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

Acute Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

Diuretics are the cornerstone of initial management for acute HFpEF to relieve symptoms of volume overload and should be administered promptly, with loop diuretics being the preferred agents. 1

Initial Assessment and Management

Volume Management

• Loop diuretics (first-line therapy):

  • Start with intravenous administration of two times the oral home dose 2
  • Furosemide: Initial dose 20-40 mg IV, usual daily dose 40-240 mg
  • Bumetanide: Initial dose 0.5-1.0 mg IV, usual daily dose 1-5 mg
  • Torasemide: Initial dose 5-10 mg IV, usual daily dose 10-20 mg 3

• Early response assessment:

  • Measure spot urinary sodium after 2 hours
  • Assess urine output after 6 hours
  • Adjust diuretic strategy based on these measurements 2

Blood Pressure Control

• Target systolic BP <130 mmHg for patients with hypertension 1
• Preferred agents:
  • ACE inhibitors or ARBs for hypertensive HFpEF patients 1
  • Avoid non-dihydropyridine calcium channel blockers (except verapamil in select cases) 3

Management of Common Comorbidities

Atrial Fibrillation

• Implement appropriate rate or rhythm control strategy 1
• If using rate control, target heart rate 60-100 bpm at rest
• Avoid combining verapamil or diltiazem with beta-blockers 1

Coronary Artery Disease

• Consider coronary angiography in patients with:
  • High risk for CAD without contraindications
  • Significant valvular disease
  • Anginal symptoms despite optimal medical therapy 3
• Coronary revascularization is reasonable in patients with CAD where symptoms or demonstrable ischemia adversely affect HFpEF 3

Valvular Heart Disease

• Evaluate for significant valvular disease that may contribute to HF symptoms
• Consider surgical intervention if appropriate 3

Pharmacological Therapy Beyond Diuretics

SGLT2 Inhibitors

• Initiate empagliflozin or dapagliflozin early in the course of treatment
• These reduce HF hospitalizations by approximately 20-30% compared to placebo
• Beneficial regardless of diabetes status 1, 4

Mineralocorticoid Receptor Antagonists (MRAs)

• Consider in patients with LVEF in the lower preservation range (50-60%)
• Initial dose: Spironolactone/eplerenone 12.5-25 mg daily
• Monitor potassium and renal function closely 1

Monitoring and Follow-up

• Frequent assessment of:

  • Volume status (daily weights, JVP, peripheral edema)
  • Renal function and electrolytes (1-2 weeks after initiation or dose changes of RAAS inhibitors)
  • Symptoms and vital signs 1

• Medication adjustments:

  • Titrate diuretics to achieve euvolemia with lowest effective dose
  • Adjust other medications based on blood pressure, heart rate, and renal function

Important Cautions

• Avoid medications known to worsen HF:

  • NSAIDs (can cause sodium retention and worsen renal function)
  • Most antiarrhythmic drugs
  • Most calcium channel blockers (except amlodipine) 3, 1

• Avoid routine use of:

  • Nitrates or phosphodiesterase-5 inhibitors (Class III: No Benefit) 1
  • Combining ARB with ACE inhibitors and beta-blockers 1
  • Long-term use of infused positive inotropic drugs 3

The management of acute HFpEF requires prompt recognition and treatment of volume overload, careful attention to comorbidities, and judicious use of evidence-based therapies. While the evidence base for HFpEF treatment is less robust than for HFrEF, diuretics remain the mainstay of acute management, with SGLT2 inhibitors emerging as important disease-modifying agents.