Is management of Heart Failure with preserved Ejection Fraction (HFpEF) similar to management of Right-sided Congestive Heart Failure (R-CHF)?

Management of HFpEF vs. Right-sided CHF

The management of Heart Failure with Preserved Ejection Fraction (HFpEF) differs significantly from right-sided congestive heart failure (R-CHF), as HFpEF primarily involves left ventricular diastolic dysfunction while maintaining normal ejection fraction, whereas R-CHF specifically involves right ventricular dysfunction.

Fundamental Differences

HFpEF:

• Defined by LVEF ≥50% with heart failure symptoms and evidence of elevated filling pressures 1, 2
• Characterized by:
  • Left atrial enlargement (volume index ≥34 mL/m²)
  • Diastolic dysfunction (E/e' ratio ≥15)
  • Left ventricular hypertrophy 2
• Particularly prevalent in elderly women with hypertension and diabetes 2

Right-sided CHF:

• Involves right ventricular dysfunction, often secondary to left-sided heart failure or pulmonary disease
• Characterized by:
  • Elevated right atrial pressure
  • Systemic venous congestion
  • Peripheral edema, hepatomegaly, ascites

Treatment Approaches

HFpEF Management:

1. SGLT2 inhibitors:

   • First-line disease-modifying therapy
   • Dapagliflozin and empagliflozin reduce HF hospitalizations 1, 2

2. Diuretics:

   • Loop diuretics for symptom relief and congestion management
   • Thiazides as adjunct therapy for hypertension or loop diuretic resistance 1

3. Other pharmacologic options:

   • Mineralocorticoid receptor antagonists (spironolactone) in selected patients 1
   • ARNI (sacubitril/valsartan) may benefit some patients 1

4. Non-pharmacologic approaches:

   • Exercise training/cardiac rehabilitation programs 1
   • Weight loss for obese patients 1, 2
   • Sodium restriction (though evidence is limited) 1

Right-sided CHF Management:

• Focuses on treating the underlying cause (left heart failure, pulmonary hypertension, etc.)
• Diuretics for volume overload
• Pulmonary vasodilators if pulmonary arterial hypertension is present
• Treatment of right ventricular dysfunction

Key Differences in Management

1. Therapeutic targets:

   • HFpEF: Focuses on diastolic function improvement, reducing left ventricular filling pressures
   • R-CHF: Focuses on improving right ventricular function and reducing pulmonary pressures

2. Medication efficacy:

   • Many medications proven effective for HFrEF have shown limited benefit in HFpEF 3
   • SGLT2 inhibitors have emerged as effective specifically for HFpEF 1

3. Comorbidity management:

   • HFpEF: Requires aggressive management of hypertension, diabetes, obesity, and atrial fibrillation 1, 2
   • R-CHF: Often requires management of pulmonary disease or left-sided heart failure

Special Considerations

• Right heart dysfunction in HFpEF: Common and contributes to poor prognosis, requiring additional attention 4
• Atrial fibrillation: Particularly challenging in HFpEF diagnosis and management 5
• Diagnostic challenges: HFpEF diagnosis is more complex, requiring specific echocardiographic parameters 2

Monitoring and Follow-up

• Both conditions require regular monitoring of:
  • Volume status
  • Renal function
  • Electrolytes
  • Symptom burden
  • Exercise capacity

Treatment Algorithm for HFpEF

1. Confirm diagnosis (LVEF ≥50%, symptoms, elevated filling pressures)
2. Start SGLT2 inhibitor (dapagliflozin or empagliflozin)
3. Use diuretics for congestion management
4. Consider MRA (spironolactone) in selected patients
5. Implement exercise training program
6. Aggressively manage comorbidities
7. Consider advanced therapies for refractory symptoms

The management approaches differ significantly based on the underlying pathophysiology, with HFpEF requiring specific attention to diastolic function and comorbidities, while R-CHF management focuses on addressing the underlying cause and right ventricular function.