Treatment of patients with heart failure and preserved ejection fraction

Abstract

Of the more than 5 million Americans who have heart failure (HF), 30% to 50% have HF with preserved ejection fraction (HF-PEF). HF-PEF commonly occurs in elderly patients, especially women, with comorbidities of hypertension, left ventricular hypertrophy, diabetes, myocardial ischemia, and obesity. HF-PEF is associated with high morbidity and mortality. Although two large multicenter randomized, placebo-controlled trials evaluating an angiotensin-converting enzyme inhibitor (ACEI) and an angiotensin receptor blocker (ARB) in patients with HF-PEF did not demonstrate any statistically significant benefit in their primary end points, they did suggest that these agents may have a modest role in reducing HF hospitalizations. Although calcium channel blockers and beta-blockers may be of benefit in patients with HF-PEF, large clinical trial data are not available to support their routine use in all patients with HF-PEF. Subgroup analysis does not support the use of digoxin in patients with HF-PEF in sinus rhythm. Current therapeutic recommendations for HF-PEF are aimed at 1) management of HF symptoms with sodium and fluid restriction along with diuretics for volume overload and 2) treatment of concomitant comorbidities, especially hypertension, rate and possibly rhythm control of atrial fibrillation, and evaluation and treatment of myocardial ischemia and anemia. ACEIs, ARBs, calcium channel blockers, and beta-blockers are recommended for HF-PEF patients who have other established indications for their use. Results are awaited from ongoing clinical trials with another ARB, irbesartan, and an aldosterone blocker, spironolactone.

Aldosterone Antagonists in Heart Failure

“…22 Remodeling that begins as a compensatory process and then transitions into a pathologic process 22,23 is associated with high intramyocardial levels of angiotensin, norepinephrine, and aldosterone. 4,26,27 Aldosterone Antagonists Used in Heart Failure 23,24 There is now speculation that the use of aldosterone antagonists may prevent the development of ventricular remodeling and thus preserve left ventricular function in postYmyocardial infarction patients, but larger studies are required to confirm this hypothesis.…”

Actual state of “triple therapy” for heart failure patients in eight regions of Japan: An analysis of a nationwide medical claims database

“…The administration of these Class I recommended drugs for patients with HF is therefore expected to lead to better prognoses for patients with HF, especially in HFrEF, and the combination therapy of ACEIs, ARBs, and MRAs is recommended by professional guidelines [14,15]. Despite evidence of the benefit of triple therapy in HFrEF patients, the role of βblockers in treating HFpEF (caused by hypertension, arrhythmias such as atrial fibrillation, coronary heart disease, diabetes mellitus, and dyslipidemia) is controversial [16]. Similarly, for ACEIs/ARBs and MRAs, no prospective interventional studies on drugs for the treatment of HFpEF have demonstrated a clear reduction in the risk of death or clinical events.…”