What is the recommended treatment for managing hypertension in patients with Heart Failure with preserved Ejection Fraction (HFpEF)?

Hypertension Management in Heart Failure with Preserved Ejection Fraction (HFpEF)

For patients with HFpEF and hypertension, first-line treatment should include diuretics for volume overload, followed by ACE inhibitors or ARBs and beta blockers titrated to achieve a systolic blood pressure target of less than 130 mmHg. 1

Initial Management Algorithm

1. Address Volume Overload

   • Diuretics are the first-line therapy for patients presenting with symptoms of volume overload 1
   • Thiazide or thiazide-like diuretics are useful for BP control and mild volume overload 1
   • Loop diuretics (e.g., furosemide, torsemide) should be used for more significant congestion 2

2. After Volume Management

   • Add ACE inhibitors or ARBs and beta blockers 1
   • Titrate to achieve SBP <130 mmHg (<140 mmHg in elderly patients) 1

Medication Selection and Considerations

First-Line Medications

• Diuretics: Essential for symptom control and volume management 1, 2
• ACE inhibitors/ARBs: Backbone of BP-lowering therapy in hypertensive patients with HFpEF 3
• Beta blockers: Important for BP control and symptom management 1

Additional Options

• Mineralocorticoid receptor antagonists (MRAs): Consider spironolactone for resistant hypertension 3
• SGLT2 inhibitors: Dapagliflozin or empagliflozin reduced HF hospitalization by approximately 20% compared to placebo 2

Medications to Avoid

• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem): Can worsen heart failure 1
• Alpha-adrenergic blockers (e.g., doxazosin): Should be avoided unless other medications are inadequate 1
• Direct vasodilators (e.g., minoxidil): Avoid due to salt and fluid retention effects 1
• NSAIDs: Use with caution due to effects on BP, volume status, and renal function 1

Blood Pressure Targets

• Target BP: <130/80 mmHg (<140/80 mmHg in elderly patients) 1
• Caution: Avoid excessive BP reduction (<120/70 mmHg) which may compromise cardiac output 1

Comprehensive Management

Lifestyle Modifications

• Sodium restriction
• Structured exercise program
• Weight reduction in overweight/obese patients
• Heart-healthy diet
• Moderation of alcohol intake 1

Monitoring

• Regular assessment of:
  • Volume status
  • Renal function
  • Electrolytes
  • Symptoms
  • Medication adherence 1

Special Considerations

Comorbidity Management

• Most HFpEF patients have multiple comorbidities including obesity, diabetes, coronary artery disease, and atrial fibrillation 2, 3, 4
• Aggressive management of these conditions is essential for improving outcomes 4

Paradox in Advanced HF

• While hypertension contributes to HF development, in advanced HF, lower BP may paradoxically be associated with worse prognosis 1
• This reflects poor cardiac output rather than a therapeutic target

Evidence Limitations

• Despite the prevalence of HFpEF, specific guideline-directed medical therapy is not as well established as for HFrEF 3
• Recent evidence suggests that treatments effective for HFrEF may also benefit HFpEF patients 4
• SGLT2 inhibitors represent a promising newer therapy with demonstrated benefits 2, 3

Remember that hypertension is present in 60-89% of HFpEF patients and is the most important cause of this condition 1. Proper BP management is crucial for preventing HF progression and reducing hospitalizations and cardiovascular events.