What is the initial management for patients with diabetes and heart failure with preserved ejection fraction (HFpEF)?

Initial Management for Patients with Diabetes and Heart Failure with Preserved Ejection Fraction (HFpEF)

SGLT2 inhibitors (empagliflozin or dapagliflozin) should be used as first-line disease-modifying therapy for patients with diabetes and HFpEF, regardless of the need for additional glucose lowering. 1, 2

Diagnostic Confirmation of HFpEF

• Confirm diagnosis with:
  • Clinical symptoms of heart failure
  • LVEF ≥50% on cardiac imaging
  • Evidence of diastolic dysfunction or elevated filling pressures
  • Elevated natriuretic peptides (NT-proBNP ≥125 ng/L in sinus rhythm or >365 ng/L in atrial fibrillation) 1

Pharmacological Management Algorithm

First-Line Therapy

• SGLT2 inhibitors:
  • Empagliflozin 10mg daily or Dapagliflozin 10mg daily 1
  • Benefits include:
    • Reduced heart failure hospitalizations (HR: 0.71-0.77)
    • Improved quality of life and exercise capacity
    • Cardiovascular benefits regardless of diabetes status 1, 2

Symptom Management

• Diuretics for congestion/volume overload:
  • Loop diuretics (furosemide 20-40mg initially, titrate to 40-240mg daily as needed)
  • Aim for euvolemia with lowest effective dose 1
  • For diuretic resistance, consider adding thiazide diuretics or MRAs 1

Blood Pressure Management

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

Glucose Management

• Incorporate SGLT2 inhibitors as part of diabetes management
• Consider GLP-1 receptor agonists as additional therapy for patients with obesity 2
• Avoid hypoglycemia risk by careful medication selection 2

Lifestyle Modifications

• Exercise: Regular aerobic exercise to improve functional capacity 1
• Diet:
  • Moderate sodium restriction (2-3g/day)
  • Weight reduction in overweight/obese patients (target ≥5-10% weight loss) 2, 1
• Self-monitoring:
  • Daily weight measurements
  • Symptom monitoring
  • Medication adherence 1

Monitoring and Follow-up

• Monitor:
  • Symptoms and volume status
  • Weight changes
  • Renal function and electrolytes (1-2 weeks after initiation or dose changes of RAAS inhibitors)
  • Repeat echocardiography with significant clinical status changes 1

Special Considerations

• Atrial fibrillation: Rate control with negative chronotropic agents and anticoagulation 1, 3
• Avoid nephrotoxic medications (e.g., NSAIDs) 1
• Coronary artery disease: Consider coronary angiography in high-risk patients 1

Clinical Pearls and Pitfalls

• Pitfall: Delaying SGLT2 inhibitor initiation due to concerns about hypoglycemia

  • Solution: SGLT2 inhibitors have low hypoglycemia risk when used without insulin/sulfonylureas 2

• Pitfall: Focusing only on glucose control without addressing the cardiovascular pathophysiology

  • Solution: SGLT2 inhibitors should be included regardless of the need for additional glucose lowering 2

• Pitfall: Inadequate blood pressure control

  • Solution: Intensive BP control is crucial to delay HFpEF progression 3

• Caveat: The benefit of SGLT2 inhibitors may be less pronounced in patients with LVEF >62.5% 1

• Important: Diabetes significantly worsens prognosis in HFpEF patients, with 5-year mortality rates dramatically higher than age-matched controls (32% vs 79%) 4, making aggressive management essential

By implementing this comprehensive approach focusing on SGLT2 inhibitors as cornerstone therapy, along with appropriate symptom management and lifestyle modifications, outcomes for patients with diabetes and HFpEF can be significantly improved.