Heart Failure with Preserved Ejection Fraction Management

Current Guideline-Directed Medical Therapy for HFpEF

The American College of Cardiology recommends SGLT2 inhibitors as first-line disease-modifying therapy for HFpEF, with additional agents selected based on specific patient characteristics 1, 2
The American College of Cardiology suggests that empagliflozin or dapagliflozin should be initiated in all patients with HFpEF to reduce cardiovascular death and heart failure hospitalizations 1, 2
Mineralocorticoid receptor antagonists are recommended as part of guideline-directed medical therapy to reduce morbidity and mortality in patients with HFpEF 1, 2
Angiotensin receptor-neprilysin inhibitors may be considered for selected patients with HFpEF, though evidence shows smaller reductions in HF hospitalizations compared to HFrEF 1, 2
The American College of Cardiology recommends loop diuretics be used judiciously as needed to reduce congestion and improve symptoms in patients with HFpEF, not as disease-modifying therapy 1, 2
Beta-blockers are not routinely recommended for HFpEF unless specific indications exist, such as prior myocardial infarction, angina, or atrial fibrillation 1, 2

The diagnosis of HFpEF requires an integrated assessment of multiple echocardiographic parameters, with no single parameter being sufficient 3
The American College of Cardiology recommends that the diagnosis of HFpEF include preserved LV systolic function, evidence of diastolic dysfunction, and structural or functional cardiac abnormalities 3
The E/e' ratio is a validated parameter for assessing diastolic function, with a ratio >15 indicating high filling pressures 4, 3

The American College of Cardiology recommends systematically excluding specific mimics that require different treatment approaches before confirming an HFpEF diagnosis, including cardiac amyloidosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, hemochromatosis, Fabry disease, high-output heart failure, and pericardial disease 1, 5, 2

Aggressive management of comorbidities is mandatory as they directly contribute to symptoms, prognosis, and pathophysiology in patients with HFpEF 1, 2, 6
The American College of Cardiology recommends addressing priority comorbidities, including hypertension, diabetes mellitus, obesity, atrial fibrillation, coronary artery disease, and chronic kidney disease 1, 2, 5

Supervised exercise training is recommended to improve symptoms and functional capacity in patients with HFpEF 1, 3

Women comprise the majority of HFpEF patients and have unique diagnostic and prognostic features, including higher ejection fractions and more preserved LV global longitudinal strain compared to men 6
A history of pre-eclampsia increases the risk for subsequent HFpEF hospitalization in women 4, 5

The American College of Cardiology recommends referring patients to a cardiologist or heart failure specialist when diagnosis remains uncertain, advanced diagnostic testing is needed, or there is an inadequate response to initial guideline-directed medical therapy 6, 3, 4, 5