What is the recommended therapy for Heart Failure with preserved Ejection Fraction (HFpEF)?

Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

SGLT2 inhibitors (dapagliflozin or empagliflozin) are recommended as first-line disease-modifying therapy for HFpEF to reduce hospitalizations and cardiovascular mortality, regardless of diabetes status, with diuretics used for symptom relief of congestion. 1

First-Line Therapies

Disease-Modifying Therapy

• SGLT2 inhibitors (dapagliflozin or empagliflozin):
  • First-line disease-modifying therapy based on the most recent guidelines 2, 1
  • Significantly reduce HF hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin)
  • Improve quality of life and exercise capacity (6-minute walk distance)
  • Recommended regardless of diabetes status

Symptomatic Management

• Diuretics (primarily loop diuretics):
  • Start with low-dose loop diuretics (e.g., furosemide 20-40 mg daily) 1
  • Goal: Achieve euvolemia with lowest effective dose
  • Monitor for excessive diuresis which can lead to hypotension and renal dysfunction
  • For refractory cases: Consider adding thiazide diuretics, particularly in hypertensive patients 2

Second-Line Therapies

For Selected Patients

• Mineralocorticoid Receptor Antagonists (MRAs):

  • Consider spironolactone in patients with LVEF 50-60% 1
  • Monitoring requirements:
    • Potassium levels <5.0 mEq/L
    • Creatinine <2.5 mg/dL in men or <2.0 mg/dL in women (or eGFR >30 mL/min) 2
    • Regular monitoring of renal function and electrolytes

• ARBs:

  • May be considered to decrease hospitalizations 2
  • Candesartan showed borderline benefit in the CHARM-Preserved trial (HR: 0.86) 1

• Sacubitril/Valsartan:

  • May benefit specific subgroups: women and those with LVEF ≤57% 1

Management of Comorbidities

Hypertension Management

• Blood Pressure Control:
  • Aggressive BP control is essential 1
  • ACE inhibitors or ARBs preferred in hypertensive HFpEF patients
  • Target BP according to current hypertension guidelines

Other Key Comorbidities

• Obesity:

  • Weight reduction in overweight/obese patients 1, 3
  • Diet-induced weight loss improves functional capacity and quality of life 3

• Diabetes:

  • Optimize glycemic control 1

• Sleep Apnea:

  • Screen and treat appropriately 2, 1

Lifestyle Modifications

• Exercise Training:

  • Supervised exercise training improves exercise capacity and quality of life 1, 3
  • Class I recommendation (Level of Evidence A) 1

• Dietary Modifications:

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

Monitoring and Follow-up

• Regular assessment of:
  • Symptoms and volume status
  • Renal function and electrolytes
  • Weight measurements to guide diuretic adjustments
  • Repeat echocardiography with significant changes in clinical status 1

Treatments to Avoid

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to myocardial depressant effects 1
• Routine use of nitrates or phosphodiesterase-5 inhibitors is ineffective for improving activity or quality of life 2

Important Considerations

• HFpEF affects approximately 3 million people in the US and has an annual mortality rate of approximately 15% 3
• Patients with HFpEF are exquisitely sensitive to changes in preload and afterload, which is particularly important in perioperative settings 4
• The condition is progressive due to complex mechanisms of systemic and cardiac adaptation that vary over time 5

By following this evidence-based approach to HFpEF management, focusing on disease-modifying therapy with SGLT2 inhibitors, symptom management with diuretics, and addressing comorbidities, clinicians can improve outcomes for patients with this challenging condition.