How to manage a patient with preserved left ventricular (LV) ejection fraction (EF) in the emergency department with medications?

Emergency Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

In the emergency setting, prioritize immediate blood pressure control with IV vasodilators (nitroglycerin or nitroprusside) combined with IV loop diuretics for patients presenting with acute decompensated HFpEF and pulmonary edema with severe hypertension. 1

Immediate Assessment and Stabilization

Rapidly assess the hemodynamic profile to determine severity of congestion and adequacy of perfusion, checking for jugular venous distention, pulmonary edema, cool extremities, narrow pulse pressure, and mental status changes. 1, 2

• Measure vital signs immediately, particularly blood pressure, as HFpEF patients commonly present with hypertensive crisis and pulmonary edema. 1, 2
• Check for elevated natriuretic peptides to confirm HF diagnosis, though sensitivity is reduced in obesity and HFpEF compared to reduced EF. 1
• Perform invasive hemodynamic monitoring if respiratory distress is present and filling pressures cannot be determined clinically. 2

Acute Pharmacologic Management

For Pulmonary Edema with Severe Hypertension (Most Common HFpEF Presentation)

Start IV vasodilators immediately as these patients require urgent blood pressure reduction. 1

• Administer IV nitroglycerin or nitroprusside when severe symptomatic fluid overload exists without systemic hypotension. 2
• Simultaneously initiate IV loop diuretics without delay—do not wait for hospital admission. 3
• The initial IV diuretic dose should equal or exceed the chronic oral daily dose if already on diuretics. 3

Rate Control for Concurrent Atrial Fibrillation

Use beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem or verapamil) as first-line agents for rate control in HFpEF patients with AF, as these patients have preserved systolic function. 1

• Target lenient rate control with resting heart rate <110 bpm initially, with stricter control only if symptoms persist. 1
• In the acute setting with hemodynamic instability, consider IV beta-blockers (esmolol, landiolol) or IV diltiazem/verapamil for rapid rate control. 1
• Combination therapy with digoxin plus beta-blocker (or calcium channel blocker) is reasonable for controlling both resting and exercise heart rate. 1
• IV digoxin or amiodarone can be used when other measures are unsuccessful or contraindicated. 1

Diuretic Management

Administer IV loop diuretics aggressively if clinical evidence of congestion exists (elevated JVP, pulmonary edema, orthopnea). 3, 2

• Monitor urine output and signs of congestion serially, titrating diuretic dose to relieve symptoms. 3
• If diuresis is inadequate, intensify using higher loop diuretic doses, addition of a second diuretic (metolazone, chlorothiazide), or continuous infusion. 3, 4
• Continue diuresis even if mild-to-moderate azotemia develops, as long as the patient remains asymptomatic. 4

Critical Monitoring Parameters

Monitor daily: 3, 2

• Fluid intake and output measurements
• Body weight
• Vital signs, particularly blood pressure
• Serum electrolytes, BUN, and creatinine
• Clinical signs of perfusion and congestion

Identify and Treat Precipitating Factors

Systematically evaluate for common triggers that precipitated the acute decompensation: 1

• Uncontrolled hypertension (most common in HFpEF)
• Acute coronary syndrome
• Atrial fibrillation or other arrhythmias
• Acute infections (pneumonia, urinary tract)
• Medication nonadherence
• NSAIDs or other sodium-retaining medications
• Anemia
• Thyroid dysfunction

Respiratory Support

Provide non-invasive ventilation (BiPAP/CPAP) for patients with respiratory distress while IV diuretics work to reduce pulmonary congestion. 3

Common Pitfalls to Avoid

• Never delay diuretic initiation waiting for admission—start in the emergency department immediately. 3
• Do not administer IV fluids to patients with clear signs of volume overload. 3
• Avoid non-dihydropyridine calcium channel blockers (verapamil, diltiazem) if there is any concern for reduced EF or overt heart failure decompensation, as they may worsen hemodynamics. 2
• Do not use digoxin as sole agent for rate control in atrial fibrillation. 2
• Do not prematurely discontinue diuretics due to rising creatinine if the patient remains asymptomatic—persistent volume overload worsens outcomes. 4
• Monitor closely for hypokalemia and hypomagnesemia, which can precipitate arrhythmias. 4

Medication Continuation During Acute Phase

Continue ACE inhibitors/ARBs and beta-blockers unless frank hemodynamic instability or specific contraindications exist, as discontinuation worsens outcomes. 2, 4

• These medications should not be reflexively stopped during acute decompensation. 2
• Temporary dose reduction may be needed if symptomatic hypotension occurs, but complete discontinuation should be avoided. 1