Consider Key Meds to Optimize HFpEF Regimens

You’ll get questions about managing heart failure with PRESERVED ejection fraction (HFpEF)...based on new guidance.

Over half of HF patients have HFpEF...and it’s a common cause of readmission, similar to heart failure with REDUCED EF (HFrEF).

But HFpEF treatment is still less clear-cut than HFrEF...since HFpEF data are less robust and meds aren’t shown to reduce mortality.

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Continue to emphasize BP may slow HFpEF progression. Optimize management of common conditions that may worsen HFpEF...such as atrial fib, COPD, and obesity.

And use loop diuretics if needed for fluid overload. But keep in mind, reducing preload too much can worsen HFpEF symptoms.

Then consider key meds that may improve HFpEF outcomes...weighing strength of evidence, side effects, cost, etc.

SGLT2 inhibitors. Consider adding before discharge if practical.

For example, dapagliflozin (Farxiga) or empagliflozin (Jardiance) prevents HF hospitalization in about 1 in 35 patients with HFpEF over about 2 years.

New sotagliflozin (Inpefa) is also an option...but has less data.

These meds may be started with eGFR down to 20 mL/min/1.73 m2. And all 3 are now approved for HF, including HFpEF...regardless of diabetes.

But weigh downsides...such as genital yeast infections, volume depletion, and cost of about $600/month.

Aldosterone antagonists. Also consider adding spironolactone. Limited evidence suggests it may reduce HFpEF hospitalizations...but only after a reanalysis of data.

ACEIs, ARBs, or sacubitril/valsartan (Entresto). Some evidence suggests any of these meds might reduce HFpEF hospitalizations. But this relies on secondary endpoints or subgroups to find benefit.

Think of sacubitril/valsartan as having stronger data than ACEIs or ARBs.

But sacubitril/valsartan isn’t always practical. For example, it may cause low BP, even in HFpEF...and costs about $670/month.

If sacubitril/valsartan isn’t an option, generally choose an ARB over an ACEI. Either is reasonable for patients with other indications (hypertension, etc)...but ACEIs have the least data suggesting benefit in HFpEF.

Access our resource, Improving Heart Failure Care, for tips on target doses, monitoring, drugs to avoid, and more.

Key References

  • J Am Coll Cardiol. 2023 May 9;81(18):1835-1878
  • Circulation. 2022 May 3;145(18):e895-e1032
  • Medication pricing by Elsevier, accessed Jun 2023
Hospital Pharmacist's Letter. July 2023, No. 390702

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