Management of Heart Failure with Preserved Ejection Fraction

Diagnostic Approach

• Heart failure with preserved ejection fraction (HFpEF) is defined as heart failure with left ventricular ejection fraction ≥50%, with symptoms/signs of HF caused by structural/functional cardiac abnormalities and either elevated natriuretic peptides or objective evidence of cardiogenic congestion, according to the American College of Cardiology 1
• Elderly patients with HFpEF often have multiple comorbidities that can mask or exacerbate HF symptoms, requiring careful evaluation, as noted by the European Heart Journal 2
• Diagnostic workup should include ECG, transthoracic echocardiogram, and blood tests for thyroid, renal, and hepatic function, as recommended by Circulation 3
• Evaluation for specific HFpEF mimics that may require different treatment approaches, such as cardiac amyloidosis or hypertrophic cardiomyopathy, is essential, according to the Journal of the American College of Cardiology 4

Management of HFpEF

• SGLT2 inhibitors (empagliflozin or dapagliflozin) are the first-line disease-modifying therapy for elderly patients with HFpEF who have concurrent lung and blood conditions, as they significantly reduce heart failure hospitalizations without negatively affecting pulmonary function or hematologic parameters, as stated by the American College of Cardiology and supported by Praxis Medical Insights 5, 6
• For HFpEF patients with COPD, optimize COPD management according to standard guidelines while monitoring for drug interactions, and use cardioselective beta-blockers cautiously when needed for rate control in AF, as recommended by Praxis Medical Insights 5
• SGLT2 inhibitors are particularly beneficial for HFpEF patients with COPD, as they do not affect respiratory function, according to the European Journal of Heart Failure 7
• The European Heart Journal recommends evaluating the underlying cause of anemia or other blood disorders in HFpEF patients, such as nutritional, chronic disease, or blood loss 2
• Polypharmacy increases the risk of adverse drug interactions and side effects in elderly HFpEF patients, requiring regular medication review, as noted by the European Heart Journal 2
• Impaired renal function is common in elderly HFpEF patients and may necessitate dose adjustments of ACEIs, ARBs, and MRAs, according to the European Heart Journal 2

Pharmacological Management

• The American College of Cardiology recommends targeting blood pressure <130/80 mmHg using appropriate medications for hypertension management in HFpEF patients 6
• For diabetes management in HFpEF patients, the American College of Cardiology prefers the use of SGLT2 inhibitors given their additional heart failure benefits 6
• The European Heart Journal recommends a rate control strategy with anticoagulation based on stroke risk for atrial fibrillation management in HFpEF patients 8
• The European Heart Journal suggests considering xanthine oxidase inhibitors (allopurinol) for prophylaxis and avoiding NSAIDs in symptomatic HF patients with gout 2

Monitoring and Follow-up

• Regular assessment of volume status, renal function, and electrolytes, especially with diuretic and MRA therapy, is crucial in HFpEF patients, as recommended by Praxis Medical Insights 5
• Monitoring for disease progression and treatment response through symptom assessment and biomarkers is essential, according to the Journal of the American College of Cardiology 4

Common Pitfalls to Avoid

• Delaying initiation of SGLT2 inhibitors, which have proven benefits in reducing hospitalizations, is a common pitfall in HFpEF management, as noted by Praxis Medical Insights 6
• Failure to recognize and treat specific HFpEF mimics that require different treatment approaches is another common pitfall, according to the Journal of the American College of Cardiology 4

Complete Heart Block and HFpEF Diagnosis

CHB as a HFpEF Mimic Requiring Exclusion

• The American College of Cardiology recommends excluding high-degree atrioventricular block as a HFpEF mimic, particularly in patients younger than 60 years, as it requires fundamentally different treatment, specifically pacemaker therapy, and misdiagnosis can lead to inappropriate therapy and delayed definitive treatment 9
• CHB can present with congestive symptoms, such as dyspnea, exercise intolerance, and fatigue, that resemble HFpEF but stem from bradycardia-induced low cardiac output rather than diastolic dysfunction 9
• The treatment paradigm for CHB is entirely different from HFpEF, with CHB requiring permanent pacemaker implantation, whereas HFpEF requires SGLT2 inhibitors, diuretics, and comorbidity management 9

Diagnostic Clues to Distinguish CHB from True HFpEF

• Marked bradycardia, typically less than 40-50 bpm at rest, is a key diagnostic clue for CHB, and should be actively screened for in patients with suspected HFpEF 9
• ECG findings showing complete dissociation between P waves and QRS complexes, with a slow ventricular escape rhythm, are indicative of CHB 9
• Age less than 60 years should heighten suspicion for CHB, as this is a specifically flagged diagnostic clue for CHB mimicking HFpEF 9
• Symptoms that improve dramatically with temporary pacing during diagnostic evaluation confirm CHB as the primary problem rather than diastolic dysfunction 9

The True Risk Factors for HFpEF Development

• Hypertension is a major risk factor for HFpEF development, and is highly prevalent in those with established HFpEF, according to the American College of Cardiology 10, 11, 12
• Obesity is present in more than 80% of HFpEF patients, with excess intra-abdominal fat playing a pivotal role in the obese/metabolic HFpEF phenotype, as noted by the American College of Cardiology 10, 11, 12
• Diabetes affects 25-50% of HFpEF patients, and confers adverse prognosis through neurohormonal activation, inflammation, and impaired skeletal muscle function, according to the American College of Cardiology 10, 11, 12
• Coronary artery disease is common in HFpEF, and associates with greater deterioration in left ventricular systolic function and worse outcomes, as reported by the American College of Cardiology 10, 11, 12
• Aging and reduced physical activity are important contributors to HFpEF development, as stated by the American College of Cardiology 10, 11, 12

Clinical Implications for Practice

• The American College of Cardiology recommends obtaining a 12-lead ECG immediately to exclude CHB and other conduction abnormalities before labeling a patient as having HFpEF 9
• If CHB is present, the American College of Cardiology advises referring urgently for permanent pacemaker implantation rather than initiating HFpEF-directed medical therapy 9

Fluid Status Assessment in CKD/HFpEF Patients on Diuretics

Introduction to Fluid Status Assessment

• Loop diuretics fundamentally alter renal tubular handling of sodium, water, and urea, rendering both urine osmolality and FeUrea unreliable for volume assessment, according to the European Society of Cardiology 13
• The American College of Cardiology recommends weight measurement at each outpatient visit as essential for assessing volume status in heart failure patients, as short-term changes in fluid status are best assessed by measuring changes in body weight 14

Guideline-Recommended Approaches to Fluid Status Assessment

• The American College of Cardiology suggests that assessment of volume status, orthostatic blood pressure changes, and physical examination findings should be performed at each visit, in line with recommendations from the European Society of Cardiology 14, 13
• Elevated natriuretic peptides correlate with worsening diastolic dysfunction and can help assess congestion, though levels are lower in HFpEF compared to HFrEF, as noted by the European Heart Journal 15, 16

Managing Diuretic Therapy

• The European Society of Cardiology recommends that when diuretics are insufficient, consider increasing loop diuretic dose, switching from furosemide to bumetanide or torasemide, adding mineralocorticoid receptor antagonist, combining loop diuretic with thiazide/metolazone, or administering loop diuretic twice daily or as continuous infusion 13
• The European Society of Cardiology also suggests checking for hypovolemia/dehydration, ensuring compliance, assessing fluid intake, and excluding nephrotoxic agents when creatinine rises 13