Table 3

Current evidence for treatment of HFpEF

TargetTherapyEvidenceLevel of evidence
Beta blockers
Mineralocorticoid receptor antagonist
No RCT evidence of benefit (possible benefit in subgroup with low BNP)49
Possible benefit on pooled analysis in patients with EF≥40%50
No RCT evidence of benefit

Hospitalisation for HFACEI/ARB
Beta blockers
Mineralocorticoid receptor antagonist
Loop diuretics
No RCT evidence of benefit (possible benefit in subgroup with low BNP)49
No RCT evidence of benefit
Benefit of spironolactone in TOPCAT (as secondary outcome)28
Benefit of diuretic therapy combined with vasodilators in CHAMPION43

IB2 or C3
SymptomsIB or C
 CongestionLoop diureticsCHAMPION trial (diuretic therapy combined with vasodilators)43
 Exercise capacityIsosorbide mononitrateAssociated with reduced activity levels in NEAT-HFpEF33 III
Management of comorbidities in HFpEFIB3 or C3
 HypertensionAntihypertensive therapyManagement of acute hypertensive oedema
BP targets extrapolated from hypertension guidelines
 Atrial fibrillation
 Stroke prevention
 Rhythm control
 Rate control
Oral anticoagulation
Beta blockers, CCB, digoxin
Risk scores extrapolated from AF guidelines
No RCT evidence of benefit (Observational single-centre data)51
No RCT evidence for rate targets

 CADPharmacotherapy (including statins)
No RCT evidence of benefit
No RCT evidence of benefit (Observational single centre data12)

 DiabetesEmpagliflozinReduction in (incident) HF hospitalisation among patients with diabetes and high CV risk (HF phenotype not reported)48
 Kidney diseaseACEI/ARB (for hypertension)
 ObesityWeight loss programme (behavioural)
Pharmacotherapy/bariatric surgery
Improvement in peak VO2 in patients≥60 years47
No RCT evidence of benefit

 Pulmonary diseaseNo RCT evidence of benefit
 Sleep disordered breathingNo RCT evidence of benefit
  • ACEI, ACE inhibitors; AF, atrial fibrillation; ARB, angiotensin receptor blockers; BNP, B-type natriuretic peptide; BP, blood pressure; CAD, coronary artery disease; CCB, calcium channel blockers; CV, cardiovascular; HF, heart failure; HFpEF, heart failure with preserved ejection fraction.