From the Guidelines
The best management of Heart Failure with preserved Ejection Fraction (HFpEF) focuses on symptom relief, treating underlying conditions, and improving quality of life, with SGLT2 inhibitors such as empagliflozin or dapagliflozin being beneficial in decreasing HF hospitalizations and cardiovascular mortality, as recommended by the 2022 AHA/ACC/HFSA guideline 1.
Key Components of HFpEF Management
- Lifestyle modifications: sodium restriction (<2-3g/day), regular physical activity, and weight management
- Diuretics: loop diuretics like furosemide (20-80mg daily) or torsemide (10-40mg daily) for congestion relief
- Blood pressure control: ACE inhibitors (e.g., lisinopril 10-40mg daily), ARBs (e.g., valsartan 80-320mg daily), or calcium channel blockers
- SGLT2 inhibitors: empagliflozin (10mg daily) or dapagliflozin (10mg daily) for reducing hospitalizations and cardiovascular death
- Management of comorbidities: coronary artery disease, diabetes, sleep apnea, and atrial fibrillation
Additional Therapies
- Beta-blockers for rate control in atrial fibrillation
- Mineralocorticoid receptor antagonists like spironolactone (25mg daily) for patients with elevated BNP and recent hospitalization
- Anticoagulation for those with atrial fibrillation
Regular Monitoring
- Symptoms, fluid status, electrolytes, and renal function
- Medication adjustments as needed The 2024 ESC guidelines for the management of chronic coronary syndromes also recommend SGLT2 inhibitors for patients with HFpEF to reduce the risk of HF hospitalization or cardiovascular death 1. Supervised exercise training has been shown to improve symptoms, exercise capacity, and quality of life in patients with HFpEF, as stated in the 2023 scientific statement from the American Heart Association and American College of Cardiology 1.
From the Research
Management of Heart Failure with Preserved Ejection Fraction (HFpEF)
The management of HFpEF is challenging due to its complex clinical syndrome and lack of effective pharmacological targets to improve outcomes 2, 3, 4, 5, 6.
- The emphasis of the management and prevention of HFpEF should be through control of risk factors, such as hypertension, diabetes, and obesity 2.
- Application of the 7 simple measures ("Life's Simple 7") proposed by the American Heart Association, which includes diet and lifestyle changes, can help control the most common comorbidities and risk factors associated with HFpEF 2.
- Treatment targets symptom relief, quality of life, and reduction of cardiac decompensations by controlling fluid retention and managing risk factors and comorbidities 3, 4, 6.
- Current management strategies include:
- Diuretics to reduce fluid retention
- Renin-angiotensin-aldosterone inhibitors, calcium channel blockers, and beta-blockers to manage hypertension and other comorbidities
- Diet and exercise recommendations to promote a healthy lifestyle
- Management of comorbidities, such as hypertension, myocardial ischemia, and atrial fibrillation 3, 5, 6
- Novel approaches, such as soluble guanylate cyclase stimulators, inorganic nitrates, and SGLT2 inhibitors, are being investigated and may offer new hopes for patients suffering from HFpEF 3, 4.
Pharmacologic Management
Pharmacologic management of HFpEF has been largely understudied, and most of the current evidence centers on morbidity benefits and symptom reduction 5.
- Antihypertensive treatment, including ACE inhibitors, ARBs, beta-blockers, and calcium-channel blockers, is recommended to control hypertension, although these agents have not demonstrated significant benefit beyond blood pressure control 5.
- Further research into the pathophysiology of HFpEF may contribute to identifying the most optimal agent in managing this disease 5.
Future Directions
Future outcome trials testing the efficacy of promising new agents will have better characterization of patient phenotype to maximize the potential response to therapies 6.
- Improved phenotyping of subgroups within the overall HFpEF population might enhance individualization of treatment 4.
- Novel therapies, such as anti-inflammatory drugs, mitochondrial-targeted antioxidants, and microRNA-guided interventions, are under investigation and may offer new treatment options for HFpEF 3, 4.