic dysfunction in patients with idiopathic dilated cardiomyopathy. Can J Cardiol. 2009; 25(5): e147–e150.
  18. Waagstein F, Caidahl K, Wallentin I, et al. Long-term beta-blockade in dilated cardiomyopathy. Effects of short- and long-term metoprolol treatment followed by withdrawal and readministration of metoprolol. Circulation. 1989; 80(3): 551–563.
  19. Kotecha D, Manzano L, Krum H, et al. Beta-Blockers in Heart Failure Collaborative Group, Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC), Meta-Analysis Global Group in Chronic Heart Failure MAGGIC, Beta-Blockers in Heart Failure Collaborative Group, Meta-analysis Global Group in Chronic Heart Failure (MAGGIC), Meta-Analysis Global Group in Chronic Heart Failure, Meta-Analysis Global Group in Chronic Heart Failure, MAGGIC Investigators, Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) Investigators, Meta-Analysis Global Group In Chronic Heart Failure (MAGGIC), Meta-analysis Global Group in Chronic Heart Failure (MAGGIC). The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction: an individual patient data meta-analysis. Eur Heart J. 2012; 33(14): 1750–1757.
  20. Wilcox JE, Fonarow GC, Yancy CW, et al. Factors associated with improvement in ejection fraction in clinical practice among patients with heart failure: findings from IMPROVE HF. Am Heart J. 2012; 163(1): 49–56.e2.
  21. Tian Y, Zhang P, Li X, et al. True complete left bundle branch block morphology strongly predicts good response to cardiac resynchronization therapy. Europace. 2013; 15(10): 1499–1506.
  22. Hsu JC, Solomon SD, Bourgoun M, et al. MADIT-CRT Executive Committee. Predictors of super-response to cardiac resynchronization therapy and associated improvement in clinical outcome: the MADIT-CRT (multicenter automatic defibrillator implantation trial with cardiac resynchronization therapy) study. J Am Coll Cardiol. 2012; 59(25): 2366–2373.
  23. Gradman A, Deedwania P, Cody R, et al. Predictors of total mortality and sudden death in mild to moderate heart failure. J Am Coll Cardiol. 1989; 14(3): 564–570.
  24. Brophy JM, Dagenais GR, McSherry F, et al. A multivariate model for predicting mortality in patients with heart failure and systolic dysfunction. Am J Med. 2004; 116(5): 300–304.
  25. Eichhor EJ. Prognosis determination in heart failure. Am J Med. 2001; 110(Suppl 7A): 14S–36S.
  26. Yancy CW, Jessup M, Bozkurt B, 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. J Am Coll Cardiol. 2013; 62: 147–239.
  27. Amorim S, Campelo M, Martins E, et al. Prevalence, predictors and prognosis of ventricular reverse remodeling in idiopathic dilated cardiomyopathy. Rev Port Cardiol. 2016; 35(5): 253–260.
  28. Pfeffer MA, Swedberg K, Granger CB, et al. CHARM Investigators and Committees. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. Lancet. 2003; 362(9386): 759–766.
  29. Svanström H, Pasternak B, Melbye M, et al. Use of different types of angiotensin converting enzyme inhibitors and mortality in systolic heart failure. Int J Cardiol. 2015; 182: 90–96.
  30. Kramer DG, Trikalinos TA, Kent DM, et al. Quantitative evaluation of drug or device effects on ventricular remodeling as predictors of therapeutic effects on mortality in patients with heart failure and reduced ejection fraction: a meta-analytic approach. J Am Coll Cardiol. 2010; 56(5): 392–406.
  31. Bonow RO, Maurer G, Lee KL, et al. STICH Trial Investigators. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med. 2011; 364(17): 1617–1625.
  32. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med. 1996; 335(26): 1933–1940.