What is the treatment for Heart Failure with preserved Ejection Fraction (HFpEF)?

Treatment for Heart Failure with Preserved Ejection Fraction (HFpEF)

SGLT2 inhibitors (dapagliflozin or empagliflozin) should be the first-line disease-modifying therapy for most patients with HFpEF, as they have demonstrated significant reductions in heart failure hospitalizations and composite cardiovascular outcomes. 1, 2

First-Line Management Approach

Disease-Modifying Therapy

• SGLT2 inhibitors are the cornerstone of HFpEF treatment with strong evidence from DELIVER and EMPEROR-PRESERVED trials showing reduction in worsening HF events and hospitalizations 1
• Initiate SGLT2 inhibitors early in the treatment course to maximize mortality and morbidity benefits 2
• Do not delay starting SGLT2 inhibitors as they have proven cardiovascular benefits across the spectrum of preserved ejection fraction 1, 2

Symptom Management

• Loop diuretics should be used at the lowest effective dose to manage fluid retention and relieve congestion 3, 1
• Titrate diuretic dose based on symptoms and volume status before considering combination diuretic strategies 3
• If initial diuretic response is inadequate, consider dose increase before adding a thiazide diuretic 3, 2

Additional Pharmacological Options

• Mineralocorticoid receptor antagonists (MRAs) like spironolactone can be considered, particularly in patients with LVEF in the lower range of preservation (40-50%) 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
• Angiotensin receptor blockers (ARBs) can be considered in specific patient populations 1
• Beta-blockers are not recommended as primary HFpEF therapy unless specific indications exist (e.g., recent myocardial infarction, angina, atrial fibrillation requiring rate control) 1

Management of Comorbidities

• Optimize blood pressure control to target <130/80 mmHg using appropriate antihypertensive medications 2
• For patients with atrial fibrillation, control rate using beta-blockers or non-dihydropyridine calcium channel blockers 2
• Manage diabetes with preference for SGLT2 inhibitors given their additional heart failure benefits 2
• Address other common comorbidities including obesity, coronary artery disease, chronic kidney disease, and obstructive sleep apnea 1

Non-Pharmacological Interventions

• Prescribe supervised exercise training programs to improve functional capacity and quality of life 2, 4
• Recommend sodium restriction (<2-3g/day) and fluid restriction when appropriate 2
• Consider weight reduction strategies for obese patients 5
• Multidisciplinary heart failure programs should be offered to all patients 3

Monitoring and Follow-up

• Regularly assess volume status, renal function, and electrolytes, especially with MRA therapy 1, 2
• Monitor symptoms and functional capacity to guide treatment adjustments 1
• Consider natriuretic peptide levels to assess disease severity 1
• Adjust therapy based on clinical response and tolerability 1
• In selected patients with recurrent hospitalizations, consider wireless pulmonary artery pressure monitoring 2

Common Pitfalls to Avoid

• Avoid excessive diuresis which can lead to hypotension and reduced tolerance of other medications 2
• Do not treat HFpEF patients the same as those with reduced ejection fraction, as response to therapies differs 3, 6
• Recognize that HFpEF is heterogeneous and may require phenotype-specific approaches 1, 4
• Don't overlook "HFpEF mimics" such as cardiac amyloidosis, hypertrophic cardiomyopathy, or pericardial disease which require specific treatments 2

Advanced Treatment Options

• For patients with advanced HFpEF refractory to standard therapies, consider referral to an advanced heart failure specialist team 3
• Cardiac transplantation can be considered in eligible patients with advanced HFpEF 3