Heart Failure Drug Withdrawal Survey in Patients With HFrEF Recovery

Goal : to assess the opinion of an international community of cardiologists, doctors and nurses with diverse backgrounds regarding the withdrawal of guideline-directed medical therapy (GDMT) in case of complete recovery from Heart Failure with Reduced Ejection Fraction (HFrEF).
The assessment will include a general case scenario, followed by 4 specific clinical scenarios representing distinct phenotypes or etiologies.

Target population : cardiologists, doctors in practice or training and heart failure nurses in the whole world.
This survey is fully anonymous.
No identifiable personal data are collected.
No IP addresses are stored. One response per device is enabled to minimise duplicate entries.

Completion time: approximately 5 minutes.

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* 1. Do you agree to participate in this study, certify that you are a cardiologist, a medical doctor or nurse and that you will answer the following questions to the best of your abilities ?

Yes

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* 2. What is your age ? (exact number of years)

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 3. What is your gender ?

Female

Male

Non binary

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* 4. What is your country ?

Question Title

* 5. What is your primary subspecialty in cardiology ?

Heart Failure

Cardio-oncology

Interventional (coronary/structure/ Rhythm)

Imaging

Prevention-Rehabilitation

General

Medical Student-Resident

HF Nurse

Other

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* 6. Where is your clinical practice base ?

University Hospital

Public Hospital

Private Clinic Hospital

Private Practice

Mixed activity

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* 7. Are you a PCHF alumnus ?

Yes

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* 8. For you, what are the parameters compulsory to define complete HF recovery under HF drug therapy (multiple answer)?

Absence of symptoms (NYHA class≤I)

LVEF ≥ 50%

Normalized cardiac structure by echocardiography

Normal NTproBNP level

Normal right heart catheterization

Normal cardiopulmonary exercise testing

HF cause cured / controlled

Normalized functional status ≥ 12 months

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* 9. In the following list of first-line, guideline-directed medical therapies for HFrEF, which one do you consider the most essential, and would be the last you would consider stopping in general (single answer)?

RASi /ARNis

MRAs

BBlockers

SGLT2i

They are more or less equivalent

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* 10. In the following list, what would be the heart failure classes you would consider essential and those less essential (if any) ?

Scenario 1 :
A patient previously diagnosed with heart failure with HFrEF has now achieved complete recovery (LVEF >50%, asymptomatic, and persistently normal NT-proBNP for at least 12 months) under optimized GDMT.
You are asked to consider adjusting or withdrawing HF therapy.

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* 11. If you were required to stop ONE therapy, which class of GDMT would you consider stopping first for this patient (single answer)?

RASi /ARNis

MRAs

BBlockers

SGLT2i

I would not stop any of them

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* 12. Would you consider stopping some (not all) HF drugs simultaneously (single answer)?

Yes routinely

Yes selectively

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* 13. In a follow-up visit, what would you check to ensure stability of the clinical status (multiple answer)?

Symptoms (NYHA class)

NTproBNP levels

Transthoracic echocardiography (LVEF)

Exercise testing

Blood pressure / heart rate

Scenario 2 :
A patient previously diagnosed with non-ischemic HFrEF (initial LVEF 30%) with a LBBB has undergone cardiac resynchronization therapy (CRT), after being optimized on HF drugs and remaining symptomatic. One year post-implantation, he/she is asymptomatic, with a left ventricular ejection fraction (LVEF) >50% and persistently normal NT-proBNP levels (for the last 12 months). He/she remains on optimized HF drug therapies.

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* 14. Which of the following do you believe primarily contributed to the LVEF recovery in this patient (single answer)?

CRT

GDMT (Heart Failure Drugs)

Combination of both

Cannot be distinguished clearly

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* 15. How would you classify this patient’s current heart failure status (single answer) ?

In remission of heart failure

Recovered

Cured

None of these propositions

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* 16. Given the recovery described, would it be clinically reasonable to consider CRT deactivation in this patient? (single answer)

Yes

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* 17. If de-escalation of pharmacologic therapy were considered, which class would you withdraw first, assuming no contraindications or side effects?

