What are the primary duties in managing patients with Heart Failure with preserved Ejection Fraction (HFpEF)?

Primary Duties in Managing HFpEF

The core duties in managing HFpEF patients center on early initiation of SGLT2 inhibitors for disease modification, diuretic optimization for symptom control, aggressive comorbidity management, and implementation of supervised exercise programs—all while maintaining regular monitoring to prevent decompensation. 1, 2

Immediate Diagnostic Confirmation

• Establish the diagnosis using a two-step approach: confirm heart failure symptoms with LVEF ≥50%, elevated natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL), and evidence of structural heart disease or diastolic dysfunction on echocardiography. 1, 2
• Rule out HFpEF mimics including cardiac amyloidosis, hypertrophic cardiomyopathy, and constrictive pericarditis, as these require entirely different treatment strategies. 1
• Proceed to stress testing (exercise echocardiography or invasive hemodynamics) if the diagnosis remains uncertain after initial evaluation. 1

Disease-Modifying Pharmacotherapy (First Priority)

SGLT2 Inhibitors - The Foundation

• Initiate dapagliflozin 10 mg daily or empagliflozin 10 mg daily immediately upon diagnosis, as these are the only medications proven to reduce cardiovascular death and heart failure hospitalizations in HFpEF. 1, 2
• Dapagliflozin reduced the composite endpoint of worsening heart failure and cardiovascular death by 18% (HR 0.82) and heart failure hospitalizations by 23% (HR 0.77) in the DELIVER trial. 2
• Empagliflozin reduced heart failure hospitalization or cardiovascular death by 21% (HR 0.79) in EMPEROR-PRESERVED. 2
• Do not delay initiation of SGLT2 inhibitors—this is a critical pitfall that deprives patients of proven mortality benefit. 1

Additional Disease-Modifying Agents

• Consider mineralocorticoid receptor antagonists (MRAs) like spironolactone 12.5-25 mg daily, particularly in patients with LVEF in the lower range of preservation (40-50%) or those with persistent symptoms despite SGLT2 inhibitors. 1, 2
• ARNIs (sacubitril/valsartan) may be beneficial in selected patients, especially women and those with LVEF below the upper range, though evidence is less robust than for SGLT2 inhibitors. 1

Symptom Management with Diuretics

• Use loop diuretics as the cornerstone for congestion relief, starting with furosemide 20-40 mg daily, bumetanide 0.5-1.0 mg daily, or torasemide 5-10 mg daily. 1, 2
• Titrate to the lowest effective dose that maintains euvolemia—excessive diuresis leads to hypotension, renal dysfunction, and impaired tolerance of other medications. 1, 2
• Increase diuretic dose before adding combination therapy if initial response is inadequate. 1
• Consider thiazide combination (metolazone 2.5 mg) only in refractory cases with eGFR >30 mL/min. 3

Aggressive Comorbidity Management

Hypertension Control

• Achieve blood pressure target <130/80 mmHg using appropriate antihypertensive medications, as hypertension is a primary driver of HFpEF pathophysiology. 1, 2
• Prioritize agents with proven benefit: ACE inhibitors, ARBs, or ARNIs combined with diuretics. 3

Atrial Fibrillation Management

• Control ventricular rate to 60-100 bpm using beta-blockers (metoprolol, carvedilol) or non-dihydropyridine calcium channel blockers (diltiazem, verapamil). 1, 4
• Anticoagulate based on CHA₂DS₂-VASc score to prevent thromboembolic events. 4
• Use cardioselective beta-blockers cautiously in patients with concurrent COPD. 4

Diabetes Management

• Prioritize SGLT2 inhibitors for glycemic control given their dual benefit for both diabetes and heart failure. 1, 2
• Consider GLP-1 receptor agonists in obese patients with HFpEF and diabetes for additional weight loss and cardiovascular benefits. 5

Coronary Artery Disease

• Evaluate for CAD in high-risk patients using stress testing or coronary angiography, as myocardial ischemia worsens diastolic dysfunction. 3
• Optimize antianginal therapy and consider revascularization if significant viable myocardium is present. 3

Non-Pharmacological Interventions (Essential Component)

Exercise Training

• Prescribe supervised exercise training programs as a Class 1 recommendation—these consistently demonstrate large, clinically meaningful improvements in exercise capacity and quality of life. 3, 1, 2
• Exercise training shows comparable or larger magnitude of improvement in exercise capacity compared to HFrEF, with effect sizes often exceeding pharmacological interventions. 3
• Structure programs to include aerobic exercise 3-5 times weekly at moderate intensity (50-70% peak heart rate) for 30-45 minutes per session. 3

Lifestyle Modifications

• Restrict sodium intake to <2-3 g/day to reduce fluid retention and congestion. 1, 2
• Recommend weight reduction in obese patients (BMI >30 kg/m²), as obesity is a major contributor to HFpEF pathophysiology. 2
• Fluid restriction may be appropriate in hyponatremic patients or those with severe congestion. 1

Regular Monitoring and Follow-Up

Routine Surveillance

• Monitor symptoms, vital signs, and daily weights at every visit to detect early decompensation. 1, 2
• Check renal function and electrolytes regularly, especially when using MRAs (monitor potassium and creatinine within 1 week of initiation, then monthly for 3 months, then quarterly). 1, 2
• Schedule follow-up visits at minimum 6-monthly intervals for stable patients, increasing frequency with worsening clinical stability. 3

Advanced Monitoring

• Consider wireless pulmonary artery pressure monitoring (CardioMEMS) in selected patients with recurrent hospitalizations despite optimal medical therapy. 1
• Reassess natriuretic peptides if clinical status changes or to guide diuretic adjustments. 3

Multidisciplinary Team Involvement

• Refer to cardiac rehabilitation programs that provide medical assessment, patient education on lifestyle modifications, psychosocial support, and structured exercise training. 3
• Engage heart failure nurses for patient education on medication adherence, symptom monitoring, and when to seek medical attention. 3
• Initiate palliative care discussions early in the disease trajectory, with referral to specialist palliative care if patient needs are unmet by the primary team. 3

Critical Pitfalls to Avoid

• Never delay SGLT2 inhibitor initiation—these are the only medications with proven mortality benefit in HFpEF. 1, 2
• Avoid excessive diuresis which causes hypotension, renal dysfunction, and prevents uptitration of disease-modifying therapies. 1, 2
• Do not extrapolate HFrEF therapies to HFpEF without evidence—many medications effective in HFrEF (high-dose beta-blockers, digoxin) lack proven benefit in HFpEF. 3
• Screen for and treat HFpEF mimics before committing to long-term HFpEF management, as conditions like cardiac amyloidosis require specific therapies. 1