Finally, researchers used an Italian registry to follow prospectively 581 patients with dilated cardiomyopathy who were enrolled over a 25-year period.19 The team found that “healing” (reverse remodeling) occurred in 16% of the patients in response to treatment with ACE inhibitors and beta-blockers. Thus, in the vast majority of patients, the underlying disorder that caused the cardiomyopathy was maintained.
Keep patients on the same meds There are no prospective RCTs investigating the continuation of ACE inhibitors, beta-blockers, or other therapy among HF patients whose EF normalized in response to treatment. Given the dramatic benefit of these medications for patients with a reduced EF, no such trial is likely to be performed. The trials noted above are instructive, however, and show that maintenance of HF medications17 (and the absence of COPD18) are predictors of sustained improvement.
Other factors to consider: Diastolic dysfunction is an ill-defined condition, and normalization of EF does not necessarily restore a patient to the same status as that of someone who never had a reduced EF. In addition, many patients with a reduced EF have concomitant CAD. In such cases, beta-blockers and ACE inhibitors are indicated as part of secondary prevention—another reason for continuation of the medication regimen, despite EF normalization.
CASE That was true for Joe, who suffered from a host of comorbidities, including CAD, as well as HF, and had been hospitalized for chest pain. His negative stress echocardiogram and improved EF suggested—although neither was definitive evidence—that his chest pain may have had a noncardiac cause. At his postdischarge follow-up visit, he was not experiencing any additional pain.
Despite Joe’s improved EF, however, his medical regimen remains unchanged. He comes in every 1 to 2 months for surveillance.
CORRESPONDENCE William E. Chavey, MD, MS, University of Michigan, 1500 East Medical Center Drive, L2003 Women’s Hospital, Ann Arbor, Mich 48109-5239; wchavey@umich.edu