RASi /ARNis

MRAs

BBlockers

SGLT2i

I would not stop any of the HF medications

Scenarios 3 :
A patient is diagnosed with HFrEF due to arrhythmic cardiomyopathy related to atrial fibrillation (LVEF at diagnosis was 30%). After initiation of GDMT he/she has undergone AF ablation with no AF recurrence. Twelve months post-ablation, he/she is asymptomatic, remains in sinus rhythm, with a left ventricular ejection fraction (LVEF) >50% and persistently normal NT-proBNP levels. He/she remains on optimized GDMT.

Question Title

* 18. If you were required to stop heart failure therapies, which classes of GDMT would you consider stopping first for this patient ?

RASi /ARNis

MRAs

BBlockers

SGLT2i

I would not stop any drug.

Other scenarios:

Question Title

* 19. In a HFrEF patient with toxic cardiomyopathy / or myocarditis with complete recovery after 12 months which classes of drugs would you withdraw first?

RASi /ARNis

MRAs

BBlockers

SGLT2i

I would not stop any drug

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* 20. In a HFrEF patient with post-partum cardiomyopathy with complete recovery after 12 months which classes of drugs would you withdraw first?

RASi /ARNis

MRAs

BBlockers

SGLT2i

I would not stop any drug

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* 21. In your experience, which of the following HFrEF etiologies is most likely to allow for safe withdrawal of heart failure therapy after recovery (rate by order of likelihood from the most probable to the least probable)?

	Most probable to allow safe withdrawal of therapy (1)	2	3	4	5	Least probable to allow safe withdrawal of therapy (6)
Ischemic Cardiomyopathy	Ischemic Cardiomyopathy Most probable to allow safe withdrawal of therapy (1)	Ischemic Cardiomyopathy 2	Ischemic Cardiomyopathy 3	Ischemic Cardiomyopathy 4	Ischemic Cardiomyopathy 5	Ischemic Cardiomyopathy Least probable to allow safe withdrawal of therapy (6)
Tachy- cardiomyopathy	Tachy- cardiomyopathy Most probable to allow safe withdrawal of therapy (1)	Tachy- cardiomyopathy 2	Tachy- cardiomyopathy 3	Tachy- cardiomyopathy 4	Tachy- cardiomyopathy 5	Tachy- cardiomyopathy Least probable to allow safe withdrawal of therapy (6)
Toxic cardiomyopathy	Toxic cardiomyopathy Most probable to allow safe withdrawal of therapy (1)	Toxic cardiomyopathy 2	Toxic cardiomyopathy 3	Toxic cardiomyopathy 4	Toxic cardiomyopathy 5	Toxic cardiomyopathy Least probable to allow safe withdrawal of therapy (6)
Myocarditis	Myocarditis Most probable to allow safe withdrawal of therapy (1)	Myocarditis 2	Myocarditis 3	Myocarditis 4	Myocarditis 5	Myocarditis Least probable to allow safe withdrawal of therapy (6)
Post-partum Cardiomyopathy	Post-partum Cardiomyopathy Most probable to allow safe withdrawal of therapy (1)	Post-partum Cardiomyopathy 2	Post-partum Cardiomyopathy 3	Post-partum Cardiomyopathy 4	Post-partum Cardiomyopathy 5	Post-partum Cardiomyopathy Least probable to allow safe withdrawal of therapy (6)
LBBB Cardiomyopathy after CRT	LBBB Cardiomyopathy after CRT Most probable to allow safe withdrawal of therapy (1)	LBBB Cardiomyopathy after CRT 2	LBBB Cardiomyopathy after CRT 3	LBBB Cardiomyopathy after CRT 4	LBBB Cardiomyopathy after CRT 5	LBBB Cardiomyopathy after CRT Least probable to allow safe withdrawal of therapy (6)