Heart failure is a complex condition where the heart cannot pump enough blood to meet the body’s needs. Heart Failure with Preserved Ejection Fraction (HFpEF) occurs when the main pumping chamber, the left ventricle, becomes stiff and cannot relax properly between beats. Unlike heart failure with reduced ejection fraction (HFrEF), the heart’s ejection fraction remains normal (typically 50% or higher). However, this stiffness impairs the heart’s ability to fill with blood, reducing the total amount of blood circulated. Treatment for HFpEF focuses on controlling symptoms and addressing the underlying systemic conditions that contribute to this stiffness and poor filling, rather than improving the muscle’s pumping strength.
Managing Common Underlying Conditions
Successful treatment for HFpEF relies on aggressively managing the medical conditions that contribute to heart muscle stiffening. Chronic conditions like high blood pressure, type 2 diabetes, and atrial fibrillation cause structural changes in the heart, leading to impaired relaxation. Hypertension, present in up to 75% of patients, is detrimental because persistent high pressure causes the heart muscle to thicken and become less flexible. Careful control of blood pressure using standard anti-hypertensive drugs is a primary strategy to prevent further damage.
Type 2 diabetes and chronic kidney disease promote inflammation and fibrosis (scarring) within the heart muscle. Targeting blood sugar control in diabetic patients is essential, often aiming for a glycosylated hemoglobin (HbA1c) goal of less than 7% to 7.5%. Atrial fibrillation (A-fib), a common irregular heart rhythm, significantly worsens symptoms by reducing the time the stiff ventricle has to fill properly, requiring rate or rhythm control. Managing sleep apnea, a frequent comorbidity, can also lessen the strain on the heart by improving cardiorespiratory fitness and reducing A-fib recurrence.
Strategies for Volume and Symptom Control
A primary goal in treating HFpEF is to relieve fluid buildup, known as congestion, which causes shortness of breath and swelling. This fluid accumulation occurs because the stiff heart cannot accept blood returning from the body, causing it to back up into the lungs and peripheral tissues. Loop diuretics, commonly called “water pills,” are the main tool for acute symptom relief, helping the kidneys excrete excess salt and water.
Diuretics like furosemide or torsemide are started at low doses and adjusted based on the patient’s fluid status and symptoms. For severe congestion, higher doses or the addition of a second diuretic, such as a thiazide, may be required to maximize fluid removal. This acute management provides symptomatic relief but does not alter the long-term progression of the disease.
Daily weight monitoring is an effective practice for managing fluid status at home, allowing for early detection of fluid retention. Patients should weigh themselves every morning; a weight gain of two to five pounds over two to three days signals fluid accumulation and necessitates contacting a healthcare provider. This proactive self-care allows for timely adjustments to diuretic doses, helping prevent emergency room visits or hospitalizations.
Disease-Modifying Medication Classes
For decades, finding medications to slow progression in HFpEF was challenging, but recent breakthroughs established two primary classes of drugs with demonstrated disease-modifying benefits. The most significant development is the widespread use of Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors, such as empagliflozin and dapagliflozin. These drugs reduce the risk of heart failure hospitalizations and cardiovascular death. Originally developed for type 2 diabetes, they work by blocking the reabsorption of glucose and sodium in the kidney, leading to a mild diuretic effect.
The benefits of SGLT2 inhibitors extend beyond fluid removal, as they also improve the function and structure of the stiff heart muscle. Proposed mechanisms include reducing inflammation and fibrosis, improving the heart’s energy metabolism, and decreasing muscle fiber stiffness. The use of SGLT2 inhibitors is now considered foundational therapy for all HFpEF patients, regardless of diabetes status.
Mineralocorticoid Receptor Antagonists (MRAs), specifically spironolactone or eplerenone, offer long-term benefit by blocking the hormone aldosterone. Aldosterone contributes to inflammation and scarring within the heart; blocking its effects can improve heart structure, reduce fibrosis, and help manage blood pressure.
MRAs are started at a low dose and carefully titrated, requiring close monitoring of kidney function and potassium levels due to the risk of hyperkalemia. While evidence suggests they reduce hospitalizations, the effect on mortality is less clear in HFpEF compared to heart failure with reduced ejection fraction. Standard blood pressure medications, such as Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs), manage coexisting hypertension but have not demonstrated the same consistent disease-modifying benefits as SGLT2 inhibitors and MRAs.
Lifestyle and Self-Management Practices
Active patient involvement through lifestyle adjustments is an important part of managing HFpEF. Dietary sodium restriction is paramount, as excessive salt intake contributes to fluid retention and increased blood volume, exacerbating congestion. Guidelines recommend limiting sodium intake to below 1,500 milligrams per day. Patients should avoid processed and packaged foods, focusing instead on cooking fresh foods at home to control intake.
Physical activity and cardiac rehabilitation are strongly recommended, as a sedentary lifestyle can worsen the condition. Structured exercise programs tailored to the individual’s capacity improve functional ability, quality of life, and overall exercise tolerance. Exercise helps the body use oxygen more efficiently and may help reverse detrimental changes in the heart and blood vessels. Strict adherence to all prescribed medications and diligent self-monitoring are necessary to prevent acute worsening, including tracking changes in symptoms like increasing shortness of breath, fatigue, or leg swelling, which warrant immediate communication with the healthcare team.