What is the treatment for heart failure with preserved ejection fraction (HFpEF)?

Treatment of Heart Failure with Preserved Ejection Fraction (HFpEF)

SGLT2 inhibitors (dapagliflozin or empagliflozin) are the cornerstone of disease-modifying therapy for HFpEF, with diuretics providing symptomatic relief of congestion. 1, 2

First-Line Pharmacological Management

Symptom Management

• Loop diuretics are unanimously recommended for treating fluid retention and providing symptomatic relief in HFpEF patients 1, 2
• Use the lowest effective dose to reduce fluid overload while avoiding excessive diuresis which can lead to hypotension and renal dysfunction 2, 3
• Consider adding thiazide diuretics as an adjunct for refractory cases, particularly in patients with hypertension or inadequate response to loop diuretics alone 1

Disease-Modifying Therapy

• SGLT2 inhibitors (dapagliflozin or empagliflozin) should be initiated early as they have demonstrated reduction in heart failure hospitalizations and mortality benefits in HFpEF patients 1, 2
• Mineralocorticoid receptor antagonists (MRAs) like spironolactone may be considered, particularly in patients with LVEF in the lower range of preservation (40-50%) 2, 1
• Angiotensin receptor-neprilysin inhibitors (ARNIs, sacubitril/valsartan) may benefit selected patients, especially women and those with LVEF in the lower preserved range 2

Management of Comorbidities

• Optimal blood pressure control (<130/80 mmHg) is essential as hypertension is a common comorbidity in HFpEF 2, 4
• For patients with atrial fibrillation, rate control using beta-blockers or non-dihydropyridine calcium channel blockers is recommended 2, 3
• Prioritize SGLT2 inhibitors for glycemic control in diabetic patients with HFpEF given their additional heart failure benefits 2, 4
• Identify and treat other common comorbidities including obesity, sleep apnea, anemia, and renal dysfunction 1, 4

Non-Pharmacological Interventions

• Supervised exercise training programs are strongly recommended to improve functional capacity and quality of life in stable HFpEF patients 1
• Exercise training has demonstrated large, clinically meaningful improvements in symptoms and objectively determined exercise capacity in HFpEF 1
• Sodium restriction (<2-3g/day) and fluid restriction are recommended dietary modifications 2, 5
• Multidisciplinary heart failure programs should be offered to provide comprehensive care, including patient education on self-management 1

Monitoring and Follow-up

• Regular monitoring of symptoms, vital signs, weight, renal function, and electrolytes is essential 2
• Adjust diuretic doses based on congestion status to maintain euvolemia 3
• Consider wireless pulmonary artery pressure monitoring in selected patients with recurrent hospitalizations 2, 3
• Cardiac rehabilitation with medical assessment, patient education, psychosocial support, and exercise training is recommended despite limited data specific to HFpEF 1

Acute Decompensation Management

• Intravenous loop diuretics are the first-line treatment for acute decompensated HFpEF 1, 3
• Initial parenteral dose should be greater than or equal to the patient's chronic oral daily dose 3
• For refractory cases, consider sequential nephron blockade with addition of thiazide diuretics or ultrafiltration 3
• Non-invasive ventilatory support may be considered for persistent hypoxia and tachypnea despite oxygen therapy 1

Common Pitfalls to Avoid

• Do not delay initiation of SGLT2 inhibitors which have proven mortality benefits 2
• Avoid excessive diuresis which can lead to hypotension and impaired tolerance of other medications 2, 3
• Do not abruptly discontinue beta-blockers in HF patients as this can lead to rebound tachycardia and worsening HF 3
• Avoid treating HFpEF patients with the same approach as HFrEF patients, as treatment efficacy differs between these conditions 5, 4

Future Directions

• Phenotype-guided approaches to HFpEF management may allow for more targeted therapies as our understanding of this heterogeneous syndrome improves 6, 4
• Further research is needed to investigate the potential benefits of combined SGLT2 and SGLT1 inhibition, GLP-1 receptor agonists, and non-steroidal MRAs in HFpEF management 1
• Ongoing trials like REHAB-HFpEF and REACH-HFpEF aim to provide more evidence on the effects of cardiac rehabilitation specifically in HFpEF patients 1