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Optimizing Heart Failure Management: Key Strategies for HFpEF Treatment

Learn strategies for managing HFpEF with medications, BP control, and comorbidity management.

As a clinical pharmacy specialist, you will often get questions about managing heart failure with preserved ejection fraction (HFpEF) based on new guidance. Over half of heart failure patients have HFpEF, defined by an ejection fraction of 50% or higher.

RxPharm-adv

Emphasize BP control as it may slow HFpEF progression. Optimize management of conditions that worsen HFpEF, like atrial fibrillation, COPD, and obesity. Use loop diuretics for fluid overload, but be cautious to avoid excessive preload reduction.

Consider key medications for improving HFpEF outcomes, weighing evidence, side effects, and cost. Add SGLT2 inhibitors if practical. For example, dapagliflozin (Forxiga) or empagliflozin (Jardiance) can prevent HF hospitalization in about 1 in 35 patients over 2 years.

  • Note that new Inpefa (sotagliflozin) is an option but has less data. These meds can be started with eGFR down to 20 mL/min/1.73 m² and are approved for HF, including HFpEF, regardless of diabetes.
  • Weigh the downsides of SGLT2 inhibitors, such as genital yeast infections, volume depletion, and cost.

Consider adding spironolactone (aldosterone antagonist) which may reduce HFpEF hospitalizations based on limited evidence. Also consider ACEIs, ARBs, or Entresto (sacubitril/valsartan) for reducing HFpEF hospitalizations. While evidence is based on secondary endpoints or subgroups, Entresto has stronger data than ACEIs or ARBs. However, Entresto may cause low BP and is expensive. If Entresto isn’t an option, generally prefer ARBs over ACEIs. Both are reasonable for patients with other indications like hypertension, but ACEIs have the least data supporting benefit in HFpEF.

Ensure close monitoring of electrolytes, kidney function, and volume status, especially when adding or titrating medications. Effective HFpEF management requires balancing treatment benefits with potential risks. Finally, check my medtweetorial on "What are the highlighted pharmacotherapy management approaches recommended in the latest guidelines for HFpEF?" for additional insights and strategies.

RxPharm-adv

Take-home points

Key strategies for managing heart failure with preserved ejection fraction (HFpEF)...

  1. Emphasize blood pressure control to potentially slow HFpEF progression.
  2. Optimize management of comorbid conditions like atrial fibrillation, COPD, and obesity.
  3. Use loop diuretics cautiously for fluid overload, avoiding excessive preload reduction.
  4. Consider adding SGLT2 inhibitors like dapagliflozin or empagliflozin for reducing HF hospitalizations.
  5. Add spironolactone (aldosterone antagonist) based on limited evidence for reducing HFpEF hospitalizations.
  6. Monitor electrolytes, kidney function, and volume status closely when adjusting medications.

References

  1. Bhatt DL, Szarek M, Steg PG, et al. Sotagliflozin in Patients with Diabetes and Recent Worsening Heart Failure. N Engl J Med. 2021;384(2):117-128. doi:10.1056/NEJMoa2030183
    2. Show more references

Keywords: Heart failure with preserved ejection fraction, HFpEF management, Blood pressure control in HFpEF, Loop diuretics for fluid overload, SGLT2 inhibitors for HFpEF, Dapagliflozin (Forxiga), Empagliflozin (Jardiance), Spironolactone for HFpEF, ACE inhibitors for HFpEF, ARBs for HFpEF, Entresto (sacubitril/valsartan), Monitoring electrolytes in HFpEF, Managing comorbid conditions in HFpEF, HFpEF treatment guidelines

Senior clinical pharmacist, "Pharmacy Practice Department, Tanta University Hospital, Egypt". Medical content writer.