From the Guidelines
The best management of Heart Failure with preserved Ejection Fraction (HFpEF) involves a comprehensive approach targeting symptom relief, comorbidity management, and prevention of hospitalizations, with SGLT2 inhibitors such as empagliflozin or dapagliflozin being recommended to decrease HF hospitalizations and cardiovascular mortality, as stated in the 2022 AHA/ACC/HFSA guideline 1.
Key Components of HFpEF Management
- Treatment should begin with diuretics like furosemide (20-80mg daily) or hydrochlorothiazide (12.5-25mg daily) to manage volume overload and reduce symptoms of congestion.
- SGLT2 inhibitors such as empagliflozin (10mg daily) or dapagliflozin (10mg daily) are recommended as they have shown mortality and hospitalization benefits in HFpEF patients, as supported by the EMPEROR PRESERVED and DELIVER trials 1.
- Blood pressure control is essential, with a target below 130/80 mmHg using ACE inhibitors, ARBs, or ARNIs like sacubitril/valsartan (starting at 24/26mg twice daily and titrating as tolerated).
- Management of comorbidities is crucial, including treating atrial fibrillation with rate control and anticoagulation, addressing coronary artery disease, and managing diabetes.
- Exercise training should be prescribed at moderate intensity for 30 minutes most days of the week, as supervised exercise training has been shown to improve symptoms, exercise capacity, and quality of life in HFpEF patients 1.
- Sodium restriction to less than 2-3g daily and fluid restriction may help manage symptoms.
- Regular monitoring of renal function, electrolytes, and clinical status is necessary to adjust medications.
Additional Considerations
- In selected patients with HFpEF, MRAs, ARBs, or ARNIs may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum, as recommended in the 2022 AHA/ACC/HFSA guideline 1.
- The use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QOL is not recommended, as they have been shown to be ineffective in HFpEF patients 1.
- Device-based solutions, such as wireless pulmonary artery pressure monitoring devices, may be considered to relieve symptoms and improve clinical outcomes in HFpEF patients, 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.