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1yr
A patient with dyspnea on exertion, orthopnea, and cough

A 68-year-old woman, Mrs. M presents with a history of hypertension and paroxysmal atrial fibrillation. She complains of fatigue, dry cough, and shortness of breath while walking her dog or lying down flat. She is not experiencing chest pain or lightheadedness. She drinks alcohol rarely, has never smoked tobacco, and does not engage in recreational drug use.

She is taking the following medications:

  • Diuretic
  • Beta-blocker
  • Angiotensin-converting enzyme inhibitor
  • Anticoagulant

Her physical exam reveals:

  • Body mass index 29 kg/m2
  • Blood pressure 128/74 mm Hg
  • Heart rate 88 beats/minute; regular rhythm; no murmur
  • Bilateral rales
  • Bilateral pedal edema

Her N-terminal pro B-type natriuretic peptide score is 990 pg/mL. All other laboratory tests are within normal limits. Electrocardiography shows normal sinus rhythm. On echocardiography, she has a left ventricular (LV) ejection fraction of 55%, LV wall thickness of 14 mm, and an average E/e’ ratio of 16.

Based on these results, you decide to initiate guideline-directed medical therapy for heart failure with preserved ejection fraction (HFpEF) and assess Mrs. M for symptomatic improvement.

Based on HFpEF guidelines, which class(es) of medication would help reduce Mrs. M’s risk of hospitalization for heart failure and cardiovascular death, and why?

  • 1yr
    She is in mild CHF so initial approach is to decongest. For the long term, treatment of her HFpEF with SGLT2i, MRA, and ARNI will help decrease risk of hospitalization and death. Additionally she should get a sleep study and long term Holter to assess atrial fib burden.
  • 1yr
    For this patient with HFPEF would add SGLT2I - Jardiance or Farxiga. As well her diuretic therapy should include MRA like spironolactone.
  • 1yr
    Would definitely recommend SGLT-2 inhibitors, either Farxiga or Jardiance
    Would also add MRA such as Aldactone
  • 1yr
    SGLT-2 Inhibitors have been shown to decrease risk of hospitalization for CHF and cardiovascular death. These agents include empagliflozin (Jardiance) and dapagliflozin (Farxiga). BP and fluid volume status should be monitored closely.
  • 1yr
    My colleagues are correct - SGLT2 inhibitors are the best options to reduce the risk of heart failure exacerbations. . From my perspective, farxiga or jardiance are equivalent.
  • 1yr
    She will likely do better with an SGLT-2 inhibitor, perhaps also spironolactone. These may provide enough diuresis to stop loop diuretics. Entresto may add some benefit instead of ACEI, but I would hesitate in adding 2 new expensive drugs at the same time. In terms of atrial fibrillation, unless her overall afib burden is quite low, would consider catheter ablation since afib would likely exacerbate her symptoms.
  • 1yr
    Would add SGLT2 and aldactone. Not sure how much changing from ACEI to Entresto would change things but that would be another option. Could increase diuretics. Restoring NSR if she is presently in Afib may markedly improve symptoms. Think dccv and ablation are part of the plan
  • 1yr
    I would consider adding an stlg2 inhibitor and likely add aldactone if blood pressure allowed. Would consider switching from the ace inhibitor to Entresto.
  • 1yr
    I recommend the addition of empagliflozin (or dapagliflozin) and spironolactone. These will increase diuresis and improve LV diastolic function by remodeling of the myocardium. This will reduce event rates and improve symptoms based on the DAPA-HF preserved trial. If heart rate declines after diuresis, consider decrease or tapering of beta blocker, as some patients are less symptomatic after beta blocker withdrawal in HFpEF. Since LV hypertrophy is present, consider cardiac MRI followed by Tc-Pyp scan if cardiac MRI suggests cardiac amyloid, since tafamidis will slow cardiac aTTR amyloid.
  • 1yr
    Would definitely add SGLT2 per guidelines.
    Would use spironolactone to facilitate diuresis, prevent hypokalemia, optimize BP control, and minimize loop diuretic dose.
    Consider Amiodarone depending on how frequent
    AF occurs and at what heart rate.
    I am not convinced of the add on benefit of Entresto vs ACE, but this is an option
  • 1yr
    For her, would add SGLT2 first; after, would transition to sac/val and add MRA, in that order, based on the magnitude of effect and guideline class of recommendation. And then test for causes for her HFpEF, in case there are depositional diseases contributory.
  • 1yr
    SGLT2 inhibitor would be most helpful in treating HFPEF and reducing morbidity and recurrent hospitalizations. MRA has been standard of care prior to SGLT2 inhibitors.
    Possibly could use ARNI in setting of EF in range of 55% to treat HFPEF as ARNI has been shown in clinical trials to reduce symptoms and BNP
  • 1yr
    SGLT2 inhibitor would be most helpful in treating HFPEF and reducing morbidity and recurrent hospitalizations. MRA has been standard of care prior to SGLT2 inhibitors.
    Possibly could use ARNI in setting of EF in range of 55% to treat HFPEF as ARNI has been shown in clinical trials to reduce symptoms and BNP
  • 1yr
    SGLT2 inhibitor would be most helpful in treating HFPEF and reducing morbidity and recurrent hospitalizations. MRA has been standard of care prior to SGLT2 inhibitors.
    Possibly could use ARNI in setting of EF in range of 55% to treat HFPEF as ARNI has been shown in clinical trials to reduce symptoms and BNP
  • 1yr
    This is a clear indication to use an SGLT2 inhibitor as first line therapy. Since her LVEF is at 55%, we can actually use Entresto over her ACEI, whereas if the LVEF was closer to 65% or higher, then an ARNI would not be as effective. MRAs would be an additional agent to use for further GDMT. With regard to her AF, maximizing HR control and/or rhythm control is just as salient as GDMT.
  • 1yr
    GDMT for managing her HFpEF should include SGLT2- inhibitors (empagliflozin). Would discontinue ACE-I and start her on Entresto [in addition to valsartan it has Sacubitril angiotensin receptor–neprilysin inhibitor (ARNIs)] as shown by superior outcome in clinical trials. Mineralocorticoid antagonists (MRAs)such as aldactone would be perhaps more useful than betablockers as she is not in atrial fibrillation (would work up the risk of AF and then treat accordingly - ie ablation or if increased bleeding risk then LAA closure}.
  • 1yr
    Best class of drugs by guidelines would be sgkt2 inhibitors
    Mra may by helpful and perhaps less so entresto
    Would keep volume optimized by diuretics as needed and good BP control
  • 1yr
    Would utilize GDMT. Would start with Entresto and beta blocker. Eventually will
    add SGLT2i and Aldactone. Would also like to better assess PAF and determine if treatment needed. Entresto in particular will be important in HF management given data suggesting its value in this scenario.

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