From the Guidelines
The management of heart failure with preserved ejection fraction (HFpEF) should focus on risk stratification, management of comorbidities, nonpharmacological management, and symptom management with disease-modifying therapy, as outlined in the 2023 ACC expert consensus decision pathway 1.
Key Components of HFpEF Management
- Risk stratification and management of comorbidities, including hypertension, diabetes, obesity, atrial fibrillation, coronary artery disease, chronic kidney disease, and obstructive sleep apnea
- Nonpharmacological management, including exercise and weight loss, and the use of wireless, implantable pulmonary artery monitors
- Symptom management with loop diuretic agents, SGLT2 inhibitors, mineralocorticoid antagonists, angiotensin receptor–neprilysin inhibitors, and angiotensin receptor blockers
Pharmacological Therapy
- SGLT2 inhibitors, such as empagliflozin or dapagliflozin, have shown benefit in reducing hospitalizations and cardiovascular death in HFpEF patients 1
- Mineralocorticoid receptor antagonists, like spironolactone, may benefit selected patients, particularly those with elevated natriuretic peptides
- Blood pressure control is crucial, with ACE inhibitors, ARBs, or beta-blockers commonly used to achieve targets below 130/80 mmHg
Lifestyle Modifications
- Exercise training and cardiac rehabilitation improve exercise capacity and quality of life 1
- Sodium restriction (<2-3 g/day) and fluid management are important lifestyle modifications
Monitoring and Follow-up
- Regular monitoring of symptoms, fluid status, electrolytes, and renal function is essential for optimizing therapy
- Multidisciplinary HF management programs can help reduce the risk of HF hospitalization and improve survival 1
From the Research
Management of Heart Failure with Preserved Ejection Fraction (HFpEF)
The management of HFpEF is complex and challenging due to the heterogeneity of the syndrome and the lack of persuasive evidence for current pharmacologic interventions that can reduce mortality 2.
- Phenotype-Guided Approach: A phenotype-guided approach to the management of patients with HFpEF has been proposed, which involves identifying the prominent sources of organ dysfunction and treating accordingly 2.
- Treatment of Comorbidities: Current practice guidelines focus on remedying volume overload, aggressively controlling hypertension, and treatment of comorbid conditions that contribute to decompensation 3.
- Lifestyle Therapy: Lifestyle therapy, such as optimization of physical activity and management of comorbidities, is also an essential component of HFpEF management 4.
- Pharmacologic Interventions: While several drugs have been investigated in clinical trials, the majority have reported disappointing results, and treatment options for HFpEF remain limited 5.
- Personalized Therapeutic Approaches: Due to the complexity of HFpEF, personalized therapeutic approaches may be beneficial, taking into account the various comorbidities and distinct phenotypes of individual patients 5.
Key Considerations
- Multimorbidity: Patients with HFpEF often have frequent multimorbidity, functional impairment, frailty, and polypharmacy, which can impact management and treatment outcomes 4.
- Symptom Relief: Treatment options for HFpEF aim primarily for symptom relief and improvement of quality of life, rather than reduction of mortality 5.
- Ongoing Research: Ongoing studies and clinical trials are investigating new pharmacotherapeutic options for HFpEF, which may lead to improved management and treatment outcomes in the future 2, 5.