Clinical Characteristics and Comprehensive Management of Heart Failure with Improved Ejection Fraction

doi:10.12114/j.issn.1007-9572.2021.01.108

Abstract

Abstract: Left ventricular ejection fraction （LVEF） is often used as a guideline for classification of heart failure（HF）. With the advancement of heart failure diagnosis and treatment technology，more heart failure patients have experienced improvement in LVEF. The 2021 report of multi-national heart failure societies denominates and defines heart failure with improved ejection fraction（HFimpEF），but there is still a lack of authoritative guidelines to discuss the diagnosis and treatment of HFimpEF. Therefore，this article will review the research progress of HFimpEF based on the existing research evidence，in order to discuss the clinical characteristics，diagnosis，and treatment of HFimpEF.

Key words: Heart failure, Left ventricular ejection fractions, Heart failure with improved ejection fraction, Disease attributes, Review

摘要： 左心室射血分数（LVEF）常作为指南对心力衰竭分类的依据。随着心力衰竭诊疗技术的进展，更多心力衰竭患者出现LVEF的改善。2021年多国心力衰竭学会联合报告，对射血分数改善型心力衰竭（HFimpEF）作了统一名称和定义，但目前仍缺乏权威指南讨论HFimpEF的诊疗。故本文将根据现有的研究证据，对HFimpEF的研究进展进行综述，以期讨论HFimpEF的临床特点、诊断与治疗。

关键词: 心力衰竭, 左心室射血分数, 射血分数改善型心力衰竭, 疾病特征, 综述

WANG Yucheng,CHEN Zhiwei,CHEN Ruizhen. Clinical Characteristics and Comprehensive Management of Heart Failure with Improved Ejection Fraction　[J]. Chinese General Practice, 2021, 24(32): 4049-4054. DOI: 10.12114/j.issn.1007-9572.2021.01.108.
王宇成,陈治伟,陈瑞珍. 射血分数改善型心力衰竭的临床特点及综合管理[J]. 中国全科医学, 2021, 24(32): 4049-4054. DOI: 10.12114/j.issn.1007-9572.2021.01.108.

