Heart failure is a complex clinical syndrome in which impaired ventricular filling and ejection of blood into circulation causes decreased stroke volume and cardiac output. Heart failure with preserved ejection fraction (50% or more) is the most common type of heart failure, and up to 1 in 10 adults will be affected in their lifetime. Clinical symptoms such as peripheral edema, dyspnea, and orthopnea, with clinical findings including jugular venous distention, third heart sound, and laterally displaced apical impulse should prompt consideration of heart failure. Laboratory values (eg, elevated N-terminal fragment of the prohormone brain natriuretic peptide) can also aid in diagnosis, which can then be confirmed with specific echocardiographic findings. Once heart failure with preserved ejection fraction is diagnosed, medications should be initiated to manage comorbid symptoms and conditions such as hypertension, obesity, and obstructive sleep apnea. Sodium-glucose cotransporter-2 inhibitors have been shown to reduce hospitalizations related to heart failure and cardiovascular-related mortality in patients with symptomatic heart failure, elevated natriuretic peptide levels, and an ejection fraction more than 40%; therefore, they should be considered in all patients with heart failure with preserved ejection fraction. Additionally, loop diuretics, mineralocorticoid receptor antagonists, and angiotensin receptor blocker/neprilysin inhibitors can be used. In patients with end-organ dysfunction or signs of refractory treatment, consultation with a heart failure specialist should be considered.
Heart failure is a complex clinical syndrome in which impaired ventricular filling and ejection of blood into circulation causes decreased stroke volume and cardiac output.1,2 Due to advancements in understanding of the underlying pathophysiology of heart failure, current clinical guidelines categorize cases by left ventricular ejection fraction to guide treatment.1
WHAT'S NEW ON THIS TOPIC
| Heart failure with preserved ejection fraction is the most common type of heart failure, with up to 1 in 10 adults being affected in their lifetimes. |
| Two industry-sponsored studies demonstrated that the sodium-glucose cotransporter-2 inhibitors empagliflozin (Jardiance) and dapagliflozin (Farxiga) reduce the composite outcome of cardiovascular mortality and hospitalizations in patients with symptomatic heart failure with preserved ejection fraction and elevated natriuretic peptide levels. |
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| In patients with symptoms suggesting heart failure, echocardiography should be performed to characterize ejection fraction and identify any findings consistent with HFpEF.2–4 | C | Consensus guidelines and reviews |
| In patients with symptoms suggesting heart failure, a validated scoring system such as H2FPEF should be used help diagnose HFpEF.2–4,11 | C | Consensus guidelines and reviews |
| In patients with HFpEF, physicians should use goal-directed medical therapy, which includes sodium-glucose cotransporter-2 inhibitors, angiotensin receptor blockers (with or without neprilysin inhibitors), and possibly mineralocorticoid receptor antagonists.9,12–15 | B | Clinical trials and consensus guidelines |
| Stable patients with HFpEF and acute signs of fluid overload should be treated with loop diuretics and managed in the outpatient setting with close follow-up. Unstable patients should be referred for emergency care, and cardiogenic shock and severe hemodynamic instability require intensive care admission.1,4,5 | C | Consensus guidelines |
| Due to the reduction in the composite outcome of heart failure hospitalizations and deaths, prescription of sodium-glucose cotransporter-2 inhibitors should be considered in patients with HFpEF with or without diabetes unless contraindicated.12,16 | A | Consistent evidence of industry-sponsored randomized controlled trials showing improved outcomes |
HFpEF = heart failure with preserved ejection fraction.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
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