Nonischemic Cardiomyopathy and Future LVEF Improvement

Better global longitudinal strain is associated with increased left ventricular ejection fraction improvement in patients with HFrEF.

Among outpatients with heart failure with reduced ejection fraction (HFrEF), those who have less impaired global longitudinal strain (GLS) have greater left ventricular ejection fraction (LVEF) improvement, according to a study in Heart.

The retrospective cohort study evaluated the proportion of patients who had LVEF improvement after up-titration in HF medications, as well as baseline characteristics and echocardiographic parameters associated with improved LVEF in an outpatient HFrEF population.

The participants were referred to an outpatient HF clinic in Denmark from 2005 to 2013. They had an HFrEF diagnosis with an LVEF of 45% or less as evaluated by a clinician and received angiography to assess coronary status.

The participants were stratified into 4 groups based on absolute LVEF change (<0%, 0%-10%, 10%-20%, or >20%). Multivariable logistic regression was used to assess parameters associated with a major increase in LVEF of more than 20%.

These results underline the potential of risk stratification of patients with HF, as differences in etiology, comorbidities, and heart structure and function may be correlated with HF prognosis and mortality.

A total of 686 patients (mean age, 65.3±11.3 years; 73.2% men) were included. Their median time from baseline to follow-up echocardiography was 1.3 years (IQR, 0.6-3.5 years).

The participants generally had improved systolic function with an increase in mean LVEF from 27.3 ± 9.1% at baseline to 36.3 ± 1.2% (P <.001) at follow-up. No improvement in systolic function (‍∆LVEF <0%) occurred in 127 patients. A small increase in LVEF (‍∆LVEF 0%-10%) was observed in 241 patients and 218 patients had a moderate increase in LVEF (‍∆LVEF 10%-20%). There were 100 patients who had major LVEF improvement (‍∆LVEF >20%).

Crude logistic regression showed that heart rate, body mass index, atrial fibrillation/flutter, sex, angina pectoris, ischemic cardiomyopathy, diabetes mellitus, GLS, left ventricular internal dimension in diastole (LVIDd), left ventricular mass index, and left atrial volume index were significantly associated with LVEF improvement of more than 20%.

The fully adjusted multivariable logistic regression model demonstrated a 36% increased odds of improving more than 20% of LVEF per percentage increase in absolute GLS at baseline (odds ratio [OR], 1.36; 95% CI, 1.08-1.71; P =.008). An increasing LVIDd level (OR, 0.7 per cm; 95% CI, 0.15-0.88; P =.024) was significantly associated with decreasing odds of improving more than 20% LVEF in the same model.

For the survival analysis, 73.2% of patients had follow-up available, of whom 12.9% died after a median follow-up of 2.5 years (IQR, 1.1-3.9 years). The overall mortality incidence rate was 5.0 per 100 person-years (95% CI, 3.9-6.3) and varied based on LVEF improvement (‍∆LVEF <0% vs ∆LVEF >0%, 8.3 vs 4.3 per 100 person years, P =.012).

The mortality risk decreased with increasing tertiles of LVEF improvement, as the risk was more than 3 times higher in patients in the lowest tertile vs those in the highest tertile in a multivariable Cox regression model (1 vs 3; hazard ratio 3.23; 95% CI, 1.39-7.51; P =.006).

Among several study limitations, selection bias and survival bias are possible, and the time from referral to the outpatient HF clinic until follow-up visits is highly heterogenous. Also, not all patients have a comprehensive echocardiographic examination or detailed etiology, biomarkers, or New York Heart Association classification, and the data reflect HF treatment until 2013.

“These results underline the potential of risk stratification of patients with HF, as differences in etiology, comorbidities, and heart structure and function may be correlated with HF prognosis and mortality,” wrote the researchers. “Patients with accumulated risk factors for a poor prognosis might benefit from more aggressive treatment and closer surveillance.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Schöps LB, Sengeløv M, Modin D, et al. Parameters associated with improvement of systolic function in patients with heart failure. Heart. Published online July 9, 2023. doi: 10.1136/heartjnl-2023-322371