What is the best treatment for diastolic heart failure with preserved Ejection Fraction (EF)?

From the Guidelines

The best treatment for diastolic heart failure with preserved Ejection Fraction (EF) focuses on symptom management and addressing underlying conditions, with diuretics, blood pressure control, and lifestyle modifications being essential components of therapy. When considering treatment options, it's crucial to prioritize morbidity, mortality, and quality of life as outcomes. The most recent and highest quality study, 1, although from 2012, provides valuable insights into the management of heart failure with preserved ejection fraction (HFpEF), highlighting the importance of controlling symptoms and managing underlying conditions. Key aspects of treatment include:

• Diuretics like furosemide (20-80mg daily) or hydrochlorothiazide (12.5-25mg daily) to reduce fluid overload and relieve symptoms such as shortness of breath and edema.
• Blood pressure control, with ACE inhibitors (like lisinopril 5-40mg daily) or ARBs (such as losartan 25-100mg daily) recommended for hypertensive patients, as suggested by 1.
• Beta-blockers (metoprolol succinate 25-200mg daily or carvedilol 3.125-25mg twice daily) can help control heart rate and improve diastolic filling time, although their use in HFpEF is more nuanced and guided by the presence of specific comorbidities like atrial fibrillation, as noted in 1.
• Lifestyle modifications are essential, including sodium restriction (<2g daily), regular physical activity, weight management, and treatment of comorbidities like sleep apnea. It's also important to consider the role of SGLT2 inhibitors for patients with diabetes, as they have shown benefit in reducing hospitalizations, although this is more directly supported by studies in the context of heart failure with reduced ejection fraction. Given the lack of treatments that definitively improve mortality in HFpEF, therapy is primarily aimed at improving quality of life and reducing hospitalizations by addressing the abnormal ventricular relaxation and increased stiffness characteristic of this condition, as discussed in 1 and 1.

From the Research

Treatment Approaches

The treatment of diastolic heart failure with preserved Ejection Fraction (EF) involves both acute and chronic management strategies.

• Acute management focuses on treating the presenting syndrome, including:
  • Correction of volume overload with sodium restriction and diuretics 2
  • Treating hypertension aggressively, using multiple agents if necessary 2
  • Alleviating ischemia and controlling tachyarrhythmias 2
• Chronic management should focus on precipitating factors, with adequate control of hypertension being paramount 2, 3

Pharmacologic Interventions

Various pharmacologic interventions have been shown to be effective in improving measures of diastolic function, including:

• Angiotensin converting enzyme inhibitors and angiotensin receptor blockers, which are recommended as first-line agents in the control of hypertension in patients with diastolic heart failure 4
• Beta-blockers, calcium channel blockers, and diuretics, which have also shown some efficacy in improved indices of diastolic filling 4, 3, 5

Management Strategies

The management of diastolic heart failure should include:

• Antihypertensive treatment 3, 5
• Maintenance of the sinus rhythm 3
• Prevention of tachycardia 3, 5
• Venous pressure reduction 3
• Prevention of myocardial ischemia 3
• Prevention of diabetes mellitus 3
• Patient education regarding dietary and medication compliance and lifestyle changes 2