How should diastolic heart failure (heart failure with preserved ejection fraction) be managed in a 75‑year‑old female with pulmonary hypertension, who is taking furosemide 60 mg daily, midodrine 5 mg three times daily, has stage 3 chronic kidney disease, and hyperlipidemia?

Management of HFpEF in a 75-Year-Old Female with Pulmonary Hypertension and Stage 3 CKD

The cornerstone of management is optimizing diuretic therapy for congestion control while initiating SGLT2 inhibitor therapy (empagliflozin or dapagliflozin) to reduce mortality and heart failure hospitalizations, with careful attention to volume status given her stage 3 CKD. 1, 2

Guideline-Directed Medical Therapy for HFpEF

First-Line Disease-Modifying Therapy

• SGLT2 inhibitors are the primary disease-modifying therapy for HFpEF with proven mortality and morbidity benefits 1, 2
  • Empagliflozin (EMPEROR-PRESERVED) showed HR 0.79 for cardiovascular death and HF hospitalization 1
  • Dapagliflozin (DELIVER) demonstrated HR 0.82 for worsening HF and cardiovascular death 1
  • Both agents reduced HF hospitalizations by approximately 20-30% 1
  • These benefits extend to patients with CKD (eGFR ≥20-25 mL/min/1.73m²) 1, 2

Diuretic Management

Continue furosemide 60 mg daily but optimize dosing based on congestion status 3, 4, 1:

• Loop diuretics should be titrated to achieve euvolemia ("dry weight") with the lowest effective dose 3
• In stage 3 CKD, loop diuretics remain preferred over thiazides (thiazides ineffective when GFR <30 mL/min) 5, 3, 6
• Monitor for excessive diuresis which can reduce cardiac output in HFpEF and worsen renal function 3
• Consider twice-daily dosing if persistent fluid retention occurs 5, 3
• Patient self-adjustment based on daily weights and symptoms is recommended 3

Critical monitoring with diuretics 7, 8:

• Check renal function, electrolytes (particularly potassium), and creatinine at baseline, 1-2 weeks after dose changes, then every 3-4 months when stable 7
• Maximum accepted creatinine rise is 50% or 266 μmol/L from baseline 7

Mineralocorticoid Receptor Antagonist Consideration

Spironolactone may provide benefit, particularly if LVEF is closer to 50% 1, 2:

• TOPCAT trial showed HR 0.83 for HF hospitalization (though primary endpoint not met overall) 1
• In stage 3 CKD, initiate at low dose (12.5-25 mg) with intensive monitoring 5, 3, 6
• Monitoring schedule: Check potassium and creatinine at 1 week, then at 1,2,3,6,9, and 12 months, then every 4 months 7
• Discontinue if potassium >6.0 mmol/L; halve dose if 5.5-6.0 mmol/L 7
• Avoid combining with ACE inhibitors/ARBs in advanced CKD due to hyperkalemia risk 3

Blood Pressure and Rate Control

Target systolic BP <130 mmHg for HFpEF management 4:

• ACE inhibitors or ARBs are recommended for persistent hypertension after volume management 4
• Beta-blockers may be beneficial for rate control in the setting of pulmonary hypertension and can improve outcomes 4, 2
• However, monitor for chronotropic incompetence which can worsen exercise tolerance in HFpEF 1

Pulmonary Hypertension Management

Treat the underlying HFpEF as the primary strategy for pulmonary hypertension 9, 10:

• Pulmonary vasodilator therapies (PDE-5 inhibitors, ERAs, prostacyclins) are NOT recommended for PH-HFpEF 2, 9, 10
• Sildenafil showed no benefit in the RELAX trial 2
• SGLT2 inhibitors and ARNIs show emerging evidence for improving hemodynamics in PH-HFpEF 9
• Ensure adequate decongestion as venous congestion directly contributes to elevated pulmonary pressures 10

Midodrine Consideration

Reassess the need for midodrine 5 mg TID in this context:

• Midodrine is a vasopressor that may worsen afterload and pulmonary hypertension 3
• If used for orthostatic hypotension, consider whether volume status optimization might allow discontinuation
• Avoid excessive diuresis that necessitates vasopressor support 3

CKD-Specific Considerations

Stage 3 CKD creates a high-risk cardiorenal phenotype requiring careful management 11, 12, 13:

• Systemic congestion is a major driver of worsening renal function in HFpEF 14, 12
• Continue ACE inhibitors/ARBs unless creatinine rises >100% or >310 μmol/L, or eGFR <20 mL/min 7
• Avoid NSAIDs which worsen both HF and renal function 3, 15, 8
• Sequential nephron blockade (adding thiazide to loop diuretic) may be considered for diuretic resistance, but monitor closely for AKI 14

Hyperlipidemia Management

• Continue statin therapy for cardiovascular risk reduction
• No specific HFpEF-related modifications needed for lipid management

Monitoring Strategy

Establish regular monitoring schedule 7, 8:

• Every 1-2 weeks after medication changes
• Every 3-4 months when stable
• Parameters: weight, symptoms, BP, heart rate, creatinine, eGFR, electrolytes (especially potassium), BUN
• Daily home weights for patient self-management of diuretics 3

Common Pitfalls to Avoid

• Over-diuresis: Can precipitate hypotension, AKI, and reduced cardiac output in HFpEF 3
• Under-treatment of congestion: Venous congestion drives both cardiac and renal dysfunction 14
• Delaying SGLT2 inhibitor initiation: These are the only proven mortality-reducing agents in HFpEF 1, 2
• Using pulmonary vasodilators: No benefit and potential harm in PH-HFpEF 2, 9
• Inadequate potassium monitoring: Critical when using MRAs with ACE inhibitors/ARBs in CKD 7