What is the management plan for acute on chronic heart failure with preserved ejection fraction (CHFpEF)?

Management of Acute on Chronic Heart Failure with Preserved Ejection Fraction (CHFpEF)

Diuretics are the first-line therapy for acute decompensated CHFpEF to achieve euvolemia, with SGLT2 inhibitors being the recommended disease-modifying therapy to reduce hospitalizations and improve outcomes. 1

Initial Management of Acute Decompensation

Immediate Assessment and Treatment

• Volume Management:

  • Administer IV loop diuretics as the cornerstone of treatment (at least equivalent to oral dose if on chronic therapy) 2
  • Diuretics can be given as intermittent boluses or continuous infusion based on clinical response 2
  • Aim for the lowest effective dose to achieve euvolemia 1

• Hemodynamic Monitoring:

  • Monitor symptoms, volume status, renal function, and electrolytes every 1-2 days during hospitalization 2
  • Consider bedside thoracic ultrasound to assess for interstitial edema 2

• Laboratory Assessment:

  • Measure natriuretic peptides (BNP, NT-proBNP) to confirm diagnosis and assess severity 2
  • Monitor creatinine, BUN, and electrolytes regularly during hospitalization 2
  • Consider pre-discharge natriuretic peptide measurement for prognostic evaluation 2

Important Cautions

• Avoid inotropic agents unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns 2
• Avoid nephrotoxic medications such as NSAIDs that can worsen renal function 1
• Evaluate for mechanical complications or acute valvular regurgitation with early echocardiography (preferably within 48 hours) 2

Chronic Management After Stabilization

Evidence-Based Pharmacologic Therapy

1. SGLT2 Inhibitors (empagliflozin or dapagliflozin):

   • First-line disease-modifying therapy regardless of diabetes status
   • Significantly reduce heart failure hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin) 1
   • Improve quality of life and exercise capacity 1

2. Diuretics:

   • Titrate to maintain euvolemia and relieve congestion
   • Adjust based on symptoms and daily weight measurements 1

3. Consider in Selected Patients:

   • MRAs (spironolactone): May decrease hospitalizations in patients with LVEF 50-60% 1
   • Sacubitril/valsartan: Potentially beneficial in women and those with LVEF ≤57% 1
   • ARBs (candesartan): Consider for patients with hypertension and HFpEF 1

Management of Comorbidities

• Hypertension: Tight control with target systolic BP <130 mmHg, preferably using ACE inhibitors or ARBs 1
• Atrial Fibrillation: Rate control or rhythm control as appropriate 1
• Diabetes: Optimize glycemic control, preferably with SGLT2 inhibitors 1
• Obesity: Weight reduction program for BMI ≥30; consider GLP-1 receptor agonists (semaglutide 2.4mg weekly) 1
• Sleep Apnea: Screening and appropriate treatment 1

Lifestyle Modifications

• Exercise Training: Regular aerobic exercise to improve functional capacity and symptoms (Class I, Level A recommendation) 2, 1
• Dietary Modifications:
  • Moderate sodium restriction (2-3g/day) 1
  • Fluid restriction as needed based on symptoms 1
• Multidisciplinary Care: Enroll patients in a multidisciplinary care management program to reduce hospitalization risk and mortality 2

Follow-up and Monitoring

• Adjust diuretic doses based on symptoms and weight measurements 1
• Monitor electrolytes and renal function 1-2 weeks after initiation or dose changes of RAAS inhibitors 1
• Repeat echocardiography when there are significant changes in clinical status 1

Common Pitfalls to Avoid

• Failing to distinguish HFpEF from other causes of dyspnea (requires demonstration of cardiac structural/functional abnormalities beyond preserved LVEF) 1
• Using calcium channel blockers (except amlodipine) which can worsen heart failure 1
• Neglecting comorbidity management, which is crucial for improving outcomes in HFpEF 1
• Overuse of inotropes, which can be harmful in HFpEF patients 2

Remember that unlike HFrEF, no medication has definitively shown mortality benefit in HFpEF, making symptom relief, reduction in hospitalizations, and aggressive management of comorbidities the primary goals of therapy 1, 3.