Heart Failure With Preserved Ejection Fraction

The H2FPEF score uses obesity, treatment with at least 2 antihypertensives, AF, estimated pulmonary artery systolic pressure above 35 mm Hg, age above 60 years, and E/e′ above 9. Scores range from 0 to 9; low scores support noncardiac causes, scores of 6 or higher strongly support HFpEF, and intermediate scores should prompt further evaluation. AHA JournalsAHA JournalsA Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction

HFA-PEFF integrates pretest assessment, natriuretic peptides, echocardiographic structure and function, functional testing, and final etiologic assessment. It is more comprehensive but often produces an intermediate result and requires tests not universally available. The 2026 ACC pathway supports H2FPEF as an accessible initial clinical tool, with HFA-PEFF or advanced testing for discordant or unresolved cases. jaccjaccManagement of Heart Failure With Preserved Ejection ...

Exercise is critical in suspected early HFpEF because filling pressures can be normal at rest yet rise abnormally with exertion. Invasive right-heart catheterization with exercise remains the reference standard when noninvasive data are equivocal. In the H2FPEF derivation cohort, HFpEF was defined by pulmonary capillary wedge pressure at least 15 mm Hg at rest or at least 25 mm Hg during exercise. jacc+1jaccHow to Manage Heart Failure With Preserved Ejection ...AHA JournalsA Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction

Noninvasive diastolic stress echocardiography can be used when available, but an equivocal stress study should not close the diagnostic evaluation in a patient with persistent exertional symptoms and substantial clinical probability. jacc+1jaccHow to Manage Heart Failure With Preserved Ejection ...jaccManagement of Heart Failure With Preserved Ejection ...

Finerenone reduced the composite of total worsening HF events and cardiovascular death in FINEARTS-HF (hazard ratio 0.82, 95% CI 0.71-0.94), primarily through fewer worsening HF events. The 2026 ACC pathway identifies finerenone as the preferred MRA in HFpEF, with spironolactone as a reasonable alternative when cost or tolerance limits use. jaccjaccManagement of Heart Failure With Preserved Ejection ...

Finerenone is started at 10 mg daily for eGFR 25 to less than 60 mL/min/1.73 m² or 20 mg daily for eGFR at least 60 mL/min/1.73 m², with targets of 20 mg and 40 mg daily, respectively. Do not initiate with potassium at least 5.0 mmol/L, eGFR below 25 mL/min/1.73 m², Addison disease, pregnancy, or strong or moderate CYP3A4 inhibitors or inducers. Monitor potassium and kidney function. jaccjaccManagement of Heart Failure With Preserved Ejection ...

Sacubitril/valsartan did not meet the overall PARAGON-HF primary endpoint, but possible benefit was greater in women and in patients with LVEF below the trial median of 57%. It is reasonable when additional blood pressure lowering is needed, especially in these subgroups. Start 24/26 mg twice daily and target 97/103 mg twice daily if tolerated; avoid with prior angioedema, pregnancy, severe hepatic impairment, or within 36 hours of ACE inhibitor exposure. jaccjaccManagement of Heart Failure With Preserved Ejection ... Candesartan is an alternative when ARNI is not feasible; start 4 to 8 mg daily and target 32 mg daily. jaccjaccManagement of Heart Failure With Preserved Ejection ...

Obesity is both a common HFpEF phenotype and a diagnostic confounder. It promotes plasma-volume expansion, elevated exercise filling pressures, inflammation, impaired exercise capacity, and lower natriuretic peptide concentrations. NEJM+1NEJMSemaglutide in Patients with Heart Failure with Preserved Ejection Fraction and ObesityjaccManagement of Heart Failure With Preserved Ejection ... Confirm HF physiology before attributing dyspnea solely to body habitus.

In STEP-HFpEF, adults with HFpEF, BMI at least 30 kg/m², and no diabetes received semaglutide 2.4 mg subcutaneously weekly or placebo for 52 weeks. Semaglutide improved KCCQ clinical summary score by 7.8 points versus placebo, produced a 10.7-percentage-point greater reduction in body weight, and improved 6-minute walk distance by 20.3 m. NEJMNEJMSemaglutide in Patients with Heart Failure with Preserved Ejection Fraction and Obesity Initiate at 0.25 mg weekly and increase every 4 weeks as tolerated to 2.4 mg weekly. NEJM+1NEJMSemaglutide in Patients with Heart Failure with Preserved Ejection Fraction and ObesityjaccManagement of Heart Failure With Preserved Ejection ...

Semaglutide and tirzepatide are appropriate considerations for selected patients with obesity-related HFpEF, but the 2026 ACC pathway emphasizes concurrent exercise and nutritional support because incretin-based therapy can reduce lean mass and contribute to sarcopenic obesity. Contraindications include personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2, pregnancy, lactation, and hypersensitivity. jaccjaccManagement of Heart Failure With Preserved Ejection ...

AF is common in HFpEF and is associated with worse symptoms, cardiac dysfunction, hospitalization, and death. Follow contemporary AF guidance for anticoagulation and rhythm or rate control. Aggressive rate slowing can worsen exertional capacity when chronotropic reserve is limited. jaccjaccManagement of Heart Failure With Preserved Ejection ...

Rhythm control, including catheter ablation in appropriate candidates, is reasonable when AF appears to drive symptoms. The supporting HFpEF evidence is largely observational, subgroup, and meta-analytic rather than definitive dedicated randomized trial evidence; discuss uncertainty explicitly. jacc+1jaccHow to Manage Heart Failure With Preserved Ejection ...jaccManagement of Heart Failure With Preserved Ejection ...

CKD is common in HFpEF and increases risk of worsening HF and death. SGLT2 inhibitors, renin-angiotensin system blockade when indicated, nonsteroidal MRAs, and GLP-1 receptor agonists in appropriate patients can provide overlapping kidney and cardiovascular benefit. jaccjaccManagement of Heart Failure With Preserved Ejection ...

Do not stop SGLT2 inhibition solely for a small early creatinine rise without assessing volume status and longer-term renal trajectory. In contrast, hyperkalemia, progressive renal dysfunction, symptomatic hypotension, or volume depletion should trigger reassessment of MRA, ARNI, ARB, diuretic, and potassium-supplement exposure. jacc+1jaccHow to Manage Heart Failure With Preserved Ejection ...jaccManagement of Heart Failure With Preserved Ejection ...

Exercise training improves exercise capacity and quality of life in HFpEF, although a reduction in HF hospitalization or death has not been consistently demonstrated. Programs should be individualized, include aerobic and resistance components when feasible, and account for frailty and musculoskeletal limitation. jacc+1jaccHow to Manage Heart Failure With Preserved Ejection ...jaccManagement of Heart Failure With Preserved Ejection ...

For recurrent hospitalization with persistent NYHA class III symptoms despite optimized therapy, unstable volume status, cardiorenal syndrome, or difficult differentiation of HF from obesity or lung disease, pulmonary artery pressure monitoring may be considered at centers able to manage transmitted data. jaccjaccManagement of Heart Failure With Preserved Ejection ... Interatrial shunting, splanchnic nerve ablation, and rate-adaptive pacing have not established routine benefit in HFpEF. jaccjaccManagement of Heart Failure With Preserved Ejection ...