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6.2 Heart failure with mildly reduced ejection fraction
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Published:November 2023
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Abstract
The 2016 European Society of Cardiology (ESC) Heart Failure Guidelines introduced heart failure with mildly reduced ejection fraction (HFmrEF) as a separate category of patients. These patients have a left ventricular ejection fraction (LVEF) of between 40% and 50%. Patients in this mildly reduced category were already acknowledged as an unidentified ‘grey area’, and the main purpose of providing this category of patients with a name was to gain knowledge on their prevalence, characteristics, clinical outcome, and treatment responses. Four years later, a large number of studies have increased our knowledge on patients with HFmrEF. Firstly, the most important lessons are that with regard to an ischaemic aetiology, HFmrEF more closely resembles heart failure with reduced ejection fraction (HFrEF) than heart failure with preserved ejection fraction (HFpEF). Secondly, the ejection fraction often changes over time and these changes seem to be prognostically more important than the baseline ejection fraction alone. Lastly, retrospective analyses from prospective randomized clinical trials, including the full spectrum of LVEF, suggest that patients with HFmrEF might benefit from therapies that have been shown to improve outcome in HFrEF, whereas no such benefit was seen in patients with HFpEF. This resulted in the renaming of ‘heart failure with mid-range ejection fraction’ to ‘heart failure with mildly reduced ejection fraction’, and in new recommendations for therapies for patients with HFmrEF in the 2021 ESC Heart Failure Guidelines.
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