30 May 2023 • Despite advances in therapy, heart failure (HF) continues to be a major cause of morbidity and mortality worldwide with a lifetime risk at age 40 years of approximately 20%. This clinical guidance document by the ACC is the first to provide clinicians with guidance on caring for this clinically challenging population.

KEY POINTS

• The causes of dyspnea in individuals with preserved left ventricular ejection fraction (LVEF) are numerous; in addition to heart failure, noncardiac causes (e.g., lung disease) must be considered. The Universal Definition of HF requires both symptoms or signs of HF and either elevated natriuretic peptides or objective evidence of cardiogenic pulmonary or systemic congestion.
• Peripheral edema is nonspecific and can be related to decreased capillary oncotic pressure (e.g., cirrhosis, nephrosis) and noncardiac causes of increased capillary hydrostatic pressure (e.g., renal failure, portal hypertension).
• Clinical risk scores — including the H2FPEF and the HFA-PEFF scores — can refine the estimate of the likelihood of HFpEF. The former depends upon readily available clinical data; the latter incorporates infrequently used functional testing.
• The recommended diagnostic approach in patients with dyspnea and/or edema is: a) to assess for noncardiac sources; b) apply the Universal Definition of HF; c) assess for mimics of HF (both noncardiac and cardiac), and; d) assess the likelihood of HFpEF based upon the H2FPEF score. Notably, the document considers specific causes such as myopathic processes, valvular, or pericardial disease as HFpEF mimics.
• The cornerstone of pharmacologic management of HFpEF is SGLT-2 inhibitors. Loop diuretics are used to manage volume overload. Other therapies to consider include mineralocorticoid receptor antagonists, angiotensin receptor–neprilysin inhibitors, or angiotensin-receptor blockers in those who cannot tolerate ARNIs, although the evidence for these treatments is not as strong as for SGLT-2 inhibitors.
• Nonpharmacological management approaches include weight loss, regular exercise, and — in higher-risk patients — the consideration of implantable pulmonary artery pressure monitoring.
• Comorbidities are common and can interact adversely with HFpEF. Those requiring particular attention include atrial fibrillation, hypertension, coronary artery disease, diabetes, chronic kidney disease, sleep apnea, and obesity.

Source: NEJM J-Watch| Read full story