Table 1.5. HFimpEF treatment recommendations.

Recommendations	Class	LE	Comments	Table 2018	Ref.
Continuing disease-modifying drug therapy used in treating HFrEF in improved dilated cardiomyopathy.	I	B	NEW: Indication supported by a randomized multicenter trial with limited sample and surrogate endpoints.	New	16
Advancements in the treatment of HF with reduced ejection fraction (HFrEF) has led to improved left ventricular ejection fraction (LVEF) and a reduction in left ventricle size of about 40 percent in patients, depending on etiology.17 In that setting, the 2013 ACC/AHA guideline for the management of HF created the term “HF with improved or recovered LVEF,” establishing a new classification for patients with prior HFrEF who improved their LVEF at rates above 40%.18 More recently, Halliday BP et al.16tested the safety of withdrawing HF medication in a small group of patients with recovered dilated cardiomyopathy in an unblinded but randomized and multicenter pilot trial. The inclusion criteria were: prior diagnosis of dilated cardiomyopathy with LVEF 40 percent or lower; absence of heart failure symptoms; treatment with loop diuretics and disease-modifying drug therapy; current LVEF of 50% or greater; left ventricular end diastolic volume indexed to normal body surface and NT-proBNP below 250 pg/mL. Patients were randomly assigned to the medication withdrawal group for 6 months and the primary endpoint was a combination of a reduction in LVEF, LV dilation, and return of HF symptoms. After 6 months of follow-up, 44% of patients assigned to the treatment withdrawal group met some of the criteria of the primary endpoint, compared to no members of the treatment continuation group, recording a 45.7% estimated event rate (95% CI 28.5–67.2; p = 0.0001). Despite a small sample size and a suboptimal design, this is the best evidence available in the HFimpEF population, suggesting that continuation of drugs in this context is the best strategy, at least until the publication of a more robust study.

This guideline uses the denominations and definitions according to the new universal classification of heart failure.¹⁸HFrEF: heart failure with reduced ejection fraction; LVEF: left ventricular ejection fraction; NT-proBNP: N-terminal portion of B-type natriuretic peptide.