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The new standard of care for HFpEF

MDlinx Mar 07, 2024

Heart failure with preserved ejection fraction (HFpEF) has traditionally been a challenging condition with limited treatment options, but recent advances offer hope to both patients and the clinicians managing this disease. 


Here, we’ll take a closer look at the new treatments and therapies for patients with HFpEF, discussing updated guidelines from the American Heart Association and American College of Cardiology.


High prevalence and high mortality


HFpEF, defined as heart failure (HF) with an ejection fraction (EF) of 50% or higher at time of diagnosis, is estimated to represent at least half of all patients with heart failure, according to the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure.

Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022;79(17):e263–e421.


HFpEF affects approximately 3 million individuals in the United States and as many as 32 million worldwide, according to authors of a review in JAMA, and its prevalence is increasing.

Redfield MM, Borlaug BA. Heart failure with preserved ejection fraction: A review. JAMA. 2023;329(10):827–838.


HFpEF is associated with significant morbidity and mortality as well as healthcare cost burden. The annual mortality rate for patients with HFpEF is 15%, and the hospitalization rate is approximately 1.4 inpatient visits per year per patient.


Management of HFpEF


Risk factors for HFpEF include obesity, hypertension, diabetes, dyslipidemia, and older age. As discussed in the JAMA review, these risk factors are modifiable (with the exception of age), and first-line management includes treatment and control of underlying risk factors and comorbid conditions. Exercise and weight loss have been shown in randomized clinical trials to result not only in risk factor improvement, but also in “clinically meaningful increases in functional capacity and quality of life.” 

Clinicians should be mindful of causes of HFpEF that may present with a similar clinical syndrome, such as valvular, infiltrative, or pericardial diseases, as these conditions also need to be identified and treated.

First-line pharmacologic therapy now consists of sodium-glucose cotransporter type 2 (SGLT2) inhibitors, such as empagliflozin or dapagliflozin. In clinical trials vs placebo, these drugs reduced HF hospitalization or cardiovascular death by approximately 20%.

Diuretics—particularly loop diuretics, such as furosemide—are recommended for patients with symptoms and signs of volume overload and congestion. Patient education regarding medication adherence and dietary restrictions, as well as monitoring of symptoms and vital signs, can help avoid decompensation and HF hospitalization and readmission.


A metabolic approach


The introduction of SGLT2 inhibitors into the latest AHA/ACC/HFSA guideline recommendations heralds a new era of effective pharmacotherapy for HFpEF, one that suggests HFpEF may in fact be a metabolic disease, given that SGLT2 inhibitors were first approved as antidiabetic agents.

Pinto YM. Heart failure with preserved ejection fraction—a metabolic disease?(editorial). N Engl J Med. 2023;389:1145–1146.


In line with this metabolic approach, a glucagon-like peptide 1 (GLP-1) agonist, semaglutide, has also now been found effective in the management of HFpEF. In the STEP-HFpEF trial of semaglutide in patients with HFpEF and obesity, semaglutide was found to reduce symptoms, improve exercise function, and induce weight loss to a greater extent than placebo.

Kosiborod MN, Abildstrøm SZ, Borlaug BA, et al. Semaglutide in patients with heart failure with preserved ejection fraction and obesity. N Engl J Med. 2023;389(12):1069–1084.




Multidisciplinary management


The 2023 Expert Consensus Decision Pathway on management of HFpEF from the ACC recommended multidisciplinary care:

Kittleson MM, Panjrath GS, Amancherla K, et al. 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure with Preserved Ejection: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2023;81(18):1835–1878.

 “Diagnosis and management of HFpEF needs multidisciplinary care involving primary care, cardiologists, and HF specialists. Referral to cardiology should be sought in the presence of comorbidities such as coronary artery disease/atrial fibrillation, HF hospitalizations, elevated natriuretic peptides, specialists needed for comorbidities, knowledge of mimics, increased diuretic needs, and New York Heart Association class III-IV.”


Members of the multidisciplinary team may also include pharmacists, dieticians, physical therapists, exercise specialists or trainers, and other healthcare professionals. This team-based approach is indicative of the complex nature of HFpEF as a disease and the need for a multipronged strategy in its management. 

This complexity is reflected in the new standard of care for HFpEF, which must integrate lifestyle modification, new metabolic agents, and multidisciplinary management to improve patient outcomes.


What this means for you

In managing patients with HFpEF, clinicians will need to utilize a multidisciplinary approach to provide comprehensive care for individuals with this complex disease. Dieticians, exercise specialists, primary care physicians, pharmacists, and other HCPs are all integral to implementing effective strategies. Metabolic factors should be considered and, in line with guideline recommendations, SGLT2 inhibitors are now indicated for patients with HFpEF.


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