What is the first line treatment for Heart Failure with preserved Ejection Fraction (HFpEF)?

First-Line Treatment for HFpEF

Diuretics should be prescribed as first-line therapy for patients with HFpEF who present with symptoms of volume overload, followed by ACE inhibitors or ARBs and beta blockers titrated to attain SBP of less than 130 mm Hg. 1

Initial Management Algorithm

1. Control Volume Status

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

2. Blood Pressure Control

   • After managing volume overload, prescribe ACE inhibitors or ARBs and beta blockers to attain SBP < 130 mm Hg 1
   • Hypertension is the most important cause of HFpEF, with a prevalence of 60-89% 1
   • Aggressive BP control is essential, with ACE inhibitors or ARBs being preferred in hypertensive HFpEF patients 2

3. Add Disease-Modifying Therapy

   • Consider SGLT2 inhibitors (dapagliflozin or empagliflozin) which have shown to reduce HF hospitalizations and improve quality of life 2, 3
   • Consider spironolactone (starting dose 12.5-25 mg daily) for patients with LVEF in the lower range of preservation (50-60%) 2

Evidence for Diuretics as First-Line Therapy

The 2017 ACC/AHA guideline clearly states that "adults with HFpEF who present with symptoms of volume overload, diuretics should be prescribed to control hypertension" with a Class I recommendation level 1. This recommendation is based on the understanding that:

• Approximately 65% of patients with HFpEF present with dyspnea and evidence of HF with overt congestion (volume overload) at rest 3
• Diuretics effectively reduce volume overload and improve symptoms in HFpEF 4
• Loop diuretics (e.g., furosemide, torsemide) are typically used for symptom relief 3

Blood Pressure Management After Volume Control

After managing volume overload, the ACC/AHA guideline recommends that "adults with HFpEF and persistent hypertension after management of volume overload should be prescribed ACE inhibitors or ARBs and beta blockers titrated to attain SBP of less than 130 mm Hg" 1. This is crucial because:

• Hypertension is the most important cause of HFpEF, with a prevalence of 60-89% 1
• BP control is important for prevention of HFpEF in patients with hypertension 1
• Patients with HFpEF have an exaggerated hypertensive response to exercise 1

Important Considerations and Pitfalls

1. Avoid Non-dihydropyridine CCBs

   • Verapamil and diltiazem have myocardial depressant activity and should be avoided in HFpEF 1, 2

2. Monitor Renal Function and Electrolytes

   • Excessive diuresis can lead to hypotension and renal dysfunction 2
   • When using spironolactone, monitor potassium and renal function closely 2
   • Avoid MRAs if serum creatinine >2.5 mg/dL in men or >2.0 mg/dL in women, or potassium >5.0 mEq/L 2

3. Address Comorbidities

   • Manage comorbidities such as diabetes, obesity, and sleep apnea 2
   • Consider weight reduction in overweight/obese patients 2, 5
   • Optimize glycemic control in diabetic patients 2

4. Lifestyle Modifications

   • Recommend supervised exercise training to improve exercise capacity and quality of life 2
   • Advise moderate sodium restriction (2-3g/day) 2
   • Implement fluid restriction as needed based on symptoms 2

By following this algorithm, clinicians can effectively manage HFpEF, starting with diuretics for volume control and then addressing blood pressure with ACE inhibitors or ARBs and beta blockers, while considering newer disease-modifying therapies like SGLT2 inhibitors when appropriate.