New Guidance for Heart Failure With Preserved Ejection Fraction

Volume 26, Issue 3

Roughly half of all patients with heart failure have a preserved ejection fraction (HFpEF), which excludes them from many of the commonly used guideline-directed medical therapies for heart failure with a reduced ejection fraction. This is because many of these medications, like ACE inhibitor and beta-blockers, failed to show any benefit in the reducing rates of death and hospitalization in patients with a preserved ejection fraction. 

The SGLT2 inhibitors blew off the doors last year with 2 randomized clinical trials demonstrating improvements in the composite endpoint of cardiovascular death and hospitalization for heart failure. The new heart failure guidelines, which were published last year in the middle of this barrage of new data, provided a relatively strong recommendation for use of these agents in patients with a preserved ejection fraction. 

In this week’s issue of Talking Therapeutics, we explore a new clinical pathway document for managing HFpEF from the American College of Cardiology. 

Point 1: SGLT2 Inhibitor Reigns Supreme

The new clinical pathway contained the following recommendations:

• SGLT2 inhibitors should be started as first-line therapy for all patients without contraindications to these agents. 
• Loop diuretics also have a strong recommendation for managing symptoms like edema and shortness of breath, although these agents do not reduce hospitalizations or mortality rates.
• For women with all ejection fractions and men with ejection fractions between 55% to 60%, mineralocorticoid receptor antagonists (eg spironolactone) can be added to SGLT2 inhibitor therapy. This is a relatively weak recommendation based on the limited evidence. 
• For women with all ejection fractions and men with ejection fractions between 55% to 60%, ARNI therapy (eg sacubitril/valsartan) can be added to SGLT2 inhibitor therapy. This is a relatively weak recommendation based on the limited evidence. 
• For patients who are eligible for ARNI therapy but cannot afford or tolerate this drug, angiotensin receptor blockers can be substituted. This is a relatively weak recommendation based on the limited evidence. 

Point 2: Much More Work to Be Done

While the approval of SGLT2 inhibitors was a watershed moment for the treatment of HFpEF, these patients still struggle due to too few drug therapy options and an unacceptably high rate of heart failure hospitalization and death. The relatively weak grade of recommendation for most of these drugs highlights this deficiency and shows that additional research is needed to identify novel drug therapies for patients with HFpEF. 

Reference:
Kittleson MM, Panjrath GS, Amancherla K, et al. 2023 ACC expert consensus decision pathway on management of heart failure with preserved ejection fraction. J Am Coll Cardiol. Published online April 19, 2023. doi:10.1016/j.jacc.2023.03.393