Management of Heart Failure with Preserved Ejection Fraction (HFpEF)
SGLT2 inhibitors should be initiated as first-line disease-modifying therapy for HFpEF patients, with diuretics used for symptom management and congestion relief. 1, 2
Diagnostic Confirmation
- Confirm HFpEF diagnosis by establishing heart failure symptoms with LVEF ≥50%, elevated natriuretic peptides, and evidence of structural heart disease or elevated filling pressures 3
- Rule out HFpEF mimics such as cardiac amyloidosis, hypertrophic cardiomyopathy, or pericardial disease which may require specific treatments 3
Pharmacological Management
First-Line Disease-Modifying Therapy
- Initiate SGLT2 inhibitors (dapagliflozin or empagliflozin) early as they have demonstrated significant reductions in heart failure hospitalizations and mortality in HFpEF patients 1, 3, 2
- The DELIVER and EMPEROR-PRESERVED trials provide strong evidence for SGLT2 inhibitors with hazard ratios of 0.82 and 0.79 respectively for the primary composite outcomes 1, 2
Symptom Management
- Use loop diuretics as the cornerstone for symptom relief in congested patients, using the lowest effective dose to reduce fluid overload 1, 3, 4
- Titrate diuretic dose based on symptoms and volume status before considering combination diuretic strategies 4, 2
- Consider increasing diuretic dose before adding a thiazide diuretic if initial response is inadequate 4, 2
Additional Pharmacological Options
- Consider mineralocorticoid receptor antagonists (MRAs) like spironolactone, particularly in patients with LVEF in the lower range of preservation (40-50%) 1, 3, 2
- The TOPCAT trial showed benefit in North American participants with a hazard ratio of 0.82 for the primary composite outcome 1
- Consider angiotensin receptor-neprilysin inhibitors (ARNIs) such as sacubitril/valsartan for selected patients, especially women and those with LVEF in the lower preserved range 3, 2
Management of Comorbidities
- Achieve optimal blood pressure control (<130/80 mmHg) using appropriate antihypertensive medications 3, 2
- For patients with atrial fibrillation, control rate using beta-blockers or non-dihydropyridine calcium channel blockers 3, 4
- Prioritize SGLT2 inhibitors for glycemic control in diabetic patients given their additional heart failure benefits 3, 2
- Address obesity through structured weight loss programs as it is a common comorbidity in HFpEF 1, 2
- Screen for and treat obstructive sleep apnea which can exacerbate HFpEF 1
Non-Pharmacological Interventions
- Prescribe supervised exercise training programs to improve functional capacity and quality of life 3, 4, 5
- Recommend sodium restriction (<2-3g/day) and fluid restriction when appropriate 3
- Offer multidisciplinary heart failure programs to all patients 2
Monitoring and Follow-up
- Monitor symptoms, vital signs, weight, renal function, and electrolytes regularly 3, 4
- Adjust diuretic doses based on congestion status to avoid overdiuresis which can lead to hypotension 3, 4
- Consider wireless pulmonary artery pressure monitoring in selected patients with recurrent hospitalizations 3
Acute Decompensation Management
- Use intravenous loop diuretics as first-line treatment for acute decompensated HFpEF 4, 6
- Initial parenteral dose should be greater than or equal to the patient's chronic oral daily dose 4
- For patients with acute exacerbation and rapid atrial fibrillation, provide rate control with negative chronotropic agents 6
Common Pitfalls to Avoid
- Do not delay initiation of SGLT2 inhibitors which have proven mortality benefits 3, 2
- Avoid excessive diuresis which can lead to hypotension and impaired tolerance of other medications 3, 4
- Do not treat HFpEF patients the same as those with reduced ejection fraction, as response to therapies differs 2, 6