From the Guidelines
No, nitrates should not be prescribed for routine use in patients with acute on chronic heart failure with preserved ejection fraction (HFpEF), as they have been shown to be ineffective in improving activity levels, quality of life, exercise tolerance, or NT-proBNP levels in these patients. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, the routine use of nitrates in patients with HFpEF does not appear beneficial, although patients with HFpEF and symptomatic CAD may still receive symptomatic relief with nitrates. The NEAT-HFpEF trial randomized 110 patients with EF ≥50% on stable HF therapy, not including nitrates, and with activity limited by dyspnea, fatigue, or chest pain, to either isosorbide mononitrate or placebo and found no beneficial effects on activity levels, QOL, exercise tolerance, or NT-proBNP levels 1.
Some key points to consider when managing HFpEF include:
- The use of mineralocorticoid receptor antagonists, such as spironolactone, may be considered in appropriately selected patients with symptomatic HFpEF, with close monitoring of potassium and renal function 1.
- The use of ARBs may be considered to decrease hospitalizations for patients with HFpEF 1.
- Routine use of nutritional supplements is not recommended for patients with HFpEF 1.
- Phosphodiesterase-5 inhibition, such as sildenafil, has not shown improvement in oxygen consumption or exercise tolerance in patients with HFpEF 1.
It's essential to note that while nitrates may not be beneficial for routine use in HFpEF, they may still be used in specific situations, such as in patients with HFpEF and symptomatic CAD, under close monitoring and with caution due to the risk of hypotension, particularly when combined with phosphodiesterase inhibitors like sildenafil.
From the FDA Drug Label
WARNINGS: ... The benefits of transdermal nitroglycerin in patients with acute myocardial infarction or congestive heart failure have not been established. If one elects to use nitroglycerin in these conditions, careful clinical or hemodynamic monitoring must be used to avoid the hazards of hypotension and tachycardia. WARNINGS The benefits of sublingual nitroglycerin in patients with acute myocardial infarction or congestive heart failure have not been established. If one elects to use nitroglycerin in these conditions, careful clinical or hemodynamic monitoring must be used because of the possibility of hypotension and tachycardia.
Nitroglycerin can be prescribed for a patient with acute on chronic HFpEF, but with caution. The benefits of nitroglycerin in patients with congestive heart failure have not been established, and careful clinical or hemodynamic monitoring must be used to avoid the hazards of hypotension and tachycardia 2 3.
- Key considerations include:
- Close monitoring of the patient's condition
- Careful dose adjustment to avoid hypotension and tachycardia
- Alternative treatments may be considered if the benefits of nitroglycerin are unclear.
From the Research
Treatment Options for HFpEF
- The treatment of heart failure with preserved ejection fraction (HFpEF) is complex and challenging, with few effective treatments currently identified 4.
- First-line pharmacologic therapy consists of sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, which reduced HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials 5.
- Diuretics (typically loop diuretics, such as furosemide or torsemide) should be prescribed to patients with overt congestion to improve symptoms 5.
- Exercise training and diet-induced weight loss produced clinically meaningful increases in functional capacity and quality of life in randomized clinical trials 5.
- Education in HF self-care (eg, adherence to medications and dietary restrictions, monitoring of symptoms and vital signs) can help avoid HF decompensation 5.
Use of Nitrates in HFpEF
- There is no direct evidence in the provided studies to support the use of nitrates in patients with acute on chronic HFpEF.
- However, nitrates are commonly used in the treatment of acute decompensated heart failure to reduce preload and afterload, and may be considered in patients with HFpEF who have evidence of volume overload or hypertension 6, 7.
- The decision to prescribe nitrates in HFpEF should be individualized and based on the patient's specific clinical presentation and response to treatment.
Management of Comorbidities
- Management of comorbidities, such as hypertension, diabetes, and obesity, is an important aspect of HFpEF treatment 6, 5, 7.
- Comprehensive management of HFpEF includes exercise as well as treatment of risk factors and comorbidities 6.
- Improved phenotyping of subgroups within the overall HFpEF population might enhance individualization of treatment 4.