You'll hear buzz about how to treat heart failure with PRESERVED ejection fraction (HFpEF)...due to anticipated med label updates.
It's different than heart failure with REDUCED ejection fraction (HFrEF), which is from a weak left ventricle that can't pump effectively.
But over half of HF patients have HFpEF...often due to high blood pressure causing a stiff left ventricle that can't adequately fill.
And there's less evidence for how to treat HFpEF.
For example, ACEIs or ARBs might reduce HFpEF hospitalizations...but don't seem to decrease mortality as they do in HFrEF. Beta-blockers don't seem to reduce mortality in HFpEF either.
Now FDA will likely expand approval of spironolactone and Entresto (sacubitril/valsartan) to some HFpEF patients. Experts predict labels may specify patients with "mildly reduced" EF, such as about 40% to 50%.
But neither is a "slam dunk" for HFpEF, regardless of label changes.
Limited evidence suggests spironolactone may reduce HFpEF hospitalizations...but only after a reanalysis of the data.
Entresto's HFpEF study only shows benefit when its original endpoint...a reduction in HF hospitalizations or CV death...is expanded to include urgent clinic or ED visits for heart failure.
Weigh downsides. For instance, spironolactone is low-cost, but hyperkalemia is common. Entresto costs about $580/mo...can't be used in patients with prior angioedema...and often causes low BP, even in HFpEF.
First, focus on BP control...it may slow HFpEF progression. Suggest meds based on comorbidities...such as an ACEI or ARB for kidney disease.
Advise cautious use of loop diuretics in HFpEF. Loops may be needed for fluid overload, but overdoing it can worsen symptoms.
Help manage anemia, COPD, obesity, or other conditions that may worsen heart failure symptoms. And stay alert for NSAIDs, alpha-blockers, and other meds with adverse effects in heart failure.
If these steps aren't enough, expect to see spironolactone or Entresto tried...especially after a recent heart failure hospitalization.
Anticipate spironolactone if cost is an issue...or Entresto instead of an ACEI or ARB if additional BP lowering is needed. It's also okay if HFpEF patients need both spironolactone and Entresto.
Get our toolbox, Improving Heart Failure Care, for strategies to improve med adherence, resources to educate patients, and more.
- Circulation 2017;136(6):e137-e161
- Circulation 2013;128(16):e240-e327
- N Engl J Med 2019;381(17):1609-20
- Circulation 2015;131(1):34-42
- Medication pricing by Elsevier, accessed Jan 2021
- Toolbox: Improving Heart Failure Care
La Thach February 21, 2021
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