Narrative review: the holy grail: update on pharmacotherapy for heart failure with preserved ejection fraction

Abstract

Heart failure with preserved ejection fraction (HFpEF) is the presence of clinical signs and/ or symptoms of heart failure with a left ventricular ejection fraction (LVEF) ≥50%. Risk factors associated with this disease include hypertension, hyperlipidemia, atrial fibrillation (AF), obesity, diabetes and coronary artery disease (CAD). Despite the multiple risk factors identified for this condition, treatment and management remain challenging and a subject of ongoing research. Since a treatment approach that alters the natural course or lowers mortality for this disease has not been found, treating co-morbidities and symptom management is essential. From the comorbidities, hypertension is identified as the main risk factor for disease development. Thus, after congestive symptom control with diuretics, blood pressure (BP) management is considered one of the most important preventive measures and also a target for treatment. Amongst antihypertensives, angiotensin receptor blockers (ARBs) and aldosterone antagonists are the therapeutic agents used that have a role in reducing hospitalizations. Implantable monitoring devices have also been shown to reduce hospitalizations in comparison to standard heart failure therapies by allowing to tailor diuretic therapy based on ongoing hemodynamic data. In this manuscript we discuss pharmacologic strategies for HFpEF patients by risk factors, including those with and without a potential role.

Prognostic impact of systolic blood pressure in acute heart failure with preserved ejection fraction in older patients

“…Blood pressure control is considered one of the most important preventive measures for HFpEF. 33 In our study, antihypertensive drugs, irrespective of the class, were associated with a trend towards an improved prognosis. To note, 42% of patients who received antihypertensive drugs had no history of hypertension.…”

“…It is therefore recommended to control cardiovascular or other comorbidities. Blood pressure control is considered one of the most important preventive measures for HFpEF 33 . In our study, antihypertensive drugs, irrespective of the class, were associated with a trend towards an improved prognosis.…”

“…Whether loop diuretics at discharge are associated with a lower mortality remains a matter of debate. 33 , 34 There is also no evidence of benefit for ACE inhibitors, ARBs, or beta‐blockers 33 in patients with HFpEF, but they do play an important role in the management of associated comorbidities like hypertension, atrial fibrillation, and coronary artery disease. The improved long‐term prognosis in patients on beta‐blockers is probably due to the large number of patients with atrial fibrillation in our study.…”

“…It is thus likely that the association of antihypertensive drugs with survival is related, at least in part, to a cardioprotective effect independent of their antihypertensive effect. Whether loop diuretics at discharge are associated with a lower mortality remains a matter of debate 33,34 . There is also no evidence of benefit for ACE inhibitors, ARBs, or beta‐blockers 33 in patients with HFpEF, but they do play an important role in the management of associated comorbidities like hypertension, atrial fibrillation, and coronary artery disease.…”