After TOPCAT: What to Do Now in HFpEF

Desai AS, Jhund PS.
After TOPCAT: What to Do Now in Heart Failure With Preserved Ejection Fraction. Eur Heart J 2016;Apr 13:[Epub ahead of print].

The following are 10 key points to remember about this update on what to do for patients with heart failure with preserved ejection fraction (HFpEF):

  1. To date, there are no specific therapies available to reduce morbidity and mortality in patients with HFpEF.
  2. Given its role in reducing morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF), the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial investigators sought to test the use of spironolactone in patients with HFpEF.
  3. In 3,445 patients in this trial, spironolactone did not reduce the incidence of the primary composite of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for HF compared with placebo.
  4. To approach a patient with HF, it is first important to confirm the diagnosis of HFpEF through signs and symptoms, Doppler echocardiogram, elevated natriuretic peptide levels, resting and exercise hemodynamics, and cardiac magnetic resonance imaging if needed to differentiate those diseases that can mimic HFpEF.
  5. When treating and following patients with HFpEF, filling pressures should be continuously optimized. Consider obtaining hemodynamics to confirm and establish target levels. Implantable hemodynamic monitors can help facilitate following hemodynamics closely.
  6. In the CHAMPION trial, patients with HFpEF who were allocated to pulmonary artery pressure guided therapy, experienced a 50% reduction in the rate of HF hospitalizations over a 17-month period compared to placebo.
  7. While treating patients with HFpEF, aggressive treatment of cardiac comorbidities that exacerbate diastolic dysfunction, such as hypertension, coronary artery disease, and atrial fibrillation, must also be targeted in therapy.
  8. Focusing on treating other noncardiac comorbidities, such as obesity, chronic kidney disease, obstructive sleep apnea, iron deficiency anemia, and lifestyle and diet modification, is just as crucial in achieving success while treating HFpEF.
  9. In the absence of alternative evidence-based therapies, spironolactone should be considered in HFpEF patients who meet TOPCAT inclusion criteria (HFpEF with prior hospitalization for HF or elevated natriuretic peptide levels), with careful monitoring of hyperkalemia and worsening renal function.
  10. New therapies to consider: Clinical trials are now targeting inflammation, deficient cGMP/PKG signaling, and comorbid illnesses with novel therapies targeted towards HFpEF.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Hypertension, Sleep Apnea

Keywords: Anemia, Iron-Deficiency, Atrial Fibrillation, Coronary Artery Disease, Echocardiography, Heart Arrest, Heart Failure, Hemodynamics, Hyperkalemia, Hypertension, Inflammation, Magnetic Resonance Imaging, Mineralocorticoid Receptor Antagonists, Natriuretic Peptides, Obesity, Renal Insufficiency, Chronic, Secondary Prevention, Sleep Apnea, Obstructive, Spironolactone, Stroke Volume

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