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

Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

SGLT2 inhibitors (dapagliflozin or empagliflozin) are the first-line disease-modifying therapy for HFpEF patients, with diuretics used for symptom relief of congestion. 1

Diagnosis and Assessment

• Diagnostic criteria for HFpEF:

  • Symptoms and/or signs of heart failure
  • LVEF ≥ 50%
  • Objective evidence of cardiac dysfunction through:
    • Elevated natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL in ambulatory setting)
    • Objective evidence of cardiogenic pulmonary/systemic congestion 2

• Key diagnostic tests:

  • Transthoracic echocardiography with LV diastolic function assessment
  • Natriuretic peptide levels
  • Consider cardiopulmonary exercise testing for uncertain dyspnea 2

Pharmacological Management

1. Disease-Modifying Therapies:

   • SGLT2 inhibitors (dapagliflozin or empagliflozin): First-line therapy regardless of diabetes status
     • Significantly reduce HF hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin)
     • Improve quality of life and exercise capacity 1

2. Symptom Management:

   • Loop diuretics: Cornerstone for managing volume overload
     • Titrate to achieve euvolemia with lowest effective dose
     • Long-acting azosemide preferred over furosemide when available 1
   • For refractory cases, consider adding thiazide diuretics 1

3. Blood Pressure Management:

   • ACE inhibitors or ARBs preferred in hypertensive HFpEF patients
   • Target SBP <130 mmHg 1
   • Tight control of hypertension is strongly recommended by multiple guidelines 2

4. Additional Therapies to Consider:

   • Mineralocorticoid Receptor Antagonists (MRAs): Consider in patients with LVEF 50-60%
     • Requires careful monitoring of potassium and renal function 1
   • Sacubitril/valsartan: May benefit women and those with LVEF ≤57% 1
   • Candesartan: Showed borderline benefit in CHARM-Preserved trial (HR: 0.86) 1

5. Medications to Avoid:

   • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
   • Routine use of nitrates or phosphodiesterase-5 inhibitors 1
   • NSAIDs, especially in patients with CKD 1

Management of Comorbidities

1. Diabetes Management:

   • SGLT2 inhibitors recommended for T2DM with high CVD risk 2
   • Finerenone recommended for T2DM with concomitant CKD 2

2. Atrial Fibrillation:

   • Consider rhythm control strategy, especially in paroxysmal or early persistent AF 3
   • Appropriate anticoagulation based on thromboembolic risk

3. Chronic Kidney Disease:

   • Careful monitoring of renal function and electrolytes with RAAS inhibitors
   • Check potassium and renal function 1-2 weeks after initiation or dose changes 1
   • Loop diuretics preferred over thiazides for CKD stage 3b (eGFR 30-44 mL/min/1.73m²) 1

4. Obesity:

   • Weight reduction is crucial for improving outcomes
   • Consider GLP-1 Receptor Agonists (e.g., semaglutide 2.4mg weekly) for patients with BMI ≥30 1

Lifestyle Modifications

1. Exercise:

   • Supervised exercise training strongly recommended (Class I, Level of Evidence A)
   • Improves exercise capacity and quality of life 1

2. Dietary Modifications:

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

3. Sleep Apnea:

   • Screen and treat appropriately 1

Monitoring and Follow-up

• Regular assessment of symptoms, volume status, renal function, and electrolytes
• Adjust diuretic doses based on symptoms and weight measurements
• Repeat echocardiography with significant changes in clinical status 1
• Monitor for excessive diuresis which can lead to hypotension and renal dysfunction 1

Pitfalls and Caveats

• HFpEF is a heterogeneous syndrome with varying pathophysiologic mechanisms
• Avoid excessive diuresis which may prevent use of disease-modifying therapies
• Be cautious with MRAs in patients with CKD due to hyperkalemia risk
• Consider phenotype-guided approach for personalized management 4
• Recognize that HFpEF often coexists with multiple comorbidities that require simultaneous management

The management of HFpEF has evolved significantly with recent evidence supporting the use of SGLT2 inhibitors as disease-modifying therapy while maintaining diuretics as the cornerstone for symptom management. A comprehensive approach addressing both cardiac dysfunction and comorbidities is essential for improving outcomes in this challenging patient population.