What is the current trend in management of Heart failure with preserved ejection fraction (HFpEF) in an older adult patient with a history of hypertension, diabetes, and obesity?

Current Trend in Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

The current trend in HFpEF management centers on early initiation of SGLT2 inhibitors (dapagliflozin or empagliflozin) as first-line disease-modifying therapy, representing a paradigm shift from the previous era of symptom-only management. 1, 2, 3

First-Line Disease-Modifying Therapy: SGLT2 Inhibitors

SGLT2 inhibitors now represent the cornerstone of HFpEF treatment based on breakthrough trial data demonstrating mortality and morbidity benefits. 1

• Empagliflozin reduced the composite endpoint of heart failure hospitalization or cardiovascular death by 21% (HR 0.79,95% CI 0.69-0.90) in the EMPEROR-PRESERVED trial 1, 2
• Dapagliflozin reduced 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
• The 2022 ACC/AHA/HFSA guidelines assign SGLT2 inhibitors a Class 2a recommendation (Level of Evidence: B-R), indicating they "can be beneficial in decreasing HF hospitalizations and cardiovascular mortality" 1, 2
• Start dapagliflozin 10 mg daily (requires eGFR >30 mL/min/1.73m²) or empagliflozin 10 mg daily (requires eGFR >60 mL/min/1.73m²) immediately upon diagnosis 3, 4

This represents a major shift from the pre-2021 era when no pharmacological agents had demonstrated survival benefits in HFpEF 2.

Symptom Management with Diuretics

• Loop diuretics (furosemide or torsemide) remain essential for managing congestion, orthopnea, and paroxysmal nocturnal dyspnea 1, 2, 5
• Use the lowest effective dose to relieve congestion while avoiding excessive diuresis that leads to hypotension and worsening renal function 2, 3, 4
• For new-onset HFpEF with congestion, start with 20-40 mg IV furosemide (or equivalent); for chronic therapy, initial IV dose should equal or exceed oral dose 2
• Titrate diuretic dose based on symptoms and volume status before adding combination diuretic strategies 2
• Consider adding a thiazide diuretic for sequential nephron blockade only if inadequate response to optimized loop diuretic therapy 2, 4

Additional Pharmacological Options for Selected Patients

Mineralocorticoid Receptor Antagonists (MRAs)

• Spironolactone has a Class 2b recommendation and "may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of this spectrum" (40-50%) 1, 2
• The TOPCAT trial showed spironolactone reduced heart failure hospitalizations (HR 0.83,95% CI 0.69-0.99) but did not significantly reduce the primary composite outcome 2
• Requires careful monitoring of potassium, renal function, and diuretic dosing to minimize hyperkalemia risk 2

Angiotensin Receptor-Neprilysin Inhibitors (ARNIs)

• Sacubitril/valsartan has a Class 2b recommendation and may be considered for selected patients 1, 2
• The PARAGON-HF trial did not achieve statistical significance for the primary endpoint (rate ratio 0.87,95% CI 0.75-1.01, p=0.06) 2
• Prespecified subgroup analyses showed potential benefit in patients with LVEF 45-57% (rate ratio 0.78,95% CI 0.64-0.95) and in women (rate ratio 0.73,95% CI 0.59-0.90) 2
• Consider particularly for female patients and those with LVEF in the lower preserved range (closer to 45-50%) 2, 4

Angiotensin Receptor Blockers (ARBs)

• ARBs have a Class 2b recommendation and may be considered to decrease hospitalizations, particularly among patients with LVEF on the lower end of the spectrum 1

Aggressive Comorbidity Management

Managing comorbidities is now recognized as critical to HFpEF outcomes, particularly in older adults with hypertension, diabetes, and obesity. 1, 6

Hypertension Control

• Target blood pressure <130/80 mmHg using appropriate antihypertensive medications 2, 3, 4
• The 2022 ACC/AHA/HFSA guidelines assign a Class 1 recommendation (Level of Evidence: C-LD) for titrating medications to attain blood pressure targets to prevent morbidity 1
• Consider RAAS antagonists (ACEi, ARB, MRA, or ARNi) as first-line agents given their experience in HFpEF trials 1
• Beta blockers may be used for patients with history of MI, symptomatic CAD, or atrial fibrillation with rapid ventricular response, but balance against potential chronotropic incompetence 1

