From the Guidelines
Heart failure with preserved ejection fraction (HfpEF) is best managed initially with diuretics, particularly loop diuretics like furosemide (20-40mg daily) or torsemide (10-20mg daily), to reduce fluid overload and improve symptoms, as well as SGLT2 inhibitors, such as empagliflozin (10mg daily), which have shown benefit in reducing hospitalizations (1). These medications should be titrated based on symptom relief and fluid status. Additionally, treating underlying conditions is crucial, including:
- Blood pressure control with ACE inhibitors or ARBs
- Managing diabetes with medications like SGLT2 inhibitors
- Addressing coronary artery disease if present Lifestyle modifications are essential components of first-line therapy, including:
- Sodium restriction (<2-3g daily)
- Regular physical activity (aim for 30 minutes of moderate exercise most days)
- Weight management for overweight patients Unlike heart failure with reduced ejection fraction, traditional heart failure medications like beta-blockers and mineralocorticoid receptor antagonists have less established benefit in HFpEF, though they may be used for specific comorbidities (1). The goal of treatment is to improve quality of life by reducing symptoms of fluid overload while addressing the underlying causes of cardiac stiffness and diastolic dysfunction. It is also important to note that the optimal blood pressure goal and antihypertensive regimens are not known for patients with HFpEF, but RAAS antagonists, including ACEi, ARB, MRA, and possibly ARNi, could be first-line agents given experience with their use in HFpEF trials (1). Overall, the management of HFpEF should be individualized and guided by the latest clinical practice guidelines and recommendations (1).
From the Research
Treatment of Heart Failure with Preserved Ejection Fraction (HFpEF)
The first line treatment for HFpEF is not clearly defined, but several studies suggest the following approaches:
- Treatment of comorbidities, such as hypertension, myocardial ischemia, and atrial fibrillation, may improve symptoms and quality of life 2, 3, 4, 5
- Control of volume status is also an important aspect of HFpEF management 4, 5
- Regular aerobic activity is recommended as an effective treatment for HFpEF 2
- Loop diuretics may be used in cases of clinical congestion 2
- ACE-inhibitors, beta-blockers, and anti-aldosterones, which are effective in heart failure with reduced ejection fraction (HFrEF), have shown limited benefit in HFpEF, with some studies suggesting a reduction in hospitalization rate 2, 6
- Mineralocorticoid receptor antagonists, soluble guanylate cyclase stimulators, and angiotensin receptor-neprilysin inhibitors are being researched as potential new therapies for HFpEF 3, 6
Ongoing Research and Future Directions
Several ongoing trials are investigating the efficacy of new therapies for HFpEF, including: