Initial Management Strategies for Heart Failure with Preserved Ejection Fraction (HFpEF)
SGLT2 inhibitors (empagliflozin 10mg or dapagliflozin 10mg daily) should be used as first-line disease-modifying therapy for HFpEF to reduce hospitalizations and improve quality of life, regardless of diabetes status. 1
Diagnosis and Definition
HFpEF is defined as:
- Clinical signs and symptoms of heart failure
- Left ventricular ejection fraction (LVEF) ≥50%
- Evidence of cardiac abnormalities consistent with left ventricular diastolic dysfunction
- Elevated natriuretic peptides (NT-proBNP ≥125 ng/L in sinus rhythm or >365 ng/L in atrial fibrillation) 1
Core Management Strategies
1. Disease-Modifying Therapies
- SGLT2 inhibitors: First-line therapy
- Empagliflozin 10mg daily or Dapagliflozin 10mg daily
- Significantly reduce heart failure hospitalizations (HR: 0.77 for dapagliflozin, 0.71 for empagliflozin) 1
- Improve quality of life and exercise capacity
2. Symptom Management
- Diuretics: Cornerstone for symptom relief in volume overload 2, 1
- Loop diuretics (Furosemide 20-40mg initially, 40-240mg usual daily dose)
- For diuretic-naïve patients: Furosemide 20-40mg IV
- Thiazide diuretics can be added if needed
- Titrate based on symptoms and weight measurements
3. Blood Pressure Control
- Target: Systolic BP <130 mmHg 1
- Preferred agents:
- ACE inhibitors or ARBs for hypertensive HFpEF patients
- Beta-blockers for rate control and hypertension management
4. Management of Comorbidities
- Hypertension: Aggressive control as per above
- Diabetes: Optimize glycemic control (SGLT2 inhibitors preferred)
- Obesity: Weight reduction program (target ≥5-10% weight loss) 1
- Atrial Fibrillation: Rate control with beta-blockers
- Coronary Artery Disease: Consider revascularization if symptomatic ischemia present 2
Lifestyle Modifications
- Sodium restriction: Moderate (2-3g/day) 1
- Regular aerobic exercise: Improves functional capacity (Class I, Level A recommendation) 1
- Weight reduction: For overweight/obese patients 1
Monitoring
- Regular assessment of symptoms, volume status, weight, renal function, and electrolytes
- Electrolyte monitoring 1-2 weeks after initiation or dose changes of RAAS inhibitors
- Repeat echocardiography with significant changes in clinical status 1
Medications to Avoid
- NSAIDs (risk of renal damage and fluid retention) 1
- Most calcium channel blockers (except amlodipine) 2
- Most antiarrhythmic drugs 2
- Thiazolidinediones 2
Additional Considerations
- Mineralocorticoid receptor antagonists (MRAs) like spironolactone 25mg daily may be considered 1
- GLP-1 receptor agonists can be considered for patients with obesity 1
- Omega-3 polyunsaturated fatty acid supplementation is reasonable as adjunctive therapy 2
Emerging Approaches
The heterogeneous nature of HFpEF suggests potential benefit from phenotype-guided approaches, targeting specific underlying mechanisms and predominant comorbidities 3, 4. This is an evolving area that may lead to more personalized treatment strategies in the future.