Heart Failure With Improved Ejection Fraction: Definitions, Epidemiology, and Management

Mauro Riccardi; Maria A Pabon; Ankeet S Bhatt; Gianluigi Savarese; Marco Metra; Maurizio Volterrani; Carlo M Lombardi; Muthiah Vaduganathan; Scott D Solomon; Orly Vardeny; Riccardo M Inciardi

doi:10.1016/j.jacc.2025.03.544

Heart Failure With Improved Ejection Fraction: Definitions, Epidemiology, and Management

J Am Coll Cardiol. 2025 Jun 24;85(24):2401-2415. doi: 10.1016/j.jacc.2025.03.544.

Affiliations

¹ Division of Cardiology, Cremona Hospital, Cremona, Italy; Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
² Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
³ Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, California, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA.
⁴ Division of Cardiology, Department of Clinical Science and Education, Center for Heart Failure and Arrhythmia, Karolinska University Hospital, Stockholm, Sweden.
⁵ Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
⁶ Department of Exercise Science and Medicine, San Raffaele Open University of Rome, Rome, Italy.
⁷ Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA. Electronic address: ovardeny@umn.edu.
⁸ Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy; Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Department of Clinical Science and Education, Center for Heart Failure and Arrhythmia, Karolinska University Hospital, Stockholm, Sweden. Electronic address: riccardo.inciardi@libero.it.

PMID: 40533130
DOI: 10.1016/j.jacc.2025.03.544

Abstract

Heart failure with improved ejection fraction (HFimpEF) has gained increasing recognition as a distinct phenotype within the spectrum of heart failure, characterized by previously reduced left ventricular ejection fraction (≤40%) that subsequently improves to >40%. HFimpEF remains relatively understudied, and uncertainty persists regarding its long-term prognosis and optimal management. Contemporary registries and clinical trials suggest a rising prevalence, likely reflecting both the increased implementation of guideline-directed medical therapy and evolving consensus definitions for its identification. Despite left ventricular ejection fraction recovery, patients with HFimpEF remain at risk for adverse outcomes, and their management remains an area of active investigation. The aim of this review is to provide an in-depth evaluation of HFimpEF, including its epidemiology, pathophysiology, prognosis, and treatment strategies. The authors also highlight existing clinical gaps and propose future research directions to refine risk stratification and therapeutic approaches for this evolving population.

Keywords: GDMT; HFimpEF; LVEF; reverse remodeling.

Publication types

Review

MeSH terms

Disease Management*
Heart Failure* / diagnosis
Heart Failure* / epidemiology
Heart Failure* / physiopathology
Heart Failure* / therapy
Humans
Prognosis
Stroke Volume* / physiology