How should I manage a patient with heart failure with preserved ejection fraction who presents with congestion, hypertension, diabetes, and atrial fibrillation?

Management of Heart Failure with Preserved Ejection Fraction (HFpEF) with Congestion, Hypertension, Diabetes, and Atrial Fibrillation

Initiate SGLT2 inhibitor therapy (dapagliflozin 10 mg or empagliflozin 10 mg daily) immediately as first-line disease-modifying treatment, use intravenous loop diuretics to relieve congestion, achieve blood pressure control <130/80 mmHg, implement rate control for atrial fibrillation with beta-blockers, and optimize diabetes management with the SGLT2 inhibitor already prescribed. 1, 2, 3

Immediate Acute Management of Congestion

Diuretic Strategy

• Start with intravenous loop diuretics at a dose equal to or greater than the patient's chronic oral daily dose if already on diuretics, or 40-80 mg IV furosemide equivalent if diuretic-naïve 4, 1, 2
• Assess diuretic response within 2-6 hours using spot urine sodium and hourly urine output 5
• If inadequate response occurs, escalate by either: (1) increasing the IV loop diuretic dose, or (2) adding a thiazide diuretic for sequential nephron blockade, or (3) adding IV acetazolamide 4, 5
• The CLOROTIC trial demonstrated that adding hydrochlorothiazide to furosemide produced greater weight loss and diuresis, though with increased rates of creatinine elevation of uncertain clinical significance 4
• Do not stop decongestion therapy based solely on serum creatinine increases, as these changes typically do not represent true worsening renal function in the context of aggressive diuresis 5

Monitoring During Acute Decongestion

• Monitor serum electrolytes, urea nitrogen, and creatinine during diuretic titration 4
• Assess for clinical euvolemia by examining jugular venous pressure, peripheral edema, orthopnea resolution, and weight changes 6
• Titrate diuretics to the lowest effective dose once euvolemia is achieved 4, 1, 7

Disease-Modifying Pharmacotherapy (Core Treatment)

SGLT2 Inhibitors (First-Line, Class 2a)

• Initiate dapagliflozin 10 mg daily or empagliflozin 10 mg daily as soon as hemodynamically stable, even during hospitalization 1, 2, 8
• Dapagliflozin reduced the composite of worsening HF and cardiovascular death by 18% (HR 0.82,95% CI 0.73-0.92) in the DELIVER trial 1, 8
• Empagliflozin reduced HF hospitalization or cardiovascular death by 21% (HR 0.79,95% CI 0.69-0.90) in EMPEROR-PRESERVED 1, 3
• Benefits occur within weeks of initiation and are independent of diabetes status, background HF medications, or age 4, 8
• Ensure eGFR >30 mL/min/1.73m² for dapagliflozin (or >20 mL/min/1.73m² per newer data) and >60 mL/min/1.73m² for empagliflozin 1
• SGLT2 inhibitors require no dose titration, do not affect blood pressure or heart rate significantly, and provide additional glycemic control for diabetes 4, 1

Mineralocorticoid Receptor Antagonists (Class 2b)

• Consider adding spironolactone 12.5-25 mg daily, particularly if LVEF is in the lower preserved range (40-50%) 1, 2
• The TOPCAT trial showed spironolactone reduced HF hospitalizations by 17% (HR 0.83,95% CI 0.69-0.99) though did not reduce mortality 1
• Monitor potassium and renal function closely to avoid hyperkalemia, especially when combined with RAAS inhibitors 1, 2

Angiotensin Receptor-Neprilysin Inhibitors (Class 2b)

• Sacubitril/valsartan may be considered specifically for women and patients with LVEF 45-57%, as these subgroups showed benefit in PARAGON-HF post-hoc analyses 1, 2
• The overall PARAGON-HF trial narrowly missed statistical significance (rate ratio 0.87,95% CI 0.75-1.01, p=0.06) 1

Management of Atrial Fibrillation in HFpEF

Rate Control Strategy (Preferred Initial Approach)

