Practical Guidance on How to Manage HFpEF: Key Points

Desai AS, Lam CS, McMurray JJ, et al.
How to Manage Heart Failure With Preserved Ejection Fraction: Practical Guidance for Clinicians. JACC Heart Fail 2023;May 3:[Epub ahead of print].

The following are key points to remember from a state-of-the-art review giving practical guidance to clinicians on how to manage patients with heart failure with preserved ejection fraction (HFpEF):

  1. Although patients with HFpEF (left ventricular EF [LVEF] ≥50%) comprise nearly half of those with chronic HF, evidence-based treatment options for this population have been limited in the past.
  2. Emerging data from prospective, randomized trials enrolling patients with HFpEF have greatly altered the range of pharmacologic options to modify disease progression in selected patients with HFpEF.
  3. Following confirmation of the diagnosis and exclusion of alternatives, treatment of HFpEF should focus on decongestion and optimal management of cardiac and noncardiac comorbidities.
  4. Optimal treatment of blood pressure to guideline-recommended targets is appropriate for all patients; coronary revascularization is appropriate for those with ischemic symptoms, and a trial of sinus rhythm maintenance/restoration may be indicated for those with atrial fibrillation.
  5. In all cases, patients should be provided with guidance for lifestyle modification and an exercise prescription to facilitate weight loss, conditioning, and improved functional capacity.
  6. Based on the cumulative evidence of efficacy, all patients with symptomatic HFpEF should be treated with sodium-glucose cotransporter-2 (SGLT2) inhibitors in the absence of contraindications or previous intolerance. For those who remain symptomatic despite SGLT2 inhibition, particularly those with hypertension, LVEF below normal, evidence of elevated natriuretic peptides, or recent HF hospitalization, addition of angiotensin receptor/neprilysin inhibitor (ARNI) or substitution of angiotensin-receptor blocker/angiotensin-converting enzyme inhibitor with ARNI is recommended.
  7. For those without advanced chronic kidney disease (estimated glomerular filtration rate <45 mL/min/1.73 m2), a three-drug regimen with further addition of mineralocorticoid receptor antagonist (MRA) may also be appropriate, provided that a framework for careful laboratory surveillance is in place.
  8. Consideration should be given to withdrawal of beta-blockers in patients without a compelling indication, with substitution of evidence-based alternatives (e.g., ARNI and MRA) for management of hypertension.
  9. Given the potential volume sensitivity of patients with HFpEF, dose reduction of loop diuretic agents following introduction of SGLT2 inhibitors, ARNIs, and MRAs (both alone and in combination) may be considered, to prevent excessive dehydration, hypotension, or worsening renal function.
  10. Optimization of loop diuretic therapy may be further guided by use of ambulatory hemodynamic monitoring in selected patients with recurrent HF hospitalization and ongoing HF symptoms despite optimization of pharmacologic therapy.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Exercise, Hypertension

Keywords: Adrenergic beta-Antagonists, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Atrial Fibrillation, Diuretics, Exercise, Glomerular Filtration Rate, Heart Failure, Hypertension, Hypotension, Life Style, Mineralocorticoid Receptor Antagonists, Natriuretic Peptides, Neprilysin, Renal Insufficiency, Chronic, Secondary Prevention, Sodium-Glucose Transporter 2 Inhibitors, Stroke Volume

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