From the Guidelines
When managing a patient with Heart Failure with preserved Ejection Fraction (HFpEF), the primary focus should be on symptom relief and addressing underlying conditions, as there are no definitive mortality-reducing therapies available, and blood pressure control is a critical component to reduce HF hospitalizations, as evidenced by the most recent study 1. Key teaching points for rounds on a patient with HFpEF include:
- Diagnosing HFpEF based on heart failure symptoms with an ejection fraction ≥50%, evidence of diastolic dysfunction, and elevated natriuretic peptides
- Understanding the pathophysiology of HFpEF, which involves impaired ventricular relaxation, increased ventricular stiffness, and elevated filling pressures, often driven by comorbidities causing systemic inflammation and endothelial dysfunction
- Implementing first-line treatments, such as:
- Diuretics (typically starting with furosemide 20-40mg daily) to manage volume overload and relieve symptoms
- SGLT2 inhibitors like empagliflozin 10mg daily or dapagliflozin 10mg daily, which have shown benefit in reducing hospitalizations
- Spironolactone may be considered in appropriately selected patients to lower hospitalizations for HF, as suggested by the TOPCAT trial 1
- Aggressively addressing comorbidities, including:
- Hypertension (target <130/80 mmHg)
- Diabetes
- Obesity
- Atrial fibrillation
- Coronary artery disease
- Emphasizing lifestyle modifications, such as:
- Sodium restriction (<2-3g/day)
- Fluid restriction if hyponatremic
- Regular physical activity, which has been shown to improve symptoms, exercise capacity, and quality of life in patients with HFpEF, as demonstrated by recent studies 1
- Weight management It is essential to note that the use of mineralocorticoid receptor antagonists, such as spironolactone, requires careful monitoring of potassium and renal function to minimize the risk of hyperkalemia and worsening renal function, as highlighted in the 2017 ACC/AHA/HFSA focused update 1. Additionally, routine use of nitrates or phosphodiesterase-5 inhibitors is not recommended for patients with HFpEF, unless they have symptomatic CAD, as they have not shown improvement in exercise tolerance or quality of life in clinical trials 1.
From the Research
Key Teaching Points for Rounds on a Patient with Heart Failure with Preserved Ejection Fraction (HFpEF)
- Establishing a clinical diagnosis of HFpEF is challenging due to the presence of multiple comorbidities and alternative reasons for symptoms such as dyspnea and exercise intolerance 2, 3
- A stepwise approach to the diagnosis and treatment of HFpEF is recommended, including:
- Establishing a clinical diagnosis of HFpEF
- Referring for invasive diagnostic testing when necessary
- Implementing current treatment approaches, including pharmacologic, nonpharmacologic, and risk factor modification interventions
- Referring to a dedicated HFpEF center or advanced heart failure specialist when necessary 2
- The treatment of HFpEF has been challenging, with few therapies shown to improve survival, and management has focused on intensive optimization of HFpEF risk factors 2, 4
- The use of diuretics for the management of congestion is a class 1 (strong) recommendation, and newer recommendations include the broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor-neprilysin inhibitors 3
- Lifestyle modifications, such as rigorous control of comorbid conditions, are also important in the management of HFpEF 4, 5
- Pathophysiological heterogeneity in the presentation of HFpEF is substantial, and ongoing studies are underway to evaluate the optimal methods to classify patients into phenotypically homogeneous subpopulations to facilitate better individualization of treatment 5