From the Guidelines
Heart failure with preserved ejection fraction (HFpEF) management should prioritize symptom relief, treating underlying conditions, and improving quality of life, with a focus on lifestyle modifications, diuretics, SGLT2 inhibitors, and aggressive management of comorbidities. Treatment begins with lifestyle modifications including sodium restriction (less than 2-3g daily), regular physical activity, and weight management. Diuretics, particularly loop diuretics like furosemide (20-80mg daily) or torsemide (10-40mg daily), are the cornerstone of therapy to relieve congestion and improve symptoms 1. SGLT2 inhibitors such as empagliflozin (10mg daily) or dapagliflozin (10mg daily) have shown benefit in reducing hospitalizations and cardiovascular death, as demonstrated in the EMPEROR PRESERVED and DELIVER trials 1. For patients with persistent symptoms, mineralocorticoid receptor antagonists like spironolactone (25-50mg daily) may be beneficial, especially in those with elevated natriuretic peptides. Aggressive management of comorbidities is essential, including hypertension (target BP <130/80 mmHg), diabetes (target HbA1c <7%), coronary artery disease, atrial fibrillation (rate control or rhythm control as appropriate), and obesity. Some key points to consider in HFpEF management include:
- The importance of exercise capacity and quality of life in these patients, as emphasized by the American Heart Association and American College of Cardiology 1
- The use of device-based solutions, such as wireless pulmonary artery pressure monitoring devices, to relieve symptoms and improve the clinical course of patients with HFpEF 1
- The potential benefits of sacubitril/valsartan in selected patients with HFpEF, as demonstrated in the PARAGON-HF trial 1
- The need for regular follow-up to monitor symptoms, adjust medications, and assess volume status. Overall, the goal of HFpEF management is to improve symptoms, reduce hospitalizations, and enhance quality of life, while also addressing underlying conditions and comorbidities.
From the Research
HFpEF Management Overview
- HFpEF is a form of heart failure where the ejection fraction is preserved, accounting for approximately half of all heart failure cases 2.
- Management of HFpEF is challenging due to its complex pathophysiological mechanisms, both cardiac and non-cardiac, and the high burden of non-cardiac comorbidities 2, 3.
Pharmacologic Management
- Several pharmacologic agents have been studied for the management of HFpEF, including sodium-glucose cotransporter 2 inhibitors, renin-angiotensin-aldosterone blockers, and angiotensin-neprilysin inhibitors 2, 4.
- Loop diuretics, mineralocorticoid receptor antagonists, and sodium glucose co-transporter-2 inhibitors are recommended for most patients with HFpEF, while angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors and glucagon-like peptide-1 receptor agonists may be considered as add-on therapies for some patients 4.
- Beta blockers may be considered for a smaller subset of patients with HFpEF, but their use must be carefully weighed against the risk of adverse effects, particularly in older adults 4, 5.
Non-Pharmacologic Management
- Comprehensive management of HFpEF includes exercise and treatment of risk factors and comorbidities, such as hypertension, diabetes, and obesity 2, 6.
- Lifestyle interventions, including dietary changes and increased physical activity, are also recommended for patients with HFpEF 6.
Diagnostic Challenges
- Diagnosis of HFpEF can be challenging due to its heterogeneous clinical presentation and the need to distinguish it from other causes of dyspnea and heart failure with reduced ejection fraction 2, 3, 6.
- Advanced diagnostic methods, such as exercise echocardiography and invasive hemodynamics, may be necessary to confirm the diagnosis of HFpEF 2.