What is the recommended medication regimen for patients with Heart Failure with Preserved Ejection Fraction (HFpEF)?

From the Guidelines

The recommended medication regimen for patients with Heart Failure with Preserved Ejection Fraction (HFpEF) should focus on blood pressure control, symptomatic treatment with diuretic agents, and management of comorbidities, as these approaches have been shown to reduce HF hospitalizations and improve quality of life. When managing HFpEF, the following key considerations should be taken into account:

• Blood pressure control is critical, as lowering BP has been shown to reduce HF hospitalizations in these patients 1.
• Diuretic agents are used for symptomatic treatment, with the goal of reducing fluid overload and improving symptoms.
• Treatment of comorbidities, such as atrial fibrillation, ischemia, and diabetes, is essential to improve overall outcomes.
• In selected patients, the use of spironolactone may be considered to lower hospitalizations for HF, although its use should be individualized based on patient characteristics and comorbidities 1. Key medications that may be used in the management of HFpEF include:
• Diuretics, such as loop diuretics (e.g., furosemide, torsemide), to reduce fluid overload and improve symptoms.
• Agents for blood pressure control, such as ACE inhibitors, ARBs, or calcium channel blockers, in hypertensive patients.
• SGLT2 inhibitors, such as empagliflozin or dapagliflozin, for patients with diabetes, as they have shown benefit in reducing hospitalizations.
• Beta-blockers for rate control in patients with atrial fibrillation, and anticoagulation therapy for stroke prevention in these patients.
• Mineralocorticoid receptor antagonists, like spironolactone, in selected patients, with careful monitoring for side effects such as hypotension, electrolyte abnormalities, and worsening renal function. It is essential to individualize treatment based on comorbidities and carefully monitor patients for potential side effects, as the primary goal in managing HFpEF is to improve quality of life and reduce hospitalizations through symptom management and addressing underlying conditions 1.

From the Research

Medication Regimen for Heart Failure with Preserved Ejection Fraction (HFpEF)

The recommended medication regimen for patients with HFpEF is focused on managing symptoms and comorbidities, as there are no approved treatments specifically indicated for HFpEF 2.

• Loop Diuretics: Used to manage symptoms of volume overload, such as edema and dyspnea 3.
• Mineralocorticoid Receptor Antagonists (MRAs): Used to reduce mortality and morbidity in patients with HFpEF, particularly those with a history of hypertension or diabetes 3.
• Sodium Glucose Co-Transporter-2 (SGLT2) Inhibitors: May be used as add-on therapy to reduce the risk of hospitalization for heart failure and cardiovascular death 3.
• Angiotensin Receptor Blockers/Angiotensin Receptor-Neprilysin Inhibitors (ARB/ARNIs): May be used as add-on therapy to reduce the risk of hospitalization for heart failure and cardiovascular death, although the risk of geriatric conditions such as falls and malnutrition must be considered 3.
• Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RAs): May be used as add-on therapy to reduce the risk of hospitalization for heart failure and cardiovascular death, although the risk of geriatric conditions such as falls and malnutrition must be considered 3.
• Beta Blockers: May be used in a smaller subset of patients with HFpEF, although the evidence is limited and the risk of adverse effects must be carefully considered 3.

Emerging Therapeutic Approaches

Several emerging therapeutic approaches are being investigated for the treatment of HFpEF, including:

• Endothelial Nitric Oxide Synthase Activators: May improve diastolic function and reduce oxidative stress and inflammation 4.
• If Current Inhibitors: May improve diastolic function and reduce oxidative stress and inflammation 4.
• Matrix Metalloproteinase 9 Inhibitors: May reduce fibrosis and improve diastolic function 4.
• Nitroxyl Donors: May improve diastolic function and reduce oxidative stress and inflammation 4.
• LCZ696: A combination drug of angiotensin II receptor blocker and neprilysin inhibitor, which may reduce the risk of hospitalization for heart failure and cardiovascular death 4.
• Spironolactone: An aldosterone receptor antagonist, which may reduce mortality and morbidity in patients with HFpEF 4.