What are key teaching points for a patient with Heart Failure with preserved Ejection Fraction (HFpEF)?

From the Guidelines

The key teaching points for a patient with Heart Failure with preserved Ejection Fraction (HFpEF) should focus on controlling systolic and diastolic blood pressure, using diuretics for symptom relief, and addressing underlying conditions, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. When managing HFpEF, it is essential to consider the unique pathophysiology and management of this condition. HFpEF represents approximately half of all heart failure cases and is characterized by normal left ventricular ejection fraction (typically ≥50%) with diastolic dysfunction. Key teaching points should include:

• Identification of risk factors such as hypertension, obesity, diabetes, and advanced age which contribute to myocardial stiffness and impaired relaxation
• Management focuses on symptom relief and addressing underlying conditions
• Diuretics, particularly loop diuretics like furosemide (20-80mg daily) or torsemide (10-40mg daily), are first-line for volume overload and symptom management, as stated in the 2013 ACCF/AHA guideline for the management of heart failure 1
• SGLT2 inhibitors such as empagliflozin (10mg daily) or dapagliflozin (10mg daily) have shown mortality benefit in HFpEF and should be considered
• Blood pressure control is crucial, targeting <130/80 mmHg, typically with ACE inhibitors or ARBs, as recommended by the 2013 ACCF/AHA guideline for the management of heart failure 1
• Rate control for patients with atrial fibrillation is important, using beta-blockers or calcium channel blockers
• Lifestyle modifications including sodium restriction (<2-3g daily), regular physical activity, and weight management are essential components of treatment Unlike HFrEF, traditional neurohormonal antagonists (beta-blockers, ACE inhibitors) have not shown the same mortality benefits in HFpEF, though they remain important for managing comorbidities, as noted in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Emphasize the importance of treating comorbidities aggressively as they directly impact HFpEF progression and outcomes. Additionally, early outpatient follow-up and structured contact with the patient within 7 days of hospital discharge are recommended to minimize gaps in understanding of changes to the care plan or knowledge of test results, as stated in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.

From the Research

Key Teaching Points for HFpEF Patients

• The patient should be educated on the importance of managing hypertension, as it is a leading risk factor for HFpEF 2
• Lifestyle modifications and rigorous control of comorbid conditions are essential for patients with HFpEF 3
• The patient should be informed about the potential benefits and risks of sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, which may be useful in treating apparent resistant hypertension in patients with HFpEF 4
• However, it is crucial to note that sacubitril-valsartan has shown little benefit in HFpEF patients in some studies 5
• Patients with HFpEF should be aware of the importance of monitoring and controlling their blood pressure, as elevated blood pressure can portend an adverse prognosis 2

Management of Hypertension in HFpEF

• Intensive blood pressure control may attenuate the processes driving the association between hypertension and HFpEF, although this hypothesis has not been tested on clinical outcomes in a dedicated randomized controlled trial in HFpEF 2
• Antihypertensive therapies can improve key surrogate markers in HFpEF, but blood pressure reduction does not always account for these benefits 2
• Clinicians should recognize the risk of disease progression and poor outcomes associated with uncontrolled hypertension in HFpEF and consider intensive blood pressure control, preferably using therapies known to improve outcomes in heart failure 2

Treatment Options for HFpEF

• With the exception of symptom mitigation, lifestyle modifications, and rigorous control of comorbid conditions, few long-term treatment options exist for patients with HFpEF 3
• Sacubitril-valsartan may be a useful treatment option for apparent resistant hypertension in patients with HFpEF, even in those who continue to have an elevated blood pressure despite treatment with at least four antihypertensive drug classes, including a mineralocorticoid receptor antagonist 4