In a new diagnosis of stable heart failure with preserved ejection fraction (EF) and moderately elevated right ventricular (RV) pressure, what is the most important cardiac medication to initiate, such as a beta-blocker or Angiotensin-Converting Enzyme (ACE) inhibitor?

From the FDA Drug Label

Enalapril maleate is indicated for the treatment of symptomatic congestive heart failure, usually in combination with diuretics and digitalis. In these patients enalapril maleate improves symptoms, increases survival, and decreases the frequency of hospitalization

The most important cardiac medication to initiate in a new diagnosis of stable heart failure with preserved ejection fraction (EF) and moderately elevated right ventricular (RV) pressure is an Angiotensin-Converting Enzyme (ACE) inhibitor, such as enalapril.

• Key benefits of ACE inhibitors in heart failure include improved symptoms, increased survival, and decreased hospitalization.
• Clinical use: Enalapril maleate is usually used in combination with diuretics and digitalis. 1

From the Research

For a new diagnosis of stable heart failure with preserved ejection fraction (HFpEF) and moderately elevated right ventricular pressure, the most important cardiac medication to initiate is a sodium-glucose co-transporter 2 (SGLT2) inhibitor, such as dapagliflozin or empagliflozin, unless contraindicated, as recommended by the most recent evidence 2.

Key Considerations

• The diagnosis of HFpEF can be challenging and requires a comprehensive approach, including the use of algorithms such as H2FPEF and HFA-PEFF to determine the likelihood of HFpEF in individuals with symptoms of heart failure 2.
• SGLT2 inhibitors have been shown to be beneficial in patients with HFpEF, and their use is recommended unless contraindicated 2.
• Diuretics, such as loop diuretics, may also be used to address volume overload and congestion, but they are not the primary recommended treatment for HFpEF 2.
• Other medications, such as ACE inhibitors, ARBs, and beta-blockers, have not consistently shown mortality benefits in HFpEF and are not the primary recommended treatment 3, 4, 5, 6.

Treatment Approach

• Initiate SGLT2 inhibitor therapy, unless contraindicated, to address the underlying pathophysiology of HFpEF 2.
• Monitor patients closely for signs and symptoms of heart failure, and adjust treatment as needed to optimize outcomes.
• Consider the use of diuretics, such as loop diuretics, to address volume overload and congestion, but use them judiciously and with careful monitoring of electrolytes, renal function, and blood pressure.
• Treat underlying conditions, such as hypertension, atrial fibrillation, and coronary artery disease, to comprehensive manage patients with HFpEF.