Heart Failure with Preserved Ejection Fraction (HFpEF) 

The following guidance applies to patients with heart failure with preserved ejection fraction (HFpEF) with a left ventricular ejection fraction (LVEF) ≥50%.

Introduction

HFpEF is highly prevalent, accounting for up to 50% of all patients with heart failure and is associated with significant morbidity and mortality. HFpEF is a heterogeneous disorder, contributed to by comorbidities that include hypertension, diabetes, obesity, coronary artery disease, chronic kidney disease and specific causes, such as cardiac amyloidosis.

For this reason, treatment should be person centred, tailored to the individual needs and comorbidities of each patient.

Diagnosis

HFpEF is difficult to diagnose and is prone to over and under diagnosis. The main symptoms are breathlessness (particularly orthopnoea and paroxysmal nocturnal dyspnoea), oedema (including ascites and pleural effusion) and cachexia.

See the flowchart below for the diagnosis and general management of patients with suspected HFpEF.

Drug therapy and treatment options

Holistic Care

Holistic care involves optimal treatment of all the related and unrelated comorbidities associated with HFpEF as below.

   - Hypertension:

  • High blood pressure promotes diastolic dysfunction and low blood pressure reduces renal perfusion.
  • Most patients who are adequately diuresed do not need additional antihypertensives.
  • Systolic BP of 110-150mmHg is acceptable in HFpEF patients.
  • If indicated, treat as per the Management of Hypertension guideline.
  • N.B. ACE inhibitors and ARBs can be used for BP control but can cause renal impairment and have no prognostic benefit in HFpEF. 

   - Atrial fibrillation (AF):

  • In patients with HFpEF, management of AF rate control can also be useful to improve symptoms.
  • Consider a 24 hour tape and aim for average HR 60-80bpm.
  • Beta blockers are preferable to calcium channel blockers.
  • If patient is too hypotensive (SBP<110mmHg) to tolerate beta blockers, then use digoxin.

Review and improve patient awareness and control of other co-morbid conditions (including diabetes, obesity, anaemia and coronary artery disease).

Fluid Management

  • Fluid management is used to control oedema, ascites, pleural effusions and pulmonary oedema.
  • Diuretic treatment without evidence of fluid overload clinically or on chest x-ray is usually unsuccessful.
  • See table below for strategies to treat and prevent fluid overload:
Fluid Intake Maximum: 1.5-2 litres of fluid per day
Loop Diuretics

Furosemide 20-240mg/day

Bumetanide 0.5-6mg/day
Mineralocorticoid Antagonists (MRA)

Spironolactone 25-50mg/day

Eplerenone 25-50mg/day

Very useful for right heart failure, ascites and when loop diuretics cause low potassium
Thiazide (and related) Diuretics

Bendroflumethiazide 2.5-10mg/day

Indapamide 2.5mg/day

Metolazone (specialist initiation)

Can be used in combination with a loop diuretic under specialist advice and close supervision
Potassium Sparing Diuretics

Amiloride 2.5-10mg/day

When MRAs are not tolerated
Notes
  • Diuretics should be titrated according to symptoms and the dose should be reduced if symptoms of dehydration (e.g. thirst, dizziness, hypotension) or if no oedema or breathlessness and condition is stable.
  • Assess patient after dose changes and hospitalisation to prevent over diuresis.
  • Check renal function approximately 2 weeks after any change in medication, and then again at 3 months.
  • If treatment is static and eGFR >30ml/min then check U&Es 6 monthly, otherwise 3 monthly.
  • Some patients with cardiorenal and renocardiac failure will have a treatment plan based on lower eGFR as advised by cardiologist or nephrologist.

Prevent Hospitalisation

  • Recent evidence has shown a significant benefit of the sodium-glucose co-transporter-2 (SGLT2) inhibitors in symptomatic patients with heart failure and LVEF >40% and elevated NT-pro BNP.
  • Addition of these medicines to patients with HFpEF can reduce hospitalisations and cardiovascular death.
  • Consider addition of a SGLT2 inhibitor (dapagliflozin or empagliflozin) for stable patients with HFpEF.
  • For detailed guidance, see the SGLT2 inhibitor initiation guidelines.
Guideline reviewed October 2022
Page updated September 2023



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