What medications are used to manage Heart Failure with preserved Ejection Fraction (HFpEF)?

From the Guidelines

The primary approach to managing Heart Failure with preserved Ejection Fraction (HFpEF) involves using SGLT2 inhibitors, such as empagliflozin or dapagliflozin, to improve outcomes, alongside blood pressure control with agents like ARBs and/or MRAs, as recommended by the 2024 ESC guidelines for patients with symptomatic HFpEF and hypertension 1.

Key Medications for HFpEF Management

• SGLT2 inhibitors: empagliflozin (10mg daily) or dapagliflozin (10mg daily) are recommended for their benefits in reducing hospitalizations and improving outcomes in patients with symptomatic HFpEF, especially those with hypertension 1.
• ARBs and/or MRAs: may be considered for patients with symptomatic HFpEF who have blood pressure above target, to reduce heart failure hospitalizations and lower blood pressure 1.
• Diuretics: while not specifically mentioned in the guidelines for HFpEF, diuretics like loop diuretics (e.g., furosemide, torsemide) are commonly used to manage fluid overload and relieve symptoms of congestion.
• ACE inhibitors or ARNi: although primarily recommended for HFrEF, these may be used in HFpEF patients for blood pressure control, considering the lack of specific superiority of any drug in HFpEF management 1.
• Beta-blockers: may be used to control heart rate and blood pressure, though their role in HFpEF is less defined compared to HFrEF.
• Mineralocorticoid receptor antagonists: like spironolactone, can be beneficial in selected patients, particularly those with resistant hypertension or significant fluid overload.

Considerations in HFpEF Management

• Comorbidities: addressing conditions such as atrial fibrillation, diabetes, and obesity is crucial, as they significantly impact the progression of HFpEF.
• Blood Pressure Control: essential for reducing the risk of further cardiac damage and improving outcomes in HFpEF patients.
• Symptom Relief: the primary goal in managing HFpEF, as no medication has definitively shown to reduce mortality in these patients.

From the Research

Medications for Heart Failure with Preserved Ejection Fraction (HFpEF)

The management of HFpEF involves a variety of medications tailored to the individual patient's needs and comorbidities. Some key points to consider include:

• The use of mineralocorticoid receptor antagonists (MRAs) has been shown to improve cardiac function in patients with HFpEF, by decreasing left ventricular filling pressure and promoting reverse cardiac remodeling 2.
• Beta-blockers, although not typically recommended for HFpEF, are commonly used for comorbidity management and may not adversely affect clinical outcomes in these patients 3.
• SGLT2 inhibitors, such as empagliflozin, have been found to reduce the risk of hospitalization for heart failure and may also allow for reduction in diuretic dose in outpatient HF patients, including those with HFpEF 4.
• Diuretics, like furosemide, are often used in the management of HFpEF, particularly for patients with lung congestion or other symptoms of volume overload 5, 6.

Specific Medication Classes

Some specific medication classes used in HFpEF management include:

• Diuretics: to reduce fluid overload and alleviate symptoms such as edema and dyspnea
• MRAs: to reduce left ventricular filling pressure and promote reverse cardiac remodeling
• Beta-blockers: for comorbidity management, such as hypertension or coronary artery disease
• SGLT2 inhibitors: to reduce the risk of hospitalization for heart failure and potentially allow for diuretic dose reduction

Considerations for Medication Use

When selecting medications for HFpEF, considerations should include:

• The patient's individual comorbidities and symptoms
• The potential benefits and risks of each medication class
• The need for ongoing monitoring and adjustment of medications to optimize patient outcomes 5, 2, 3, 4