Missed Milestones: Two-Thirds of Patients with HFrEF Face LVEF Assessment Gap, Finds JAMA Study
USA: A cohort study highlighted a significant gap between evidence and real-world practice in patients with newly identified heart failure with reduced ejection fraction (HFrEF). Nearly two-thirds of patients did not undergo repeat left ventricular ejection fraction assessment, missing opportunities to confirm persistent dysfunction, evaluate reverse remodeling, and identify candidates for advanced therapy. Use of guideline-directed medical therapy (GDMT) was also suboptimal across all groups, including among patients with persistent HFrEF who are most likely to benefit from these treatments.
A research letter published in JAMA Network Open by Duy Do and colleagues from Truveta examined patterns of cardiac function recovery and treatment use in a large real-world cohort. HFrEF is a serious condition associated with considerable morbidity and mortality, and current clinical guidelines emphasize timely reassessment of left ventricular ejection fraction (LVEF) along with optimization of medical therapy. However, how closely these recommendations are followed in routine practice has remained uncertain.
To investigate this, the researchers analyzed electronic health record data from more than 120 million individuals across US healthcare systems between 2019 and 2022. The study included over 340,000 adults with newly diagnosed HFrEF, defined by an initial echocardiogram showing an LVEF of 40% or lower. Patients were followed for 12 months to assess repeat imaging, treatment patterns, and clinical outcomes.
The researchers reported the following findings:
- Only about one-third of patients underwent repeat echocardiographic assessment within one year, with a median reassessment time of approximately five months.
- Among those reassessed, nearly 30% had persistent HFrEF, around 8% showed partial improvement, and over 60% achieved normalization of ejection fraction.
- Patients who experienced recovery were more likely to be women and had relatively higher baseline LVEF values.
- Twelve-month mortality was highest in patients with persistent HFrEF, exceeding 21%.
- Mortality was lower in patients with partial improvement and those without follow-up imaging, and lowest among those with normalized ejection fraction, although risk remained clinically significant.
- Use of GDMT was overall modest across the cohort.
- Fewer than half of patients received ACE inhibitors or related agents, while just over half were prescribed beta-blockers.
- A smaller proportion received mineralocorticoid receptor antagonists or triple therapy.
- GDMT use declined progressively in patients with improved ejection fraction, indicating possible premature reduction or discontinuation of therapy.
These findings raise concerns about therapeutic inertia and highlight a disconnect between clinical guidelines and actual practice. While many patients demonstrated improvement in cardiac function, the authors caution that recovery does not equate to a cure. Discontinuing or reducing therapy may increase the risk of relapse, underscoring the importance of continued adherence to guideline-based treatment.
Overall, the study highlights the importance of systematic follow-up and the sustained use of evidence-based therapies in patients with HFrEF. Improving adherence to recommended imaging and treatment strategies could play a crucial role in optimizing long-term outcomes for this high-risk population.
Reference:
Do D, Murugiah K, Sawano M, et al. Heart Failure Trajectories After Guideline-Directed Medical Therapy. JAMA Netw Open. 2026;9(5):e2613955. doi:10.1001/jamanetworkopen.2026.13955
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