Congestive heart failure with preserved EF pharmacotherapy

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Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

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Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

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Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Treatment of HFpEF is focused on treating underlying disease, such as hypertension, coronary artery disease and atrial fibrillation. Diuretics are the mainstay of pharmacotherapy. Other effective measures to control HFpEF include exercise, weight control and lipid control.

HFpEF pharmacotherapy

Treatment for HFpEF is based on underlying associated conditions. These measure are mainly focused on:

It is recommended to maintain BP less than 150/90 mm Hg in persons who are 60 years of age or older in the general population and of less than 140/90 mm Hg in persons with kidney disease (estimated GFR<60 ml per minute per 1.73 m2 of body-surface area or >30 mg of albumin per gram of creatinine,regardless of diabetic status) and for persons with diabetes, regardless of age.[2]
  • Control of volume overload[3][4]
Diuretics must be used to relief symptoms of volume overload according to patients' weight, symptoms and electrolyte status. Also, sodium restriction may be helpful in patients who are prone to volume overload.[5]
Patients with Atrial fibrillation (AF) must be treated according to last guideline for rate control and anti coagulation but if the symptoms remained consider rhythm control.[7]

Medications

Aldosterone Antagonists

May lead to improvement in diastolic function and hypertrophy but not in clinical outcomes.[11][12] However, a subgroup analysis of patients in the TOPCAT trial with brain natriuretic peptide levels showed benefit[12].

Diuretics

Diuretics are useful to control volume overload and decrease the preload.[13]

Angiotensin receptor neprilysin inhibitors

They may improve symptoms and quality of life in HFpEF patients but clinical trials to evaluate their effectiveness are ongoing.[14][15][16]

ACE inhibitors

ACE inhibitors do not have direct effect on mortality and morbidity in HFpEF but they have great role on hypertension, renal function, CAD and diabetes as underlying disease.[17][18]

Angiotensin II receptor blockers

There is no evidence that they improve morbidity or mortality in HFpEF patients.[18]

β-blockers

β-blockers have not shown benefits in HFpEF.[19][20]

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure/2013 ACCF/AHA Guideline for the Management of Heart Failure.[21] (DO NOT EDIT)

Class I
"1. Systolic and diastolic blood pressure should be controlled according to published guidelines.[22][23](Level of Evidence: B)"
"2. Diuretics should be used for relief of symptoms due to volume overload.(Level of Evidence: C)"
Class III (No Benefit)
"1. Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QoL in patients with HFpEF is ineffective.[24][25](Level of Evidence: B-R)"
"2. Routine use of nutritional supplements is not recommended for patients with HFpEF.(Level of Evidence: C)"
Class IIa
"1. Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial ischemia is present despite medical therapy (Level of Evidence: C)"
"2. Management of atrial fibrillation according to published guidelines in patients with HFpEF is reasonable to improve symptomatic HF (Level of Evidence: C)"
"3. Use of β-blockers, ACE inhibitors, and ARBs for hypertension in patients with HFpEF. (Level of Evidence: C)"
Class IIb
"1.ARBs might be considered to decrease hospitalizations for patients with HFpEF.[18] (Level of Evidence: B)"
"2.In appropriately selected patients with HFpEF (with EF ≥45%, elevated BNP levels or HF admission within 1 year, estimated glomerular filtration rate >30 mL/min, creatinine <2.5 mg/dL, potassium <5.0 mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalizations.[26][27] (Level of Evidence: B-R)"

References

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