Thread by @HFpEF

1/ #HFpEF treatment algorithm #tweetorial. This is the algorithm I currently use to treat HFpEF based on evidence we have thus far and my anecdotal experience treating patients over the past 16 years in the @NMCardioVasc HFpEF Clinic.

2/ This treatment algorithm was recently published in @JACCJournals with my friends and co-authors Barry Borlaug, @KSharmaMD, and @JenHoCardiology (who provided great feedback!). jacc.org/doi/abs/10.101…

3/ Step 1: Start by confirming the #HFpEF diagnosis. In equivocal cases, remember to use provocative testing, preferably exercise testing! ncbi.nlm.nih.gov/pmc/articles/P…

4/ Step 2: Once the diagnosis of HFpEF is made based on elevated LV filling pressures at rest or with exercise in the setting of an LVEF ≥50%, first evaluate for masqueraders…

5/ …if you take care of patients with HFpEF, you need to know your zebras!

6/ Step 3: Start with an SGLT2i in all pts but use with caution in pts with exercise-induced LA hypertension (EILAH) because they have normal filling pressures at rest. See our recent paper on EILAH in @JACCJournals: sciencedirect.com/science/articl…

7/ Step 4: Is volume overload present? If so, start diuretics, with preferential up-front use of an MRA (e.g., spironolactone) and loop diuretics as needed (but minimize loop diuretic dose once euvolemic)

8/ Step 5: Treat comorbidities…

9/ Step 6: Start ARNI (sacubitril/valsartan) if not yet started for high BP if the patient is (1) still symptomatic, (2) LVEF <55-60% or frequent HF hospitalizations or +residual congestion, and (3) systolic BP >110 mmHg, and up-titrate as tolerated

10/ Step 7: Ask 6 key questions in all patients:
(1) Is the pt on an SGLT2i? If not, why not?
(2) Is the pt on an MRA? If not, why not?
(3) Is the pt on an ARNI? If not, why not?
(4) Is the patient on K+? If yes, replace with (or up-titrate) MRA if possible

11/ Step 7 (continued):
(5) Is the patient on a nitrate or pulmonary vasodilator? Discontinue if possible
(6) Is the patient on a beta-blocker? Wean off unless using for AF, angina, or MI, or other non-HFpEF indication

12/ Step 8a: Implement HF education in all patients (daily weights, BP, and HR; establish “dry weight” for volume overloaded pts to guide diuretic dosing [esp loop diuretics])

13/ Step 8b: Educate pts on an exercise training regimen that combines aerobic training + resistance training (maintaining muscle mass and reducing risk for worsening frailty is critical!). Phase 3 cardiac rehab or Rx pulmonary rehab in pts with concomitant pulmonary disease

14/ Step 9: For persistent symptoms and/or HF hospitalizations ➡️ HF clinic referral, reevaluate for HFpEF masqueraders, check for worsening comorbidities, if persistent fluid overload Rx HCTZ, use implantable PA monitoring, and evaluate for chronotropic incompetence

15/ Step 10: ENROLL IN A HFpEF CLINICAL TRIAL!

16/ Additional tip #1: In patients with persistent fluid overload on SGLT2i, MRA, and loop diuretic, avoid metolazone! Low-dose HCTZ typically works because of the benefit of sequential nephron blockade...

17/ ...The distal convoluted tubule is amped up if already on SGLT2i, MRA, and loop diuretic, so just a little bit of HCTZ (e.g., 12.5 mg qd) can result in significant diuresis. What if eGFR is very low? No problem, if still making urine, HCTZ will still usually work in HF pts.

18/ Additional tip #2: Which exercise training regimen do you prescribe? I try to mimic what’s been done in trials of exercise in HFpEF patients… ahajournals.org/doi/10.1161/CI…

19/ Additional tip #4: Pathophys often changes in HFpEF pts as they have events (e.g., hospitalization; changes in lifestyle, diet, environment; new meds started for other conditions; new-onset comorbidities or cardiac conditions). Don’t get complacent when caring for HFpEF pts!

20/ Additional tip #5: When caring for HFpEF pts, we often become the coordinator of care ➡️ need to treat the WHOLE patient in order to make them feel better. Provide a multi-disciplinary Rx plan.

21/ Additional tip #6: Avoid polypharmacy, use combo meds when possible (many are generic), and watch out for adverse effects of non-cardiac medications that may exacerbate HFpEF.

22/ Finally… there are many patients with HFpEF that need our help. Please consider starting a dedicated HFpEF program at your institution if you don’t have one already. This paper explains how to do it 😊… link.springer.com/article/10.100…

23/ Caveats (the fine print): SGLT2i should be considered in all patients except those with type 1 diabetes, orthostatic hypotension, eGFR <20-25, or very frequent yeast infections (or history of severe GU infections).

24/ Caveats (cont’d): Yeast infections are readily treatable, usually not a reason to permanently stop SGLT2i. Instruct pts to hold SGLT2i therapy for a few days on “sick days” (GI illness, dehydration, active infections). High HgbA1c not a contraindication to SGLT2i.

25/ Caveats (cont’d): MRA should be considered in all pts except those with K+ >5.0 or eGFR <30. Replace K+ supplementation with MRA whenever possible. Re-check K+ and renal function 1 week and 1 month after initiation, and q3-6 months thereafter.

26/ Caveats (cont’d): ARNI most effective if EF <55-60% or frequent HF hosp (congested phenotype); avoid in pts with history of angioedema, low BP, orthostatic hypotension, restrictive cardiomyopathy, pulmonary arterial hypertension, constrictive pericarditis, cardiac amyloidosis

27/ Caveats (cont’d): AF patients often have low stroke volume and inability to augment stroke volume during exertion due to LA dysfunction. Avoid excessive rate control in these patients.