Management of Acute Decompensated Heart Failure with Preserved Ejection Fraction in the Elderly

Initial Management of Acute Decompensation

The European Society of Cardiology recommends loop diuretics as the first-line treatment for fluid overload in acute HFpEF, with furosemide being the most commonly used agent 1, 2
Initial parenteral dose should be greater than or equal to the patient's chronic oral daily dose, with serial adjustments based on response 2
The American College of Cardiology recommends considering higher doses of intravenous loop diuretics or addition of a thiazide diuretic for sequential nephron blockade and enhanced diuretic synergy when diuresis is inadequate 1, 2, 3
For refractory cases, ultrafiltration may be considered for patients with obvious volume overload 2

The European Society of Cardiology recommends careful monitoring of blood pressure as elderly patients with HFpEF often have hypertension that requires treatment 1, 3
In patients with hypotension and tachycardia, evaluate for atrial fibrillation which is common in elderly HFpEF patients 4, 5
The American College of Cardiology recommends intravenous beta-blocker administration or a non-dihydropyridine calcium channel antagonist to slow ventricular response in patients with AF and rapid ventricular response 4, 5

Patients with HFpEF receiving guideline-directed medical therapy should continue these medications except in cases of hemodynamic instability 2
Common precipitating factors for acute HF should be identified and addressed promptly 2
Electrolytes, urea nitrogen, and creatinine should be monitored during medication titration, especially with diuretics 2

The European Society of Cardiology recommends adequate treatment of hypertension and myocardial ischemia in HFpEF 1
Control of ventricular rate in patients with atrial fibrillation is essential 1, 4, 5
The heart rate-limiting calcium channel blocker verapamil may improve exercise capacity and symptoms in HFpEF patients 1

The European Heart Journal recommends considering sodium-glucose cotransporter 2 (SGLT2) inhibitors for long-term management regardless of diabetes status 3
Supervised exercise training should be considered after stabilization as it provides substantial improvements in exercise capacity and quality of life 7

Avoid excessive diuresis which may lead to renal dysfunction and electrolyte abnormalities 1
Do not abruptly discontinue beta-blockers in HF patients as this can lead to rebound tachycardia and worsening HF 6
Avoid non-dihydropyridine calcium channel blockers in patients with decompensated HF 4, 6