Diabetes Management

• Prioritize SGLT2 inhibitors for glycemic control given their dual benefits for diabetes and heart failure 2, 3, 4
• This represents an important trend toward integrated cardiometabolic management 1

Atrial Fibrillation Management

• Management of atrial fibrillation is useful to improve symptoms (Class 2a recommendation, Level of Evidence: C-EO) 1
• Control ventricular rate using beta-blockers or non-dihydropyridine calcium channel blockers 4

Obesity Management

• Exercise training and diet-induced weight loss produced clinically meaningful increases in functional capacity and quality of life 5
• Emerging evidence supports glucagon-like peptide-1 receptor agonists for obese HFpEF patients 7

Non-Pharmacological Interventions

• Supervised exercise training programs have a Class 1 recommendation (Level of Evidence: A) to improve functional capacity and quality of life 2, 3, 4
• Prescribe sodium restriction to <2-3 g/day to reduce congestive symptoms 3, 4
• Weight reduction is recommended for obese patients 3
• Multidisciplinary heart failure programs should be offered to all patients 2

Monitoring and Follow-Up Strategy

• Monitor symptoms, vital signs, weight, renal function, and electrolytes regularly 3, 4
• Adjust diuretic doses based on congestion status to avoid overdiuresis leading to hypotension 3, 4
• Consider wireless implantable pulmonary artery monitors in selected patients with recurrent hospitalizations for optimizing volume status 2, 4

Critical Pitfalls to Avoid

• Do not delay initiation of SGLT2 inhibitors – they have proven mortality and morbidity benefits and should be started immediately upon diagnosis 4
• Do not treat HFpEF patients the same as those with reduced ejection fraction – response to therapies differs significantly between these populations 2
• Avoid excessive diuresis which leads to hypotension, worsening renal function, and impaired tolerance of other medications 2, 4
• Do not use diltiazem or verapamil in HFpEF patients as they increase the risk of heart failure worsening and hospitalization 2
• Do not routinely use nitrates or phosphodiesterase-5 inhibitors to increase activity or quality of life – they are ineffective (Class 3: No-Benefit recommendation, Level of Evidence: B-R) 1
• Do not overlook the importance of managing comorbidities (hypertension, diabetes, obesity, atrial fibrillation) which significantly impact outcomes 2, 4

Advanced Treatment Considerations

• Consider referral to an advanced heart failure specialist team for patients with advanced HFpEF refractory to standard therapies 2
• Cardiac transplantation can be considered in eligible patients with advanced HFpEF 2

Treatment Algorithm for Older Adults with Hypertension, Diabetes, and Obesity

1. Confirm diagnosis: LVEF ≥50%, elevated natriuretic peptides, evidence of structural heart disease or elevated filling pressures 3, 4
2. Initiate SGLT2 inhibitor immediately: Dapagliflozin 10 mg daily or empagliflozin 10 mg daily 2, 3, 4
3. Manage congestion: Loop diuretics at lowest effective dose if orthopnea/PND present 2, 3, 4
4. Optimize blood pressure: Target <130/80 mmHg, preferentially using RAAS antagonists 2, 3, 4
5. Consider adding spironolactone: Particularly if LVEF 40-50% 1, 2
6. Consider sacubitril/valsartan: Particularly for women or LVEF 45-57% 2, 4
7. Prescribe supervised exercise training 2, 3, 4
8. Implement sodium restriction <2-3 g/day 3, 4
9. Promote weight loss through diet and exercise 5
10. Manage atrial fibrillation if present with rate control 1, 4

The most important trend is the shift from nihilistic symptom-only management to proactive disease-modifying therapy with SGLT2 inhibitors, combined with aggressive comorbidity management and structured exercise programs. 1, 2