From the Guidelines
Treatment of heart failure with normal ejection fraction (HFpEF) should prioritize symptom management, addressing underlying conditions, and lifestyle modifications, with a focus on improving quality of life and reducing morbidity and mortality, as evidenced by recent studies 1. The management of HFpEF involves a multifaceted approach, including:
- Diuretics, such as loop diuretics like furosemide (20-80mg daily) or torsemide (10-20mg daily), for fluid overload and symptom relief
- Blood pressure control using ACE inhibitors (like lisinopril 10-40mg daily), ARBs (such as losartan 25-100mg daily), or the combination of sacubitril/valsartan (24/26mg to 97/103mg twice daily)
- Beta-blockers (metoprolol succinate 25-200mg daily or carvedilol 3.125-25mg twice daily) to control heart rate and improve symptoms
- SGLT2 inhibitors like empagliflozin (10mg daily) or dapagliflozin (10mg daily) for patients with diabetes, which have shown mortality benefits 1
- Lifestyle modifications, including sodium restriction (<2-3g daily), fluid restriction if needed, regular physical activity, and weight management
- Treatment of comorbidities such as atrial fibrillation, coronary artery disease, and sleep apnea Supervised exercise training has also been shown to improve symptoms, exercise capacity, and quality of life in patients with HFpEF, with a comparable or larger magnitude of improvement compared to heart failure with reduced ejection fraction 1. It is essential to note that HFpEF lacks therapies that definitively improve mortality, making symptom management and addressing underlying conditions the primary focus of treatment, as highlighted in recent clinical practice guidelines and recommendations 1.
From the Research
Treatment Approaches
- The treatment of heart failure with normal ejection fraction (HFNEF) should focus on reducing left ventricular (LV) filling pressure, controlling hypertension, modifying ischemia, and improving LV relaxation 2.
- Diuretics are suitable for HFNEF patients to reduce ventricular filling pressure 2.
- Hypertension can be treated by using multiple agents if necessary, with calcium channel blockers (CCBs) and antagonists of the renin-angiotensin-aldosterone system, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and aldosterone antagonists, being of particular interest 2.
- Ischemic heart disease can be treated with antiplatelet therapy, anticoagulants, and β-blockers 2.
- Heart rate control in atrial fibrillation can be achieved with β-blockers and digoxin 2.
Pharmacologic Interventions
- ACE inhibitors and ARBs could potentially decrease LV hypertrophy in hypertensive patients with HFNEF 2.
- The combination of beta-blockers and ACE inhibitors has been shown to be effective in managing various cardiovascular diseases, including hypertension, arrhythmias, and heart failure 3.
- A comparison of ACE inhibitors and ARBs found no evidence of a difference in total mortality or cardiovascular outcomes, but ARBs caused slightly fewer withdrawals due to adverse effects than ACE inhibitors 4.
Diagnosis and Management
- Making the diagnosis of heart failure with preserved ejection fraction (HFpEF) is often challenging due to the presence of multiple comorbidities and alternative reasons for symptoms 5.
- A stepwise approach to the diagnosis and treatment of HFpEF, including establishing a clinical diagnosis, referring for invasive diagnostic testing, and optimizing treatment, can help improve accurate diagnosis and management of the disease 5.