What medications are used to manage patients with high Ejection Fraction (EF)?

Medications for High Ejection Fraction Heart Failure

For patients with heart failure and preserved ejection fraction (HFpEF, typically EF >50%), SGLT2 inhibitors are the primary evidence-based medication class recommended to improve outcomes, while blood pressure control and symptom management with diuretics form the foundation of therapy. 1

Primary Pharmacologic Approach

SGLT2 Inhibitors (First-Line for Symptomatic HFpEF)

• SGLT2 inhibitors are specifically recommended in hypertensive patients with symptomatic HFpEF to improve outcomes, leveraging their modest blood pressure-lowering properties 1
• This represents the only medication class with a Class I recommendation for improving outcomes in HFpEF 1

Blood Pressure Management

• Systolic and diastolic blood pressure must be controlled according to published guidelines to prevent morbidity 1
• All major antihypertensive agents can be used since no specific drug class has proven superiority in HFpEF 1
• Target blood pressure should be individualized based on comorbidities (diabetes, CKD, etc.) 1

Diuretics for Volume Management

• Diuretics should be used for relief of symptoms due to volume overload 1
• This is a Class I, Level of Evidence C recommendation for symptomatic relief 1
• Loop diuretics (furosemide, bumetanide, torsemide) are typically first-line for acute volume overload 1

Secondary Considerations

ARBs and Mineralocorticoid Receptor Antagonists

• In patients with symptomatic HFpEF who have blood pressure above target, ARBs and/or MRAs may be considered to reduce heart failure hospitalizations and reduce blood pressure 1
• This carries a Class IIb recommendation, indicating weaker evidence 1

Omega-3 Fatty Acids

• Omega-3 polyunsaturated fatty acid supplementation is reasonable as adjunctive therapy in NYHA class II-IV symptoms with HFpEF to reduce mortality and cardiovascular hospitalizations 1

Coronary Revascularization

• Coronary revascularization is reasonable in patients with CAD where symptoms (angina) or demonstrable myocardial ischemia adversely affects symptomatic HFpEF despite guideline-directed medical therapy 1

Critical Medications to AVOID in High EF

Contraindicated or Harmful Agents

• Most calcium channel blockers with negative inotropic effects should be avoided, though they may be used cautiously for hypertension management in HFpEF 1
• Verapamil specifically should be avoided in patients with severe left ventricular dysfunction (EF <30%) or any degree of ventricular dysfunction if receiving beta-blockers 2
• NSAIDs should be avoided as they adversely affect clinical status 1
• Most antiarrhythmic drugs should be avoided 1

Medications Without Proven Benefit

• Statins are not beneficial as adjunctive therapy when prescribed solely for the diagnosis of heart failure in the absence of other indications 1
• Nutritional supplements as treatment for heart failure are not recommended 1
• Hormonal therapies other than to correct deficiencies are not recommended 1

Important Clinical Distinctions

HFpEF vs HFrEF Management Differs Fundamentally

The evidence provided focuses heavily on HFrEF (reduced EF, typically <40%), where ACE inhibitors, ARBs, beta-blockers (bisoprolol, carvedilol, metoprolol succinate), and aldosterone antagonists form the cornerstone 1, 3. These medications proven to reduce mortality in HFrEF do NOT have the same evidence base in HFpEF 1, 4.

Common Pitfalls to Avoid

• Do not extrapolate HFrEF treatment algorithms to HFpEF patients - the pathophysiology and treatment responses differ significantly 4
• Avoid aggressive beta-blocker therapy in HFpEF unless specifically indicated for rate control in atrial fibrillation or ischemic heart disease 4
• Do not withhold diuretics in symptomatic patients due to concerns about "overdiuresis" - symptom relief is a primary goal 1
• Recognize that tachycardia and rapid supraventricular arrhythmias may precipitate or exacerbate HFpEF and require rate control 1, 4

Treatment of Precipitating Factors

Focus on identifying and treating precipitating factors including: volume overload, tachycardia, hypertension, myocardial ischemia, arrhythmias (especially atrial fibrillation), increased salt intake, and systemic stressors 4.