AAC's expert consensus on management of heart failure with preserved ejection fraction: Key takeaways
USA: The American College of Cardiology (ACC) has released a 2023 expert consensus decision pathway on managing heart failure with preserved ejection fraction (HFpEF). The consensus was published in the Journal of the American College of Cardiology on Apr 19, 2023.
Heart failure with preserved ejection fraction is defined as signs and symptoms of HF with left ventricular EF (LVEF) ≥50%. HFpEF diagnosis and management require multidisciplinary care involving primary care, cardiology, and HF specialists. Referral to cardiology should be sought in the presence of comorbidities such as coronary artery disease/atrial fibrillation (AF), elevated natriuretic peptides, HF hospitalizations, specialists needed for comorbidities, increased diuretic needs, knowledge of mimics, and New York Heart Association (NYHA) class III-IV.
The document states, "Referral to HF specialists should be considered if there is intolerance to medical therapy, NYHA class III-IV symptoms, HF hospitalization, end-organ dysfunction, or escalating diuretic needs."
The following are the key takeaways from the consensus:
- Two scoring systems: H2FPEF and HFA-PEFF, may be used to estimate the probability of HFpEF. H2FPEF assesses presence of hypertension, heavy body mass index (>30 kg/m2), AF, pulmonary hypertension, elderly (>60 years), and elevated filling pressures. HFA-PEFF involves pretest assessment of HF, echocardiography and natriuretic peptide score, functional testing including diastolic stress test/right heart catheterization, and special imaging/biopsy/genetic testing to identify cause.
- Natriuretic peptides are lower in obese individuals with HFpEF. High suspicion of HFpEF is required in obese individuals with obesity and dyspnea.
- Women with HFpEF have more dyspnea with worse health status. Women with HFpEF have more concentric remodeling on echocardiography with more diastolic stiffness, smaller LV size, and higher LVEF compared with men. Accordingly, an EF of 50-55% may be abnormal in women.
- Noncardiac mimics of HFpEF include renal disease, cirrhosis, and chronic venous insufficiency. Special cardiomyopathies can also present as HFpEF including infiltrative cardiomyopathy, hypertrophic cardiomyopathy, amyloidosis, valvular heart disease, or pericardial disease.
- Management of HFpEF centers around managing comorbidities first including hypertension, obesity, diabetes, AF, and sleep apnea. Hypertension should be optimally controlled to systolic blood pressure <130 mm Hg. Agents of choice include diuretics, angiotensin receptor–neprilysin inhibitors (ARNIs), angiotensin receptor blockers (ARBs), and mineralocorticoid antagonists (MRAs).
- Target for glycosylated hemoglobin HbA1c is <7-7.5% for individuals with lower comorbidity burden or less severe HF and HbA1c target is <8-8.5% for more severe HF, higher comorbidity burden, and the elderly. SGLT2 inhibitors should be first line for diabetic HFpEF. Metformin may be considered if estimated glomerular filtration rate (eGFR) is >30. Glucagon-like peptide-1 (GLP-1) agonists or GIP antagonist may be considered for obese individuals with diabetes mellitus and HFpEF. Dipeptidyl peptidase-4 (DPP4) inhibitors saxagliptin and alogliptin and thiazolidinediones are contraindicated in HF. Agents slowing progression for diabetic nephropathy include angiotensin-converting enzyme (ACE) inhibitors, ARBs, sodium-glucose cotransporter-2 (SGLT2) inhibitors, MRA (finerenone), ARNIs, and SGLT2 inhibitors.
- SGLT2 inhibitors should be initiated in all HFpEF patients without contraindications, ideally once stable during hospitalization for index event. Spironolactones may be beneficial in some HFpEF subsets with LVEF <55-60% or elevated B-type natriuretic peptide with close monitoring of potassium and renal function. ARNIs have been proven to be beneficial in HFpEF patients with EF 45-57% and women. ARBs can be used when ARNI is cost prohibitive. Beta-blockers should be considered in patients with a history of myocardial infarction or AF for rate control.
- Pulmonary artery pressure monitoring with CardioMEMS reduces risk for HFpEF hospitalizations. It may be most useful for individuals with recurrent hospitalizations and those who experience lability in volume status.
- Polysomnography to detect sleep apnea should be considered for HFpEF. A multidisciplinary approach for weight loss should be considered in obese individuals with HFpEF. Cardiac rehabilitation may improve functionality in HFpEF but is currently not covered by insurance.
- Standard guidelines for revascularization and management of hyperlipidemia apply to HFpEF. Long-acting nitrates are not routinely recommended for HFpEF.
- For AF, nondihydropyridine calcium channel blockers and beta-blockers are first line for rate control with addition of digoxin. Subgroup trial analysis suggests a more beneficial effect of rhythm control in HFpEF with AF. Anticoagulation should be considered based on CHA2DS2-VASc score.
Reference:
2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure With Preserved Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023;Apr 19:[Epub ahead of print].
