How should I manage a 68-year-old man with hypertension who presents with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, basal crackles, an S4 gallop, an ejection murmur, and echocardiogram showing left ventricular hypertrophy with a preserved ejection fraction of 55%?

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Management of Heart Failure with Preserved Ejection Fraction (HFpEF) Secondary to Hypertensive Heart Disease

This 68-year-old man has HFpEF secondary to chronic hypertension with left ventricular hypertrophy, and management must prioritize aggressive blood pressure control to target <130/80 mmHg, immediate diuretic therapy for congestion relief, and initiation of SGLT2 inhibitors as disease-modifying therapy. 1

Diagnostic Confirmation

This patient meets all diagnostic criteria for HFpEF:

  • Preserved ejection fraction of 55% satisfies the threshold (≥50%) required for HFpEF diagnosis 1
  • Classic heart failure symptoms including orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion are cardinal manifestations 1
  • Physical examination findings of bibasilar crackles (pulmonary congestion) and S4 gallop (elevated filling pressures) confirm the diagnosis 1
  • Left ventricular hypertrophy on echocardiogram provides the structural cardiac abnormality required for HFpEF 1
  • Chronic hypertension is the most common cause of HFpEF, driving pressure overload that leads to LVH and diastolic dysfunction 1, 2

The S4 gallop (not S3 as mentioned in some references) indicates atrial contraction against a stiff, hypertrophied ventricle, while the ejection murmur likely represents dynamic LV outflow tract obstruction related to hypertrophy or concurrent valvular sclerosis 1.

Immediate Management Priorities

1. Aggressive Blood Pressure Control

Target blood pressure <130/80 mmHg is the cornerstone of HFpEF management in hypertensive heart disease 1. This patient's current hypertension is driving ongoing LV remodeling and must be addressed urgently.

  • Preferred antihypertensive agents include ACE inhibitors, ARBs, or calcium channel blockers, as these classes demonstrate specific effects on LVH regression independent of blood pressure reduction 3
  • Renin-angiotensin system blockade is particularly important given the correlation between RAS activity and left ventricular mass 3
  • Blood pressure control not only improves symptoms but also prevents progression from adaptive to maladaptive LVH 2

2. Diuretic Therapy for Congestion

Loop diuretics should be initiated immediately to relieve pulmonary congestion evidenced by orthopnea, paroxysmal nocturnal dyspnea, and bibasilar crackles 4, 1.

  • Diuretics must be used judiciously to reduce congestion and improve symptoms without causing excessive volume depletion 4
  • The goal is to eliminate pulmonary crackles and resolve orthopnea while maintaining adequate perfusion 1

3. SGLT2 Inhibitor Initiation

SGLT2 inhibitors (dapagliflozin or empagliflozin) have demonstrated benefit across the heart failure spectrum, including HFpEF, and should be initiated 4, 1.

  • The DELIVER and EMPEROR-PRESERVED trials showed significant reductions in cardiovascular death and heart failure hospitalizations in HFpEF patients with EF >40% 4
  • SGLT2 inhibitors provide disease-modifying therapy beyond symptom relief 4
  • These agents are safe and effective in both acute and chronic care settings 4

Additional Guideline-Directed Medical Therapy

Mineralocorticoid Receptor Antagonists

Consider spironolactone as part of GDMT for HFpEF 4.

  • The TOPCAT trial demonstrated benefit in HFpEF patients, though results were more modest than with SGLT2 inhibitors 4
  • MRAs are particularly useful when additional blood pressure control is needed 4

Angiotensin Receptor-Neprilysin Inhibitors

Sacubitril/valsartan may be considered, particularly if the patient has an EF closer to the lower end of the preserved range 4.

  • The PARAGON-HF trial showed benefit in HFpEF patients, especially those with EF 45-57% 4
  • ARNIs provide combined RAS blockade and neprilysin inhibition 4

Beta-Blocker Considerations

Beta-blockers are NOT routinely indicated for HFpEF unless specific comorbidities exist 4.

  • Use beta-blockers only if the patient has prior myocardial infarction (within 3 years), angina, or atrial fibrillation 4
  • Monitor exercise tolerance carefully due to potential for chronotropic incompetence in HFpEF patients 4
  • This patient does not have documented coronary disease or atrial fibrillation based on the presentation, so beta-blockers should be avoided 4

Comorbidity Management

Aggressive management of hypertension, obesity, and screening for obstructive sleep apnea are essential components of HFpEF care 4.

  • The patient's age and presentation suggest possible sleep apnea, which should be evaluated 4
  • Weight loss and exercise programs improve symptoms and functional capacity in HFpEF 4

Monitoring and Follow-Up

Initiate GDMT safely in either acute or chronic care settings with close monitoring 4.

  • Titrate medications to target doses as outlined in guideline recommendations 4
  • Monitor renal function and electrolytes when initiating RAS blockade and MRAs 4
  • Reassess volume status and adjust diuretics based on clinical response 4

Critical Pitfalls to Avoid

Do not treat this as HFrEF – the management strategies differ significantly, and beta-blockers are not routinely beneficial in HFpEF 4.

Do not under-treat blood pressure – aggressive BP control to <130/80 mmHg is essential to prevent progression of LVH and worsening diastolic dysfunction 1.

Do not overlook SGLT2 inhibitors – these are now considered foundational therapy in HFpEF with proven mortality and morbidity benefits 4, 1.

Do not over-diurese – excessive diuresis can reduce preload in a stiff ventricle and worsen symptoms despite preserved EF 4.

References

1
Guideline

Diagnostic Criteria and Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Research

Hypertension and left ventricular hypertrophy.

Journal of hypertension, 2024

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.