What is the role of diltiazem (calcium channel blocker) in the treatment of Heart Failure with preserved Ejection Fraction (HFpEF)?

Diltiazem in Heart Failure with Preserved Ejection Fraction (HFpEF)

Diltiazem should NOT be used in the treatment of Heart Failure with Preserved Ejection Fraction (HFpEF) due to its negative inotropic effects and potential to worsen heart failure outcomes. 1

Contraindication of Diltiazem in Heart Failure

Evidence Against Diltiazem Use in HF

• Nondihydropyridine calcium channel blockers (including diltiazem and verapamil) are myocardial depressants and generally not well tolerated in heart failure 1
• Clinical trials have demonstrated either no clinical benefit or worse outcomes in patients with heart failure treated with these drugs 1
• The 2022 ACC/AHA/HFSA guidelines explicitly state that nondihydropyridine calcium channel blockers are harmful (Class III: Harm, Level of Evidence: A) in patients with HFrEF 1

Specific Concerns with Diltiazem in HFpEF

• While the strongest evidence against diltiazem exists for HFrEF, the negative inotropic effects are concerning across the heart failure spectrum
• In patients with HFpEF who develop atrial fibrillation, diltiazem may be considered for rate control only if the ejection fraction is well-preserved and there are no signs of decompensation 1
• Recent research suggests that diltiazem use in HFpEF patients may be associated with worsening heart failure symptoms, with one study showing a 33% incidence of worsening heart failure symptoms compared to 15% with metoprolol 2

Recommended Pharmacological Approach for HFpEF

First-Line Therapies for HFpEF

1. Diuretics: Should be prescribed as first-line therapy for patients with HFpEF who present with symptoms of volume overload (Class I, Level of Evidence: C-EO) 1

   • Loop diuretics are the mainstay for controlling congestion and improving symptoms

2. SGLT2 inhibitors: Recent evidence supports their use in HFpEF 1, 3

   • Dapagliflozin 10 mg daily or empagliflozin 10 mg daily

3. ACE inhibitors/ARBs: For persistent hypertension after management of volume overload (Class I, Level of Evidence: C-LD) 1

   • Titrated to achieve systolic blood pressure of less than 130 mm Hg

4. Beta-blockers: For persistent hypertension after management of volume overload (Class I, Level of Evidence: C-LD) 1

   • Evidence-based options include carvedilol, metoprolol succinate, or bisoprolol

Management of Comorbidities

• Hypertension: Aggressive control is crucial as it's the most important cause of HFpEF (prevalence 60-89%) 1
• Atrial Fibrillation: Common in HFpEF; rate control with beta-blockers is preferred over nondihydropyridine calcium channel blockers 1
• Obesity, Diabetes, CAD: These comorbidities should be actively managed as they contribute to HFpEF pathophysiology 1

Clinical Pitfalls to Avoid

1. Misuse of calcium channel blockers: Avoid nondihydropyridine calcium channel blockers (diltiazem, verapamil) in any form of heart failure due to their negative inotropic effects 1, 3

2. Inadequate volume management: Failure to optimize volume status with appropriate diuretic therapy is a common pitfall in HFpEF management 4

3. Overlooking atrial fibrillation: When AF occurs with HFpEF, beta-blockers should be preferred over diltiazem for rate control 1

4. Inappropriate medication choices: Using medications proven harmful in HFrEF (like diltiazem) in HFpEF patients without strong evidence of safety 1

5. Ignoring recent evidence: Recent studies suggest that diltiazem use in HFpEF patients with atrial fibrillation may be associated with worsening heart failure symptoms 2, 5

Conclusion for Clinical Practice

When treating HFpEF, focus on diuretics for symptom relief, SGLT2 inhibitors for disease modification, and appropriate management of comorbidities like hypertension and atrial fibrillation. Diltiazem should be avoided due to its negative inotropic effects and potential to worsen heart failure outcomes, with beta-blockers being the preferred option when rate control is needed for atrial fibrillation in the HFpEF population.