What is the initial management for patients with heart failure with preserved ejection fraction?

Initial Management of Heart Failure with Preserved Ejection Fraction

Start an SGLT2 inhibitor (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) immediately upon diagnosis as first-line disease-modifying therapy, combined with loop diuretics at the lowest effective dose for symptom relief. 1

First-Line Disease-Modifying Therapy

• SGLT2 inhibitors represent the cornerstone of HFpEF treatment with the strongest evidence for reducing cardiovascular death and heart failure hospitalizations 2

• Dapagliflozin reduced the composite endpoint of worsening heart failure and cardiovascular death by 18% (HR 0.82,95% CI 0.73-0.92) and heart failure hospitalizations by 23% (HR 0.77,95% CI 0.67-0.89) in the DELIVER trial 1, 3

• Empagliflozin reduced heart failure hospitalization or cardiovascular death by 21% (HR 0.79,95% CI 0.69-0.90) in EMPEROR-PRESERVED 1, 3

• The American College of Cardiology and European Society of Cardiology both recommend initiating SGLT2 inhibitors early in the treatment course to maximize mortality and morbidity benefits 1

• Ensure eGFR >30 mL/min/1.73m² for dapagliflozin and >60 mL/min/1.73m² for empagliflozin before initiation 1

Symptom Management with Diuretics

• Loop diuretics should be used at the lowest effective dose to manage fluid retention and relieve congestion, with dose titration based on symptoms and volume status 1, 3

• For new-onset HFpEF with orthopnea/paroxysmal nocturnal dyspnea, start with 20-40 mg IV furosemide (or equivalent); for those on chronic diuretic therapy, initial IV dose should be at least equivalent to oral dose 1

• If inadequate response to initial loop diuretic therapy despite dose increases, consider changing to a different loop diuretic or adding a thiazide diuretic for sequential nephron blockade 1

• Avoid excessive diuresis which may lead to hypotension and worsening renal function 1

Additional Pharmacological Options

• Consider adding spironolactone (mineralocorticoid receptor antagonist) particularly in patients with LVEF in the lower range of preservation (40-50%), though this has only a Class 2b recommendation 1, 3

• Spironolactone reduced heart failure hospitalizations (HR 0.83,95% CI 0.69-0.99) in the TOPCAT trial but did not significantly reduce the primary composite outcome 1

• Sacubitril/valsartan may be considered for selected patients, especially women and those with LVEF 45-57%, though evidence is weaker (Class 2b recommendation) 1

• When prescribing spironolactone, carefully monitor potassium, renal function, and diuretic dosing to minimize the risk of hyperkalemia and worsening renal function 1

Management of Comorbidities

• Optimize blood pressure control to target <130/80 mmHg using appropriate antihypertensive medications 1, 3

• Manage diabetes with preference for SGLT2 inhibitors given their additional heart failure benefits 1, 3

• Diltiazem or verapamil are not recommended in HFpEF patients, as they increase the risk of heart failure worsening and hospitalization 1

• Control of reversible cardiovascular risk factors through lifestyle modification and pharmacological therapy is essential for prevention 2

Non-Pharmacological Interventions

• Prescribe supervised exercise training programs (Class 1 recommendation) to improve functional capacity and quality of life 1, 3

• Recommend sodium restriction to <2-3 g/day and weight reduction in obese patients 3

• Offer multidisciplinary heart failure programs to all patients 1

Monitoring and Follow-Up

• Regularly assess volume status, renal function, and electrolytes, especially with mineralocorticoid receptor antagonist therapy 1, 3

• Monitor symptoms and functional capacity to guide treatment adjustments 1

• Adjust diuretic doses based on congestion status to avoid overdiuresis leading to hypotension 3

• Consider wireless, implantable pulmonary artery monitors in selected patients for optimizing volume status 1

Critical Pitfalls to Avoid

• Do not treat HFpEF patients the same as those with reduced ejection fraction, as response to therapies differs significantly between these populations 1

• Do not overlook the importance of managing comorbidities including hypertension, diabetes, obesity, and atrial fibrillation, which significantly impact outcomes 1

• Do not delay initiation of SGLT2 inhibitors which have proven mortality benefits 4

Advanced Treatment Considerations

• Consider referral to an advanced heart failure specialist team for patients with advanced HFpEF refractory to standard therapies 1

• Cardiac transplantation can be considered in eligible patients with advanced HFpEF 1