Management of Pulmonary Hypertension in Patients with Probable Heart Failure with Preserved Ejection Fraction

Evaluation and Diagnosis

The American College of Cardiology suggests that echocardiographic findings (VRT 3.1, E/E' 10, PSAP 40) along with an H2FPEF score of 46.6% indicate a moderate probability of heart failure with preserved ejection fraction (HFpEF) with associated pulmonary hypertension 1, 2
The diagnosis of HFpEF should be confirmed using the Universal Definition of Heart Failure, which requires symptoms and/or signs caused by cardiac structural-functional abnormalities and at least one of: 1) elevated natriuretic peptides; or 2) objective evidence of pulmonary or systemic congestion 3, 4

The American College of Cardiology recommends initiating SGLT2 inhibitors (such as dapagliflozina or empagliflozina) as first-line therapy for their demonstrated benefits in reducing hospitalizations and cardiovascular outcomes in patients with HFpEF 5, 2
Loop diuretics are essential for symptomatic relief in patients with congestion, using the lowest effective dose to reduce fluid overload 2
Mineralocorticoid receptor antagonists (such as spironolactone) should be considered, particularly in patients with a left ventricular ejection fraction in the lower preservation range (40-50%) 2

The American Heart Association recommends achieving optimal blood pressure control (<130/80 mmHg) using appropriate antihypertensive medications 6, 2
If atrial fibrillation is present, heart rate should be controlled with beta-blockers or non-dihydropyridine calcium channel blockers, and anticoagulation should be considered based on the CHA₂DS₂-VASc score 5, 2
If chronic obstructive pulmonary disease (COPD) is present, management should be optimized according to standard guidelines, taking care to avoid potential drug interactions 5

The American Thoracic Society notes that pulmonary hypertension in HFpEF is generally postcapillary and primarily due to elevated left ventricular filling pressures 7

Regular evaluation of volume status, renal function, and electrolytes is essential, especially with mineralocorticoid receptor antagonist therapy 2
Wireless monitoring of pulmonary artery pressure should be considered in selected patients with recurrent hospitalizations 2
Diuretic doses should be adjusted according to congestion status to avoid overdiuresis that may lead to hypotension 2

Confirm the diagnosis of HFpEF and characterize the type of pulmonary hypertension (postcapillary vs. precapillary) 1, 4
Initiate SGLT2 inhibitor as disease-modifying therapy 5, 2
Titrate loop diuretics to alleviate congestive symptoms 2
Optimize blood pressure control (<130/80 mmHg) 6, 2
Consider mineralocorticoid receptor antagonists if left ventricular ejection fraction is in the 40-50% range 2
Manage specific comorbidities (atrial fibrillation, COPD, etc.) 5
Regularly monitor renal function, electrolytes, and volume status 2