What is the proper diagnosis and treatment for a patient with hypertensive cardiovascular disease and a preserved ejection fraction (EF) of 66%?

Proper Diagnosis for Hypertensive Cardiovascular Disease with EF 66%

The correct diagnosis is "Hypertensive Heart Disease with Heart Failure with Preserved Ejection Fraction (HFpEF)" or "Hypertensive Cardiovascular Disease with HFpEF." An ejection fraction of 66% is preserved (≥50%), and when combined with hypertension and cardiovascular involvement, this represents HFpEF rather than heart failure with reduced ejection fraction 1.

Diagnostic Terminology

• Use "HFpEF" (Heart Failure with Preserved Ejection Fraction) when the ejection fraction is ≥50%, which applies to your patient with EF 66% 1
• The diagnosis should specify both the underlying etiology (hypertension) and the cardiac manifestation (HFpEF) 1
• Hypertension is the most important cause of HFpEF, with prevalence of 60-89% in large trials and registries 1

Clinical Context

• Hypertension is a risk factor for development of both HFrEF and HFpEF, with worse clinical outcomes and increased mortality in hypertensive patients with heart failure 1
• The transition from hypertension to HFpEF involves diastolic dysfunction, concentric left ventricular hypertrophy, and progressive filling abnormalities 2, 3
• Approximately 50% of all heart failure patients have HFpEF, and these patients are typically older with history of hypertension 1

Treatment Approach for This Diagnosis

Blood Pressure Management

• Target blood pressure <130/80 mmHg (but >120/70 mmHg) if BP is ≥140/90 mmHg 1
• In elderly patients, target <140/80 mmHg 1
• Rigorous blood pressure control reduces the risk of incident heart failure and HF hospitalization 1, 4

First-Line Pharmacotherapy

• Diuretics should be prescribed to control volume overload and improve symptoms in patients with evidence of fluid retention 1
• RAS blockers (ACE inhibitors or ARBs) are first-line agents for blood pressure control and should be titrated to achieve target BP 1
• Beta-blockers should be added and titrated appropriately, particularly if there is history of MI, symptomatic CAD, or atrial fibrillation 1
• The same treatment strategy used for HFrEF can be applied to HFpEF, though optimal treatment strategy for HFpEF is not fully established 1

Emerging Therapies

• SGLT2 inhibitors (empagliflozin) are recommended for symptomatic HFpEF patients with elevated natriuretic peptides, showing 21% reduction in the composite endpoint of HF hospitalization or cardiovascular death 1
• The benefit was driven primarily by 29% reduction in HF hospitalization 1
• Sacubitril-valsartan (ARNI) can be considered as an alternative to ACE inhibitors or ARBs, though evidence is less robust than for HFrEF 1

Additional Risk Factor Management

• Lifestyle modifications are mandatory: diet modification, exercise, weight control, and smoking cessation if applicable 1
• Lipid-lowering treatment should be initiated according to cardiovascular risk profile 1
• Manage comorbidities including coronary artery disease, diabetes, obesity, chronic kidney disease, and atrial fibrillation 1

Common Pitfalls to Avoid

• Do not use non-dihydropyridine calcium channel blockers (verapamil, diltiazem) as they have myocardial depressant activity and may worsen outcomes 1
• Avoid labeling as "HFrEF" when ejection fraction is preserved, as treatment strategies differ 1
• Do not overlook volume status: diuretics are crucial for symptom management but must be dosed appropriately to avoid volume depletion or overload 1
• Monitor for "decapitated hypertension": blood pressure may decrease as heart failure progresses due to reduced pump function 2