Left ventricular ejection fraction (LVEF) predicts outcomes in HF patients. In patients with HF and reduced LVEF, rates of LV recovery (LVR) range between 19% and 50%, but factors predictive of LVR remain unclear.
Review of the electronic medical record identified between 2006 and 2016 224 consecutive patients aged > 18 years, new HF diagnosis and a LVEF = 35% who received guidelines-directed medical therapy (GDMT) and were followed = 1year. LVR was defined as a rise in LVEF = 40%. Stress-induced cardiomyopathies were excluded. After determination of LVR rates, patients with LVR were compared with those with persistent LV dysfunction (LVD) in terms of clinical characteristics and the composite outcome of death and HF hospitalization using the log-rank test. Multivariate logistic regression analysis was utilized to identify baseline clinical variables predictive of LVR. LVEF was serially measured by echocardiogram. GDMT target doses were per published guidelines.
Population characteristics were: age = 63±13; 38.5 % female; 83.2% Caucasian; 38.1% ischemic HF; baseline LVEF = 23% ± 6%; baseline heart rate = 75 ± 13 bpm. Background GDMT: ACE inhibitors (ACEi) = 74.3%; Angiotensin receptor blockers (ARB) = 19.7%; Beta blocker (BB) = 95.4%; Aldosterone antagonist (AA) = 34.0%; the % of patients achieving target doses of ACEi and BB were, respectively, 33.7 and 40.2. LVR occurred in 154/244 patients (63.1%), and the median time to LVR was 9.0 months (IQR = 4.5-19.0). Average final EF in LVR patients was 49% ± 6%. Compared to LVD, LVR included fewer patients with ischemic HF (54.4% vs. 28.6%, p < 0.001) and CKD (3.9% vs. 11.1%, p = 0.028), and more subjects on ACEi (67.4% vs. 80.3%, p = 0.025), and target BB doses (30.9% vs. 46.1% p = 0.029). By multivariable analysis baseline heart rate < 70 bpm was the only independent predictor of LVR (OR = 3.39, 95% CI = 1.5-7.5, p = 0.003); hypertension, segmental wall motion abnormalities, and ICD were negative predictors of LVR (Fig). Presence or absence of ARB or AA and target doses of ACEi, ARB, or AA did not predict LVR.
Time to HF hospitalization or death was significantly longer in LVR than LVD subjects (105.5 ± 3.8 days vs. 90.6 ± 6.2 days, p = 0.04). This composite endpoint was less frequent in those who achieved target BB doses (5.4% vs. 16.7%, p = 0.027). Time to all-cause mortality was longer for LVR than LVD patients (115.8 ± 2.6 days vs. 96.4 ± 5.5 days, p = 0.001).
LVR rates in contemporary HF patients are higher than previously reported. Whereas hypertension, segmental wall motion abnormalities and ICD decrease the likelihood of LVR, a baseline HR = 70 bpm is the sole independent predictor of LVR. These findings suggest that early modulation of heart rate in de-novo HF patients may facilitate LVR.