A large National Institutes of Health-sponsored trial is underway to determine if the drug is beneficial for patients with preserved LVEF, and will build on a small study in which 30 patients with HFPEF showed improved myocardial function after treatment with spironolactone.35 Until more data become available, the risks of using aldosterone antagonists outweigh the evidence to support their use in this patient population.
Diuretics are an important component of treatment for all patients with HF and fluid overload. The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) showed a reduced incidence of symptomatic HFPEF in patients taking diuretics.28 As is the case with patients with reduced EF, those with preserved EF should be treated with diuretics if they have symptoms of fluid overload.
Statins. Intensive lipid lowering with statin therapy has been shown in observational studies to benefit patients with HFPEF with respect to mortality, independent of baseline low-density lipoprotein cholesterol.29 RCTs are needed to confirm these observations, but statin therapy is recommended for the secondary prevention of cardiovascular disease, independent of the presence of diastolic dysfunction or HFPEF.
Guard against hypotension. Patients with diastolic dysfunction are susceptible to hypotension if there is a rapid reduction in preload with diuretics, nonselective CCBs, or nitrates, so it is important that doses be titrated slowly.
Nonpharmacologic measures are important, too
In addition to optimizing treatment of comorbid conditions, patients with HFPEF should be advised that lifestyle modifications such as weight loss, smoking cessation, and dietary changes can do much to reduce the risk. You can help by providing an exercise “prescription” (with a specified intensity, frequency, and duration) and dietary guidelines, with emphasis on the importance of a low-sodium diet to prevent fluid overload.14,30 Recommend local programs for patients with HF, which many hospitals and health systems offer as part of their efforts to reduce readmission rates.
Consider cardioversion
Tachycardia shortens the time for filling during diastole; thus, it is poorly tolerated in patients with diastolic dysfunction and could trigger acute decompensation. To avoid the risk, restoration of sinus rhythm should be considered for patients with HFPEF and atrial fibrillation. Patients with known paroxysmal or permanent atrial fibrillation and preserved EF should be seen by a cardiologist to determine whether direct current cardioversion or ablation with a permanent pacemaker is appropriate.11 When cardioversion is contraindicated, a beta-blocker is needed to control heart rate and improve hemodynamics.
Patients with stable angina and HFPEF should be evaluated for revascularization when medical therapy alone is not sufficient for symptom relief.10 Here, too, a cardiology consult is indicated for any patient who has HF and an abnormal noninvasive stress test or persistent symptoms despite optimal drug therapy.
Recognizing and responding to acute decompensated HFPEF
The initial response to acute decompensated HFPEF, like that of HF with reduced EF, should be focused on restoring volume status and providing oxygenation, ventilation, and vasodilator therapy in some cases.11 Unlike those with acute decompensated HF with reduced EF, however, patients with HFPEF can safely tolerate the initiation of beta-blockers in the acute phase, especially when rate control is needed.3 Inotropic agents like digoxin and dobutamine, however, are contraindicated.3
Guidelines recommend hospitalization for patients with abnormal vital signs, arrhythmia, and suspected acute coronary syndromes, and consideration of hospitalization for those with associated comorbid conditions, new HF, or progressive fluid overload.13
CASE Because Ms. W has a normal BP and heart rate and is feeling well, you decline to alter her medication regimen. You do, however, recommend that she begin an exercise program, adopt a low-sodium diet, and maintain regular contact with your office so you can evaluate any changes in status.
You introduce Ms. W to the nurse case manager in your office. The nurse works with the patient to develop an action plan that includes daily tracking of her weight and sodium intake; a progressive walking program, starting with 2-minute sessions and progressing to 15 to 30 minutes 3 to 5 times a week; weekly telephone checkins; and immediate calls to report any weight increase or symptoms of HF.
At follow-up 6 months later, Ms. W has improved BP and reports that she enjoys her new exercise routine. She has more energy and denies any edema or breathing difficulties.