What is the assessment and treatment plan for Heart Failure with preserved Ejection Fraction (HFpEF)?

Assessment and Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

SGLT2 inhibitors (empagliflozin or dapagliflozin) should be used as first-line disease-modifying therapy for HFpEF to reduce hospitalizations and improve quality of life, regardless of diabetes status. 1

Diagnostic Assessment

Definition and Confirmation

• HFpEF is defined as clinical signs and symptoms of heart failure with LVEF ≥50% 2
• Diagnostic criteria require:
  • Clinical symptoms of heart failure
  • LVEF ≥50% on cardiac imaging
  • Evidence of cardiac abnormalities consistent with LV diastolic dysfunction or raised LV filling pressures
  • Elevated natriuretic peptides

Key Diagnostic Tests

1. Natriuretic Peptides:

   • NT-proBNP ≥125 ng/L (sinus rhythm) or >365 ng/L (atrial fibrillation)
   • BNP >35 pg/mL (sinus rhythm) or >50 pg/mL (atrial fibrillation) 2

2. Transthoracic Echocardiography with assessment of:

   • LV diastolic function
   • Average E/e' ≥15 (indicates raised LV filling pressures)
   • Septal e' <7 cm/s (female) or <10 cm/s (male)
   • Left atrial volume index ≥40 mL/m²
   • LV mass index ≥95 g/m² 2

3. Additional Testing when diagnosis is uncertain:

   • Cardiopulmonary exercise testing to identify cause of dyspnea
   • Cardiovascular magnetic resonance for structural assessment
   • Right heart catheterization to aid diagnosis in selected cases
   • Endomyocardial biopsy if specific causes like amyloidosis are suspected 2

Treatment Plan

1. Disease-Modifying Therapies

• First-line: SGLT2 inhibitors (empagliflozin or dapagliflozin)

  • Significantly reduce heart failure hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin)
  • Improve quality of life and exercise capacity
  • Use regardless of diabetes status 1

• Consider in selected patients:

  • Sacubitril/valsartan (particularly in women and those with LVEF ≤57%)
  • Candesartan (showed borderline benefit in CHARM-Preserved trial) 1
  • Mineralocorticoid receptor antagonists (MRAs) like spironolactone to decrease hospitalizations (use cautiously in CKD) 1

2. Volume Management

• Diuretics: Cornerstone for symptom relief

  • Loop diuretics (furosemide): Initial dose 20-40mg, usual daily dose 40-240mg
  • Goal: Achieve euvolemia with lowest effective dose
  • Monitor symptoms, volume status, renal function, and electrolytes regularly 2, 1

• For diuretic resistance:

  • Consider adding thiazide diuretics
  • Consider adding MRAs (spironolactone/eplerenone 12.5-25mg, up to 50mg daily) 2

3. Blood Pressure Control

• Target: Systolic BP <130 mmHg 1
• Preferred agents:
  • ACE inhibitors or ARBs for hypertensive HFpEF patients
  • Beta-blockers can be used for rate control and hypertension management 1

4. Management of Comorbidities

• Atrial Fibrillation:

  • Rate control with negative chronotropic agents
  • Anticoagulation as appropriate 2

• Obesity:

  • Weight reduction is crucial for improving outcomes
  • Consider GLP-1 receptor agonists (e.g., semaglutide 2.4mg weekly) for patients with BMI ≥30 1

• Iron Deficiency:

  • Consider intravenous iron therapy if present 1

• Coronary Artery Disease:

  • Consider coronary angiography in high-risk patients
  • Revascularization based on viability assessment 2

5. Lifestyle Modifications

• Exercise Training:

  • Regular aerobic exercise to improve functional capacity (Class I, Level A recommendation)
  • Supervised exercise training program 1

• Dietary Measures:

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

• Multidisciplinary Care:

  • Enroll in heart failure management program
  • Regular follow-up and monitoring 1

Monitoring and Follow-up

• Monitor symptoms, volume status, weight, renal function, and electrolytes
• Check potassium and renal function 1-2 weeks after initiation or dose changes of RAAS inhibitors
• Repeat echocardiography with significant changes in clinical status
• Avoid nephrotoxic medications (e.g., NSAIDs) 1

Treatment Algorithm

1. Confirm diagnosis with clinical symptoms, preserved EF, and supporting evidence
2. Start SGLT2 inhibitor as first-line disease-modifying therapy
3. Initiate/optimize diuretic therapy for volume management
4. Control blood pressure to target <130 mmHg systolic
5. Address specific comorbidities (AF, obesity, iron deficiency, CAD)
6. Implement lifestyle modifications (exercise, diet, multidisciplinary care)
7. Consider additional therapies based on specific phenotype (MRAs, sacubitril/valsartan, or candesartan)

Caution

• Avoid routine use of statins unless there is a specific indication 2
• Monitor renal function and electrolytes closely when using RAAS inhibitors and diuretics
• Carefully titrate medications in elderly patients with multiple comorbidities