Factors Associated with Maintenance of an Improved Ejection Fraction: An Echocardiogram-based Registry Study

Background: Heart failure with improved ejection fraction (HFimpEF) is increasingly recognized as a sizable and distinct entity. While the features associated with improved ejection fraction have been explored and new guidelines have emerged, factors associated with sustaining an improved ejection fraction over time have not been defined. Objective: We aimed to assess factors associated with maintenance of an improved ejection fraction in a large real-world patient cohort. Methods: A total of 7,070 participants with heart failure with improved ejection fraction and a subsequent echocardiogram (ECHO) performed after at least nine months of follow-up were included in a retrospective study conducted at the Cleveland Clinic in Cleveland, OH. Multiple logistic regression models, adjusted for demographics, comorbidities, and medications were built to identify characteristics and therapeutic interventions associated with maintaining an improved ejection fraction. Results: Mean age (SD) was 64.9 (13.8) years, 62.7% were men, and 75.1% were White. White race and the use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or angiotensin receptor-neprilysin inhibitors were correlated with maintaining the ejection fraction at least nine months after ejection fraction improvement. In contrast, male sex, or having atrial fibrillation/flutter, coronary artery disease, history of myocardial infarction, presence of an implanted cardioverter defibrillator, and use of loop diuretics were correlated with a decline in ejection fraction after previously documented improvement. Conclusion: Continued use of renin-angiotensin aldosterone system inhibitors was associated with maintaining the ejection fraction beyond the initial improvement phase. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement No funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study protocol was approved by the Cleveland Clinic Institutional Review Board. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes To ensure participant privacy, the raw data used in this study are not publicly available. However, upon request, the raw data can be made accessible to authorized individuals through the Cleveland Clinic Research Institute, subject to appropriate privacy and data protection protocols.