What are the management guidelines for patients with preserved heart failure?

Management Guidelines for Heart Failure with Preserved Ejection Fraction (HFpEF)

First-Line Pharmacological Therapy

SGLT2 inhibitors (dapagliflozin or empagliflozin) should be initiated in all patients with HFpEF regardless of diabetes status, as they reduce heart failure hospitalizations by 18-23% based on the DELIVER and EMPEROR-PRESERVED trials. 1, 2

• Start dapagliflozin 10 mg daily or empagliflozin 10 mg daily as foundational therapy 1
• These agents demonstrate consistent benefit across the ejection fraction spectrum and represent the strongest evidence-based therapy for reducing morbidity in HFpEF 2

Symptomatic Management

Diuretics must be used at the lowest effective dose for relief of congestion and volume overload, though they do not improve survival. 3, 1, 2

• Loop diuretics (furosemide 20-240 mg daily, bumetanide 1-5 mg daily, or torasemide 10-20 mg daily) are first-line for fluid management 3
• Titrate to relieve dyspnea and edema while avoiding excessive diuresis that can reduce preload, stroke volume, and worsen renal function 3, 1
• Monitor electrolytes and renal function closely during diuresis 1

Mineralocorticoid Receptor Antagonists

Spironolactone may be considered in appropriately selected patients to reduce hospitalizations, though evidence is mixed. 3, 1, 2

• Use only in patients meeting strict criteria: EF ≥45%, elevated BNP or HF admission within 1 year, eGFR >30 mL/min, creatinine <2.5 mg/dL (men) or <2.0 mg/dL (women), and potassium <5.0 mEq/L 3
• Start spironolactone 12.5-25 mg daily, maximum 50 mg daily 3
• The TOPCAT trial showed regional variation in efficacy, with benefit primarily in the Americas (HR 0.83) but not Russia/Georgia 3
• Monitor potassium and renal function rigorously to prevent hyperkalemia 3, 2

Blood Pressure Control

Aggressive blood pressure control is mandatory, targeting <130/80 mmHg in high-risk patients or <140/90 mmHg in others. 3, 1

• ACE inhibitors, ARBs, or beta-blockers are reasonable first choices for hypertension management in HFpEF 3
• Hypertension directly impairs ventricular relaxation and promotes adverse remodeling 3
• Consider even lower targets (<130/80 mmHg) than standard hypertension guidelines 3

Management of Atrial Fibrillation

Rate control with beta-blockers is the primary strategy for atrial fibrillation in HFpEF, with target heart rate allowing adequate diastolic filling time. 3

• Beta-blockers are first-line for rate control (or amiodarone if beta-blockers contraindicated) 3
• Digoxin may be added for additional rate control if needed 3
• Anticoagulation is mandatory for patients with paroxysmal or chronic atrial fibrillation 3
• Electrical cardioversion should be considered for persistent atrial fibrillation, though success depends on duration and left atrial size 3

Coronary Artery Disease Management

Coronary revascularization is reasonable when angina or demonstrable ischemia adversely affects HFpEF symptoms despite optimal medical therapy. 3

• Myocardial ischemia impairs ventricular relaxation and should be aggressively treated 3
• Use nitrates and beta-blockers (with diuretics) for angina management 3
• Revascularization decisions should consider coronary anatomy, extent of viable myocardium, procedural risk, and comorbidities 3

Therapies to Avoid

Routine use of nitrates or phosphodiesterase-5 inhibitors does not improve activity or quality of life in HFpEF and should not be used. 3

• These agents showed no benefit in randomized controlled trials for HFpEF 3
• Avoid applying HFrEF-specific therapies without HFpEF evidence 2

Acute Decompensated HFpEF

Intravenous loop diuretics are first-line for acute fluid overload, starting with a parenteral dose equal to or greater than the chronic oral daily dose. 1

• Monitor electrolytes, renal function, and blood pressure during aggressive diuresis 1
• Avoid excessive diuresis leading to hypotension and renal dysfunction 1, 2

Additional Considerations

ARBs might be considered to decrease hospitalizations, though evidence is weaker than for SGLT2 inhibitors. 3

• The CHARM-Preserved trial showed reduction in HF admissions but not the primary composite endpoint 3
• ARBs may be particularly useful in patients with hypertension requiring additional blood pressure control 3

Calcium channel blockers (verapamil-type) may improve exercise capacity in small studies, particularly in hypertrophic cardiomyopathy. 3

• Limited evidence supports routine use, but may be considered for rate control or hypertension 3

Common Pitfalls

• Do not assume HFrEF therapies work in HFpEF—most lack evidence in this population 3, 2
• Avoid over-diuresis, which reduces preload excessively and worsens cardiac output 3, 1
• Do not neglect comorbidity management (diabetes, obesity, sleep apnea, chronic kidney disease), which significantly impacts outcomes 2
• Ensure proper diagnosis by excluding valvular disease and confirming elevated natriuretic peptides (BNP ≥35 pg/mL or NT-proBNP ≥125 ng/L) 1