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

Treatment Plan for Heart Failure with Preserved Ejection Fraction (HFpEF)

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

Pharmacological Management

First-Line Therapy

• SGLT2 inhibitors:
  • Empagliflozin 10mg daily 2, 1
  • Dapagliflozin 10mg daily 1
  • Benefits: 21% reduction in composite endpoint of HF hospitalization or cardiovascular death, 29% reduction in HF hospitalizations 2

Symptom Management

• Diuretics:
  • Loop diuretics (e.g., furosemide 20-40mg initially, titrate to 40-240mg daily) 1
  • Goal: Achieve euvolemia with lowest effective dose
  • For diuretic resistance: Add thiazide diuretics or mineralocorticoid receptor antagonists (MRAs) 1

Blood Pressure Management

• Target: Systolic BP <130 mmHg 1
• Preferred agents:
  • ACE inhibitors or ARBs for hypertensive HFpEF patients 1
  • Beta-blockers for patients with history of MI, symptomatic CAD, or AF with rapid ventricular response 2
  • Caution: Balance beta-blocker use with potential contribution to chronotropic incompetence 2

Management of Common Comorbidities

Atrial Fibrillation

• Rate control with appropriate negative chronotropic agents 1
• Anticoagulation as appropriate 1
• Consider digoxin as an alternative to beta-blockers for rate control in elderly patients 2

Coronary Artery Disease

• Consider coronary angiography in high-risk patients 1
• Revascularization based on viability assessment 1

Lifestyle Modifications

• Exercise: Regular aerobic exercise to improve functional capacity 1
• Sodium restriction: Moderate (2-3g/day) 1
• Fluid restriction: Based on symptoms 1
• Weight reduction: Critical for overweight/obese patients 1

Monitoring and Follow-up

1. Regular monitoring of:

   • Symptoms
   • Volume status
   • Weight
   • Renal function
   • Electrolytes

2. Adjust diuretic dose based on symptoms and weight measurements 1

3. Repeat echocardiography with significant changes in clinical status 1

4. Monitor electrolytes and renal function 1-2 weeks after initiation or dose changes of RAAS inhibitors 1

5. Avoid nephrotoxic medications (e.g., NSAIDs) 1

Clinical Pearls and Pitfalls

• HFpEF is a heterogeneous syndrome with multiple phenotypes, requiring targeted therapy based on predominant symptoms and comorbidities 3, 4
• Patients with HFpEF are exquisitely sensitive to changes in preload and afterload, which is particularly important during perioperative management 5
• The benefit of SGLT2 inhibitors may be less pronounced in patients with LVEF >62.5% 2
• Unlike HFrEF, which has well-established mortality benefits from multiple drug classes, HFpEF treatment has historically shown only modest benefits on hospitalizations until the recent SGLT2 inhibitor trials 6

By following this treatment plan, clinicians can provide evidence-based care for patients with HFpEF, focusing on reducing hospitalizations, improving symptoms, and enhancing quality of life.