What is the recommended management for heart failure with preserved ejection fraction?

Management of Heart Failure with Preserved Ejection Fraction

For heart failure with preserved ejection fraction (HFpEF), SGLT2 inhibitors are the cornerstone of disease-modifying therapy, with diuretics as the primary symptomatic treatment. 1

Diagnosis and Initial Assessment

• HFpEF should be suspected in patients with typical heart failure symptoms (fatigue, dyspnea, orthopnea, edema) with echocardiographic findings of normal ejection fraction (>40-50%) with impaired diastolic function 1, 2
• Diagnostic workup should include:
  • Natriuretic peptide measurement (BNP ≥35 pg/mL or NT-proBNP ≥125 ng/L) 1
  • Transthoracic echocardiography with diastolic function assessment 1
  • Assessment for elevated LV filling pressures (E/e' ≥15, LA volume index ≥40 mL/m²) 1

Pharmacological Management

First-Line Treatments

• Diuretics: Loop diuretics (furosemide) at the lowest effective dose for symptomatic relief of fluid retention 1

  • While diuretics improve symptoms, they have not been shown to improve prognosis in HFpEF 1
  • Consider thiazide diuretics in combination with loop diuretics for refractory fluid overload 3

• SGLT2 inhibitors: Dapagliflozin or empagliflozin regardless of diabetes status 1, 4

  • Reduce hospitalizations for heart failure (HR: 0.77-0.82) based on DELIVER and EMPEROR-PRESERVED trials 1
  • Can be initiated safely in both acute and chronic settings 1

Additional Therapies to Consider

• Mineralocorticoid Receptor Antagonists (MRAs): Consider spironolactone in selected patients 1

  • May reduce hospitalizations for heart failure based on regional data from TOPCAT trial 1
  • Indicated primarily for NYHA Class II-IV symptoms 1

• Beta-blockers or Calcium Channel Blockers: Consider for symptomatic improvement 1

  • Beta-blockers, verapamil, or diltiazem may be beneficial for patients with NYHA Class II-IV symptoms 1
  • These agents help improve heart failure symptoms by slowing heart rate and improving LV filling 1

• Angiotensin Receptor-Neprilysin Inhibitors (ARNIs): Consider sacubitril/valsartan in selected patients 1

  • May provide modest benefit in reducing heart failure hospitalizations 1
  • More effective in patients with ejection fraction in the lower range of preservation (45-57%) 1, 5

Management of Comorbidities

• Hypertension: Tight blood pressure control is essential 1

  • Target BP <140/90 mmHg, or <130/80 mmHg in patients with high cardiovascular risk 1
  • ACE inhibitors, ARBs, and calcium channel blockers may be used 1, 6

• Atrial Fibrillation: Rate control strategy with appropriate anticoagulation 3, 2

  • Beta-blockers or non-dihydropyridine calcium channel blockers for rate control 3
  • Evaluate for and treat atrial fibrillation, which is common in HFpEF patients 3

• Diabetes: Consider SGLT2 inhibitors as first-line therapy 1

  • Also consider GLP-1 receptor agonists, particularly in obese diabetic patients 4

• Obesity: Weight reduction and regular physical activity 1, 5

  • Supervised exercise training improves exercise capacity and quality of life 3

Acute Decompensated HFpEF Management

• Intravenous loop diuretics are first-line for acute fluid overload 3

  • Initial parenteral dose should be greater than or equal to the patient's chronic oral daily dose 3
  • Consider higher doses or addition of thiazide diuretics if diuresis is inadequate 3

• Monitor electrolytes, renal function, and blood pressure during diuresis 3

  • Avoid excessive diuresis which may lead to renal dysfunction 3

• Continue guideline-directed medical therapy during hospitalization unless hemodynamically unstable 3

Common Pitfalls to Avoid

• Avoid excessive diuresis leading to renal dysfunction and electrolyte abnormalities 3
• Don't abruptly discontinue beta-blockers in heart failure patients 3
• Avoid non-dihydropyridine calcium channel blockers in patients with decompensated heart failure 3
• Don't overlook the importance of treating comorbidities, which significantly impact outcomes in HFpEF 1, 5

Advanced Options

• Consider cardiac transplantation in eligible patients with advanced HFpEF 1
• Consider referral to a heart failure specialist for patients with refractory symptoms despite optimal medical therapy 1