JAMA Netw Open
Most HFrEF patients improve EF—but many miss follow-up imaging and guideline therapy
Clinical Takeaway: Repeat echocardiography within the first year after HFrEF diagnosis may help identify patients with EF recovery, but GDMT should generally be maintained even when LVEF improves because recovery does not necessarily equal cure.
Timely reassessment of ejection fraction and continued use of guideline-directed medical therapy (GDMT) are central to heart failure care, but this study suggests many patients may be missing opportunities for treatment optimization and risk reduction.
In a large US cohort study of more than 340,000 adults with newly documented heart failure with reduced ejection fraction (HFrEF), most patients who underwent repeat imaging showed improvement in left ventricular ejection fraction (LVEF), yet repeat reassessment and GDMT use remained surprisingly low.
Investigators analyzed electronic health record data from 2019-2022 and found that only 33.8% of patients underwent repeat echocardiography within 12 months after an index echocardiogram showing LVEF ≤40%. Among those reassessed, 62.7% transitioned to heart failure remission (LVEF ≥50%), 8.1% improved to an LVEF of 41%-49%, and 29.2% had persistent HFrEF.
Mortality outcomes varied substantially by trajectory. Twelve-month mortality was 21.3% among patients with persistent HFrEF, compared with 14.0% in those with improved EF and 11.3% among those whose EF normalized.
Use of GDMT was modest overall. At 12 months, 45.2% of patients were taking an ACE inhibitor, ARB, or ARNI; 55.1% were taking a beta-blocker; and just 12.4% were receiving triple therapy. Even among patients with persistent HFrEF, only 19.5% received triple therapy.
“The findings of this cohort study underscore a gap between evidence and practice,” the authors wrote, noting that lower GDMT use among patients with improved EF may reflect “premature de-escalation or therapeutic inertia.”
The authors concluded that standardizing timely LVEF reassessment and maintaining GDMT are critical to improving outcomes in newly diagnosed HFrEF.
Source: Do D, et al. (2026, May 21). JAMA Netw Open. Heart Failure Trajectories After Guideline-Directed Medical Therapy