What is the recommended management for a patient with a left‑ventricular ejection fraction of about 60% and grade 2 diastolic dysfunction (heart‑failure with preserved ejection fraction)?

Management of HFpEF with Grade 2 Diastolic Dysfunction (LVEF 60%)

Start an SGLT2 inhibitor (dapagliflozin or empagliflozin) immediately as foundational therapy, as this is the only medication class proven to reduce cardiovascular death and heart failure hospitalizations in HFpEF. 1

Core Pharmacological Strategy

First-Line Disease-Modifying Therapy

• SGLT2 inhibitors (dapagliflozin 10 mg daily or empagliflozin 10 mg daily) represent breakthrough therapy with proven reduction in the composite endpoint of cardiovascular death and HF hospitalizations in randomized controlled trials 1
• This should be initiated regardless of diabetes status and can be started even with eGFR as low as 20 mL/min/1.73 m² 2

Symptomatic Management with Diuretics

• Loop diuretics (furosemide as first choice) should be used at the lowest effective dose to relieve congestion and pulmonary symptoms 1, 3
• Critical pitfall: Avoid excessive diuresis that drops filling pressures too low, as this will precipitate hypotension and reduce cardiac output in patients who are preload-dependent 3
• Consider adding thiazide diuretics as adjunctive therapy if the patient remains hypertensive or has refractory edema despite loop diuretics 1

Blood Pressure Control

• Achieve aggressive blood pressure control with target <130/80 mmHg to promote regression of left ventricular hypertrophy and improve diastolic compliance 3
• ACE inhibitors or ARBs should be used to improve relaxation and cardiac compliance, particularly in hypertensive patients 1, 3

Heart Rate Management

• Beta-blockers are the preferred agents for rate control to improve ventricular filling time, as diastolic filling is critically time-dependent 1, 3
• Target heart rate control is especially important during exercise, with adjustment of pharmacological treatment to keep the rate in the physiological range 1
• Nondihydropyridine calcium channel blockers (verapamil or diltiazem) are reasonable alternatives for rate control, particularly if beta-blockers are contraindicated 1

Consideration of Sacubitril-Valsartan (ARNI)

• Sacubitril-valsartan may be considered for patients with LVEF closer to 50% (your patient at 60% is at the upper end of the benefit range) 1
• The PARAGON-HF trial showed a signal of benefit for HF hospitalizations (rate ratio 0.85) in patients with LVEF 45-57%, with greater benefit observed in women 1
• This represents a Class IIb recommendation (may be considered) rather than routine use 1

Management of Comorbidities and Precipitating Factors

Atrial Fibrillation (if present)

• Control ventricular rate aggressively using beta-blockers or nondihydropyridine calcium channel blockers 1, 3
• Consider rhythm control strategy if symptoms persist despite rate control 1
• Digoxin can be added for additional rate control in combination with beta-blockers 1

Coronary Artery Disease

• Coronary revascularization is reasonable when symptomatic or demonstrable myocardial ischemia adversely affects diastolic function 1, 3
• All patients with HFpEF should be systematically evaluated for the presence of coronary artery disease 4

Metabolic Factors

• Sodium restriction to reduce congestive symptoms, though the optimal level of restriction remains uncertain 1
• Optimize diabetes control and consider metabolic phenotype-directed therapy 5

What NOT to Do: Critical Contraindications

• Do NOT use positive inotropic agents (digoxin for inotropy, not rate control) in the absence of systolic dysfunction, as they provide no benefit and are contraindicated 3
• Avoid nitrates for routine use, as the NEAT-HFpEF trial showed no beneficial effects on activity levels, quality of life, or exercise tolerance 1
• Do NOT use phosphodiesterase-5 inhibitors (sildenafil), as the RELAX trial demonstrated no improvement in oxygen consumption or exercise tolerance 1

Monitoring and Follow-Up

• Serial assessment of symptoms, functional capacity, and volume status 1
• Monitor natriuretic peptides, though interpretation is complicated by age, obesity, and atrial fibrillation 1
• Echocardiographic surveillance for progression of diastolic dysfunction using E/e' ratio, left atrial volume index, and tricuspid regurgitation velocity 1

Phenotype-Based Approach

Given the heterogeneity of HFpEF, consider tailoring therapy to the patient's specific phenotype beyond the universal SGLT2 inhibitor recommendation 5:

• Hypertensive phenotype: Aggressive BP control with ACE inhibitors/ARBs
• Atrial fibrillation phenotype: Rate/rhythm control strategy
• Ischemic phenotype: Revascularization consideration
• Metabolic phenotype: SGLT2 inhibitors (already recommended for all)

Prognosis Context

The annual mortality rate for diastolic heart failure is approximately 8%, with substantial morbidity including frequent hospitalizations, significant dyspnea, fatigue, and reduced exercise tolerance 3. This underscores the importance of aggressive risk factor modification and the use of proven disease-modifying therapy with SGLT2 inhibitors 1.