Heart failure with preserved ejection fraction: strategies for disease management and emerging therapeutic approaches

There is an increasing incidence of Heart failure (HF) with preserved ejection fraction (HFpEF) as compared to HF with reduced ejection fraction (HFrEF). Still, there is a lack of approved treatments specifically for HFpEF. Hence, Peter P. Toth and colleagues published a paper in Taylor and Francis open journal under the title “Heart failure with preserved ejection fraction: strategies for disease management and emerging therapeutic approaches”. The summary of these management strategies can be read below:

Objective:

To provide current strategies for disease management and new and emerging therapeutic approaches for HFpEF.

Method:

The strategies were concluded from the currently available evidence and scientific and medical knowledge.

Findings:

Management of patients with HFpEF

A) The role of PCPs in the management of HFpEF

 Early diagnosis as it is crucial to ensure optimal management
 Patient care throughout the disease trajectory of HF
 Ensuring that patients receive comprehensive, coordinated care across specialties
 Make appropriate referrals
 Provide specialists with the necessary patient information and medical history, and work together with specialists
 Manage risk factors and risk stratification of patients with existing comorbidities
 Manage stable HF; and in instances of suspected acute HF, initiate nitrates and loop diuretics; and, when indicated, refer to an HF specialist for advanced management and/or end-of-life care support.
 Collaborate with patients and their caregivers to assess and address any frailty issues.

B) Use of pharmacologic treatments in the management of HFpEF

 The only guideline-recommended treatment for HFpEF is loop diuretics in congested
patients to alleviate signs and symptoms
 Patients with HFpEF need a different approach to management than patients with HFrEF.
 Currently emerging treatment strategies in patients with HFpEF includes combination therapy with an ARB and a neprilysin inhibitor, in the form of an angiotensin receptor–neprilysin inhibitor and the sodium glucose transport protein inhibitor (SGLT2i) dapagliflozin

C) A stage-based approach to HFpEF management

As mentioned in the ACCF/AHA guidelines, the management and treatment of patients with HFpEF should follow a similar approach to that used for patients with HFrEF. The management strategies should be categorize according to stages of HF..
Stage A:  at risk for HF but without structural heart disease or symptoms of HF
Management- treatment of hypertension and hyperlipidemia with antihypertensive drugs and statins, management of other conditions (e.g. obesity, cardiotoxic agents) that may increase risk of HF should also be addressed.

Stage B: Patients have structural heart disease without signs or symptoms of HF
Management- focuses on prevention of symptomatic HF and CV events with statins and antihypertensive drugs. Patients with HFpEF may receive treatment with guideline-directed medical therapy similar to patients with HFrEF such as ACEI, ARBs, and/or β-blockers.

Stage C: patients with structural heart disease with prior or current symptoms of HF. Management- treating volume overload with diuretics, controlling blood pressure according to standard clinical guidelines and treating hypertension with β-blockers, ACEIs, and/or ARBs, and treating atrial fibrillation according to standard clinical guidelines. Mineralocorticoid-receptor antagonist, in select patients, and ARBs might be considered to decrease hospitalizations.

Stage D: patients with refractory HF requiring specialized interventions Management- Advanced interventions (i.e. left ventricular assist devices, transplantation) are required to manage patients with stage D HF

D) Lifestyle intervention

 Improving exercise capacity should be a key focus of disease management.
 Salt restriction, Dietary Approaches to Stop Hypertension may be beneficial for patients with hypertensive HFpEF.
 Other dietary restrictions to improve glucose control in patients with HFpEF should also be considered;

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