Medical Management of Heart Failure with Preserved Ejection Fraction (HFpEF)
SGLT2 inhibitors (dapagliflozin or empagliflozin) should be considered first-line disease-modifying therapy for HFpEF patients, as they have demonstrated significant reductions in heart failure hospitalizations and cardiovascular death. 1, 2
Core Pharmacological Management
Disease-Modifying Therapies
- SGLT2 inhibitors (dapagliflozin or empagliflozin) are the cornerstone of HFpEF management, with strong evidence demonstrating approximately 20% reduction in heart failure hospitalization and cardiovascular death compared to placebo 2, 3
- Mineralocorticoid receptor antagonists (MRAs) like spironolactone should be considered, particularly in patients with LVEF in the 40-50% range, as they can reduce heart failure hospitalizations 1, 2
- Angiotensin receptor-neprilysin inhibitors (ARNIs) such as sacubitril/valsartan may benefit selected patients, especially women and those with LVEF in the lower preserved range 1, 2
Symptom Management
- Loop diuretics remain the cornerstone for symptom relief in congested patients, using the lowest effective dose to reduce fluid overload 1, 4
- Diuretic doses should be adjusted based on congestion status to avoid overdiuresis which can lead to hypotension 1
- Consider increasing diuretic dose before adding combination therapy if initial response is inadequate 1
Management of Comorbidities
- Optimal blood pressure control (<130/80 mmHg) is essential using appropriate antihypertensive medications 1
- For patients with atrial fibrillation, control rate using beta-blockers or non-dihydropyridine calcium channel blockers 1
- SGLT2 inhibitors should be prioritized for glycemic control in diabetic patients given their additional heart failure benefits 1, 3
- Address obesity through structured weight loss programs, as obesity is a significant risk factor for HFpEF 3, 5
- Screen for and treat sleep apnea, which is common in HFpEF patients and can worsen outcomes 5
Non-Pharmacological Interventions
- Supervised exercise training programs should be prescribed to improve functional capacity and quality of life 6, 1
- Sodium restriction (<2-3g/day) and fluid restriction when appropriate are recommended 1
- Education in heart failure self-care (medication adherence, dietary restrictions, symptom monitoring) is crucial to prevent decompensation 3
- Consider wireless pulmonary artery pressure monitoring in selected patients with recurrent hospitalizations 1, 4
Monitoring and Follow-up
- Regular monitoring of symptoms, vital signs, weight, renal function, and electrolytes is essential, especially with MRA therapy 1, 2
- Natriuretic peptide levels can be used to assess disease severity, though NT-proBNP-guided therapy may not be beneficial in HFpEF (in contrast to HFrEF) 7
- Therapy should be adjusted based on clinical response and tolerability 2
Prognostic Considerations
- Several factors predict worse outcomes in HFpEF, including age >80 years, serum albumin <3.2 g/dl, NT-proBNP >5,000 pg/mL, and medial E/e' ≥20 8
- The annual mortality rate for HFpEF is approximately 15%, highlighting the importance of optimal management 3
Common Pitfalls to Avoid
- Delaying initiation of SGLT2 inhibitors, which have proven mortality benefits 1
- Excessive diuresis leading to hypotension and impaired tolerance of other medications 1
- Failing to address comorbidities, which significantly contribute to HFpEF pathophysiology and progression 5
- Overlooking non-pharmacological interventions like exercise and weight loss, which can produce clinically meaningful increases in functional capacity 3