Management of Heart Failure with Preserved Ejection Fraction (HFpEF)
SGLT2 inhibitors (empagliflozin or dapagliflozin) are recommended as first-line disease-modifying therapy for HFpEF to reduce hospitalizations and cardiovascular mortality, regardless of diabetes status. 1
Pharmacological Management
First-line Therapies
- SGLT2 inhibitors: Empagliflozin or dapagliflozin significantly reduce heart failure hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin) and improve quality of life and exercise capacity 1
- Diuretics: Cornerstone for symptom relief in volume overload
- Goal: Achieve euvolemia with lowest effective dose
- Monitor: Symptoms, volume status, renal function, electrolytes every 1-2 days during hospitalization 1
- Note: While diuretics improve symptoms, they have no established mortality benefit
Second-line Therapies
- Mineralocorticoid Receptor Antagonists (MRAs): May be considered in selected patients to decrease hospitalizations 1
- Sacubitril/valsartan: Consider for selected patients, particularly women and those with LVEF ≤57% 1
- Candesartan: May provide borderline benefit (HR: 0.86 in CHARM-Preserved trial) 1
- ARBs/ACE inhibitors: Consider for HFpEF patients with hypertension 1
Medications to Avoid
- Inotropic agents: Avoid unless patient is symptomatically hypotensive or hypoperfused 1
- NSAIDs: Can worsen heart failure and renal function 1
- Most antiarrhythmic drugs: May worsen heart failure 1
- Most calcium channel blockers: Except amlodipine 1
Comorbidity Management
Aggressive management of comorbidities is crucial in HFpEF:
- Hypertension: Target systolic BP <130 mmHg, preferably with ACE inhibitors or ARBs 1
- Atrial fibrillation: Consider rate control with beta-blockers 1
- Diabetes: Optimize glycemic control, preferably with SGLT2 inhibitors 1
- Obesity:
- Sleep apnea: Screen and treat appropriately 1
Non-pharmacological Management
Exercise and Rehabilitation
- Supervised exercise training: Class I recommendation (Level of Evidence A) to improve exercise capacity and quality of life 1
- Regular aerobic exercise improves functional capacity and symptoms 1
Dietary Modifications
Multidisciplinary Care
- Enroll patients in multidisciplinary care management programs to reduce hospitalization risk and mortality 1
Monitoring and Follow-up
Regular Assessment
- Monitor symptoms, volume status, renal function, and electrolytes 1
- Adjust diuretic doses based on symptoms and weight measurements 1
- Consider bedside thoracic ultrasound to assess for interstitial edema 1
Laboratory Monitoring
- Measure natriuretic peptides (BNP, NT-proBNP) to confirm diagnosis and assess severity 1
- Monitor creatinine, BUN, and electrolytes regularly 1
- Check potassium and renal function 1-2 weeks after initiation or dose changes of RAAS inhibitors 1
Imaging
- Repeat echocardiography with significant changes in clinical status 1
Emerging Approaches
Phenotype-Guided Management
Recent research suggests tailoring therapy based on predominant phenotypes:
- Lung congestion
- Chronotropic incompetence
- Pulmonary hypertension
- Skeletal muscle weakness 2
Device-Based Therapies
For specific HFpEF phenotypes, consider:
- Inter-atrial shunt to reduce left ventricular filling pressure
- Implantable heart failure monitors to guide diuresis
- Left atrial pacing for interatrial dyssynchrony 3
Common Pitfalls to Avoid
- Treating HFpEF like HFrEF: Many medications effective for HFrEF show less benefit in HFpEF 4
- Overlooking comorbidities: HFpEF is heavily influenced by comorbidity burden 5
- Relying solely on ejection fraction: HFpEF is a heterogeneous syndrome requiring comprehensive assessment beyond LVEF 6
- Using nephrotoxic medications: Strictly avoid NSAIDs in patients with HFpEF and CKD 1