What is the acute and long‑term management of a patient with heart‑failure with preserved ejection fraction who experienced a flash‑edema episode after a Valsalva‑type strain?

Management of HFpEF with Flash Pulmonary Edema After Valsalva Strain

Acute Management – Immediate Decongestion

Initiate intravenous loop diuretics immediately at a dose equal to or greater than the patient's chronic oral dose (or 40–80 mg furosemide-equivalent IV if diuretic-naïve) to achieve rapid relief of flash pulmonary edema. 1

• If the initial diuretic response is inadequate within 6–12 hours, escalate by either (1) doubling the IV loop diuretic dose, (2) adding a thiazide diuretic (e.g., metolazone 2.5–5 mg or hydrochlorothiazide 25–50 mg) for sequential nephron blockade, or (3) adding IV acetazolamide 500 mg once daily. 1
• Monitor serum electrolytes, blood urea nitrogen, and creatinine every 12–24 hours during aggressive diuresis to detect hyperkalemia, hypokalemia, and acute kidney injury. 1
• Once clinical euvolemia is achieved (resolution of orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema), taper diuretics to the lowest dose that maintains volume balance. 1

Blood Pressure Management During Acute Episode

Target systolic blood pressure <130/80 mmHg using agents that provide heart-failure benefit; ACE inhibitors or ARBs are first-line for additional blood pressure control after volume optimization. 1

• Hypertension is present in 60–89% of HFpEF patients and represents the most important modifiable risk factor for flash pulmonary edema. 1
• Loop diuretics are the only antihypertensive agents that reliably address fluid retention in heart failure and should be prioritized during acute decompensation. 1
• Avoid nondihydropyridine calcium-channel blockers (diltiazem, verapamil) because they have negative inotropic effects and increase the risk of heart failure worsening and hospitalization. 1
• Avoid nitrates in HFpEF, as they are associated with a signal of harm in this population. 2, 1

Disease-Modifying Therapy – Initiate Immediately After Stabilization

Start dapagliflozin 10 mg daily (if eGFR >30 mL/min/1.73 m²) or empagliflozin 10 mg daily (if eGFR >60 mL/min/1.73 m²) as the cornerstone of HFpEF treatment, regardless of diabetes status. 1, 3

• SGLT2 inhibitors reduce the composite of worsening heart failure and cardiovascular death (HR 0.82,95% CI 0.73–0.92 for dapagliflozin; HR 0.79,95% CI 0.69–0.90 for empagliflozin), with benefits occurring within weeks and independent of background therapy. 1, 3
• SGLT2 inhibitors reduce heart failure hospitalizations by 23% (HR 0.77,95% CI 0.67–0.89) and require no dose titration, making them ideal for patients recovering from flash edema. 1, 3
• These agents have minimal impact on blood pressure and heart rate, reducing the risk of precipitating hypotension in volume-depleted patients. 1

Additional Pharmacologic Options for Selected Patients

Consider adding spironolactone 12.5–25 mg daily if LVEF is in the lower preserved range (40–50%), with careful monitoring of potassium and renal function. 2, 1

• Spironolactone reduced heart failure hospitalizations (HR 0.83,95% CI 0.69–0.99) in the TOPCAT trial, particularly in patients with LVEF closer to 45%. 2, 1
• Creatinine should be <2.5 mg/dL in men or <2.0 mg/dL in women (or eGFR >30 mL/min) and potassium <5.0 mEq/L before initiation. 2
• Monitor potassium and creatinine within 3 days of initiation and weekly for the first month, then monthly thereafter. 2

Sacubitril/valsartan may be considered specifically for women and patients with LVEF 45–57%, as these subgroups showed benefit in post-hoc analyses. 2, 1

• The PARAGON-HF trial showed a signal of benefit for heart failure hospitalizations (rate ratio 0.85,95% CI 0.72–1.00) but did not meet its primary endpoint. 2
• Greater benefit was observed in patients with LVEF below the median (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

Prevention of Recurrent Flash Edema Episodes

Advise dietary sodium restriction to <2–3 g per day to lessen congestive symptoms and support diuretic effectiveness. 1

Prescribe supervised exercise training programs (3 sessions per week for 1–8 months at 40–90% of exercise capacity) to improve functional capacity by 12–14% and quality of life. 2, 1

• Exercise training has consistently demonstrated large, clinically meaningful improvements in symptoms and objectively determined exercise capacity in HFpEF, with effect sizes comparable to or larger than those seen in HFrEF. 2
• Exercise addresses the peripheral vascular, skeletal muscle, and cardiovascular abnormalities that contribute to exercise intolerance and may reduce the risk of recurrent decompensation. 2

Management of Atrial Fibrillation (If Present)

If atrial fibrillation is present, use beta-blockers as first-line for rate control, targeting resting heart rate <110 bpm. 4

• Beta-blockers improve heart failure symptoms in HFpEF by slowing heart rate, lengthening diastolic filling time, and lowering left ventricular diastolic pressures. 4
• Avoid nondihydropyridine calcium-channel blockers in HFpEF patients with atrial fibrillation because they increase the risk of heart failure worsening. 4
• Anticoagulation should be prescribed based on CHA₂DS₂-VASc score; patients ≥60 years old with heart failure have a score of at least 2, indicating clear indication for oral anticoagulation. 4

Advanced Therapies for Refractory Cases

In patients with recurrent flash edema episodes despite optimal diuretic therapy, ultrafiltration may be employed as a last-resort strategy. 1

Wireless, implantable pulmonary-artery pressure monitors can be considered in selected patients with prior decompensated heart failure admissions to facilitate volume-status optimization and prevent recurrent flash edema. 1

Referral to an advanced heart failure specialist team is advised for HFpEF patients who remain refractory to standard therapies. 1

Critical Pitfalls to Avoid

• Do not treat HFpEF patients the same as those with reduced ejection fraction; response to therapies differs significantly between these populations. 1
• Avoid excessive diuresis, which can precipitate hypotension and worsening renal function, thereby compromising tolerance of other guideline-directed therapies. 1
• Do not overlook the importance of managing comorbidities (hypertension, diabetes, obesity, atrial fibrillation), which significantly impact outcomes and risk of recurrent flash edema in HFpEF. 1
• Avoid thiazolidinediones (pioglitazone, rosiglitazone) and DPP-4 inhibitors (saxagliptin, alogliptin), as they increase the risk of heart failure hospitalization. 1

Long-Term Monitoring

• Regularly assess volume status, renal function, and electrolytes, especially with MRA therapy, to guide treatment adjustments and prevent recurrent decompensation. 1
• Monitor symptoms and functional capacity to guide treatment adjustments and identify early signs of recurrent congestion. 1