• Rate control is generally preferred over rhythm control as the initial strategy in HFpEF patients with AF 3
• Use beta-blockers as first-line agents for rate control due to favorable effects on controlling ventricular response 3
• Non-dihydropyridine calcium channel blockers (diltiazem or verapamil) can be used for rate control, particularly in combination with digoxin, but avoid in patients with overt systolic dysfunction 3
• Target resting heart rate <80 bpm and <110 bpm with exertion 3

When to Consider Advanced AF Management

• Consider AV node ablation with cardiac resynchronization therapy device placement only when rate control cannot be achieved due to drug inefficacy or intolerance 3
• Do not perform AV node ablation without first attempting pharmacological rate control 3

Blood Pressure Management

Target and Agents

• Achieve blood pressure <130/80 mmHg using guideline-directed HF medications 1, 2, 3
• The beta-blocker prescribed for AF rate control will contribute to blood pressure lowering 3
• If additional blood pressure control is needed, use ACE inhibitors or ARBs (though these have not shown mortality benefit in HFpEF, they are reasonable for hypertension management) 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) as primary antihypertensives due to negative inotropic effects and increased risk of HF worsening 1

Diabetes Management

Integrated Approach

• The SGLT2 inhibitor prescribed for HFpEF provides dual benefit for both heart failure and glycemic control 4, 1, 3
• Continue metformin if already prescribed and no contraindications exist 9
• Avoid thiazolidinediones (pioglitazone, rosiglitazone) as they cause fluid retention and worsen HF 9

Non-Pharmacological Interventions

Exercise Training (Class 1 Recommendation)

• Prescribe supervised exercise training programs consisting of 3 sessions per week for 1-8 months at 40-90% of exercise capacity 1
• Exercise training improves aerobic exercise capacity by 12-14% and produces clinically meaningful improvements in quality of life 1
• Modalities include walking, stationary cycling, or high-intensity interval training 1

Dietary Modifications

• Recommend sodium restriction to <2-3 g/day to reduce congestive symptoms 4, 2
• For patients with obesity, diet-induced weight loss produces clinically meaningful increases in functional capacity and quality of life 7

Ongoing Monitoring and Follow-Up

Clinical Parameters

• Monitor symptoms, vital signs, daily weights, and signs of congestion at each visit 2
• Assess functional capacity using NYHA class and 6-minute walk distance when appropriate 2
• Regularly check renal function and electrolytes, especially when using MRAs or during diuretic adjustments 4, 2

Diuretic Adjustments

• Adjust loop diuretic doses based on congestion status to maintain euvolemia while avoiding overdiuresis 2
• Patients should be educated on self-adjustment of diuretics based on daily weights and symptoms 7

Advanced Monitoring

• Consider wireless pulmonary artery pressure monitoring in patients with recurrent hospitalizations to optimize volume status 1, 2

Critical Pitfalls to Avoid

Medication Errors

• Do not delay SGLT2 inhibitor initiation – these agents have proven mortality and morbidity benefits and should be started early 2
• Avoid excessive diuresis leading to hypotension and worsening renal function, which impairs tolerance of other guideline-directed medications 4, 2
• Do not discontinue guideline-directed medical therapy during hospitalization unless hemodynamic instability or specific contraindications exist 4
• Never use nitrates in HFpEF as they are associated with a signal of harm 1

Management Misconceptions

• Do not treat HFpEF patients identically to those with HFrEF – response to therapies differs significantly between these populations 4, 1
• Do not assume traditional HF medications (ACE inhibitors, ARBs, beta-blockers alone) improve survival in HFpEF – only SGLT2 inhibitors have shown consistent benefit across the HFpEF spectrum 1, 7, 10
• Do not stop decongestion therapy based solely on creatinine increases during acute diuresis, as these typically represent hemodynamic changes rather than true kidney injury 5

Comorbidity Management

• Do not overlook the importance of managing comorbidities (hypertension, diabetes, obesity, AF) which significantly impact HFpEF outcomes 4, 1, 2

When to Consider Advanced Therapies

Referral Indications

• Refer to an advanced heart failure specialist for patients with advanced HFpEF refractory to standard therapies 1
• Cardiac transplantation can be considered in eligible patients with advanced HFpEF 1
• Ultrafiltration may be considered as a last resort for refractory fluid overload unresponsive to maximal diuretic therapy 4