What is the initial management for patients with Heart Failure with Preserved Ejection Fraction (HFpEF)?

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

SGLT2 inhibitors (empagliflozin or dapagliflozin) and diuretics form the cornerstone of initial management for patients with HFpEF, with SGLT2 inhibitors providing disease-modifying benefits by reducing hospitalizations and improving quality of life, while diuretics offer symptomatic relief of volume overload. 1

Diagnosis Confirmation

• Confirm HFpEF diagnosis through:
  • Symptoms: fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema
  • Signs: S3 heart sound, displaced apical pulse, jugular venous distension
  • Echocardiography: normal ejection fraction with impaired diastolic function
  • Elevated natriuretic peptides (BNP, NT-proBNP)

Initial Pharmacological Management

First-Line Therapies

1. Diuretics

   • Loop diuretics for symptom relief in volume overload
   • Goal: achieve euvolemia with lowest effective dose
   • Monitor symptoms, volume status, renal function, and electrolytes every 1-2 days
   • No mortality benefit associated with diuretic use 1

2. SGLT2 Inhibitors

   • Empagliflozin or dapagliflozin regardless of diabetes status
   • Significant reduction in heart failure hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin)
   • Improves quality of life and exercise capacity
   • Class of Recommendation 2a, Level of Evidence I 1

Second-Line/Adjunctive Therapies

1. Mineralocorticoid Receptor Antagonists (MRAs)

   • Consider in selected patients to decrease hospitalizations
   • No established mortality benefit 1

2. Hypertension Management

   • Target systolic blood pressure <130 mmHg
   • Prefer ACE inhibitors or ARBs in hypertensive HFpEF patients 1

3. Consider in Selected Patients

   • Sacubitril/valsartan: potentially beneficial in women and those with LVEF ≤57%
   • Candesartan: showed borderline benefit in CHARM-Preserved trial (HR: 0.86) 1
   • GLP-1 Receptor Agonists (e.g., semaglutide 2.4mg weekly) for patients with obesity (BMI ≥30) 1

Non-Pharmacological Management

1. Exercise Training

   • Supervised exercise program to improve exercise capacity and quality of life
   • Class I recommendation (Level of Evidence A) 1

2. Dietary Modifications

   • Moderate sodium restriction (2-3g/day)
   • Fluid restriction based on symptoms 1

3. Weight Management

   • Weight reduction in overweight/obese patients 1

4. Multidisciplinary Care

   • Enroll in multidisciplinary care management program
   • Reduces hospitalization risk and mortality 1

Management of Common Comorbidities

1. Atrial Fibrillation

   • Rate-control strategy with appropriate anticoagulation 1

2. Coronary Artery Disease

   • Consider revascularization when appropriate 1

3. Sleep Apnea

   • Screening and treatment as indicated 1

4. Diabetes

   • Optimize glycemic control 1

Monitoring and Follow-up

1. Regular Assessment

   • Monitor symptoms, volume status, renal function, and electrolytes
   • Adjust diuretic dose based on symptoms and weight measurements 1

2. Laboratory Monitoring

   • Check potassium and renal function 1-2 weeks after initiation or dose changes of RAAS inhibitors
   • Consider pre-discharge natriuretic peptide measurement for prognostic evaluation 1

3. Imaging

   • Repeat echocardiography with significant changes in clinical status 1

Important Cautions

1. Avoid Harmful Medications

   • NSAIDs
   • Most antiarrhythmic drugs
   • Most calcium channel blockers (except amlodipine)
   • Nephrotoxic medications in patients with CKD 1

2. Use Inotropes with Caution

   • Avoid unless patient is symptomatically hypotensive or hypoperfused 1

3. Beta-Blockers

   • No established mortality benefits in HFpEF
   • Use only for specific indications (hypertension, history of MI, rate control in atrial fibrillation) 1

The management of HFpEF remains challenging due to its heterogeneous nature 2, but early initiation of SGLT2 inhibitors alongside diuretics for symptom relief, combined with aggressive management of comorbidities and lifestyle modifications, currently represents the best evidence-based approach to improve outcomes and quality of life.