What is the medical management of congestive heart failure (CHF) with preserved ejection fraction (EF)?

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