What is the initial management for patients with Heart Failure with preserved Ejection Fraction (HFpEF)?

Initial Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

The initial management of HFpEF should focus on three key strategies: diuretics for symptom relief, SGLT2 inhibitors for disease modification, and comprehensive management of comorbidities. 1

Diagnostic Confirmation

• Confirm HFpEF diagnosis using a two-step approach: first establish heart failure symptoms with LVEF ≥50%, elevated natriuretic peptides, and evidence of structural heart disease or elevated filling pressures; if uncertain, proceed to stress testing 1, 2
• Rule out HFpEF mimics such as cardiac amyloidosis, hypertrophic cardiomyopathy, or pericardial disease which may require specific treatments 1
• Consider using diagnostic algorithms like H2PEF or HFA-PEFF scores when initial investigations are equivocal despite high clinical suspicion 1

First-Line Pharmacological Management

Symptom Management

• Loop diuretics are the cornerstone for symptom relief in congested patients, using the lowest effective dose to reduce fluid overload 1
• Monitor for electrolyte abnormalities and renal dysfunction when using diuretics, especially in elderly patients 3
• Consider increasing diuretic dose before adding combination therapy if initial response is inadequate 1

Disease-Modifying Therapy

• SGLT2 inhibitors (dapagliflozin or empagliflozin) should be initiated early as they have demonstrated mortality and morbidity benefits in HFpEF patients 1, 2
• Consider mineralocorticoid receptor antagonists (MRAs) like spironolactone, particularly in patients with LVEF in the lower range of preservation (40-50%) 1
• ARNIs (sacubitril/valsartan) may be beneficial in selected patients, especially women and those with LVEF below the upper range 1

Management of Comorbidities

• Hypertension: Achieve optimal blood pressure control (<130/80 mmHg) using appropriate antihypertensive medications 1
• Atrial fibrillation: Control rate using beta-blockers or non-dihydropyridine calcium channel blockers in HFpEF patients 1
• Diabetes: Prioritize SGLT2 inhibitors for glycemic control given their additional heart failure benefits 1, 3
• Obesity: Recommend supervised weight loss programs as obesity is a major driver of HFpEF pathophysiology 1, 2
• Coronary artery disease: Optimize anti-ischemic therapy and consider revascularization when appropriate 1, 3
• Sleep apnea: Screen for and treat obstructive sleep apnea which can exacerbate HFpEF 1, 3

Non-Pharmacological Interventions

• Prescribe supervised exercise training programs to improve functional capacity and quality of life 1, 2
• Recommend sodium restriction (<2-3g/day) and fluid restriction when appropriate 1
• Consider cardiac rehabilitation programs which can improve exercise tolerance 1, 3
• Implement a multidisciplinary team approach including HF specialists, nurses, dieticians, and physiotherapists 1, 3

Monitoring and Follow-up

• Monitor symptoms, vital signs, weight, renal function, and electrolytes regularly 1, 3
• Adjust diuretic doses based on congestion status to avoid overdiuresis which can lead to hypotension 1, 4
• Consider wireless pulmonary artery pressure monitoring in selected patients with recurrent hospitalizations 1

Special Considerations for Elderly Patients

• Start medications at lower doses and titrate more gradually in elderly patients 3
• Be vigilant for polypharmacy issues and potential drug interactions 3
• Pay particular attention to renal function monitoring as elderly patients are more susceptible to kidney injury 1, 3

Common Pitfalls to Avoid

• Don't delay initiation of SGLT2 inhibitors which have proven mortality benefits 1
• Avoid excessive diuresis which can lead to hypotension and impaired tolerance of other medications 1, 4
• Don't use beta-blockers as primary therapy unless there are specific indications (e.g., prior MI, angina, or AF) 1
• Recognize that HFpEF is heterogeneous and may require phenotype-specific approaches 5, 6