What is the initial treatment approach for patients with Heart Failure with preserved Ejection Fraction (HFpEF) presenting with symptoms of orthopnea and Paroxysmal Nocturnal Dyspnea (PND)?

Initial Treatment for HFpEF with Orthopnea and PND

Loop diuretics are the first-line treatment for patients with Heart Failure with Preserved Ejection Fraction (HFpEF) presenting with orthopnea and Paroxysmal Nocturnal Dyspnea (PND) to relieve congestion and improve symptoms. 1

Diuretic Therapy for Symptom Management

• Start with loop diuretics (furosemide, torsemide, or bumetanide) at the lowest effective dose to manage fluid retention and relieve congestion 1, 2
• For new-onset HFpEF with orthopnea/PND, the initial recommended dose is 20-40 mg IV furosemide (or equivalent); for those on chronic diuretic therapy, initial IV dose should be at least equivalent to oral dose 1
• Titrate diuretic dose based on symptoms, urine output, renal function, and electrolytes 1, 2
• If inadequate response to initial loop diuretic therapy despite dose increases, consider:
  • Changing to a different loop diuretic 1
  • Adding a thiazide diuretic for sequential nephron blockade 1
  • Adding spironolactone in selected patients 1, 2

Disease-Modifying Therapy

After achieving euvolemia with diuretics, initiate disease-modifying therapy:

• SGLT2 inhibitors (dapagliflozin or empagliflozin) should be initiated as first-line disease-modifying therapy for HFpEF 1, 2, 3

  • DELIVER trial showed dapagliflozin reduced worsening HF and CV death (HR: 0.82; 95% CI: 0.73-0.92) 1, 2
  • EMPEROR-PRESERVED trial showed empagliflozin reduced hospitalization for HF and CV death (HR: 0.79; 95% CI: 0.69-0.90) 1, 2
  • Ensure eGFR >30 mL/min/1.73m² for dapagliflozin and >60 mL/min/1.73m² for empagliflozin before initiation 1

• Mineralocorticoid receptor antagonists (MRAs) like spironolactone may be considered, particularly in patients with LVEF in the lower range of preservation (40-50%) 1, 2

  • TOPCAT trial showed spironolactone reduced heart failure hospitalizations (HR: 0.83; 95% CI: 0.69-0.99) 1, 2
  • Monitor potassium, renal function, and diuretic dosing closely to minimize risk of hyperkalemia 1, 2

• Sacubitril/valsartan may be considered for selected patients, especially women and those with LVEF in the lower preserved range (45-57%) 1, 2

  • PARAGON-HF trial showed potential benefit in specific subgroups, though it did not meet its primary endpoint in the overall population 2, 4

Management of Comorbidities

• Optimize blood pressure control to target <130/80 mmHg using appropriate antihypertensive medications 2
• Manage atrial fibrillation if present with rate control and anticoagulation based on CHA₂DS₂-VASc score 5
• Address other common comorbidities including diabetes, obesity, and sleep apnea 1, 3

Non-Pharmacological Interventions

• Prescribe supervised exercise training programs to improve functional capacity and quality of life 2, 3, 6
• Consider dietary sodium restriction and fluid restriction in patients with significant fluid retention 1
• Provide education on heart failure self-care (medication adherence, symptom monitoring, dietary restrictions) 3

Monitoring and Follow-up

• Regularly assess volume status, renal function, and electrolytes, especially with diuretic and MRA therapy 2, 7
• Monitor for improvement in orthopnea and PND as indicators of treatment success 4, 8
• Consider wireless, implantable pulmonary artery monitors in selected patients for optimizing volume status 1

Common Pitfalls to Avoid

• Don't delay diuretic therapy when orthopnea and PND are present, as these are clear signs of congestion requiring prompt treatment 7, 8
• Avoid treating HFpEF patients the same as those with reduced ejection fraction, as response to therapies differs 2
• Don't overlook the importance of managing comorbidities, which significantly impact outcomes in HFpEF 1
• Avoid excessive diuresis which may lead to hypotension and worsening renal function 1, 7