What is the recommended management plan for an older adult patient with Heart Failure with preserved Ejection Fraction (HFpEF), hypertension, and diabetes?

Guideline-Directed Medical Therapy for HFpEF in Older Adults with Hypertension and Diabetes

Start an SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily) immediately upon diagnosis, as this is the only therapy proven to reduce cardiovascular death and heart failure hospitalizations in HFpEF. 1, 2

First-Line Disease-Modifying Therapy

SGLT2 inhibitors are the cornerstone of HFpEF management and should be initiated early in all patients unless contraindicated. 2, 3

• 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. 2, 3
• Empagliflozin reduced heart failure hospitalization or cardiovascular death by 21% (HR 0.79,95% CI 0.69-0.90) in EMPEROR-PRESERVED. 1, 2, 3
• These benefits occur regardless of diabetes status, making them ideal for your patient with diabetes. 1
• Ensure eGFR >30 mL/min/1.73m² for dapagliflozin and >60 mL/min/1.73m² for empagliflozin before initiation. 3

Symptom Management with Diuretics

Use loop diuretics at the lowest effective dose to relieve congestion, orthopnea, and paroxysmal nocturnal dyspnea. 1, 2, 4

• Start with furosemide 20-40 mg daily (or equivalent torsemide/bumetanide) and titrate based on volume status. 1, 4, 3
• If inadequate response despite dose increases, consider switching to a different loop diuretic or adding a thiazide for sequential nephron blockade. 1, 4, 3
• Avoid excessive diuresis, which can lead to hypotension, worsening renal function, and impaired tolerance of other medications. 4, 3

Blood Pressure Management

Target blood pressure <130/80 mmHg using appropriate antihypertensive medications. 1, 2, 3

• Prioritize RAAS antagonists (ACE inhibitors, ARBs, or MRAs) as first-line agents given their experience in HFpEF trials. 1
• Beta-blockers may be used if the patient has a history of MI, symptomatic CAD, or atrial fibrillation with rapid ventricular response. 1
• Avoid diltiazem or verapamil, as they increase the risk of heart failure worsening and hospitalization. 3

Diabetes Management

Continue or switch to an SGLT2 inhibitor for glycemic control, as this provides dual benefits for both diabetes and heart failure. 2, 4

Additional Pharmacological Considerations

Consider adding spironolactone 12.5-25 mg daily (Class 2b recommendation) particularly if LVEF is in the lower preserved range (40-50%). 1, 3

• Spironolactone reduced heart failure hospitalizations (HR 0.83,95% CI 0.69-0.99) in the TOPCAT trial. 3
• Monitor potassium and renal function closely: creatinine should be ≤2.5 mg/dL in men or ≤2.0 mg/dL in women, and potassium should be <5.0 mEq/L. 1, 3

Sacubitril/valsartan may be considered (Class 2b recommendation) for selected patients, particularly women and those with LVEF 45-57%. 3

• The PARAGON-HF trial showed potential benefit in these subgroups (rate ratio 0.78,95% CI 0.64-0.95 for LVEF 45-57%; rate ratio 0.73,95% CI 0.59-0.90 for women). 3

Non-Pharmacological Interventions

Prescribe supervised exercise training programs (Class 1 recommendation) to improve functional capacity and quality of life. 1, 2, 4, 3

Recommend sodium restriction to <2-3 g/day and weight reduction if the patient is obese. 2, 4, 3

Monitoring and Follow-Up

Monitor symptoms, vital signs, weight, renal function, and electrolytes regularly. 2, 4

• Adjust diuretic doses based on congestion status to maintain euvolemia without causing hypotension. 2, 4
• If on spironolactone, check potassium and creatinine within 1 week of initiation and regularly thereafter. 3

Critical Pitfalls to Avoid

Do not delay SGLT2 inhibitor initiation, as this is the only therapy with proven mortality and morbidity benefits. 4, 3

Do not treat HFpEF patients the same as those with HFrEF, as most traditional heart failure therapies (ACE inhibitors, ARBs, beta-blockers) have not shown efficacy in HFpEF. 4, 3

Do not use nitrates or phosphodiesterase-5 inhibitors routinely, as they are ineffective for increasing activity or quality of life in HFpEF. 1

In older adults, be particularly vigilant for adverse drug events due to age-related changes in pharmacokinetics and pharmacodynamics, polypharmacy, and frailty. 5

Atrial Fibrillation Management (if present)

Control heart rate using beta-blockers or non-dihydropyridine calcium channel blockers if the patient has atrial fibrillation. 4

• The RATE-AF trial showed similar quality of life outcomes between bisoprolol and digoxin in elderly patients with AF and HF symptoms. 1

Multidisciplinary Care

Refer to cardiac rehabilitation for medical assessment, patient education on lifestyle modifications, psychosocial support, and exercise training. 1

Address palliative care needs early in the disease trajectory, with referral to specialist palliative care if patient needs are unmet. 1