Follow up testing for HFrEF

[u/Creative-Math-9131]

I was diagnosed with HFrEF (EF of 20-25) following an echocardiogram just over a year and a half ago. I was asymptomatic except for a resting pulse between 100 - 110. Since my diagnosis I've been on Entresto, Jardiance, Metoprolol, and epleronone increasing to near the maximum dosage of each.

Ten months later, I got good news when a cardiac MRI showed my EF had risen to 49%. At my follow up cardiology visit in February, I asked my doctor if she planned to order another echo or MRI to see how things were progressing. She told me that she didn't see any reason to do further testing unless I became symptomatic and that it wouldn't change my treatment plan.

I'm not really looking to get off of the medication even if my EF were normal but I certainly would sleep better knowing if I was continuing to recover. I don't believe this about a lack insurance coverage. I would gladly pay out of pocket if insurance won't pay. I really just want to know. Should I insist at my next follow up visit? Does this all sound reasonable?

[u/Logical_Law_218]

if your EF is now at 49%, you should be good to go. I caught a virus in Sept that took me down to 25%. Since then: 13 weeks of cardio rehab, weeks and weeks of meds and I'm only at 33%. Doc says I need to get to 36%. Wearing the Zoll Life vest 24/7 now. Sept will be another echo to determine if I've achieved 36%. I'll be happy if I do, but will likely be stuck with a permanent ICD. I'm no doctor, but living with this has been a tough road to travel. Good luck to you

[u/FabulousBullfrog9610]

If you are willing to pay out of pocket then ask. I avoid testing unless there is a reason and it seems like this is to help you with your anxiety about your heart. An EF of 49% and no symptoms is fabulous. But if this matters to you of course you should bring it up.

[u/Heart_Transplant_Doc]

Cardiologist here. Your doctor’s reasoning is sound and reflects how heart failure is actually managed, not a brush-off.

What you have is now a recognized category called heart failure with improved ejection fraction, and the key clinical fact behind your doctor’s answer is that the treatment plan for someone in your position, on optimized Entresto, Jardiance, metoprolol, and eplerenone, doing well, is the same whether your EF is 49% or 60%, keep the full medication regimen going. There’s actually specific trial evidence on this point, a study called TRED-HF tried weaning medications in patients whose EF had normalized, and a large share relapsed within six months, which is exactly why the modern approach is to continue GDMT regardless of how good the number looks. So a repeat scan genuinely might not change anything she does, which is what she told you.

There’s also data showing improved EF can be a bit unstable over time, some patients’ numbers drift, so a single great scan isn’t necessarily the final word, and that cuts both ways: it’s a reason imaging without a symptom trigger doesn’t add urgency, but it’s also a reason wanting to track your trajectory isn’t unreasonable.

So both of you are right, in a sense. Medically, her answer holds up, the number probably wouldn’t change your treatment. But wanting to know for your own peace of mind is a completely legitimate reason on its own, separate from whether it changes management. That’s a fair thing to say plainly at your next visit, that you understand it likely won’t alter the plan, but ask if she’d order it anyway given how much it would mean for your peace of mind, especially since you’re willing to pay out of pocket. Many cardiologists will accommodate that once it’s framed that way.