Heart Failure with Preserved Ejection Fraction (HFpEF) Management

Patient Assessment and Diagnosis

• Patients with HFpEF, typically elderly women with hypertension, often present with hyperdynamic LVEF, concentric LVH, mildly dilated left atrium, and mild to moderate mitral regurgitation, indicating a possible compensatory mechanism and pressure overload, according to the American Heart Association 1.
• Diagnosis of LVH relies on echocardiography, with two-dimensional echocardiography with Doppler being the most useful diagnostic test for evaluating left ventricular ejection fraction, ventricular structure and geometry, wall thickness, atrial size, valvular abnormalities, and right ventricular function 2.
• Left ventricular hypertrophy (LVH) can result from various causes, including hypertension, hypertrophic cardiomyopathy (HCM), valvular disease, infiltrative diseases, endocrine disorders, drug-induced, and physiologic causes, such as athletic training, with diagnosis requiring echocardiography showing wall thickness ≥15 mm in adults or z-score >2 in children that cannot be explained solely by loading conditions 3.

Treatment and Management

• The American College of Cardiology recommends first-line therapy with ACE inhibitors or ARBs to promote LVH regression and prevent progression of cardiac remodeling in patients with HFpEF 1.
• The American College of Cardiology and the European Society of Cardiology recommend ACE inhibitors or ARBs as first-line therapy for LVH regression, with evidence showing superior efficacy compared to beta-blockers 4, 5.
• Beta-blockers are first-line for symptom relief and LVOT gradient reduction in HCM, with calcium channel blockers (verapamil) recommended for patients intolerant to beta-blockers 6.
• The following table summarizes the recommended pharmacological therapy for patients with LVH:

• Regular physical activity, at least 30 minutes per day, most days of the week, is recommended to facilitate regression of LVH, according to the American Heart Association 5.
• The DASH diet is recommended to promote weight loss and blood pressure reduction, and facilitate regression of LVH, according to the American College of Cardiology 5.
• Weight reduction is recommended for overweight or obese patients, with a strength of evidence classified as low, according to the American Heart Association 7.
• Smoking cessation is crucial, with a strength of evidence classified as high, according to the American College of Cardiology 7.
• Reduction of sodium intake, increased consumption of fruits, vegetables, and low-fat dairy products, and moderation of alcohol intake are recommended, according to the American Heart Association 8.

Monitoring and Follow-up

• Regular blood pressure monitoring, including home monitoring, and echocardiographic follow-up every 6-12 months are necessary to assess LVH regression, mitral regurgitation progression, left atrial size, and LVEF changes 1.
• Laboratory monitoring of electrolytes, renal function, and BNP/NT-proBNP levels can help detect early heart failure progression 1.
• Cardiac reassessment, including echocardiography every 6-12 months to assess LVH regression, and ECG monitoring for progression of electrical abnormalities, is recommended for these patients 9.
• Regular blood pressure monitoring, including home blood pressure monitoring and periodic 24-hour ambulatory monitoring, is necessary to assess control in patients with LVH 9.

Potential Pitfalls and Considerations

• Delaying treatment with appropriate medical therapy can lead to progression of LVH and development of heart failure symptoms, emphasizing the importance of early intervention 1.
• The European Society of Cardiology recommends septal myectomy as a treatment option for HCM patients with refractory symptoms, which involves creating a trough in the basal septum 3.
• For HCM with refractory symptoms, septal myectomy, alcohol septal ablation, and ICD placement for high-risk patients are recommended 6.
• An implantable cardioverter-defibrillator (ICD) is reasonable in patients with asymptomatic ischemic cardiomyopathy who are at least 40 days post-MI, have an LVEF ≤30%, and are on guideline-directed medical therapy, with a Class IIa recommendation and Level B evidence, according to the American College of Cardiology 10.
• Cardiac resynchronization therapy should be considered in patients with left bundle branch block (LBBB) and QRS duration ≥150 ms, according to the Heart Rhythm Society, with a strength of evidence classified as moderate 11.
• Statins are recommended for all patients with a history of myocardial infarction or atherosclerotic disease, with a strength of evidence classified as moderate and a Class I recommendation, according to the American College of Cardiology 7, 12, 10.
• Angiotensin Receptor Blockers (ARBs) are a reasonable alternative for patients who cannot tolerate ACE inhibitors, with a Class I recommendation and Level A evidence, according to the American College of Cardiology 10.
• For supraventricular ectopics and non-sustained supraventricular tachycardia, optimization of blood pressure control and beta-blockade is recommended, along with addressing precipitants such as caffeine, alcohol, and stress, according to the European Heart Journal 9.
• For atrial fibrillation, restoration and maintenance of sinus rhythm is recommended when possible, along with rate control using beta-blockers if persistent atrial fibrillation is present, and anticoagulation based on the CHA₂DS₂-VASc score, according to the American College of Cardiology 13.
• For ventricular arrhythmias, beta-blockers are first-line therapy, and Class IC antiarrhythmics, such as flecainide and propafenone, and sotalol should be avoided in patients with LVH, according to the European Heart Journal 9.