What is the initial management strategy for patients with Heart Failure with preserved Ejection Fraction (HEpEF)?

Initial Management Strategy for Heart Failure with Preserved Ejection Fraction (HFpEF)

The initial management of HFpEF should focus on SGLT2 inhibitors as first-line disease-modifying therapy, along with diuretics for symptom control, management of comorbidities, and implementation of exercise training. 1

Diagnostic Confirmation

Before initiating treatment, confirm HFpEF diagnosis with:

• Transthoracic echocardiography showing:
  • LVEF ≥50%
  • Evidence of diastolic dysfunction (E/e' ≥15, septal e' <7 cm/s in females or <10 cm/s in males)
  • Left atrial enlargement (volume index ≥40 mL/m²)
• Elevated natriuretic peptides:
  • BNP ≥35 pg/mL (sinus rhythm) or ≥50 pg/mL (atrial fibrillation)
  • NT-proBNP ≥125 ng/L (sinus rhythm) or ≥365 ng/L (atrial fibrillation)
• Rule out HFpEF mimics such as:
  • Cardiac amyloidosis
  • Hypertrophic cardiomyopathy
  • Pericardial disease
  • Valvular heart disease

Pharmacological Management

First-Line Therapy

1. SGLT2 Inhibitors:

   • Dapagliflozin 10 mg daily or Empagliflozin 10 mg daily
   • These reduced HF hospitalization by approximately 20% in clinical trials 1, 2
   • Shown to reduce the composite of worsening HF and CV death (HR: 0.82 for dapagliflozin, HR: 0.79 for empagliflozin) 1

2. Diuretics:

   • Loop diuretics (e.g., furosemide) for congestion and symptom relief
   • Use judiciously and titrate to achieve euvolemia
   • Consider thiazides as adjunct therapy in hypertensive patients or those with refractory edema 1

Additional Pharmacological Options

1. Mineralocorticoid Receptor Antagonists (MRAs):

   • Spironolactone (starting at 12.5-25 mg daily)
   • Consider in patients who remain symptomatic despite first-line therapy 1
   • TOPCAT trial showed reduction in HF hospitalization (HR: 0.83) 1

2. ARNI/ARB:

   • Sacubitril/valsartan or candesartan
   • Consider in patients who remain symptomatic despite first-line therapy 1
   • Modest benefit in reducing HF hospitalizations 1

Management of Comorbidities

1. Hypertension:

   • Target BP <130/80 mmHg in high cardiovascular risk patients 1
   • Optimize antihypertensive therapy

2. Diabetes:

   • Prioritize SGLT2 inhibitors for patients with T2DM
   • Consider finerenone in patients with T2DM and CKD 1

3. Obesity:

   • Implement weight loss strategies for patients with BMI >30 kg/m²
   • Diet-induced weight loss has shown meaningful increases in functional capacity 2

4. Atrial Fibrillation:

   • Rate control with beta-blockers if indicated
   • Anticoagulation based on CHA₂DS₂-VASc score
   • Note: Beta-blockers should be used cautiously in HFpEF and monitored for potential chronotropic incompetence 1

5. Sleep Apnea:

   • Screen and treat obstructive sleep apnea

Non-Pharmacological Management

1. Exercise Training:

   • Supervised exercise training programs show substantial improvements in exercise capacity and quality of life 1
   • Recommend 30-40 minutes of moderate-intensity aerobic exercise 3-5 times weekly
   • Consider formal cardiac rehabilitation referral 1

2. Dietary Sodium Restriction:

   • Moderate sodium restriction to reduce congestive symptoms 1
   • Consider dietitian referral for personalized guidance

3. Self-Care Education:

   • Educate on medication adherence, symptom monitoring, and dietary restrictions
   • Daily weight monitoring and recognition of worsening symptoms 2

Monitoring and Follow-up

• Regular assessment of symptoms, volume status, and medication tolerance
• Consider cardiopulmonary exercise testing to quantify functional capacity in unclear cases 1
• Monitor renal function and electrolytes, particularly when using diuretics, SGLT2 inhibitors, or MRAs

Common Pitfalls to Avoid

1. Overdiuresis: Patients with HFpEF are preload-dependent and sensitive to volume depletion, which can lead to hypotension and worsening renal function.

2. Inappropriate beta-blocker use: Unlike in HFrEF, beta-blockers have not shown mortality benefit in HFpEF and may worsen exercise intolerance due to chronotropic incompetence. Use only for specific indications (e.g., CAD, atrial fibrillation) 1.

3. Failure to address comorbidities: HFpEF is often driven by multiple comorbidities, and failure to address these can limit treatment effectiveness.

4. Misdiagnosis: Ensure proper diagnosis and rule out HFpEF mimics that require specific treatments (e.g., amyloidosis, constrictive pericarditis) 1.

By implementing this comprehensive management approach with emphasis on SGLT2 inhibitors, symptom management with diuretics, comorbidity control, and exercise training, clinicians can effectively manage patients with HFpEF and improve their quality of life and outcomes.