From the Guidelines
The guideline-directed medical therapy (GDMT) for heart failure with preserved ejection fraction (HFpEF) includes controlling systolic and diastolic blood pressure, using diuretics for symptom relief, and managing comorbidities such as hypertension, diabetes, and coronary artery disease. According to the most recent evidence 1, blood pressure control is a critical component in reducing HF hospitalizations in HFpEF patients. Key aspects of GDMT for HFpEF include:
- Controlling blood pressure according to published clinical practice guidelines, as recommended by the 2013 ACCF/AHA guideline 1
- Using diuretics for relief of symptoms due to volume overload, as recommended by the 2013 ACCF/AHA guideline 1
- Managing comorbidities such as hypertension, diabetes, and coronary artery disease, as suggested by the 2022 JACC review 1
- Considering the use of spironolactone to lower hospitalizations for HF in appropriately selected patients, as mentioned in the 2022 JACC review 1 It is essential to note that there is no FDA-approved therapy specifically for HFpEF, and the treatment approach is largely focused on managing underlying conditions and symptoms. When initiating these therapies, it is crucial to monitor renal function, electrolytes, and blood pressure, and to educate patients about potential side effects and the importance of adherence to the medication regimen. These therapies work by reducing fluid retention, improving cardiac remodeling, and modulating neurohormonal activation, which are key pathophysiological mechanisms in HFpEF. In clinical practice, the treatment of HFpEF should prioritize controlling blood pressure, managing symptoms, and addressing comorbidities, as these approaches have been shown to improve outcomes in HFpEF patients 1.
From the Research
Guideline-Directed Medical Therapies (GDMT) for Heart Failure with Preserved Ejection Fraction (HFpEF)
The management of HFpEF remains a challenge due to its heterogeneous presentation and pathophysiology, as well as the scarcity of evidence on therapeutic benefits on outcome 2, 3. The current treatment targets symptom relief, quality of life, and reduction of cardiac decompensations by controlling fluid retention and managing risk factors and comorbidities.
Medications
- Renin-angiotensin-aldosterone inhibitors: Although large-scale clinical trials have provided limited evidence of clinical benefit, these medications are still considered important in the management of HFpEF 2, 4.
- Diuretics: Used to control fluid retention and manage symptoms 2.
- Calcium channel blockers (CCB): May be used to manage hypertension and reduce symptoms 2.
- Beta-blockers: Although not proven to reduce mortality, beta-blockers may be used to manage symptoms and improve quality of life 2.
- Sodium-glucose cotransporter 2 inhibitors: Have been shown to reduce the risk of composite cardiovascular events, driven by a reduction in HF hospitalizations 5.
- Angiotensin-neprilysin inhibitors: Result in smaller reductions in HF hospitalizations among patients with HFpEF 5.
Non-Pharmacological Interventions
- Exercise: Comprehensive management of HFpEF includes exercise to improve symptoms and quality of life 5.
- Treatment of risk factors and comorbidities: Aggressive management of contributing factors, including hypertension, atrial fibrillation, and myocardial ischemia, is key in the management of HFpEF 3, 5.
- Diet and lifestyle recommendations: Important in managing symptoms and improving quality of life 2.
Future Directions
- Personalized therapeutic approaches: HFpEF is a complex clinical syndrome with various comorbidities and overlapping distinct phenotypes that could benefit from personalized therapeutic approaches 6.
- New pharmacotherapeutic options: Several drugs are being investigated in clinical trials, including soluble guanylate cyclase stimulators, inorganic nitrates, and SGLT2 inhibitors 2, 6.