ACC 2023 Expert Consensus: How to Optimize Diagnosis and Treatment of Heart Failure with Preserved EF LK
Heart failure (HF) remains a significant cause of morbidity and mortality, with the incidence and prevalence of HF with preserved left ventricular ejection fraction (HFpEF) rising. The following document focuses on individuals with HFpEF and supports the principles of evidence-based diagnosis and treatment of HF from 2022. It emphasizes the need for individualized care and multidisciplinary cooperation.
Key Opportunity for Progress
The authors highlight the difficulties in diagnosing and managing HFpEF due to the heterogeneity of the disease and its multifactorial etiology. However, they state that despite this, there is a significant opportunity to redefine the care of patients with this condition. Diagnostic challenges include determining the EF LK threshold for HFpEF or distinguishing between HFpEF and diastolic dysfunction. Expert groups agree on new therapeutic frameworks for HFpEF. They recommend multidisciplinary collaboration and emphasize that in patient care decisions, it is important to consider both the physician's opinion and the patient's preferences.
Diagnostic Challenges Persist, More Significant in Women
The diagnosis of HFpEF is based on the universal definition of HF and includes relevant differential diagnosis of dyspnea and edema (their presence may not indicate HF). HF can be masked by a number of other conditions, whether nephrological, hepatological, hematological, respiratory, or obesity, as well as by several other cardiological diseases. Therefore, individuals with congestion symptoms and preserved EF LK should undergo further examination. Clinical scoring systems can help with the diagnosis of HFpEF.
The authors of the document point out that diagnostic and treatment challenges in HFpEF are even more significant in women. Differences between genders in HFpEF cannot be ignored (for example, women more frequently experience significant dyspnea symptoms), as “gender-neutral” thresholds for normal values may lead to underestimation of LK dysfunction in women.
Beware of Comorbidities
The clinical context, including the identification of comorbidities, is crucial for the diagnosis of HFpEF, affecting treatment strategy selection. HFpEF is often associated with conditions such as hypertension, diabetes mellitus (DM), obesity, atrial fibrillation (AF), ischemic heart disease (IHD), chronic kidney disease (CKD), or obstructive sleep apnea (OSA). Managing these conditions is essential in treating patients with HFpEF; effective management can contribute to overall improvement in quality of life and reduce the risk of cardiovascular (CV) complications.
The presence of DM in patients with HFpEF represents a risk in terms of CV complications and mortality. Therefore, glycemic control must be part of a comprehensive treatment plan. DM management in HFpEF follows DM treatment standards, emphasizing the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, i.e., gliflozins). SGLT2i have proven effective in treating both DM and HF (including HFpEF) and have the potential to improve CV outcomes in patients with both conditions.
Blood pressure monitoring and controlling possible hypertension are also important. A significant aspect of HFpEF treatment is monitoring pulmonary arterial hypertension, which is often associated with disease progression
Treatment Options
HFpEF management includes both non-pharmacological and pharmacological approaches, along with risk assessment and comorbidity treatment. Lifestyle modifications play a key role, making patient education, recommended behavioral changes, and support and motivation for regular physical activity crucial.
Pharmacotherapy primarily includes SGLT2i. For patients with congestion and NYHA class II–IV, loop diuretics and mineralocorticoid receptor antagonists (MRA) are also suitable. MRA are also recommended for men with EF LK < 55% and for all women with HFpEF, as well as angiotensin receptor-neprilysin inhibitors (ARNI). For patients who cannot use ARNI, angiotensin II type 1 receptor blockers (ARBs, i.e., sartans) are recommended. SGLT2i have demonstrated significant reductions in hospitalization and CV mortality risk across all EF LK subgroups in treating heart failure. MRA improve diastolic function and may reduce the risk of HF-related hospitalization in specific HFpEF subgroups. Regarding ARNI, combined therapy with sacubitril/valsartan appears to be more advantageous than valsartan alone for HFpEF patients.
The document emphasizes that the response to HFpEF therapy varies between men and women, which should be considered when selecting treatment. All HFpEF patients should receive SGLT2i, with other drug groups considered based on individual characteristics.
How to Optimize Care?
According to the authors, improving clinical outcomes for HFpEF patients is essential by enhancing the availability of physicians knowledgeable in HFpEF and improving patient communication. Complex diagnostics justify the referral to a specialist upon suspected HFpEF, and specialized care for HFpEF patients is associated with lower mortality risk. Multidisciplinary teams are crucial for optimizing management, especially in patients with comorbidities. A treatment plan and a comprehensive approach are essential. Timely initiation of palliative care can significantly improve quality of life.
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Source: Kittleson M. M. et al. 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. JACC 2023 May 9; 81 (18): 1835–1878, doi: 10.1016/j.jacc.2023.03.393.
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