What is the initial treatment approach for new onset Heart Failure with preserved Ejection Fraction (HFpEF)?

Treatment of New Onset HFpEF

For new onset heart failure with preserved ejection fraction (HFpEF), diuretics are the cornerstone of initial therapy to relieve congestion, with SGLT2 inhibitors (dapagliflozin or empagliflozin) as the first-line disease-modifying therapy to reduce hospitalizations and cardiovascular mortality. 1

Initial Pharmacological Management

First-line Therapies:

1. Loop Diuretics

   • Start with low-dose loop diuretics (e.g., furosemide 20-40 mg daily) to control fluid retention and relieve symptoms 2
   • Adjust dose based on symptoms, volume status, and renal function
   • Target euvolemia (patient's "dry weight") with the lowest effective dose 2
   • Monitor for dehydration, hypotension, and renal dysfunction

2. SGLT2 Inhibitors

   • Initiate dapagliflozin or empagliflozin regardless of diabetes status 2, 1
   • These agents have demonstrated significant reduction in HF hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin) 1
   • Monitor for genital mycotic infections, volume depletion, and diabetic ketoacidosis

Second-line Therapies:

1. Mineralocorticoid Receptor Antagonists (MRAs)

   • Consider spironolactone (starting dose 12.5-25 mg daily) 2
   • Particularly beneficial in patients with LVEF in the lower range of preservation (50-60%) 3
   • Monitor potassium and renal function closely
   • Avoid if serum creatinine >2.5 mg/dL in men or >2.0 mg/dL in women, or potassium >5.0 mEq/L 2

2. ARNIs or ARBs

   • Consider sacubitril/valsartan or candesartan in selected patients 2, 1
   • Sacubitril/valsartan may be particularly beneficial in women and those with LVEF ≤57% 1

Management of Comorbidities

1. Hypertension

   • Aggressive BP control is essential 1
   • ACE inhibitors or ARBs are preferred in hypertensive HFpEF patients 2
   • Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) 1

2. Atrial Fibrillation

   • Control ventricular rate with beta-blockers 2
   • Consider rhythm control strategies, particularly in early persistent AF 4
   • Anticoagulation based on CHA₂DS₂-VASc score

3. Diabetes and Obesity

   • SGLT2 inhibitors provide dual benefit for diabetes and HFpEF 1
   • Weight reduction in overweight/obese patients 1
   • Optimize glycemic control

Non-Pharmacological Interventions

1. Exercise Training

   • Supervised exercise improves exercise capacity and quality of life 1
   • Start with low-intensity exercise and gradually increase as tolerated

2. Dietary Modifications

   • Moderate sodium restriction (2-3g/day) 1
   • Fluid restriction as needed based on symptoms

Monitoring and Follow-up

1. Regular Assessment

   • Monitor symptoms, volume status, renal function, and electrolytes
   • Adjust diuretic dose based on symptoms and weight measurements
   • Many patients can be trained to self-adjust diuretic doses 2

2. Echocardiographic Follow-up

   • Repeat echocardiography with significant changes in clinical status 2

Common Pitfalls to Avoid

1. Overdiuresis

   • Excessive diuresis can lead to hypotension and renal dysfunction 2
   • May prevent use of disease-modifying therapies

2. Inappropriate Medication Use

   • Beta-blockers have not shown mortality benefit in HFpEF and should be used only for specific indications (prior MI, angina, AF) 1
   • Non-dihydropyridine calcium channel blockers should be used cautiously due to negative inotropic effects 1

3. Neglecting Comorbidities

   • Failure to address hypertension, diabetes, obesity, and sleep apnea can worsen HFpEF outcomes 2

By following this algorithm-based approach to new onset HFpEF, clinicians can effectively manage symptoms, improve quality of life, and potentially reduce hospitalizations and mortality in this challenging patient population.