From the Guidelines
Heart failure with preserved ejection fraction (HFpEF) management should prioritize symptom relief and addressing underlying conditions, with SGLT2 inhibitors such as empagliflozin or dapagliflozin recommended to reduce hospitalizations and cardiovascular death, as supported by recent guidelines 1.
Presentation of HFpEF
HFpEF typically presents with symptoms of heart failure despite a normal ejection fraction (≥50%), including dyspnea, fatigue, exercise intolerance, and fluid retention. Diagnosis requires clinical symptoms of heart failure, preserved left ventricular ejection fraction, and evidence of diastolic dysfunction or elevated filling pressures.
Management of HFpEF
Management focuses on symptom relief and addressing underlying conditions. Diuretics like furosemide (20-80mg daily) are first-line for congestion.
- SGLT2 inhibitors such as empagliflozin (10mg daily) or dapagliflozin (10mg daily) have shown benefit in reducing hospitalizations and cardiovascular death 1.
- Blood pressure control is essential, with ACE inhibitors, ARBs, or beta-blockers as appropriate.
- For patients with specific comorbidities, additional therapies may include spironolactone (25mg daily) for those with elevated BNP levels and recent hospitalization.
- Management of atrial fibrillation, coronary artery disease, and other comorbidities is crucial.
- Lifestyle modifications including sodium restriction (<2g daily), regular physical activity, and weight management are fundamental components of treatment.
Key Considerations
Unlike heart failure with reduced ejection fraction, HFpEF lacks therapies that consistently improve mortality, making symptom management and addressing underlying conditions the cornerstone of treatment. Regular monitoring of symptoms, fluid status, electrolytes, and renal function is necessary to optimize therapy, as recommended by recent guidelines 1.
From the Research
Heart Failure with Preserved Ejection Fraction (HFpEF) Presentation
- HFpEF accounts for approximately 50% of patients with heart failure, with increasing incidence relative to heart failure with reduced ejection fraction (HFrEF) 2, 3, 4.
- The prevalence of HFpEF is growing rapidly due to the aging population and rising prevalence of obesity, diabetes, and hypertension 4.
- HFpEF is associated with high morbidity and mortality, with fewer than 25% of patients surviving beyond 5 years after diagnosis 5.
Diagnosis and Challenges
- Diagnosis of HFpEF in the outpatient setting presents unique challenges due to a high burden of comorbidities and difficulties in distinguishing HFpEF from normal aging 2.
- Primary care providers play a pivotal role in the delivery of holistic, patient-centric care from diagnosis to management and palliative care 2.
Management of HFpEF
- Current therapy for HFpEF is largely focused on management of symptoms and comorbidities, with no approved treatments specifically indicated for HFpEF 2, 3, 4.
- Management of HFpEF still focuses on optimally managing underlying diseases, such as hypertension 6.
- Antihypertensive treatment, including ACE inhibitors, ARBs, β-blockers, and calcium-channel blockers, is recommended to control the disease in this patient population, although these agents have not demonstrated significant benefit beyond blood pressure control 6.
- Recent studies have demonstrated benefits for novel therapeutic classes, including sodium-glucose cotransporter 2 inhibitors (SGLT2i), non-steroidal mineralocorticoid receptor antagonists (Ns-MRAs), and glucagon-like peptide-1 (GLP-1) receptor agonists, particularly for the obesity-related HFpEF phenotype 5.
Treatment Strategies
- Improved phenotyping of subgroups within the overall HFpEF population might enhance individualization of treatment 4.
- Decongestion by diuretics, promotion of a healthy active lifestyle, and management of comorbidities are current treatment strategies for HFpEF 4.
- Emerging therapeutic approaches, including novel pharmacologic agents and device-based therapies, are being developed and tested in ongoing and forthcoming trials 3, 5.