Managing diastolic or preserved ejection fraction heart failure (HFpEF)

Beta-blockers don't seem to reduce mortality either. ACEIs or ARBs might reduce hospitalizations, but don't seem to decrease mortality.....

How to treat "DIASTOLIC" heart failure or heart failure with a PRESERVED ejection fraction (HFpEF)? Over HALF of heart failure patients have this type, which is due to a stiff left ventricle that can't adequately fill. This is different from "SYSTOLIC" heart failure or heart failure with a REDUCED ejection fraction (HFrEF). These patients have a weak left ventricle that can't pump effectively.

There's less evidence for how to treat heart failure with a preserved ejection fraction, so the medications used may be different. Beta-blockers don't seem to reduce mortality either. ACEIs or ARBs might reduce hospitalizations, but don't seem to decrease mortality like they do in reduced ejection fraction heart failure. Recommend treating hypertension.

Most patients with preserved ejection fraction HF have high blood pressure, and blood pressure control may slow progression. Suggest antihypertensive medications based on the patient's other conditions, such as an ACEI or ARB for kidney disease or a beta-blocker or amlodipine (Norvasc) for angina. It's also okay to suggest a thiazide diuretic. According to diuretics, expect to see less use of loop diuretics (furosemide, etc) in preserved ejection fraction heart failure. Loops may be needed for fluid overload, but overdoing it may worsen symptoms. If these measures aren't enough, don't be surprised to see spironolactone (Aldactone) added. Early evidence suggests it may be helpful for preserved ejection fraction heart failure, but hyperkalemia is common.

Don't recommend Entresto (sacubitril/valsartan) or Procoralan (ivabradine). It's too soon to say if they improve outcomes in this case. And help manage other comorbidities that can aggravate heart failure symptoms such as (atrial fibrillation, COPD, obesity, sleep apnea, etc).

References

Redfield, M.M. (2016). Heart Failure with Preserved Ejection Fraction. New England Journal of Medicine, [online] 375(19), pp.1868–1877. Available at: https://www.cardioaragon.com/wp-content/uploads/Heart_Failure_Preserved_Ejection_Fraction.REVIEW.nejm_.2016.pdf

Pfeffer, M.A., Claggett, B., and others (2015). Regional variation in patients and outcomes in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) trial. Circulation, [online] 131(1), pp.34–42. Available at: https://pubmed.ncbi.nlm.nih.gov/25406305

Shah, S.J., Kitzman, D.W., Borlaug, B.A., van Heerebeek, L., Zile, M.R., Kass, D.A. and Paulus, W.J. (2016). Phenotype-Specific Treatment of Heart Failure With Preserved Ejection Fraction. Circulation, 134(1), pp.73–90. Available at: https://www.ahajournals.org/doi/10.1161/circulationaha.116.021884