What is the immediate management for a patient presenting with acute left ventricular failure (LVF) and heart failure with preserved ejection fraction (HFpEF)?

Immediate Management of Acute Left Ventricular Failure with HFpEF

Start intravenous loop diuretics immediately at a dose equal to or exceeding the patient's chronic oral daily dose (or 40-80 mg IV furosemide if diuretic-naïve), and initiate SGLT2 inhibitor therapy (dapagliflozin 10 mg or empagliflozin 10 mg daily) once the patient is stabilized and volume status is optimizing, as these are the only disease-modifying therapies proven to reduce heart failure hospitalizations and cardiovascular death in HFpEF. 1

Acute Decongestion: First Priority

Intravenous loop diuretics are the cornerstone of immediate management for patients presenting with volume overload, pulmonary congestion, or peripheral edema. 2, 1

• Dosing strategy: If the patient is already on oral diuretics, the initial IV dose should equal or exceed their chronic oral daily dose; if diuretic-naïve, start with 40-80 mg IV furosemide. 2, 1
• Titration approach: Monitor urine output hourly and aggressively titrate the diuretic dose upward if response is inadequate, targeting more than 100-150 mL/hour of urine output. 1
• Continuous infusion consideration: Low-dose continuous infusion of furosemide (5-6 mg/hour) can be effective and safe, achieving significant increases in mean hourly urine output (from 116 to 150 mL/hour) without detectable worsening of renal function. 3

Important caveat: HFpEF patients may respond differently to aggressive diuresis compared to HFrEF patients. High-dose diuretic strategies in HFpEF have been associated with increased creatinine and cystatin C elevation without proportional improvements in decongestion, suggesting a more cautious approach may be warranted once initial stabilization is achieved. 4

Critical Monitoring During Acute Phase

Daily assessments must include: 1

• Fluid intake and output with hourly urine output monitoring
• Daily weights
• Vital signs with attention to blood pressure and orthostatic changes
• Serum electrolytes (particularly potassium), BUN, and creatinine
• Clinical signs of persistent congestion (jugular venous distension, pulmonary rales, peripheral edema)
• Signs of hypoperfusion (cool extremities, altered mental status, oliguria)

Identify and Address Precipitating Factors

Common triggers requiring immediate attention include: 2

• Acute coronary syndrome (obtain ECG and cardiac troponin immediately)
• Uncontrolled hypertension
• Atrial fibrillation with rapid ventricular response
• Medication noncompliance or recent addition of negative inotropic drugs
• Concurrent infections (especially pneumonia)
• Pulmonary embolism
• Renal dysfunction
• Excessive sodium/fluid intake

Disease-Modifying Therapy: SGLT2 Inhibitors

SGLT2 inhibitors represent the most important breakthrough in HFpEF management and should be initiated during hospitalization. 2, 1

• Timing: Start once volume status is optimizing and the patient is hemodynamically stable—do not delay until discharge. 1
• Agent selection: Dapagliflozin 10 mg daily or empagliflozin 10 mg daily are first-line choices. 2, 1
• Evidence base: The DELIVER and EMPEROR-PRESERVED trials demonstrated 21-29% reductions in heart failure hospitalizations with these agents. 2
• Renal considerations: Can be used with eGFR ≥20-30 mL/min/1.73m². 2

This is the only therapy class with proven mortality and morbidity benefits in HFpEF and should not be delayed. 1, 5

Additional Pharmacotherapy Considerations

Mineralocorticoid receptor antagonists (MRAs):

• Consider spironolactone 12.5-25 mg daily, particularly if LVEF is in the lower preserved range (closer to 50%). 2, 1
• Monitor potassium and creatinine closely due to hyperkalemia risk. 1
• The TOPCAT trial showed benefit in North American patients (HR 0.82 for the primary composite outcome). 2

Sacubitril/valsartan (ARNI):

• May be considered for selected patients, particularly women and those with LVEF 45-57%, though evidence is weaker than for SGLT2 inhibitors. 2, 1
• PARAGON-HF showed a trend toward benefit (rate ratio 0.87) but did not reach statistical significance for the primary endpoint. 2

Beta-blockers:

• Use only if specific indications exist: prior myocardial infarction (within 3 years), angina, or atrial fibrillation requiring rate control. 2
• Monitor exercise tolerance due to potential for chronotropic incompetence. 2

Management of Atrial Fibrillation (if present)

Rate control is the preferred strategy over rhythm control in HFpEF. 5

• First-line agent: Beta-blockers for rate control. 5
• Alternative: Non-dihydropyridine calcium channel blockers (diltiazem) can be effective, particularly in combination with digoxin. 5
• Anticoagulation: Prescribe based on CHA₂DS₂-VASc score. 5, 6

Blood Pressure Management

Target blood pressure <130/80 mmHg using evidence-based antihypertensives, optimizing during hospitalization as tolerated by volume status. 1, 5

Hypertension is present in the majority of HFpEF cases worldwide and is a critical therapeutic target. 7

Transition to Oral Therapy

Careful transition from IV to oral diuretics is essential: 1

• Use equivalent dosing when converting from IV to oral route
• Monitor closely for 24-48 hours after transition for:
  • Adequate diuresis
  • Electrolyte abnormalities
  • Orthostatic hypotension
• Adjust to the lowest effective maintenance dose

Discharge Planning and Follow-up

Comprehensive discharge instructions must include: 1

• Dietary sodium restriction (typically <2-3 grams daily)
• Medication reconciliation ensuring SGLT2 inhibitor is prescribed
• Daily weight monitoring with clear instructions on when to call (typically >2-3 pounds in 1 day or >5 pounds in 1 week)
• Activity level recommendations
• Follow-up appointments within 7-14 days
• What to do if symptoms worsen

Medication reconciliation priorities: 1

• Ensure SGLT2 inhibitor prescription and patient understanding of its importance
• Adjust diuretic dose to lowest effective maintenance dose
• Continue GDMT except in cases of hemodynamic instability or contraindications

Common Pitfalls to Avoid

• Over-diuresis: HFpEF patients are particularly sensitive to volume depletion, which can worsen hypotension and renal function without improving outcomes. 4
• Delaying SGLT2 inhibitor initiation: These agents have proven mortality benefits and should be started before discharge, not deferred to outpatient follow-up. 1, 5
• Using therapies without evidence in HFpEF: Avoid routine use of ACE inhibitors, standard ARBs (without neprilysin inhibition), nitrates, digoxin, ivabradine, or sildenafil as primary HFpEF therapies, as these have not shown benefit. 2
• Invasive hemodynamic monitoring in stable patients: Not recommended for normotensive patients responding to diuretics and vasodilators. 2
• Routine inotropes: Not indicated in normotensive patients without evidence of decreased organ perfusion. 2