Management of Heart Failure with Preserved Ejection Fraction

Evidence-Based Rationale

• The American Heart Association and American College of Cardiology guidelines explicitly recommend the combination of hydralazine and isosorbide dinitrate only for patients with reduced ejection fraction (EF ≤35-40%), not preserved ejection fraction 1, 2, 3
• The Class I recommendation for hydralazine-isosorbide dinitrate applies exclusively to self-identified African American patients with NYHA class III-IV HFrEF who remain symptomatic despite optimal therapy with ACE inhibitors, beta-blockers, and aldosterone antagonists 2, 3, 4

Appropriate Management of HFpEF with Hypertension and Diabetes

• Beta-blockers, ACE inhibitors, or ARBs are reasonable for blood pressure control in HFpEF (Class IIa recommendation) 1
• ARBs may be considered to decrease hospitalizations in HFpEF patients 1
• Loop diuretics can be used for symptom management when volume overload is present 1
• Hypertension control is particularly important in HFpEF, as these patients often have left ventricular hypertrophy that may regress with adequate blood pressure control 1
• Thiazide or thiazide-like diuretics are more effective than loop diuretics for blood pressure control in HFpEF (Class IIa) 1

Critical Pitfalls to Avoid

• The mortality and morbidity benefits demonstrated in HFrEF trials do not apply to HFpEF 3, 4
• Even in appropriate HFrEF populations, adherence to hydralazine-isosorbide dinitrate is challenging due to three-times-daily dosing and side effects (headache, dizziness, gastrointestinal complaints) 5, 4