De-escalating Medical Therapy in Heart Failure With Improved Left Ventricular Ejection Fraction

1/3 https://e-kcj.orgThe field of heart failure (HF) management has seen remarkable therapeutic advances, especially in patients with HF with reduced ejection fraction (HFrEF). 1) As a result, a growing number of patients experience significant recovery of left ventricular ejection fraction (LVEF), often termed 'HF with improved ejection fraction (HFimpEF)'.These patients generally have a more favorable prognosis than those with persistent HFrEF. 2)However, the clinical implications of improved LVEF remain unclear.Improved LVEF does not necessarily indicate full myocardial recovery.The TRED-HF trial demonstrated that withdrawal of all guideline-directed medical therapy (GDMT) in patients with recovered dilated cardiomyopathy led to a high relapse rate. 3)Long-term follow-up revealed ongoing risk of relapse beyond the initial 6 months, suggesting persistent vulnerability despite apparent recovery (Table 1). 4)Consequently, current HF guidelines recommend continued GDMT in patients with HFimpEF. 5)Still, this strategy warrants reassessment.LVEF alone may not capture true myocardial recovery.Other parameters-such as LV remodeling indices, strain imaging, and clinical status-may offer more insight for guiding therapy.Furthermore, the burden of polypharmacy raises concerns about adverse events, reduced adherence, and healthcare costs.Not all GDMT may be essential for every patient transitioning to HFimpEF.In the current issue of the Korean Circulation Journal, Hyun et al. 6) present the With-HF trial, which provides timely insight.This randomized pilot study evaluated the safety of withdrawing mineralocorticoid receptor antagonists (MRAs) in HFimpEF patients with LVEF 50%.Selective MRA withdrawal was not associated with significant deterioration in LVEF, echocardiographic indices, or natriuretic peptide levels.Importantly, no adverse clinical events occurred in either group during the 6-month follow-up.This contrasts with the 'all-or-nothing' approach in TRED-HF.While differences in design, endpoints, and background therapy-particularly the high use of angiotensin receptorneprilysin inhibitors in With-HF-limit direct comparisons, the low relapse rate (6.7%) suggests that individualized de-escalation based on patient characteristics and disease trajectory may be safe in select cases.The CATHEDRAL-HF trial further supports this notion. 7)In that study, carvedilol was maintained while other therapies were withdrawn.LVEF