From the Guidelines
The management of hypertension (HTN) in heart failure with preserved ejection fraction (HFpEF) should prioritize the use of SGLT2 inhibitors, such as empagliflozin, to improve outcomes, as recommended by the 2024 ESC guidelines 1.
Key Considerations
- The goal of treatment is to achieve blood pressure targets below 130/80 mmHg while addressing the underlying pathophysiology of HFpEF.
- SGLT2 inhibitors have been shown to improve outcomes in patients with HFpEF, particularly those with diabetes or chronic kidney disease.
- Angiotensin receptor blockers (ARBs) and mineralocorticoid receptor antagonists (MRAs) may be considered to reduce heart failure hospitalizations and lower blood pressure.
Treatment Approach
- First-line treatment: SGLT2 inhibitors, such as empagliflozin (10-25 mg daily).
- Additional agents:
- ARBs, such as valsartan (80-320 mg daily).
- MRAs, such as spironolactone, in appropriately selected patients with HFpEF.
- Diuretics, such as thiazides or loop diuretics, for volume management and symptom relief.
- Beta-blockers, such as metoprolol succinate, for patients with concurrent coronary artery disease or atrial fibrillation.
Monitoring and Titration
- Treatment should be initiated at lower doses and titrated gradually while monitoring for hypotension, electrolyte abnormalities, and worsening renal function.
- Regular monitoring of blood pressure, renal function, and electrolyte levels is essential to minimize the risk of adverse effects. The 2024 ESC guidelines 1 provide the most recent and highest-quality evidence for the management of HTN in HFpEF, and their recommendations should be prioritized in clinical practice.
From the FDA Drug Label
Spironolactone tablets are indicated as add-on therapy for the treatment of hypertension, to lower blood pressure in patients who are not adequately controlled on other agents. Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)
The treatment of hypertension in HFpEF (Heart Failure with preserved Ejection Fraction) involves a comprehensive approach, including:
- Lifestyle modifications: such as limited sodium intake, exercise, and smoking cessation
- Pharmacological therapy: with the goal of achieving blood pressure control, which may require more than one drug
- Add-on therapy: with spironolactone, as indicated for the treatment of hypertension, to lower blood pressure in patients who are not adequately controlled on other agents 2 It is recommended to follow published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), for specific advice on goals and management 2.
From the Research
Treatment Guidelines for Hypertension in HFpEF
- The treatment of hypertension is crucial in the management of heart failure with preserved ejection fraction (HFpEF) 3, 4, 5, 6, 7
- Control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF 4
- Blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients 4
- A treat-to-target blood pressure (BP) strategy could be employed, such as systolic BP < 130 mmHg 5
- Non-medical therapies, including lifestyle modifications, such as physical activity, weight loss, and sleep apnea management, can also be used to control BP in HFpEF patients 5
Antihypertensive Medications
- Angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) are recommended for the treatment of hypertension in HFpEF patients 3, 4, 7
- Beta-blockers and calcium-channel blockers can also be used to control BP in HFpEF patients 7
- Spironolactone can be used in addition to other antihypertensive medications for the treatment of resistant hypertension in HFpEF patients 4
- Novel agents, such as sodium-glucose co-transporter-2 inhibitors and finerenone, may also be beneficial in the treatment of HFpEF, but further research is needed 4