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 recommended for most patients to reduce HF hospitalizations and cardiovascular mortality, as supported by the 2022 AHA/ACC/HFSA guideline 1.
Key Management Strategies
- Aggressive management of comorbidities including hypertension, diabetes, obesity, and coronary artery disease
- Diuretics, particularly loop diuretics like furosemide (20-80mg daily) or torsemide (10-20mg daily), for symptom relief of fluid overload
- SGLT2 inhibitors such as empagliflozin (10mg daily) or dapagliflozin (10mg daily) for mortality benefit
- ACE inhibitors (like lisinopril 10-40mg daily) or ARBs (such as losartan 25-100mg daily) for patients with elevated blood pressure
- Spironolactone (25mg daily) may benefit selected patients, particularly those with ejection fraction in the 40-50% range
- Beta-blockers for rate control in patients with atrial fibrillation
- Lifestyle modifications including sodium restriction (<2-3g daily), regular physical activity, and weight loss for obese patients
- Cardiac rehabilitation programs to improve exercise capacity and quality of life, as highlighted in the 2023 American Heart Association/American College of Cardiology scientific statement 1
Additional Considerations
- Supervised exercise training has been shown to improve symptoms, exercise capacity, and quality of life in patients with HFpEF, with benefits comparable to or larger than those seen in patients with heart failure with reduced ejection fraction 1
- Device-based solutions, such as wireless pulmonary artery pressure monitoring devices, may also be effective in reducing hospitalizations and improving outcomes in patients with HFpEF 1
- The 2024 ESC guidelines for the management of chronic coronary syndromes recommend the use of SGLT2 inhibitors in patients with HFpEF to reduce the risk of HF hospitalization or cardiovascular death 1
From the Research
Management of Heart Failure with Preserved Ejection Fraction (HFpEF)
The management of HFpEF is a complex clinical syndrome that constitutes nearly half of all heart failure cases. The emphasis of the management and prevention of HFpEF should be through control of risk factors, as there are no effective pharmacological targets to improve outcomes 2.
Current Management Approaches
Current management approaches for HFpEF include:
- Symptomatic relief of congestion with diuretics 3, 4
- Risk factor modification, such as controlling hypertension, diabetes, and obesity 2, 5
- Promotion of a healthy active lifestyle, including diet and exercise recommendations 2, 5, 4
- Management of comorbidities, such as atrial fibrillation and coronary artery disease 6
Pharmacological Therapies
Pharmacological therapies for HFpEF include:
- Diuretics to control fluid retention 5, 3, 4
- Renin-angiotensin-aldosterone inhibitors, such as sacubitrilvalsartan 6
- Empagliflozin, which has shown promising results in reducing heart failure hospitalizations 6
- Dapagliflozin, which has also shown promising results in the management of HFpEF 6
Future Directions
Future directions for the management of HFpEF include:
- Identification of new treatment targets, such as soluble guanylate cyclase stimulators and angiotensin receptor neprilysin inhibitors 5
- Development of new disease-modifying strategies, including anti-inflammatory drugs and mitochondrial-targeted antioxidants 5
- Improved phenotyping of subgroups within the overall HFpEF population to enhance individualization of treatment 4