Decision support only — not a substitute for the 2023 ESC focused update, NHFA/CSANZ, or eTG. HFpEF (LVEF ≥50%) was once the syndrome where "nothing worked"; SGLT2 inhibitors changed that. Two jobs: confirm it's really HFpEF and find the specific cause (some are treatable and missed), then layer SGLT2i + diuretics + aggressive comorbidity control. Verify all doses.
1 Treatment — what finally works
Foundationfor everyone
Confirmed HFpEF.
SGLT2 inhibitor (dapagliflozin or empagliflozin) — Class I, the first therapy to reduce HF events across the EF spectrum EMPEROR-Preserved DELIVER.
Congestionsymptom relief
Fluid overload.
Loop diuretic, titrated to euvolaemia — relieves symptoms but doesn't change prognosis. Use the lowest effective dose.
Treat the comorbiditiesHFpEF IS the comorbidities
Hypertension, AF, obesity, CAD, CKD, OSA, diabetes.
Aggressive comorbidity control is core therapy — especially blood pressure (the dominant driver), AF (rate/rhythm + anticoagulation), and weight.
Add-on / phenotypeweaker or selective evidence
Persistent symptoms / specific phenotype.
Finerenone (nonsteroidal MRA) FINEARTS-HF; obesity phenotype → GLP-1/incretin (semaglutide STEP-HFpEF, tirzepatide SUMMIT); ARNI/ARB only at the lower-EF end.
SGLT2i overturned the old "nothing works in HFpEF." Be honest about the rest: sacubitril/valsartan (PARAGON-HF) and spironolactone (TOPCAT) were neutral overall, with benefit concentrated at the lower-EF end and in women. HFmrEF (41–49%) → treat toward the HFrEF four pillars.
2 Diagnose it — a diagnosis of inference
The definition
- Three partsHF symptoms/signs + LVEF ≥50% + objective evidence (raised natriuretic peptides and/or structural/functional echo abnormality).
- EF bandsHFrEF ≤40 · HFmrEF 41–49 · HFpEF ≥50.
- EchoLA enlargement, LVH, raised E/e′, elevated estimated filling pressures, raised TR velocity.
When it's not obvious
- ScoresH2FPEF and HFA-PEFF estimate probability when the diagnosis is uncertain.
- BNP trapNatriuretic peptides can be normal in HFpEF — especially in obesity — a normal level doesn't exclude it.
- Provoke itDiastolic stress echo or exercise right-heart catheter when resting data are equivocal.
3 Don't miss the treatable cause hiding as "HFpEF"
Cardiac amyloidosis — actively look
- SuspectOlder man, bilateral carpal tunnel or spinal stenosis, LVH on echo with low/normal ECG voltages, apical-sparing on strain.
- ConfirmBone scintigraphy (DPD/PYP) + exclude a plasma-cell dyscrasia (serum free light chains, electrophoresis).
- WhyATTR is treatable (tafamidis) — and increasingly common with age.
The other mimics
- HCMHypertrophic cardiomyopathy — cardiac myosin inhibitors (mavacamten) for obstruction.
- ConstrictionConstrictive pericarditis — surgically correctable; look for it.
- ValveSevere AS or MR can masquerade — echo carefully.
- OtherInfiltrative (sarcoid), high-output states. "HFpEF" is a label, not a final diagnosis.
4 The traps & the whole patient
Don't harm
- Over-diureseThe stiff, small-cavity ventricle is preload-dependent — aggressive diuresis can drop output and BP. Titrate carefully.
- Don't anchorDon't settle on "HFpEF" before excluding the treatable mimics above.
The whole patient
- ComorbidityHFpEF is driven by comorbidities — treating BP, AF, obesity, CKD and sleep apnoea is the disease-modifying work.
- ExerciseSupervised exercise/cardiac rehab improves exercise capacity and symptoms.
- HFmrEFTreat toward the HFrEF four pillars — the EF bands are a spectrum, not silos.
Sources.
2023 ESC focused update of the 2021 HF guidelines (SGLT2 inhibitors recommended across the whole EF spectrum — Class I in HFpEF); Universal Definition of Heart Failure (EF bands). NHFA/CSANZ Australian HF guidelines; eTG; PBS for SGLT2i/finerenone criteria.
Key trials: EMPEROR-Preserved (empagliflozin) & DELIVER (dapagliflozin) — SGLT2i reduce HF events in HFpEF; FINEARTS-HF (finerenone — positive); PARAGON-HF (sacubitril/valsartan — neutral) & TOPCAT (spironolactone — neutral overall); STEP-HFpEF (semaglutide) & SUMMIT (tirzepatide) in obesity-HFpEF; CHARM-Preserved (candesartan).
Caveats: finerenone and the incretin agents post-date the 2023 update — strong trial evidence, but check current guideline status and PBS access in Australia (HF indications for SGLT2i are funded; finerenone/GLP-1 HF indications are more restricted). MRA/ARNI benefit is concentrated at the lower-EF end. HFpEF severity grading and the diagnosis itself are imaging- and context-dependent. Verify all doses. Companion to the HFrEF sheet.