What are the most important cardiac medications to initiate in a patient with Heart Failure (HF) with preserved Ejection Fraction (EF) and moderately elevated right-sided pressures, such as beta blockers (e.g. Beta Blocker) and Angiotensin-Converting Enzyme (ACE) inhibitors?

From the Guidelines

For a patient with Heart Failure (HF) with preserved Ejection Fraction (EF) and moderately elevated right-sided pressures, the most important cardiac medications to initiate are beta blockers, such as metoprolol succinate, and Angiotensin-Converting Enzyme (ACE) inhibitors, like lisinopril, to control heart rate, improve diastolic filling time, and manage comorbidities like hypertension. The use of beta blockers in HFpEF is supported by the 2022 AHA/ACC/HFSA guideline for the management of heart failure, which recommends the use of beta blockers, specifically bisoprolol, sustained-release metoprolol, and carvedilol, in patients with heart failure, although the evidence is more robust for heart failure with reduced ejection fraction (HFrEF) 1. In the context of HFpEF, beta blockers like metoprolol succinate (25-200mg daily) can help control heart rate and improve diastolic filling time, which is beneficial for patients with elevated right-sided pressures. Additionally, ACE inhibitors, such as lisinopril (starting at 2.5-5mg daily), are essential for blood pressure control and can help reduce afterload, which is beneficial for patients with HFpEF and elevated right-sided pressures. The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation also supports the use of beta blockers to control resting heart rate in patients with persistent or permanent AF and compensated HF with preserved ejection fraction (HFpEF) 1. It is crucial to individualize treatment based on the patient's specific comorbidities, such as hypertension, atrial fibrillation, or coronary artery disease, which often drive therapy in HFpEF. Mineralocorticoid receptor antagonists like spironolactone (25mg daily) may also be beneficial, especially if there's evidence of pulmonary hypertension. The primary goal of treatment in HFpEF is symptom management and treating comorbidities, as the evidence for mortality benefit with these medications is less robust compared to HFrEF. Diuretics, particularly loop diuretics like furosemide (20-40mg daily or twice daily), are also essential to reduce fluid overload and congestive symptoms by decreasing preload and lowering right-sided pressures. In summary, the treatment of HFpEF with elevated right-sided pressures should focus on controlling heart rate, managing comorbidities, and reducing fluid overload, with beta blockers, ACE inhibitors, and diuretics being the cornerstone of therapy.

From the Research

Important Cardiac Medications for Heart Failure with Preserved Ejection Fraction

The most important cardiac medications to initiate in a patient with Heart Failure (HF) with preserved Ejection Fraction (EF) and moderately elevated right-sided pressures include:

• Beta blockers (e.g. Beta Blocker)
• Angiotensin-Converting Enzyme (ACE) inhibitors

Rationale for Initiating Beta Blockers and ACE Inhibitors

The rationale for initiating these medications is based on several studies, including:

• A study published in 2006 2 which found that initiating therapy with a beta-blocker followed by an ACEI was similarly efficacious to the opposite sequence in terms of combined mortality and all-cause hospitalization in patients with systolic CHF.
• A study published in 2018 3 which found that high-dose beta-blocker use was associated with a significantly lower risk of death in patients with HFpEF and heart rate ≥70 beats per minute.
• A study published in 2019 4 which found that higher doses of ACEIs and ARBs reduced the risk of HF worsening compared to lower doses, and higher doses of ARBs also reduced the risk of HF hospitalization.

Considerations for Combining Beta Blockers and ACE Inhibitors

When combining beta blockers and ACE inhibitors, considerations include:

• The potential for increased risk of adverse events, such as hypotension, dizziness, and hyperkalemia 4.
• The importance of tailoring therapy to individual patients based on their hypertension subclass and cardiovascular risk profile 5.
• The use of single-pill combinations to improve adherence and achieve treatment targets 5.

Additional Considerations for Patients with Heart Failure

Additional considerations for patients with heart failure include:

• The use of beta blockers and ACEIs as initial therapy, followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic based on volume status 6.
• The importance of optimizing treatment to achieve adequate blood pressure control and reduce cardiovascular risk 6.