p.34 抽出テキスト

capacity or QOL in HFpEF, e.g. NEAT-HFpEF,280 INDIE-HFpEF,281 VITALITY-HFpEF,282 and CAPACITY-HFpEF (praliciguat).283 Despite the lack of evidence for specific disease-modifying therapies in HFpEF, as the vast majority of HFpEF patients have underlying hypertension and/or CAD, many are already treated with ACE-I/ ARB, beta-blockers, or MRAs. In the PARAGON-HF study at baseline, more than 86% of patients were on ACE-I/ARBs, 80% were on beta-blockers, and more than 24% were on MRAs.13 The Task Force acknowledge that the treatment options for HFpEF are being revised as this guideline is being published. We note that the Food and Drug Administration (FDA) has endorsed the use of sacubitril/valsartan and spironolactone in those with an LVEF ‘less than normal’. These statements relate to patients within both the HFmrEF and HFpEF categories. For sacubitril/valsartan, this decision was based on the subgroup analysis from the PARAGON-HF study, which showed a reduction in HF hospitalizations in those with an LVEF <57%, and a meta-analysis of the PARADIGM-HF and PARAGON-HF studies, showing a reduction in CV death and HF hospitalization in those with an LVEF below the normal range.247 Regarding spironolactone, the subgroup of individuals in the TOPCAT study recruited in the Americas had a significant reduction in the primary endpoint of CV death and HF hospitalization, and a subsequent post hoc analysis by EF showed a significant reduction in outcomes for those with an LVEF <55%.9,247 There are also ongoing trials with SGLT2 inhibitors. These developments may well accelerate a redefinition of HFpEF in the future and have therapeutic implications. In the absence of recommendations regarding disease-modifying therapies, treatment should be aimed at reducing symptoms of congestion with diuretics. Loop diuretics are preferred, although thiazide diuretics may be useful for managing hypertension. Reducing body weight in obese patients and increasing exercise may further improve symptoms and exercise capacity and should therefore be considered in appropriate patients.284,285 It is important to identify and treat the underlying risk factors, aetiology, and coexisting comorbidities in HFpEF (e.g. hypertension in section 12.4, CAD in section 12.2, amyloidosis in section 14.6, AF in section 12.1.1, and valvular heart disease in section 12.3). Undoubtably, treatment of some of the underlying phenotypes of the the HFpEF syndrome leads to improved outcomes.

Recommendations for the treatment of patients with heart failure with preserved ejection fraction

Recommendations Classa Levelb

Screening for, and treatment of, aetiologies, and cardiovascular and non-cardiovascular comorbidities is recommended in patients with HFpEF (see relevant sections of this document). I C Diuretics are recommended in congested patients with HFpEF in order to alleviate symptoms and signs.137 I C

HFpEF = heart failure with preserved ejection fraction. aClass of recommendation. bLevel of evidence. ESC 2021 ESC 2021

Table 10 Risk factors for the development of heart failure and potential corrective actions

Risk factors for heart failure Preventive strategies Sedentary habit Regular physical activity Cigarette smoking Cigarette smoking cessation Obesity Physical activity and healthy diet Excessive alcohol intake286 General population: no/light alcohol

intake is beneficial Patients with alcohol-induced CMP

should abstain from alcohol

Influenza Influenza vaccination Microbes (e.g. Trypanosoma cruzi, Streptococci) Early diagnosis, specific antimicrobial

therapy for either prevention and/or treatment

Cardiotoxic drugs (e.g., anthracyclines) Cardiac function and side effect monitoring, dose adaptation, change of

chemotherapy

Chest radiation Cardiac function and side effect monitoring, dose adaptation Hypertension Lifestyle changes, antihypertensive

therapy

Dyslipidaemia Healthy diet, statins Diabetes mellitus Physical activity and healthy diet, SGLT2 inhibitors CAD Lifestyle changes, statin therapy CAD = coronary artery disease; CMP = cardiomyopathy; SGLT2 = sodium-glucose co-transporter 2.

ESC 2021

Recommendations for the primary prevention of heart failure in patients with risk factors for its development

Recommendations Classa Levelb

Treatment of hypertension is recommended to prevent or delay the onset of HF, and to prevent HF hospitalizations.287290 I A Treatment with statins is recommended in patients at high risk of CV disease or with CV disease in order to prevent or delay the onset of HF, and to prevent HF hospitalizations.291,292 I A SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, sotagliflozin) are recommended in patients with diabetes at high risk of CV disease or with CV disease in order to prevent HF hospitalizations.293297 I A Counselling against sedentary habit, obesity, cigarette smoking, and alcohol abuse is recommended to prevent or delay the onset of HF.298302 I C

CV=cardiovascular; HF= heart failure; SGLT2= sodium-glucose co-transporter 2. aClass of recommendation. bLevel of evidence. ............................................................................................................................................................................ Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026