What is the initial management for a patient with Heart Failure with preserved Ejection Fraction (HFpEF) and Chronic Kidney Disease (CKD) stage 3b/A3?

Initial Management of HFpEF with CKD Stage 3b/A3

SGLT2 inhibitors (empagliflozin or dapagliflozin) are the first-line disease-modifying therapy for patients with HFpEF and CKD 3b/A3, along with diuretics for symptom relief of volume overload. 1

Diagnostic Considerations

Before initiating treatment, confirm the diagnosis of HFpEF by:

• Documenting preserved ejection fraction (≥50%)
• Excluding HFpEF mimics such as infiltrative cardiomyopathies, valvular disease, and pericardial disease 2
• Assessing for comorbidities that contribute to HFpEF phenotype, particularly focusing on CKD status

First-Line Pharmacological Management

1. Volume Management:

   • Loop diuretics (e.g., furosemide) as cornerstone therapy for symptom relief of volume overload 2
   • Titrate to achieve euvolemia with the lowest effective dose
   • Monitor renal function, electrolytes, and volume status every 1-2 days during dose adjustments 1

2. Disease-Modifying Therapy:

   • SGLT2 inhibitors (empagliflozin or dapagliflozin) regardless of diabetes status 2, 1
     • Reduce heart failure hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin)
     • Improve quality of life and exercise capacity
     • Provide renoprotective effects beneficial in CKD 3, 4

3. Blood Pressure Control:

   • Target systolic blood pressure <130 mmHg 1
   • Preferred agents:
     • ACE inhibitors or ARBs for patients with hypertension 2
     • Beta-blockers can be used for hypertension control 2

Second-Line Pharmacological Options

1. Mineralocorticoid Receptor Antagonists (MRAs):

   • Consider in selected patients to decrease hospitalizations 2, 1
   • Use with caution in CKD 3b due to hyperkalemia risk
   • Monitor potassium levels closely

2. Other Considerations:

   • Sacubitril/valsartan may be beneficial in selected patients, particularly women and those with LVEF ≤57% 1
   • For patients with obesity (BMI ≥30), consider GLP-1 receptor agonists 1

Non-Pharmacological Management

1. Multidisciplinary Care:

   • Enroll in a multidisciplinary heart failure program 1
   • Consider combined cardiology-nephrology management 5

2. Lifestyle Modifications:

   • Regular aerobic exercise to improve functional capacity (Class I recommendation) 1
   • Moderate sodium restriction (2-3g/day) 1
   • Weight reduction for overweight/obese patients 1

Monitoring and Follow-up

1. Regular Monitoring:

   • Renal function and electrolytes 1-2 weeks after initiation or dose changes of RAAS inhibitors 1
   • Symptoms and weight measurements to guide diuretic adjustments 1

2. Medication Precautions:

   • Avoid nephrotoxic medications (NSAIDs) 1
   • Avoid medications that worsen HF: most antiarrhythmic drugs and calcium channel blockers (except amlodipine) 1

Special Considerations for CKD 3b/A3

• More aggressive monitoring of renal function when using diuretics and RAAS inhibitors
• Higher risk of hyperkalemia with MRAs and RAAS inhibitors
• SGLT2 inhibitors have demonstrated benefits in patients with eGFR as low as 20 ml/min/1.73m² 5
• Consider intravenous iron therapy if iron deficiency is present 2

Pitfalls to Avoid

1. Underutilization of SGLT2 inhibitors due to concerns about renal function, despite evidence supporting their use and benefit in CKD 3, 4
2. Excessive diuresis leading to worsening renal function
3. Failure to monitor electrolytes, particularly potassium, when using RAAS inhibitors in CKD
4. Neglecting to address comorbidities that contribute to both HFpEF and CKD progression
5. Using inotropic agents unless the patient is symptomatically hypotensive or hypoperfused 1

The combination of HFpEF and CKD represents a complex clinical scenario requiring careful balance between optimal heart failure management and preservation of renal function. SGLT2 inhibitors offer a unique advantage in this population by addressing both cardiac and renal pathophysiology.