What are the management strategies for Heart Failure with preserved Ejection Fraction (HFpEF)?

Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

SGLT2 inhibitors should be the cornerstone of disease-modifying therapy for HFpEF patients, alongside diuretics for symptom management and comprehensive treatment of underlying comorbidities. 1

Diagnostic Considerations

Before initiating treatment, it's important to confirm the diagnosis of HFpEF and rule out mimics:

• HFpEF is defined by:

  • Clinical symptoms and signs of heart failure
  • LVEF ≥50%
  • Evidence of diastolic dysfunction
  • Elevated natriuretic peptides

• Common HFpEF mimics to exclude 1:

  • Cardiac amyloidosis
  • Hypertrophic cardiomyopathy
  • Cardiac sarcoidosis
  • Hemochromatosis
  • Fabry disease
  • High-output heart failure
  • Myocarditis
  • Pericardial disease

Management Algorithm

Step 1: Symptom Management

• Diuretics: First-line therapy for congestion
  • Loop diuretics (furosemide) at lowest effective dose
  • Titrate based on symptoms and volume status
  • For refractory cases, consider adding thiazide diuretics 1
  • Monitor for electrolyte abnormalities and renal dysfunction

Step 2: Disease-Modifying Therapy

1. SGLT2 inhibitors (First priority)

   • Dapagliflozin or empagliflozin
   • Demonstrated reduction in HF hospitalizations and composite endpoints in DELIVER and EMPEROR-PRESERVED trials 1
   • Benefits persist across the spectrum of preserved ejection fraction
   • Monitor for genital mycotic infections and volume depletion

2. Mineralocorticoid Receptor Antagonists (MRAs)

   • Spironolactone showed benefit in the North American cohort of TOPCAT trial 1
   • Monitor potassium and renal function
   • Particularly useful in patients with hypertension

3. ARNI/ARB consideration

   • Sacubitril/valsartan or valsartan may be considered in selected patients
   • Modest reduction in HF hospitalizations in PARAGON-HF trial 1
   • More beneficial in women and those with LVEF at the lower end of the preserved range

Step 3: Comorbidity Management

HFpEF is strongly associated with multiple comorbidities that drive its pathophysiology and must be aggressively treated:

• Hypertension: Target BP <130/80 mmHg
• Diabetes: Optimize glycemic control (preferably with SGLT2 inhibitors)
• Obesity: Weight loss interventions and exercise programs
• Atrial Fibrillation: Rate/rhythm control and anticoagulation
• Coronary Artery Disease: Appropriate anti-ischemic therapy
• Chronic Kidney Disease: Nephrology co-management
• Obstructive Sleep Apnea: CPAP therapy when indicated

Step 4: Non-Pharmacological Interventions

• Exercise Training: Structured cardiac rehabilitation programs
• Dietary Sodium Restriction: Limit to <2-3g/day
• Fluid Restriction: Consider in hyponatremic patients
• Multidisciplinary Team Approach: Involving cardiology, primary care, and other specialists as needed 1

Special Considerations

Acute Decompensated HFpEF

• Intravenous loop diuretics as first-line therapy
• For refractory cases, consider sequential nephron blockade with thiazide-like diuretics
• Monitor for electrolyte abnormalities and renal dysfunction
• Non-invasive ventilation for respiratory distress 1

Advanced HFpEF

• Consider referral to advanced heart failure specialists
• Cardiac transplantation may be considered in eligible patients with advanced disease 1

Monitoring and Follow-up

• Regular assessment of volume status and symptoms
• Monitoring of renal function and electrolytes
• Titration of medications based on clinical response
• Patient education on self-management strategies

Pitfalls and Caveats

• Avoid excessive diuresis which may lead to hypotension and renal dysfunction
• Beta-blockers should only be used for specific indications (prior MI, angina, AF) as they may worsen exercise intolerance due to chronotropic incompetence 1
• Recognize that HFpEF is heterogeneous, and treatment response may vary
• Non-cardiac causes of symptoms (e.g., lung disease, anemia) may coexist and require specific management

By following this structured approach to HFpEF management with emphasis on SGLT2 inhibitors as disease-modifying therapy, diuretics for symptom control, and comprehensive management of comorbidities, clinicians can improve outcomes in this challenging patient population.