Updated October 2025
HFpEF Care Pathway
Management of Heart Failure with Preserved Ejection Fraction (HFpEF)
HFpEF care focuses on decongestion, cardiometabolic risk control, evidence-based disease-modifying drugs (SGLT2 inhibitors first-line), comorbidity treatment, lifestyle interventions, and careful phenotyping. Contemporary guidance emphasizes SGLT2 inhibitors for nearly all patients, with selective use of ARNI and MRA, aggressive blood pressure and volume management, and targeted management of AF, obesity, pulmonary hypertension, CKD, and diabetes.
Clinical question
What are the current evidence-based strategies for diagnosis, treatment, and longitudinal management of HFpEF in adults?
HFpEFHeart FailureSGLT2 InhibitorsARNIMRADiureticsAFHypertensionObesity
Key points
Confirm the phenotype
Verify HF symptoms/signs, LVEF ≥50%, structural/functional abnormalities or elevated natriuretic peptides (noting they can be normal in ~20%), and identify dominant drivers (hypertensive, ischemic, AF-related, obesity/OSA, right-sided/pulmonary hypertension, infiltrative) [3].
Relieve congestion early
Use loop diuretics and sodium restriction to achieve euvolemia; adjust carefully to avoid renal dysfunction or hypotension [4], [5].
Initiate disease-modifying drugs
Start an SGLT2 inhibitor for most HFpEF patients; consider ARNI and/or MRA based on blood pressure, potassium, renal function, and phenotype [1], [2].
Prioritize lifestyle therapy
Structured exercise, weight loss in obesity, and cardiac rehabilitation improve capacity and quality of life in HFpEF [5], [6].
Treat comorbidities
Optimize BP, rhythm/rate control for AF, manage diabetes and CKD, screen/treat sleep apnea, and consider pulmonary hypertension evaluation when suspected [1], [4], [3].
Evidence highlights
SGLT2 inhibitor for nearly all patients [1], [2]
Core therapy
HFpEF ≥50% (HFmrEF 41–49%) [3]
LVEF definition
Up to ~20% HFpEF have normal natriuretic peptides [3]
NP caveat
Stepwise HFpEF Management
A practical, phenotype-driven algorithm integrating guideline-based pharmacotherapy and comorbidity control.
1
1) Confirm HFpEF and phenotype
Establish HF symptoms/signs plus LVEF ≥50% with objective evidence of structural/functional heart disease or elevated natriuretic peptides; recognize that NPs can be normal in ~20% of true HFpEF. Characterize predominant drivers (hypertension with concentric remodeling, ischemic disease, atrial dysfunction/AF, obesity/OSA, pulmonary vascular disease, infiltrative cardiomyopathy) to tailor therapy [3].
2
2) Decongest
Initiate loop diuretics to relieve congestion; titrate to euvolemia. Consider thiazide-type add-on for diuretic resistance. Educate on daily weights and sodium restriction; reassess renal function and potassium after dose changes [4], [5].
3
3) Start disease-modifying therapy
Begin an SGLT2 inhibitor unless contraindicated. Consider ARNI if blood pressure tolerates and symptoms persist; add MRA for further decongestion and potential rehospitalization reduction, monitoring K+ and eGFR. Prioritize simple, well-tolerated regimens [1], [2].
4
4) Control blood pressure and heart rate
Target strict BP control with ACEi/ARB/ARNI, diuretics, and calcium channel blockers as appropriate; beta-blockers primarily for ischemia, rate control, or AF indications. Avoid excessive bradycardia which may worsen filling pressures [4], [2].
5
5) Manage comorbidities
AF: pursue rhythm or strict rate control; anticoagulate per CHA2DS2-VASc. Diabetes: prefer SGLT2 inhibitors; consider GLP-1 receptor agonists for obesity/diabetes. CKD: adjust diuretics and RAAS agents, monitor electrolytes. Evaluate for OSA and treat; address iron deficiency when present [1], [4], [5], [3].
6
6) Lifestyle, rehab, and weight management
Recommend supervised exercise training/cardiac rehabilitation to improve peak VO2 and quality of life. In obesity, structured weight loss improves symptoms and hemodynamics; consider multidisciplinary programs [5], [6].
