Heart failure with reduced ejection fraction (HFrEF) is a common complication of acute myocardial infarction (AMI), driven by significant myocardial injury and subsequent ventricular remodeling (1, 2). While many patients experience persistent ventricular dysfunction, others achieve substantial recovery of left ventricular ejection fraction (LVEF), a condition termed heart failure with recovered ejection fraction (HFrecEF) (2). This phenomenon has garnered increasing clinical attention due to its implications for long-term outcomes and management strategies (3, 4).

Despite the improved prognosis associated with HFrecEF, the underlying mechanisms facilitating LVEF recovery remain poorly understood. Factors such as age, baseline LVEF, adherence to guideline-directed medical therapy (GDMT), and comorbidities have been proposed as potential contributors (2, 4, 5). Moreover, the prognostic disparities between patients with persistent HFrEF and HFrecEF highlight the need for a nuanced approach to post-AMI care.

This study aims to investigate the prognostic differences between persistent HFrEF and HFrecEF following AMI. By identifying predictors of LVEF recovery and examining associated clinical outcomes, we seek to inform strategies for optimizing management and improving long-term survival in this population.

This study adds to the growing body of evidence on the prognostic significance of early LVEF recovery following AMI by comparing clinical outcomes between patients with persistent HFrEF and those with HFrecEF. Patients with HFrecEF demonstrated more favorable outcomes, including lower rates of cardiovascular mortality and heart failure rehospitalization. These findings support the clinical relevance of early post-AMI echocardiographic reassessment and may inform future strategies for risk stratification and individualized management across different heart failure phenotypes.The results highlight that the importance of adhering to guideline-directed medical therapy (GDMT) and serial assessment of left ventricular function by echocardiography can be used to predict the clinical outcome of patients underwent PCI due to ACS (8, 9).

Younger age and the use of beta-blockers and RAS inhibitors emerged as pivotal predictors of LVEF recovery, offering actionable insights into optimizing care for at-risk populations (2). This aligns with prior evidence suggesting that early initiation of GDMT, combined with consistent patient adherence, can significantly enhance outcomes in heart failure patients (8, 9).

Despite these advancements, persistent HFrEF remains a challenging phenotype, characterized by higher risks and poor outcomes. Comprehensive, individualized approaches combining pharmacological and non-pharmacological strategies are needed to address this group effectively. Device-based therapies, such as implantable cardioverter defibrillators (ICDs) or cardiac resynchronization therapy (CRT), may offer additional benefits for patients with severe ventricular dysfunction (7, 9). Moreover, lifestyle interventions, including dietary optimization and supervised exercise programs, could further improve functional status and quality of life (10, 11).

These findings underline the heterogeneity in heart failure phenotypes and the necessity for precision medicine in this domain. Future research should focus on exploring novel pharmacological agents, such as SGLT2 inhibitors, which have shown promise in recent trials for heart failure management (7, 9, 12). Furthermore, long-term studies investigating the durability of LVEF recovery and its impact on survival will be crucial for advancing care in this population. Younger age and the use of beta-blockers and RAS inhibitors emerged as pivotal predictors of LVEF recovery, offering actionable insights into optimizing care for at-risk populations. Although younger age was identified as a predictor of LVEF recovery, this could also underscore the importance of early detection, close follow-up, and the optimization of medical therapy in elderly patients, who may have more a limited potential for spontaneous recovery. Strategies such as comprehensive geriatric assessment, frailty screening, and enhanced support for medication adherence may contribute to improve outcomes in this population.

Nonetheless, a significant proportion of patients continue to experience persistent HFrEF, highlighting an unmet clinical need. Comprehensive, individualized approaches combining pharmacological and non-pharmacological strategies are needed to address this group effectively. These findings underline the heterogeneity in heart failure phenotypes and the necessity for precision medicine in this domain.

This study has certain limitations. First, as a single-cohort study, residual confounding cannot be ruled out. Factors such as infarct size, extent of coronary artery disease, prior revascularization history, adherence to medications, and socioeconomic variables were not fully captured in our dataset and may influence the observed associations. Second, the exclusion of patients with unmeasured LVEF or major clinical events may have resulted in a selection bias And due to the nature of our registry, written informed consent was obtained only from patients who survived the initial 1-month post-AMI period without major events, in accordance with IRB requirements. As a result, patients with early death or major complications were not enrolled, which may introduce selection bias and limit the generalizability of our findings. Third, our dataset lacked comprehensive information on the use of mineralocorticoid receptor antagonists (MRAs) and sodium-glucose co-transporter 2 (SGLT2) inhibitors. As a result, our analysis could not fully assess the implementation of contemporary guideline-directed medical therapy (GDMT), and the findings regarding pharmacologic treatment are primarily limited to RAS inhibitors and β-blockers. Fourth, interobserver variability in echocardiographic assessments could influence group classification.

Finally, although the study used a 1-month follow-up period in accordance with routine post-AMI clinical practice, we acknowledge that this time frame may not fully capture the extent or durability of left ventricular reverse remodeling, which can evolve over 3 to 6 months. Future studies incorporating serial echocardiographic evaluations over longer follow-up periods and multicenter validation are warranted to confirm and extend our findings.

In conclusion, this study highlights the critical prognostic differences between persistent HFrEF and HFrecEF following AMI. The transition to HFrecEF is associated with significantly better outcomes, driven by predictors such as younger age and the use of beta-blockers and RAS inhibitors. These findings underscore the importance of regular echocardiographic monitoring and tailored therapeutic strategies to optimize recovery.