From the Guidelines
The best treatment for Heart Failure with Preserved Ejection Fraction (HFpEF) involves a combination of lifestyle changes and medications, with SGLT2 inhibitors being recommended to improve outcomes in hypertensive patients with symptomatic HFpEF, as stated in the 2024 ESC guidelines 1. When managing HFpEF, it's essential to consider the following approaches:
- Lifestyle modifications:
- Reduce salt intake to less than 2 grams per day
- Engage in regular aerobic exercise, starting with 15-30 minutes 3-5 times per week
- Maintain a healthy weight
- Quit smoking if applicable
- Medications:
- Diuretics: Start with furosemide 20-40 mg daily, adjust as needed
- SGLT2 inhibitors: Recommended for hypertensive patients with symptomatic HFpEF to improve outcomes 1
- ARBs and/or MRAs: May be considered to reduce heart failure hospitalizations and reduce BP in patients with symptomatic HFpEF who have BP above target 1
- Blood pressure control: Aim for a target of <130/80 mmHg
- Manage underlying conditions: Treat hypertension, diabetes, and coronary artery disease if present
- Regular follow-ups: Schedule appointments every 3-6 months to monitor progress and adjust treatment It's crucial to note that no specific drug has proven its superiority in HFpEF, and all major agents can be used 1. However, the 2022 AHA/ACC/HFSA guideline suggests that RAAS inhibition strategies, which have been successful in HFrEF, have not shown significant benefit in patients with HFpEF 1. Therefore, the focus should be on managing symptoms, controlling blood pressure, and improving overall cardiovascular health.
From the Research
Treatment Options for Heart Failure with Preserved Ejection Fraction (HFpEF)
- There is no unified approach to the treatment of diastolic heart failure, which is characterized by preserved left ventricular ejection fraction 2.
- The treatment of HFpEF is often empirical and may involve a combination of symptomatic, causal, and prognostic treatments 2, 3.
- Pharmacologic treatment of HFpEF may focus on:
- Normalizing blood pressure
- Promoting regression of left ventricular hypertrophy
- Avoiding tachycardia
- Treating symptoms of congestion
- Maintaining normal atrial contraction when possible 3
- Diuretic therapy is the mainstay of treatment for preventing pulmonary congestion, while beta blockers may be useful in preventing tachycardia and prolonging left ventricular diastolic filling time 3.
- Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers may be beneficial in patients with diastolic dysfunction, especially those with hypertension 3, 4.
- Calcium channel antagonists, beta-adrenergic blocking agents, diuretic agents, and angiotensin-converting-enzyme inhibitors may also be used in the treatment of HFpEF 4.
Challenges and Future Directions
- There is a need for more randomized clinical trials on nonpharmacological and pharmacological management of HFpEF to establish evidence-based guidelines 5.
- The development of standardized guidelines for HFpEF patients is necessary to improve treatment outcomes 5.
- Successful treatment of HFpEF requires tailoring a treatment plan to suit each individual patient's needs and involving the family in the treatment process 5.