Management of Heart Failure with Preserved Ejection Fraction

Disease Diagnosis and Confirmation

The American College of Cardiology recommends establishing the diagnosis of heart failure with preserved ejection fraction (HFpEF) using a two-step approach: confirm heart failure symptoms with LVEF ≥50%, elevated natriuretic peptides, and evidence of structural heart disease or diastolic dysfunction on echocardiography 1, 2
Rule out HFpEF mimics including cardiac amyloidosis, hypertrophic cardiomyopathy, and constrictive pericarditis, as these require entirely different treatment strategies 1
Proceed to stress testing (exercise echocardiography or invasive hemodynamics) if the diagnosis remains uncertain after initial evaluation 1

The European Society of Cardiology recommends initiating dapagliflozin 10 mg daily or empagliflozin 10 mg daily immediately upon diagnosis, as these are the only medications proven to reduce cardiovascular death and heart failure hospitalizations in HFpEF 1, 2
Dapagliflozin reduced the composite endpoint of worsening heart failure and cardiovascular death by 18% (HR 0.82) and heart failure hospitalizations by 23% (HR 0.77) in the DELIVER trial 2
Empagliflozin reduced heart failure hospitalization or cardiovascular death by 21% (HR 0.79) in EMPEROR-PRESERVED 2
Consider mineralocorticoid receptor antagonists (MRAs) like spironolactone 12.5-25 mg daily, particularly in patients with LVEF in the lower range of preservation (40-50%) or those with persistent symptoms despite SGLT2 inhibitors 1, 2

Use loop diuretics as the cornerstone for congestion relief, starting with furosemide 20-40 mg daily, bumetanide 0.5-1.0 mg daily, or torasemide 5-10 mg daily 1, 2
Titrate to the lowest effective dose that maintains euvolemia—excessive diuresis leads to hypotension, renal dysfunction, and impaired tolerance of other medications 1, 2
Consider thiazide combination (metolazone 2.5 mg) only in refractory cases with eGFR >30 mL/min 3

Achieve blood pressure target <130/80 mmHg using appropriate antihypertensive medications, as hypertension is a primary driver of HFpEF pathophysiology 1, 2
Prioritize agents with proven benefit: ACE inhibitors, ARBs, or ARNIs combined with diuretics 4, 5
Control ventricular rate to 60-100 bpm using beta-blockers (metoprolol, carvedilol) or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with atrial fibrillation 1, 6
Anticoagulate based on CHA₂DS₂-VASc score to prevent thromboembolic events in patients with atrial fibrillation 6

Prescribe supervised exercise training programs as a Class 1 recommendation—these consistently demonstrate large, clinically meaningful improvements in exercise capacity and quality of life 7, 1, 2
Restrict sodium intake to <2-3 g/day to reduce fluid retention and congestion 1, 2
Recommend weight reduction in obese patients (BMI >30 kg/m²), as obesity is a major contributor to HFpEF pathophysiology 2

Monitor symptoms, vital signs, and daily weights at every visit to detect early decompensation 1, 2
Check renal function and electrolytes regularly, especially when using MRAs (monitor potassium and creatinine within 1 week of initiation, then monthly for 3 months, then quarterly) 1, 2
Schedule follow-up visits at minimum 6-monthly intervals for stable patients, increasing frequency with worsening clinical stability 8

Refer to cardiac rehabilitation programs that provide medical assessment, patient education on lifestyle modifications, psychosocial support, and structured exercise training 8
Engage heart failure nurses for patient education on medication adherence, symptom monitoring, and when to seek medical attention 8
Initiate palliative care discussions early in the disease trajectory, with referral to specialist palliative care if patient needs are unmet by the primary team 8