Primary prevention

Primary prevention is important for those at risk for heart failure (HF; stage A) and for those with pre-HF (stage B).[3]​

HF is the final pathway for a wide array of pathophysiological processes. Interventions that reduce the risk of development of any cardiovascular disease will ultimately reduce the incidence of HF.[52][53]​​​​ Thus, key public health targets are prevention of development of underlying causes and comorbidities: hypertension, diabetes, dyslipidaemia, obesity (i.e., metabolic syndrome), and ischaemic heart disease.

  • Lifestyle modifications, such as increasing physical activity, reducing tobacco use, reducing alcohol and recreational drug use, reducing daily salt intake, and proper medical treatment of established diseases such as hypertension, diabetes, and coronary artery disease, are expected to help reduce incident heart failure.[3][52][53][54][55]

  • The US Preventive Services Task Force recommends that adults at increased risk of cardiovascular disease are offered behavioural counselling interventions to promote a healthy diet and physical activity; those not at high risk may also be considered for behavioural counselling interventions.[56][57]

Secondary prevention

Risk factor modification and management of comorbidities that might contribute to symptoms are the key to preventing or delaying the onset of overt clinical heart failure. Physicians are advised to:

  • Monitor blood pressure (BP) as closely as necessary to meet targets based on guidelines. The American College of Cardiology/American Heart Association guidelines recommend a target of <130 mmHg for patients with HFpEF, avoiding the use of nitrates.​[152]

  • Monitor volume status (daily weights and adjustment of diuretic dose as necessary).

  • Pursue revascularisation in patients with coronary artery disease, when appropriate; aggressive medical management of ischaemia is advised.

  • Maintain adequate rate control in patients with tachyarrhythmias (e.g., atrial fibrillation); if there is difficulty in achieving rate control or there is substantial symptom burden from the arrhythmia, rhythm control, and maintenance of sinus rhythm should be considered. Anticoagulation should be considered in all patients with atrial fibrillation (based on validated clinical risk score, such as CHA2DS2-VASc) unless contraindicated. Very aggressive rate control (especially with beta blockers) should be avoided, as patients may have significant LA dysfunction with low stroke volume and inability to increase stroke volume during exercise.

  • In patients with type 2 diabetes mellitus, the target HbA1c is <7.0% to 7.5% for those with a lower comorbidity burden or less severe HF, with higher targets for older patients with higher comorbidity burden or advanced HF. Start SGLT2 inhibitor as first line therapy. Glucagon-like peptide-1 receptor agonist is an option if the patient has obesity or is at high risk for ASCVD. Avoid alogliptin, saxagliptin, and thiazolidinediones.[2]

  • In patients with chronic kidney disease, renin-angiotensin-aldosterone system blockers and SGLT2 inhibitors may slow progression of renal disease.[2]

  • Treat obstructive sleep apnoea if present.

  • Promote weight loss in overweight patients. Surgically induced weight loss may be considered in patients with class III obesity (BMI 40 or above).

  • Encourage tobacco and alcohol discontinuation.

  • Encourage regular aerobic exercise and consider cardiac rehabilitation when appropriate. Exercise training has been shown to improve exercise capacity, as well as quality of life, in patients with HPpEF.[157]

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