What is the management for Heart Failure with preserved Ejection Fraction (HFpEF)?

GDMT for HFpEF

Start an SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily) immediately upon diagnosis—this is the only proven disease-modifying therapy that reduces heart failure hospitalizations and cardiovascular death in HFpEF. 1, 2

First-Line Disease-Modifying Therapy

• SGLT2 inhibitors are the cornerstone of HFpEF management with proven mortality and morbidity benefits that should be initiated without delay 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 1
• Empagliflozin reduced heart failure hospitalization or cardiovascular death by 21% (HR 0.79) in EMPEROR-PRESERVED 1
• A critical pitfall is delaying SGLT2 inhibitor initiation—these should be started at the first visit after diagnosis 2

Symptom Management with Diuretics

• Use loop diuretics at the lowest effective dose to relieve congestion, targeting symptoms like orthopnea and paroxysmal nocturnal dyspnea 1, 2
• Titrate diuretic doses based on daily weights, edema, and congestion status 2
• Avoid excessive diuresis which leads to hypotension, renal dysfunction, and impaired tolerance of other medications 2
• Consider increasing the loop diuretic dose before adding combination diuretic therapy if initial response is inadequate 2
• Thiazides can be added as adjunctive therapy in hypertensive patients or those with refractory edema despite loop diuretics 3

Additional Pharmacological Considerations

• Mineralocorticoid receptor antagonists (spironolactone) should be considered particularly in patients with LVEF in the lower range of preservation (40-50%) 2
• ARNIs (sacubitril/valsartan) may benefit selected patients, especially women and those with LVEF below the upper range 2
• Monitor renal function and electrolytes regularly when using MRAs 4

Comorbidity Management

Hypertension

• Achieve blood pressure target <130/80 mmHg using appropriate antihypertensive medications 1, 2

Diabetes

• Prioritize SGLT2 inhibitors for glycemic control given their dual benefits for both diabetes and heart failure 1, 2

Atrial Fibrillation

• Control ventricular rate using beta-blockers or non-dihydropyridine calcium channel blockers 2
• Prescribe anticoagulation based on CHA₂DS₂-VASc score 4
• Use cardioselective beta-blockers cautiously in patients with concurrent COPD 4

Non-Pharmacological Interventions

• Refer to supervised exercise training programs (Class 1 recommendation)—these provide substantial, clinically relevant improvements in aerobic exercise capacity and quality of life comparable to or greater than pharmacological interventions 3, 1, 2
• Exercise therapy is safe in chronic, stable HFpEF and should be pursued aggressively for referral and adherence 3
• Prescribe sodium restriction to <2-3 g/day to reduce congestive symptoms 3, 1, 2
• Recommend weight reduction in obese patients as obesity is a key modifiable target in the cardiometabolic HFpEF phenotype 1, 5

Monitoring Strategy

• Monitor symptoms, vital signs, daily weights, renal function, and electrolytes regularly 1, 2
• Adjust diuretic doses based on congestion status to prevent both under- and over-diuresis 1, 2
• Consider wireless pulmonary artery pressure monitoring in selected patients with recurrent hospitalizations 2

Key Pitfalls to Avoid

• Do not delay SGLT2 inhibitor initiation—this is the only therapy with proven mortality benefits and should be started immediately 2
• Avoid excessive diuresis leading to hypotension, azotemia, and medication intolerance 2
• Do not assume all heart failure medications work in HFpEF—unlike HFrEF, most traditional heart failure therapies have not shown efficacy in HFpEF 3
• Rule out HFpEF mimics (cardiac amyloidosis, hypertrophic cardiomyopathy, pericardial disease) that require specific treatments 2