Congestive heart failure with preserved EF pharmacotherapy

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Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Treatment of HFpEF is focused on treating underlying disease, such as hypertension, coronary artery disease and atrial fibrillation. Diuretics are the mainstay of pharmacotherapy. Other effective measures to control HFpEF include exercise, weight control and lipid control.

Heart failure mildly reduced ejection fraction (HPmrEF), EF (41-49%)

The diagnosis of heart failure with mildly reduced ejection fraction

• The diagnosis of HFmrEF requires the presence of symptoms and/or signs of HF, and a mildly reduced EF (41-49%) The presence of elevated NPs (BNP >_35 pg/mL or NT-proBNP >_125 pg/mL) and other evidence of structural heart disease including increased left atrial (LA) size, LVH or echocardiographic measures of LV filling.

Clinical characteristics

• Clinical characteristics, risk factors, patterns of cardiac remodelling are similar to other subgroups of HF.
• HFmrEF is more common in men, younger, and are more likely to have CAD (50-60%) and less likely to have AF and non-cardiac comorbidities. ambulatory
• HFmrEF have lower mortality rate than those with HFrEF.

Angiotensin-converting enzyme inhibitors

• ACE-I may be considered in patients with HFmrEF and underlying CAD, hypertension, or post-MI LV systolic dysfunction.

Angiotensin receptor II type 1 receptor blockers

• Candesartan reduced the number of patients hospitalized for HF among those with HFmrEF.
• Treatment with ARBs may be considered in patients with HFmrEF patients with other cardiovascular indications.

Beta-blockers

• Treatment with beta-blockers may be considered in patients with HFmrEF and another cardiovascular indication, such as AF or angina.

Mineralocorticoid receptor antagonists

• In a retrospective analysis of the TOPCAT trial in patients with LVEF >_45%, spironolactone reduced hospitalizations for HF in patients with an LVEF <55%.
• Treatment with an MRA may be considered in patients with HFmrEF.

Angiotensin receptor-neprilysin inhibitor

• Analysis of the PARADIGM-HF and PARAGON-HF trials showed that sacubitril/valsartan, compared to other forms of RAAS blockade reduced hospitalizations in patients with HFmrEF.

Other drugs

• In the DIG trial, use of digoxin for patients with HFmrEF in sinus rhythm was associated with fewer hospitalizations but no reduction in mortality and a trend to increase of cardiovascular deaths.
• Therefore, there are insufficient data to recommend its use.
• There are insufficient data on ivabradine in HFmrEF.

Devices

• There is insufficient evidence regarding CRT or ICD therapy in patients with HFmrEF.

Medications indicated in patients with New York Heart Association (NYHA class II–IV) HFmrEF (heart failure with mildly reduced ejection fraction) (LVEF41-49%)

Recommedation for patients with NYHA class 2-4 heart failure with mildly reduced ejection fraction

Diuretics (Class I, Level of Evidence C):

❑ Diuretics are recommended in patients with congestion and HFmrEF in order reduce symptoms and signs

ACEI (Class IIb, Level of Evidence C):

❑ ACE-I may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death ❑ ARB may be indicated for patients with HFmrEF to reduce the risk of HF hospitalization and death ❑ Beta-blocker may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death, ❑ MRA may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death ❑Sacubitril/valsartan may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death

The above table adopted from 2021 ESC Guideline

Heart failure preserved ejection fraction (HFpEF)

Clinical characteristics

• HFpEF patients are older and more often female.
• AF, CKD, and non-cardiovascular comorbidities are more common in patients with HFpEF.
• It is important to exclude other conditions that might mimic the HFpEF syndrome including lung disease, anaemia, obesity, and deconditioning.

The diagnosis of heart failure preserved ejection fraction

• Echocardiographic criteria:

• LA size (LA volume index >32 mL/m2)
• Mitral E velocity <90 cm/s
• Septal e' velocity <9 cm/s
• E/e' ratio >9

  The diagnosis is made when there are the following:

(1) Symptoms and signs of HF
(2) An LVEF >_50%
(3) Evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/ raised LV filling pressures, including raised NPs

• In the presence of AF, the threshold for LA volume index is >40 mL/m2
• Exercise stress thresholds include E/e' ratio at peak stress >_15 or tricuspid regurgitation (TR) velocity at peak stress >3.4 m/s
• LV global longitudinal strain <16%

• An invasively measured pulmonary capillary wedge pressure (PCWP) of >_15 mmHg (at rest) or >_25 mmHg (with exercise) or LV end-diastolic pressure >_16 mmHg (at rest) is generally considered diagnostic.
• In the presence of non-invasive markers of raised LV filling pressures, the probability of a diagnosis of HFpEF increases.
• No treatment has been shown to reduce mortality and morbidity in patients with HFpEF.
• Hospitalizations for HF were reduced by candesartan and spironolactone, sacubitril/valsartan.
• Many of HFpEF patients have underlying hypertension and/or CAD, treated with ACE-I/ARB, beta-blockers, or MRAs.
• The Food and Drug Administration (FDA) has confirmed the use of sacubitril/valsartan and spironolactone in those with an LVEF ‘less than normal’.
• These statements relate to patients within both the HFmrEF and HFpEF categories.
• For sacubitril/valsartan, subgroup analysis from the PARAGON-HF study showed a reduction in HF hospitalizations in patients with LVEF <57%, and a meta-analysis of the PARADIGM-HF and PARAGON-HF studies showed a reduction in cardiovascular death and HF hospitalization in patients with LVEF below the normal range.
• Use of spironolactone, in TOPCAT study was associated with reduced cardiovascular death and HF hospitalization,
• treatment should be aimed at reducing symptoms of congestion with diuretics such as loop diuretic.
• Thiazide diuretics may be useful for managing hypertension.
• Reducing body weight in obese patients and increasing exercise may further improve symptoms and exercise capacity.
• Notably, in HFpEF treatment of underlying risk factors, etiology, and coexisting comorbidities such as hypertension, CAD, AF, valvular heart disease are recommended.

Recommedation for treatment of patients with HFpEF (heart failure preserved ejection fraction)

(Class I, Level of Evidence C):

❑ Screening, treatment, investigation about underlying etiologies, and cardiovascular and non-cardiovascular comorbidities is recommended in patients with HFpEF ❑Diuretics are recommended in congested patients with HFpEF to improve symptoms and signs

The above table adopted from 2021 ESC Guideline