The following are key points to remember from a 2023 ACC Expert Consensus Decision Pathway on management of heart failure with preserved ejection fraction (HFpEF):

1. Heart failure with preserved ejection fraction (HFpEF) is defined as signs and symptoms of HF with left ventricular EF (LVEF) ≥50%.
2. Diagnosis and management of HFpEF needs multidisciplinary care involving primary care, cardiology, and HF specialists. Referral to cardiology should be sought in the presence of comorbidities such as coronary artery disease/atrial fibrillation (AF), HF hospitalizations, elevated natriuretic peptides, specialists needed for comorbidities, knowledge of mimics, increased diuretic needs, and New York Heart Association (NYHA) class III-IV. Referral to HF specialists should be considered if there is intolerance to medical therapy, NYHA class III-IV symptoms, HF hospitalization, end-organ dysfunction, or escalating diuretic needs.
3. Two scoring systems: H₂FPEF and HFA-PEFF, may be used to estimate the probability of HFpEF. H₂FPEF assesses presence of hypertension, heavy body mass index (>30 kg/m²), AF, pulmonary hypertension, elderly (>60 years), and elevated filling pressures. HFA-PEFF involves pretest assessment of HF, echocardiography and natriuretic peptide score, functional testing including diastolic stress test/right heart catheterization, and special imaging/biopsy/genetic testing to identify cause.
4. Natriuretic peptides are lower in obese individuals with HFpEF. High suspicion of HFpEF is needed in obese individuals with dyspnea and obesity.
5. Women with HFpEF have more dyspnea with worse health status. Women with HFpEF have more concentric remodeling on echocardiography with more diastolic stiffness, smaller LV size, and higher LVEF compared with men. Accordingly, an EF of 50-55% may be abnormal in women.
6. Noncardiac mimics of HFpEF include renal disease, cirrhosis, and chronic venous insufficiency. Special cardiomyopathies can also present as HFpEF including infiltrative cardiomyopathy, hypertrophic cardiomyopathy, amyloidosis, valvular heart disease, or pericardial disease.
7. Management of HFpEF centers around managing comorbidities first including hypertension, obesity, diabetes, AF, and sleep apnea. Hypertension should be optimally controlled to systolic blood pressure <130 mm Hg. Agents of choice include diuretics, angiotensin receptor–neprilysin inhibitors (ARNIs), angiotensin receptor blockers (ARBs), and mineralocorticoid antagonists (MRAs).
8. Target for glycosylated hemoglobin HbA_1c is <7-7.5% for individuals with lower comorbidity burden or less severe HF and HbA_1c target is <8-8.5% for more severe HF, higher comorbidity burden, and the elderly. SGLT2 inhibitors should be first line for diabetic HFpEF. Metformin may be considered if estimated glomerular filtration rate (eGFR) is >30. Glucagon-like peptide-1 (GLP-1) agonists or GIP antagonist may be considered for obese individuals with diabetes mellitus and HFpEF. Dipeptidyl peptidase-4 (DPP4) inhibitors saxagliptin and alogliptin and thiazolidinediones are contraindicated in HF. Agents slowing progression for diabetic nephropathy include angiotensin-converting enzyme (ACE) inhibitors, ARBs, sodium-glucose cotransporter-2 (SGLT2) inhibitors, MRA (finerenone), ARNIs, and SGLT2 inhibitors.
9. For AF, beta-blockers and nondihydropyridine calcium channel blockers are first line for rate control with addition of digoxin. Subgroup trial analysis suggests a more beneficial effect of rhythm control in HFpEF with AF. Anticoagulation should be considered based on CHA₂DS₂-VASc score.
10. Standard guidelines for revascularization and management of hyperlipidemia apply to HFpEF. Long-acting nitrates are not routinely recommended for HFpEF.
11. Polysomnography to detect sleep apnea should be considered for HFpEF. A multidisciplinary approach for weight loss should be considered in obese individuals with HFpEF. Cardiac rehabilitation may improve functionality in HFpEF but is currently not covered by insurance.
12. Pulmonary artery pressure monitoring with CardioMEMS reduces risk for HFpEF hospitalizations. It may be most useful for individuals with recurrent hospitalizations and those who experience lability in volume status.
13. SGLT2 inhibitors should be initiated in all HFpEF patients without contraindications, ideally once stable during hospitalization for index event. MRA may be beneficial in some HFpEF subsets with LVEF <55-60% or elevated B-type natriuretic peptide with close monitoring of potassium and renal function. ARNIs have been proven to be beneficial in HFpEF patients with EF <60% and women. ARBs can be used when ARNI is cost prohibitive. Beta-blockers should be considered in patients with a history of myocardial infarction or AF for rate control.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Chronic Heart Failure, Heart Failure and Cardiac Biomarkers, Heart Transplant, Interventions and Imaging, Echocardiography/Ultrasound, Hypertension, Sleep Apnea

Keywords: Adrenergic beta-Antagonists, Angiotensin Receptor Antagonists, Anticoagulants, Atrial Fibrillation, Biomarkers, Cardiomyopathies, Comorbidity, Diabetes Mellitus, Diuretics, Dyspnea, Echocardiography, Edema, Geriatrics, Heart Failure, Heart Failure, Diastolic, Heart Transplantation, Hypertension, Mineralocorticoid Receptor Antagonists, Natriuretic Peptides, Obesity, Palliative Care, Physicians, Primary Care, Risk Factors, Secondary Prevention, Sleep Apnea Syndromes, Sodium-Glucose Transporter 2 Inhibitors, Stroke Volume

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