7
7) Reassess and personalize
Use serial assessments of volume status, BP, renal function, potassium, symptoms, natriuretic peptides, and functional capacity to titrate therapy. Refer for advanced diagnostics (invasive hemodynamics, amyloid evaluation) in atypical or refractory cases [1], [2], [3].
Evidence-Guided Pharmacotherapy
Core agents and when to use them; integrate BP, renal function, and phenotype.
SGLT2 inhibitors (first-line)
Start in most HFpEF patients; improves HF outcomes regardless of diabetes status; generally well tolerated [1], [2].
Monitor for volume depletion; hold during acute illness or peri-procedure.
Additive to ARNI, MRA, and diuretics.
ARNI (sacubitril/valsartan)
Consider for symptomatic HFpEF, especially with higher natriuretic peptides or hypertensive phenotype and adequate BP [1], [2].
Benefits include symptom relief and potential reduction in HF events; watch for hypotension and renal effects.
Washout if switching from ACE inhibitor.
MRA (spironolactone/eplerenone)
Useful for persistent congestion and selected patients to reduce HF hospitalization risk; monitor K+ and eGFR closely [1], [2].
Avoid if hyperkalemia or advanced CKD; consider low starting doses.
Diuretics
Loop diuretics are cornerstone for symptom relief; use thiazide synergy for resistance [4], [5].
Aim for euvolemia to avoid renal dysfunction.
Educate on weight-based self-adjustment where appropriate.
Blood pressure control
Target guideline-directed BP goals; ARNI/ACEi/ARB, diuretics, and CCBs commonly used [4].
Avoid excessive beta-blockade unless specific indications (AF/ischemia).
Diabetes/obesity therapies
SGLT2 inhibitors for HF benefit; GLP-1 RAs for weight loss and metabolic control in obese/diabetic HFpEF [5], [6].
Avoid agents that cause sodium/water retention.
Targeted Comorbidity Management
Addressing contributors is essential to outcomes in HFpEF.
Atrial fibrillation
Early rhythm control or strict rate control; consider catheter ablation in symptomatic patients.
Anticoagulate per CHA2DS2-VASc; reassess burden with ambulatory monitoring [1], [4], [2].
Pulmonary hypertension/right heart dysfunction
Assess with echocardiography; consider right heart catheterization if disproportionate symptoms.
Treat volume overload, BP, and AF; PAH-specific drugs generally not indicated unless Group 1 PH [1], [3].
Sleep apnea and obesity
Screen for OSA; treat with CPAP where indicated.
Structured exercise and weight reduction are recommended; supervised programs preferred [5], [6].
Renal disease and electrolytes
Monitor eGFR and K+ after changes in diuretics, MRA, ARNI.
Adjust doses to avoid hyperkalemia and AKI [4], [5].
Follow-up cadence
Early follow-up 1–2 weeks after therapy changes; then every 1–3 months until stable.
Use weight logs, symptom diaries, and home BP monitoring.
Nonpharmacologic Interventions
Functional capacity and quality of life gains are clinically meaningful.
Exercise training
Supervised exercise and cardiac rehab improve peak VO2, 6MWD, and QoL in HFpEF [5], [6].
Combine aerobic and resistance training; progress gradually.
Diet and self-care
Sodium moderation, fluid management individualized by volume status.
Daily weights; action plan for rapid weight gain or dyspnea.
Weight management
Clinically supervised weight loss for obesity improves symptoms and hemodynamics [6].
Consider adjunct pharmacotherapy for obesity where appropriate.
References
Source material
Primary literature that informs this article.
How to Manage Heart Failure With Preserved Ejection ...
www.sciencedirect.com
Practical Guidance on How to Manage HFpEF: Key Points
www.acc.org
Management of patients with heart failure and preserved ...
pmc.ncbi.nlm.nih.gov
Heart failure with preserved ejection fraction management
academic.oup.com
Treatment and prognosis of heart failure with preserved ...
www.uptodate.com
2024 Guidelines of the Taiwan Society of Cardiology for ...
pmc.ncbi.nlm.nih.gov
From JACC: HFpEF: Practical Guidance for Clinicians
www.acc.org
Management of heart failure with preserved ejection fraction
pubmed.ncbi.nlm.nih.gov
Management of Heart Failure with Preserved Ejection ...
pubmed.ncbi.nlm.nih.gov