S-29-2: MEDICAL THERAPY FOR HEART FAILURE WITH PRESERVED EJECTION FRACTION

Abstract

Hypertension constitutes the major risk factor for heart failure (HF) with preserved ejection fraction (HFpEF); prevalences above 90% have been reported. HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality comparable to HFrEF. Long specific guideline-directed medical therapy (GDMT) for HFpEF was hard to establish due to lack of convincing positive outcome data from randomized controlled trials (RCTs) mainly because of major limitations of the available studies. Available evidence has however increased with recent and larger RCTs with statistical power. Besides, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) provides the backbone of BP lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, except for in re-analysis with adjustment for commonly available baseline characteristics or repeat event analysis, we propose that this core drug treatment strategy is applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone (MRA) apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor (ARNi). In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors (SGLT2-i) and finerenone (non-steroidal MRA) represent promising therapies. Besides, beta-blocker therapy is widely indicated in 60–80% of HFpEF patients due to HT with rapid heart rate (>80 beats/min), rapid atrial fibrillation and/or coronary heart disease. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high quality RCTs are coming towards firmer conclusions.