Sustained Remission of New-onset Heart Failure in Genetic Cardiomyopathy Without Contemporary Four-pillar Therapy: Implications for ‘Personalized Guideline-directed Medical Therapy’

A 40-year-old woman with new-onset heart failure with reduced ejection fraction (HFrEF) attributed to a titin-truncating variant achieved remission while being treated with carvedilol, lisinopril (first 4 years), and losartan (for 1 year following lisinopril cessation). The patient never received an angiotensin receptor–neprilysin inhibitor, mineralocorticoid receptor antagonist, or sodium–glucose cotransporter 2 inhibitor. Her left ventricular ejection fraction rose from <25% to >50%, her N-terminal pro-B-type natriuretic peptide level dropped from 1,980 pg/ml to 79 pg/ml, and she regained New York Heart Association I status. Her remission persists more than a decade after condition onset. This case demonstrates that patients with genetic cardiomyopathy can achieve durable remission with a narrower set of medications than quadruple therapy.