What is the Guideline-Directed Medical Therapy (GDMT) for Heart Failure with preserved Ejection Fraction (HFpEF)?

From the Guidelines

Guideline-directed medical therapy (GDMT) for heart failure with preserved ejection fraction (HFpEF) should focus on symptom management, addressing underlying conditions, and controlling blood pressure, with consideration of SGLT2 inhibitors, mineralocorticoid receptor antagonists, and diuretics as key components of treatment. The management of HFpEF has evolved, with recent studies highlighting the importance of controlling blood pressure and using specific medications to reduce hospitalizations and improve symptoms 1. Key aspects of GDMT for HFpEF include:

• Controlling blood pressure, with a target systolic BP <130 mmHg, using ACE inhibitors, ARBs, or beta-blockers as appropriate options
• Using diuretics, such as furosemide or hydrochlorothiazide, to manage volume overload and relieve symptoms like dyspnea and edema
• Considering the use of SGLT2 inhibitors, which have been shown to reduce hospitalizations and cardiovascular death in patients with HFpEF 1
• Using mineralocorticoid receptor antagonists, such as spironolactone, in selected patients, particularly those with elevated BNP levels and without significant renal dysfunction
• Managing comorbidities, including diabetes, obesity, and sleep apnea, and controlling rate in patients with atrial fibrillation

It is essential to individualize treatment based on specific patient characteristics, comorbidities, and symptom burden, as traditional heart failure medications like ACE inhibitors and beta-blockers have not shown mortality benefits specifically for HFpEF but may be used for comorbid conditions 1. The most recent guidelines and recommendations should be consulted to ensure optimal management of HFpEF, as the field is rapidly evolving with new evidence and breakthroughs in treatment 1.

From the Research

Guideline-Directed Medical Therapy (GDMT) for Heart Failure with Preserved Ejection Fraction (HFpEF)

• The management of HFpEF is largely focused on the treatment of symptoms and comorbidities, as there are no approved treatments specifically indicated for HFpEF 2, 3.
• Current treatment strategies for HFpEF include decongestion by diuretics, promotion of a healthy active lifestyle, and management of comorbidities 3.
• Medication classes that are efficacious in HF with reduced ejection fraction (HFrEF) have been less effective in HFpEF, with some exceptions such as sodium-glucose cotransporter 2 inhibitors, which reduce the risk of composite cardiovascular events 4.
• Renin-angiotensin-aldosterone blockers and angiotensin-neprilysin inhibitors result in smaller reductions in HF hospitalizations among patients with HFpEF 4.
• Comprehensive management of HFpEF includes exercise, as well as treatment of risk factors and comorbidities 4.
• Classification based on phenotypes may facilitate a more targeted approach to treatment than left ventricular ejection fraction (LVEF) categorization, which sets arbitrary cut-points when LVEF is a continuum 4.
• Recent data from prospective, randomized trials have altered the range of pharmacologic options to modify disease progression in selected patients with HFpEF, and clinicians are in need of practical guidance regarding the best approach to management of this growing population 5.
• The use of RAAS blockers, including mineralocorticoid receptor antagonists, is recommended in the treatment of patients with HFpEF, despite the lack of statistically significant findings in previous clinical trials 6.

Treatment Strategies

• Sodium-glucose cotransporter 2 inhibitors: reduce the risk of composite cardiovascular events 4.
• Renin-angiotensin-aldosterone blockers: result in smaller reductions in HF hospitalizations among patients with HFpEF 4.
• Angiotensin-neprilysin inhibitors: result in smaller reductions in HF hospitalizations among patients with HFpEF 4.
• Diuretics: used for decongestion 3.
• RAAS blockers: recommended for use in HFpEF, despite limited evidence 6.

Management Approach

• Comprehensive management of HFpEF includes exercise, as well as treatment of risk factors and comorbidities 4.
• Classification based on phenotypes may facilitate a more targeted approach to treatment than LVEF categorization 4.
• Practical guidance is needed for clinicians to manage the growing population of patients with HFpEF 5.