What are the treatment options for patients with heart failure with preserved ejection fraction (HFpEF)?

Treatment Options for Heart Failure with Preserved Ejection Fraction (HFpEF)

SGLT2 inhibitors (dapagliflozin or empagliflozin) should be the first-line disease-modifying therapy for patients with HFpEF due to their proven benefits in reducing hospitalization and cardiovascular death. 1, 2

Pharmacological Management

Disease-Modifying Therapies

• SGLT2 inhibitors (dapagliflozin, empagliflozin) have demonstrated significant reduction in the primary composite outcome of worsening heart failure and cardiovascular death (HR: 0.82 and 0.79 respectively) and should be initiated early in treatment 1
• Mineralocorticoid receptor antagonists (MRAs) like spironolactone can be considered, particularly in patients with LVEF in the 40-50% range, based on post-hoc analyses of the TOPCAT trial showing reduction in heart failure hospitalizations 1, 2
• Sacubitril/valsartan (ARNI) may benefit selected patients, especially women and those with LVEF in the lower preserved range (45-57%), based on FDA approval and the PARAGON-HF trial 1, 2
• ARBs such as candesartan may be considered in patients who cannot tolerate other therapies, though evidence for mortality benefit is limited 1

Symptom Management

• Loop diuretics remain the cornerstone for symptom relief in congested patients and should be used at the lowest effective dose to reduce fluid overload and improve exercise capacity 1, 2
• Thiazide diuretics may be used alone or in combination with loop diuretics for resistant edema 1
• Careful diuretic titration is essential to avoid dehydration, hypotension, and renal dysfunction 1, 2

Non-Pharmacological Interventions

• Supervised exercise training is strongly recommended to improve functional capacity, quality of life, and exercise tolerance in HFpEF patients 1, 2
• Sodium restriction (<2-3g/day) and fluid restriction when appropriate should be recommended to all patients 2
• Weight loss should be encouraged in obese patients with HFpEF as it can improve exercise capacity and symptoms 1, 3
• Wireless pulmonary artery pressure monitoring may be beneficial in selected patients with recurrent hospitalizations 1, 2

Management of Comorbidities

• Hypertension should be aggressively controlled to target <130/80 mmHg using appropriate antihypertensive medications 1, 2
• For patients with atrial fibrillation, rate control using beta-blockers or non-dihydropyridine calcium channel blockers is recommended 1, 2
• Coronary revascularization should be considered for patients with HFpEF and significant coronary artery disease 4
• SGLT2 inhibitors should be prioritized for glycemic control in diabetic patients with HFpEF 2

Treatment Algorithm

1. First step: Confirm HFpEF diagnosis and rule out mimics (cardiac amyloidosis, hypertrophic cardiomyopathy) 2
2. Second step: Initiate loop diuretics for symptom relief if congestion is present 1, 2
3. Third step: Start SGLT2 inhibitor (dapagliflozin or empagliflozin) as first-line disease-modifying therapy 1, 2
4. Fourth step: Consider adding MRA (spironolactone) particularly if LVEF is 40-50% 1, 2
5. Fifth step: Consider ARNI (sacubitril/valsartan) in selected patients, especially women and those with LVEF <57% 1, 2
6. Sixth step: Optimize management of comorbidities (hypertension, atrial fibrillation, diabetes) 1, 2
7. Seventh step: Prescribe supervised exercise training program 1

Common Pitfalls to Avoid

• Delaying initiation of SGLT2 inhibitors which have proven mortality benefits 1, 2
• Excessive diuresis leading to hypotension and impaired tolerance of other medications 1, 2
• Using treatments proven effective in HFrEF without evidence in HFpEF (such as beta-blockers for patients without specific indications like prior MI, angina, or AF) 1, 5
• Failing to address underlying comorbidities that contribute significantly to HFpEF pathophysiology 3, 6
• Overlooking the importance of exercise training, which has shown benefits for improving functional capacity 1