What is the management plan for a patient with an ejection fraction (EF) of 55-60%, moderate left ventricular hypertrophy (LVH), and grade 1 diastolic dysfunction (DD)?

Management of Heart Failure with Preserved Ejection Fraction (HFpEF) and Left Ventricular Hypertrophy

For a patient with EF 55-60%, moderate LVH, and grade 1 diastolic dysfunction, initiate SGLT2 inhibitor therapy immediately, aggressively control blood pressure to target <130/80 mmHg using guideline-directed medical therapy, and address all cardiovascular risk factors including diabetes and hyperlipidemia. 1

Primary Therapeutic Interventions

SGLT2 Inhibitors (First-Line Therapy)

• SGLT2 inhibitors with proven cardiovascular benefit are recommended for all patients with heart failure and preserved ejection fraction to reduce heart failure hospitalizations and improve quality of life. 1
• This recommendation applies regardless of diabetes status, as SGLT2 inhibitors have demonstrated consistent benefit across the ejection fraction spectrum, including patients with EF ≥50%. 1, 2
• Dapagliflozin specifically has shown safety and efficacy in reducing cardiovascular death or worsening heart failure events in patients with preserved EF. 2

Blood Pressure Control (Critical Foundation)

• Blood pressure must be controlled in accordance with guideline-directed medical therapy for hypertension to prevent progression to symptomatic heart failure. 1
• Target blood pressure should be <130/80 mmHg based on current hypertension guidelines. 1
• Hypertension precedes heart failure development in approximately 90% of patients and is especially important in those with LVH. 1

Symptom Management for HFpEF

• Beta-blockers, verapamil, or diltiazem should be considered for patients with NYHA class II-IV symptoms, preserved EF ≥50%, and no evidence of left ventricular outflow tract obstruction. 1
• The choice between these agents depends on heart rate, blood pressure, and presence of atrial fibrillation. 1
• Low-dose loop or thiazide diuretics should be considered if volume overload symptoms develop. 1

Risk Factor Modification

Diabetes Management

• If type 2 diabetes is present or develops, SGLT2 inhibitors are doubly indicated—both for heart failure management and glycemic control. 1
• SGLT2 inhibitors should be used in patients with type 2 diabetes and either established cardiovascular disease or high cardiovascular risk to prevent heart failure hospitalizations. 1

Lipid Management

• Statin therapy is recommended if coronary artery disease is present or suspected, with LDL-C goal <55 mg/dL (1.4 mmol/L) and ≥50% reduction from baseline. 1
• For patients not achieving goal on maximum tolerated statin plus ezetimibe, combination with bempedoic acid should be considered. 1

Lifestyle Modifications

• Regular physical activity, maintaining normal weight, healthy dietary patterns, and smoking cessation are essential to reduce future heart failure risk. 1
• Sodium restriction (<2-3 grams daily) is particularly important in patients with diastolic dysfunction and LVH. 1

Monitoring and Follow-Up Strategy

Serial Echocardiographic Assessment

• Repeat echocardiography every 6-12 months to monitor for:
  • Progression of LVH (wall thickness >15 mm warrants closer surveillance) 1
  • Worsening diastolic dysfunction (progression to grade 2-3) 3, 4
  • Development of reduced ejection fraction (<50%) 1
  • New valvular abnormalities 1

Clinical Surveillance

• Assess for symptom development at each visit, as patients with diastolic dysfunction may progress to symptomatic heart failure. 5, 3
• Monitor for exercise intolerance, dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea. 4
• Natriuretic peptide biomarker screening (BNP or NT-proBNP) can be useful for early detection of heart failure progression. 1

Laboratory Monitoring

• Check renal function (creatinine, eGFR) and electrolytes (potassium) 1-2 weeks after initiating SGLT2 inhibitors or RAAS inhibitors. 6
• Monitor for hyperkalemia, though levels <5.5 mEq/L can often be managed with dietary modification rather than discontinuing therapy. 6

Medications to Avoid

Contraindicated Agents

• Thiazolidinediones should not be used as they increase heart failure risk and hospitalizations. 1
• Nondihydropyridine calcium channel blockers (verapamil, diltiazem) should be avoided if ejection fraction falls below 50% due to negative inotropic effects. 1
• Erythropoietin-stimulating agents should not be used even if anemia develops. 1

Special Considerations

If Atrial Fibrillation Develops

• Anticoagulation with direct oral anticoagulants (DOACs) is recommended as first-line, independent of CHA2DS2-VASc score in patients with hypertrophic cardiomyopathy or structural heart disease. 1
• Rate control with beta-blockers, verapamil, or diltiazem is recommended based on patient preferences and comorbidities. 1

If Ejection Fraction Declines Below 50%

• Immediately transition to heart failure with reduced ejection fraction (HFrEF) guideline-directed medical therapy: 1
  • ACE inhibitor or ARB (if ACE inhibitor not tolerated) 1
  • Evidence-based beta-blocker 1
  • Mineralocorticoid receptor antagonist (MRA) for persistent NYHA class II-IV symptoms 1
  • Continue SGLT2 inhibitor 1
  • Low-dose loop diuretics for volume management 1

Iron Deficiency Management

• If iron deficiency develops (with or without anemia), intravenous iron replacement is reasonable to improve functional status and quality of life. 1

Common Pitfalls to Avoid

1. Do not delay SGLT2 inhibitor initiation—these agents are now first-line therapy for HFpEF regardless of diabetes status. 1
2. Do not assume asymptomatic patients are low-risk—diastolic dysfunction with LVH can progress rapidly, and early intervention prevents adverse remodeling. 5, 3
3. Do not discontinue therapy for asymptomatic hypotension—systolic blood pressure 80-100 mmHg with adequate organ perfusion is not a contraindication to GDMT. 6
4. Do not stop medications for modest creatinine elevation—up to 30% increase above baseline is acceptable and expected with RAAS inhibition. 6