Management of Hypertension and Obesity in Heart Failure with Preserved Ejection Fraction

Pathophysiology and Risk Factors

The combination of hypertension and obesity drives left ventricular hypertrophy and contributes to heart failure with preserved ejection fraction (HFpEF), with the American College of Cardiology recommending aggressive management of these risk factors 1, 2
Obesity is strongly associated with hypertension, with 35.7% of obese individuals having hypertension, amplifying atherosclerotic burden and vascular remodeling 2
The American Heart Association suggests that hypertension treatment reduces the risk of heart failure by approximately 50%, demonstrating its causal role 5

Exertional dyspnea with mild LVH and preserved ejection fraction is classic for HFpEF, with the European Heart Society noting that obesity is present in >70% of adult HFpEF patients 1, 4
The American College of Cardiology recommends that exercise intolerance requiring medical evaluation is never "normal for age" and represents pathology requiring intervention 1, 5

Strict blood pressure control is imperative, with target <140/90 mmHg, using agents that promote LVH regression, as recommended by the American Heart Association 7, 1
Achieving ideal body weight is a core component of therapy and addresses multiple pathophysiological mechanisms, with comprehensive lifestyle interventions recommended for achieving and maintaining weight loss 2, 1
SGLT2 inhibitors should be initiated as first-line disease-modifying therapy for HFpEF, reducing heart failure hospitalizations and cardiovascular death in HFpEF patients 4
A supervised walking program is cornerstone therapy despite initial discomfort, increasing pain-free and maximum walking distances, as suggested by the American College of Sports Medicine 2