From the Guidelines
The most effective treatment for heart failure with preserved ejection fraction (HFpEF) involves the use of SGLT2 inhibitors, such as empagliflozin, to reduce hospitalizations and improve quality of life, as evidenced by the EMPEROR-Preserved trial 1.
Key Recommendations
- SGLT2 inhibitors, like empagliflozin (10 mg daily), are recommended for symptomatic HFpEF patients with LVEF >40% and elevated natriuretic peptides 1.
- Diuretics, particularly loop diuretics, are used as needed to reduce fluid overload and improve symptoms.
- Blood pressure control is essential, with ACE inhibitors, ARBs, or ARNIs recommended for patients with hypertension.
- Mineralocorticoid receptor antagonists, such as spironolactone, may be beneficial in selected patients.
Treatment Considerations
- The EMPEROR-Preserved trial demonstrated a significant benefit of empagliflozin in reducing hospitalizations and improving quality of life in patients with HFpEF, with a 21% reduction in the primary composite endpoint of time to HF hospitalization or cardiovascular death 1.
- The 2022 AHA/ACC/HFSA guideline recommends SGLT2 inhibitors, such as empagliflozin, for symptomatic HFpEF patients with LVEF >40% and elevated natriuretic peptides, with a Class IIa recommendation 1.
- Treatment should also address comorbidities like hypertension, diabetes, obesity, and atrial fibrillation to improve overall outcomes.
Medication Options
- Empagliflozin (10 mg daily) or dapagliflozin (10 mg daily) for SGLT2 inhibition
- ACE inhibitors, such as lisinopril (5-40 mg daily), or ARBs, such as valsartan (40-320 mg daily), for blood pressure control
- ARNIs, such as sacubitril/valsartan (24/26 mg to 97/103 mg twice daily), for patients with hypertension and HFpEF
- Mineralocorticoid receptor antagonists, such as spironolactone (25 mg daily), for selected patients
From the Research
Guidelines for Medications in Heart Failure with Preserved Ejection Fraction
- The current best drug treatment for hypertensive heart failure with preserved ejection fraction includes angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor neprilysin inhibitors, selected beta-blockers, steroidal and non-steroidal mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors 2.
- Treatment of heart failure with preserved ejection fraction (HFpEF) should be directed by symptoms, signs, severity, and concomitant diseases and conditions, rather than left ventricular ejection fraction (LVEF)-guided treatment 2.
- Medication classes that are efficacious in heart failure with reduced ejection fraction (HFrEF) have been less effective in HFpEF, decreasing the risk of heart failure hospitalization but not cardiovascular or all-cause death 3.
- Sodium-glucose cotransporter 2 inhibitors reduce the risk of composite cardiovascular events, driven by a reduction in heart failure hospitalizations, in patients with HFpEF 3.
- Renin-angiotensin-aldosterone blockers and angiotensin-neprilysin inhibitors result in smaller reductions in heart failure hospitalizations among patients with HFpEF 3.
- Diuretics reduce congestion in patients with HFpEF, but comparison of clinical effects across diuretic classes or combinations of diuretics in patients with HFpEF are not well described 4.
- Comprehensive management of HFpEF includes exercise, as well as treatment of risk factors and comorbidities 3.
- Classification based on phenotypes may facilitate a more targeted approach to treatment than LVEF categorization, which sets arbitrary cut-points when LVEF is a continuum 3.
- Primary care providers play a pivotal role in the delivery of holistic, patient-centric care from diagnosis to management and palliative care for patients with HFpEF 5.
- Improved phenotyping of subgroups within the overall HFpEF population might enhance individualization of treatment 6.