What is the treatment approach for a patient with heart failure with preserved ejection fraction (HFpEF), atrial fibrillation, and chronic obstructive pulmonary disease (COPD)?

Treatment for Heart Failure with Preserved Ejection Fraction with Atrial Fibrillation and COPD

SGLT2 inhibitors (empagliflozin or dapagliflozin) should be the first-line disease-modifying therapy for patients with HFpEF who have atrial fibrillation and COPD. 1, 2, 3

First-Line Disease-Modifying Therapy

• SGLT2 inhibitors have demonstrated significant reductions in heart failure hospitalizations and composite cardiovascular outcomes in patients with HFpEF, as evidenced by the DELIVER and EMPEROR-PRESERVED trials 2, 4
• These medications should be initiated early in the treatment course to maximize mortality and morbidity benefits 2
• SGLT2 inhibitors are particularly beneficial in HFpEF patients with comorbidities including atrial fibrillation 3, 4

Management of Atrial Fibrillation in HFpEF

• Rate control is generally the preferred initial strategy over rhythm control for HFpEF patients with AF 3, 5
• Beta-blockers are the preferred agents for achieving rate control in HFpEF patients with AF due to their favorable effects on controlling ventricular response 3, 6
• Non-dihydropyridine calcium channel antagonists (such as diltiazem) can be effective for rate control, particularly when used in combination with digoxin 3
• Anticoagulation should be prescribed based on CHA₂DS₂-VASc score to prevent thromboembolic events 1, 5

Symptom Management and Volume Control

• Loop diuretics should be used at the lowest effective dose to manage fluid retention and relieve congestion 2, 3, 4
• Titrate the diuretic dose based on symptoms and volume status before considering combination diuretic strategies 2
• Consider increasing the dose of loop diuretics before adding a thiazide diuretic if the initial diuretic response is inadequate 2

Additional Pharmacological Options

• Mineralocorticoid receptor antagonists (MRAs) like spironolactone should be considered, particularly in patients with LVEF in the lower range of preservation (40-50%) 2, 4
• Angiotensin receptor-neprilysin inhibitors (ARNIs) such as sacubitril/valsartan may be beneficial for selected patients, especially women and those with LVEF in the lower preserved range 2, 4
• Careful monitoring of renal function and electrolytes is essential when using MRAs, especially in patients with COPD who may be on other medications 4

Management of COPD in HFpEF Patients

• Optimize COPD management according to standard guidelines while being mindful of potential drug interactions 1
• Beta-blockers for AF rate control should be used cautiously in patients with COPD, with preference for cardioselective agents 1, 3
• Avoid medications that may worsen either condition (e.g., non-selective beta-blockers may exacerbate bronchospasm in COPD) 1

Management of Other Comorbidities

• Optimize blood pressure control to target <130/80 mmHg using appropriate antihypertensive medications 2, 3
• Manage diabetes with preference for SGLT2 inhibitors given their additional heart failure benefits 2, 3
• Address obesity through structured weight loss programs, as weight reduction can improve both HFpEF and AF symptoms 2, 7

Non-Pharmacological Interventions

• Prescribe supervised exercise training programs to improve functional capacity and quality of life 2
• Offer multidisciplinary heart failure programs to all patients 2
• Salt and fluid restriction should be recommended to help manage volume status 8

Monitoring and Follow-up

• Regularly assess volume status, renal function, and electrolytes, especially with MRA therapy 2, 4
• Monitor symptoms and functional capacity to guide treatment adjustments 2, 4
• Consider wireless pulmonary artery pressure monitoring in selected cases to guide volume management 4

Advanced Treatment Options

• Consider AV node ablation and cardiac resynchronization therapy device placement when rate control cannot be achieved either because of drug inefficacy or intolerance 3
• Referral to an advanced heart failure specialist team should be considered for patients with advanced HFpEF refractory to standard therapies 2