Management of Heart Failure with Preserved Ejection Fraction

Diagnostic Confirmation

The American College of Cardiology recommends that a patient with an E/E' ratio of 15.96 and EF of 58% be diagnosed with heart failure with preserved ejection fraction (HFpEF) based on elevated E/E' ratio and EF ≥50% 1, 2
The patient's echocardiographic findings, including preserved EF of 58%, elevated E/E' ratio of 15.96, increased relative wall thickness (RWT) of 0.44, left atrial enlargement (4.1 cm), and short mitral deceleration time (103 ms), support a diagnosis of HFpEF 1, 2, 3, 4, 5

The American College of Cardiology recommends initiating SGLT2 inhibitors, such as dapagliflozin or empagliflozin, as first-line therapy for HFpEF, with a reduction in HF hospitalization or cardiovascular death by approximately 20% in randomized trials 6
Loop diuretics, such as furosemide, should be prescribed to manage congestion, with a starting dose of 20-40 mg daily and titration based on symptoms 1, 4, 6

Mineralocorticoid receptor antagonists (MRAs), such as spironolactone, may be considered in selected HFpEF patients, particularly women and those with lower ejection fractions, with a starting dose of 25 mg daily and monitoring of potassium and renal function 6
ARNI (sacubitril/valsartan) may be considered in selected patients, particularly those who remain symptomatic despite first-line therapy, with potential benefit in women and those with LVEF below normal range 1, 6

Exercise training should be recommended to improve functional capacity and quality of life, with supervised cardiac rehabilitation if available 6
Weight loss should be targeted in patients with obesity, with a goal of 5-10% weight reduction, and daily weight monitoring to detect early fluid retention 6

Hypertension management is critical, with a target BP <130/80 mmHg, and consideration of the patient's concentric remodeling (RWT 0.44) suggesting chronic pressure overload 1, 4
Sleep apnea should be screened for with a sleep study if clinically indicated, and managed accordingly 1, 6

Regular clinical assessment should be performed for symptoms and signs of congestion, with echocardiographic follow-up to assess response to therapy, and natriuretic peptide levels to monitor disease activity 2, 5, 6
Pulmonary artery pressure monitoring should be considered in patients with recurrent hospitalizations 6

HFpEF mimics, such as infiltrative cardiomyopathies, hypertrophic cardiomyopathy, valvular heart disease, and pericardial disease, should be ruled out before finalizing diagnosis 1, 2, 4, 5
Medications that may worsen HFpEF, such as NSAIDs, should be avoided 6
Beta-blockers should only be used if there are specific indications, such as prior myocardial infarction, angina, or atrial fibrillation requiring rate control 2, 6

The American College of Cardiology defines heart failure with reduced ejection fraction (HFrEF) as left ventricular ejection fraction (LVEF) ≤ 40 %, heart failure with preserved ejection fraction (HFpEF) as LVEF ≥ 50 %, and an intermediate “mid‑range” category (HFmrEF) with LVEF 41–49 % that behaves more like HFrEF. 7

Diagnosis requires typical heart‑failure symptoms or signs plus at least one of the following objective findings, per ACC guidance:
- Elevated natriuretic peptide levels—BNP > 35 pg/mL in ambulatory settings or > 100 pg/mL during hospitalization; NT‑proBNP > 125 pg/mL ambulatory or > 300 pg/mL hospitalized. 8
- Direct evidence of cardiogenic pulmonary or systemic congestion (e.g., imaging, physical exam). 8

In HFpEF, natriuretic peptide concentrations are typically lower than in HFrEF for comparable left‑ventricular end‑diastolic pressure, and higher body‑mass index—common in HFpEF—further suppresses these levels. 8

Clinicians should not attribute all dyspnea in patients with preserved EF to HFpEF; systematic exclusion of pulmonary, renal, and other cardiac etiologies is essential. 8

For women with HFpEF, a history of pre‑eclampsia is an important risk factor that increases the likelihood of subsequent HFpEF‑related hospitalization. 9