Factors Associated with Maintenance of an Improved Ejection Fraction: An Echocardiogram-based Registry Study

Background Heart failure with improved ejection fraction (HFimpEF) is increasingly recognized as a sizable and distinct entity. While the features associated with improved ejection fraction have been explored and new guidelines have emerged, factors associated with sustaining an improved ejection fraction over time have not been defined. Objective We aimed to assess factors associated with maintenance of an improved ejection fraction in a large real-world patient cohort. Methods A total of 7,070 participants with heart failure with improved ejection fraction and a subsequent echocardiogram (ECHO) performed after at least nine months of follow-up were included in a retrospective study conducted at the Cleveland Clinic in Cleveland, OH. Multiple logistic regression models, adjusted for demographics, comorbidities, and medications were built to identify characteristics and therapeutic interventions associated with maintaining an improved ejection fraction. Results Mean age (SD) was 64.9 (13.8) years, 62.7% were men, and 75.1% were White. White race and the use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or angiotensin receptor-neprilysin inhibitors were correlated with maintaining the ejection fraction at least nine months after ejection fraction improvement. In contrast, male sex, or having atrial fibrillation/flutter, coronary artery disease, history of myocardial infarction, presence of an implanted cardioverter defibrillator, and use of loop diuretics were correlated with a decline in ejection fraction after previously documented improvement. Conclusion Continued use of renin-angiotensin aldosterone system inhibitors was associated with maintaining the ejection fraction beyond the initial improvement phase.