References

［1］SAVARESE G，LUND L H. Global public health burden of heart failure［J］. Card Fail Rev，2017，3（1）：7-11. DOI：10.15420/cfr.2016:25:2.
［2］PONIKOWSKI P，VOORS A A，ANKER S D，et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure：the task force for the diagnosis 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［J］. Eur Heart J，2016，37（27）：2129-2200. DOI：10.1093/eurheartj/ehw128.
［3］中华医学会心血管病学分会心力衰竭学组，中国医师协会心力衰竭专业委员会，中华心血管病杂志编辑委员会. 中国心力衰竭诊断和治疗指南2018［J］.中华心血管病杂志，2018，46（10）：760-789. DOI：10.3760/cma.j.issn.0253-3758.2018.10.004.
［4］WRITING COMMITTEE MEMBERS，YANCY C W，JESSUP M，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］. Circulation，2013，128（16）：e240-327. DOI：10.1161/CIR.0b013e31829e8776.
［5］TSUTSUI H，ISOBE M，ITO H，et al. JCS 2017/JHFS 2017 guideline on diagnosis and treatment of acute and chronic heart failure-digest version［J］. Circ J，2019，83（10）：2084-2184. DOI：10.1253/circj.CJ-19-0342.
［6］STEVENSON L W. Heart failure with better ejection fraction：a modern diagnosis［J］. Circulation，2014，129（23）：2364-2367. DOI：10.1161/CIRCULATIONAHA.114.010194.
［7］FLOREA V G，RECTOR T S，ANAND I S，et al. Heart failure with improved ejection fraction：clinical characteristics，correlates of recovery，and survival：results from the valsartan heart failure trial［J］. Circ Heart fail，2016，9（7）：e003123. DOI：10.1161/CIRCHEARTFAILURE.116.003123.
［8］BOZKURT B，COATS A J S，TSUTSUI H，et al. Universal definition and classification of heart failure：a report of the Heart Failure Society of America，Heart Failure Association of the European Society of Cardiology，Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure：Endorsed by Canadian Heart Failure Society，Heart Failure Association of India，the Cardiac Society of Australia and New Zealand，and the Chinese Heart Failure Association［J］. Eur J Heart Fail，2021，23（3）：352-380. DOI：10.1002/ejhf.2115.
［9］GULATI G，UDELSON J E. Heart failure with improved ejection fraction：is it possible to escape one's past？［J］. JACC Heart Fail，2018，6（9）：725-733. DOI：10.1016/j.jchf.2018.05.004.
［10］PILLARISETTI J，KONDUR A，ALANI A，et al. Peripartum cardiomyopathy：predictors of recovery and current state of implantable cardioverter-defibrillator use［J］. J Am Coll Cardiol，2014，63（25）：2831-2839. DOI：10.1016/j.jacc.2014.04.014.
［11］BITEKER M，?ZLEK B，?ZLEK E，et al. Predictors of early and delayed recovery in peripartum cardiomyopathy：a prospective study of 52 Patients［J］. J Matern Fetal Neonatal Med，2020，33（3）：390-397. DOI：10.1080/14767058.2018.1494146.
［12］BITEKER M，ILHAN E，BITEKER G，et al. Delayed recovery in peripartum cardiomyopathy：an indication for long-term follow-up and sustained therapy［J］. Eur J Heart Fail，2012，14（8）：895-901. DOI：10.1093/eurjhf/hfs070.
［13］AMOR-SALAMANCA A，GUZZO-MERELLO G，GONZáLEZ-LóPEZ E，et al. Prognostic impact and predictors of ejection fraction recovery in patients with alcoholic cardiomyopathy［J］. Rev Esp Cardiol（Engl Ed），2018，71（8）：612-619. DOI：10.1016/j.rec.2017.11.032.
［14］OHTANI K，FUJINO T，IDE T，et al. Recovery from left ventricular dysfunction was associated with the early introduction of heart failure medical treatment in cancer patients with anthracycline-induced cardiotoxicity［J］. Clin Res Cardiol，2019，108（6）：600-611. DOI：10.1007/s00392-018-1386-0.
［15］EVERITT M D，SLEEPER L A，LU M M，et al. Recovery of echocardiographic function in children with idiopathic dilated cardiomyopathy：results from the pediatric cardiomyopathy registry［J］. J Am Coll Cardiol，2014，63（14）：1405-1413. DOI：10.1016/j.jacc.2013.11.059.
［16］SWAT S A，COHEN D，SHAH S J，et al. Baseline longitudinal strain predicts recovery of left ventricular ejection fraction in hospitalized patients with nonischemic cardiomyopathy［J］. J Am Heart Assoc，2018，7（20）：e09841. DOI：10.1161/JAHA.118.009841.
［17］KALOGEROPOULOS A P，FONAROW G C，GEORGIOPOULOU V，et al. Characteristics and outcomes of adult outpatients with heart failure and improved or recovered ejection fraction［J］. JAMA Cardiol，2016，1（5）：510-518. DOI：10.1001/jamacardio.2016.1325.
［18］PARK C S，PARK J J，MEBAZAA A，et al. Characteristics，outcomes，and treatment of heart failure with improved ejection fraction［J］. J Am Heart Assoc，2019，8（6）：e011077. DOI：10.1161/JAHA.118.011077.
［19］GHIMIRE A，FINE N，EZEKOWITZ J A，et al. Frequency，predictors，and prognosis of ejection fraction improvement in heart failure：an echocardiogram-based registry study［J］. Eur Heart J，2019，40（26）：2110-2117. DOI：10.1093/eurheartj/ehz233.
［20］PUNNOOSE L R，GIVERTZ M M，LEWIS E F，et al. Heart failure with recovered ejection fraction：a distinct clinical entity［J］. J Card Fail，2011，17（7）：527-532. DOI：10.1016/j.cardfail.2011.03.005.
［21］LUPóN J，DíEZ-LóPEZ C，DE ANTONIO M，et al. Recovered heart failure with reduced ejection fraction and outcomes：a prospective study［J］. Eur J Heart Fail，2017，19（12）：1615-1623. DOI：10.1002/ejhf.824.
［22］GUPTA A，GOYAL P，BAHL A. Frequency of recovery and relapse in patients with nonischemic dilated cardiomyopathy on guideline-directed medical therapy［J］. Am J Cardiol，2014，114
（6）：883-889. DOI：10.1016/j.amjcard.2014.06.021.
［23］WOHLFAHRT P，NATIVI-NICOLAU J，ZHANG M，et al. Quality of life in patients with heart failure with recovered ejection fraction［J］. JAMA Cardiol，2021，6（8）：957-962. DOI：10.1001/jamacardio.2021.0939.
［24］NIJST P，MARTENS P，MULLENS W. Heart failure with myocardial recovery - the patient whose heart failure has improved：what next？［J］. Prog Cardiovasc Dis，2017，60（2）：226-236. DOI：10.1016/j.pcad.2017.05.009.
［25］KIM G H，URIEL N，BURKHOFF D. Reverse remodelling and myocardial recovery in heart failure［J］. Nat Rev Cardiol，2018，15（2）：83-96. DOI：10.1038/nrcardio.2017.139.
［26］ADAMO L，YU J S，ROCHA-RESENDE C，et al. Proteomic signatures of heart failure in relation to left ventricular ejection fraction［J］. J Am Coll Cardiol，2020，76（17）：1982-1994. DOI：10.1016/j.jacc.2020.08.061.
［27］KLOTZ S，DANSER A H J，FORONJY R F，et al. The impact of angiotensin-converting enzyme inhibitor therapy on the extracellular collagen matrix during left ventricular assist device support in patients with end-stage heart failure［J］. J Am Coll Cardiol，2007，49（11）：1166-1174. DOI：10.1016/j.jacc.2006.10.071.
［28］HOWLETT J G，SHARMA N，ALEMAYEHU W G，et al. Circulating troponin and further left ventricular ejection fraction improvement in patients with previously recovered left ventricular ejection fraction［J］. ESC Heart Fail，2020，7（5）：2725-2733. DOI：10.1002/ehf2.12863.
［29］BASURAY A，FRENCH B，KY B，et al. Heart failure with recovered ejection fraction：clinical description，biomarkers，and outcomes［J］. Circulation，2014，129（23）：2380-2387. DOI：10.1161/CIRCULATIONAHA.113.006855.
［30］AHMAD S，OTAAL P S，RAI T S，et al. Circulating proinflammatory cytokines and N-terminal pro-brain natriuretic peptide significantly decrease with recovery of left ventricular function in patients with dilated cardiomyopathy［J］. Mol Cell Biochem，2009，324（1/2）：139-145. DOI：10.1007/s11010-008-9992-1.
［31］GOLAND S，WEINSTEIN J M，ZALIK A，et al. Angiogenic imbalance and residual myocardial injury in recovered peripartum cardiomyopathy patients［J］. Circ Heart Fail，2016，9（11）：e003349. DOI：10.1161/CIRCHEARTFAILURE.116.003349.
［32］BINKLEY P F，LESINSKI A，FERGUSON J P，et al. Recovery of normal ventricular function in patients with dilated cardiomyopathy：predictors of an increasingly prevalent clinical event［J］. Am Heart J，2008，155（1）：69-74. DOI：10.1016/j.ahj.2007.08.010.
［33］PRENNER S B，SWAT SA，NG J，et al. Parameters of repolarization heterogeneity are associated with myocardial recovery in acute heart failure［J］. Int J Cardiol，2020，301：147-151. DOI：10.1016/j.ijcard.2019.08.048.
［34］ADAMO L，PERRY A，NOVAK E，et al. Abnormal global longitudinal strain predicts future deterioration of left ventricular function in heart failure patients with a recovered left ventricular ejection fraction［J］. Circ Heart Fail，2017，10（6）：e003788. DOI：10.1161/CIRCHEARTFAILURE.116.003788.
［35］SHAH M A，SOOFI M A，JAFARY Z，et al. Echocardiographic parameters associated with recovery in heart failure with reduced ejection fraction［J］. Echocardiography，2020，37（10）：1574-1582. DOI：10.1111/echo.14859.
［36］LIANG Y D，XU Y W，LI W H，et al. Left ventricular function recovery in peripartum cardiomyopathy：a cardiovascular magnetic resonance study by myocardial T1 and T2 mapping［J］. J Cardiovasc MagnReson，2020，22（1）：1-10. DOI：10.1186/s12968-019-0590-z.
［37］TAYAL U，WAGE R，NEWSOME S，et al. Predictors of left ventricular remodelling in patients with dilated cardiomyopathy-a cardiovascular magnetic resonance study［J］. Eur J Heart Fail，2020，22（7）：1160-1170. DOI：10.1002/ejhf.1734.
［38］HALLIDAY B P，OWEN R，GREGSON J，et al. Myocardial remodelling after withdrawing therapy for heart failure in patients with recovered dilated cardiomyopathy：insights from TRED-HF［J］. Eur J Heart Fail，2021，23（2）：293-301. DOI：10.1002/ejhf.2063.
［39］KIM M S，KIM J S，KIM Y R，et al. Cerebral blood flow as a marker for recovery of left ventricular systolic dysfunction in patients with idiopathic dilated cardiomyopathy［J］. J Card Fail，2012，18（7）：549-555. DOI：10.1016/j.cardfail.2012.04.007.
［40］JOHANSSON M C，BARASA A，BASIC C，et al. Increased arterial stiffness and reduced left ventricular long-axis function in patients recovered from peripartum cardiomyopathy［J］. Clin Physiol Funct Imaging，2021，41（1）：95-102. DOI：10.1111/cpf.12671.
［41］MOON J，KO Y G，CHUNG N，et al. Recovery and recurrence of left ventricular systolic dysfunction in patients with idiopathic dilated cardiomyopathy［J］. Can J Cardiol，2009，25（5）：e147-150. DOI：10.1016/S0828-282X（09）70497-0.
［42］HALLIDAY B P，WASSALL R，LOTA A S，et al. Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy（TRED-HF）：an open-label，pilot，randomised trial［J］. Lancet，2019，393（10166）：61-73. DOI：10.1016/S0140-6736（18）32484-X.
［43］CHANG H Y，CHEN K C，FONG M C，et al. Recovery of left ventricular dysfunction after sacubitril/valsartan：predictors and management［J］. J Cardiol，2020，75（3）：233-241. DOI：10.1016/j.jjcc.2019.08.005.
［44］YU C M，CHAU E，SANDERSON J E，et al. Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure［J］. Circulation，2002，105（4）：438-445. DOI：10.1161/hc0402.102623.

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