Current evidence for treatment of HFpEF
| Target | Therapy | Evidence | Level of evidence |
| Survival | ACEI/ARB 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 HF | ACEI/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 | – – IIA4 IB2 or C3 |
| Symptoms | IB or C | ||
| Congestion | Loop diuretics | CHAMPION trial (diuretic therapy combined with vasodilators)43 | |
| Exercise capacity | Isosorbide mononitrate | Associated with reduced activity levels in NEAT-HFpEF33 | III |
| Management of comorbidities in HFpEF | IB3 or C3 | ||
| Hypertension | Antihypertensive therapy | Management of acute hypertensive oedema BP targets extrapolated from hypertension guidelines | – |
| Atrial fibrillation | |||
| Stroke prevention Rhythm control Rate control | Oral anticoagulation Ablation 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 | IA (AF) – – |
| CAD | Pharmacotherapy (including statins) Revascularisation | No RCT evidence of benefit No RCT evidence of benefit (Observational single centre data12) | – – |
| Diabetes | Empagliflozin | Reduction in (incident) HF hospitalisation among patients with diabetes and high CV risk (HF phenotype not reported)48 | – |
| Kidney disease | ACEI/ARB (for hypertension) | – | |
| Obesity | Weight loss programme (behavioural) Pharmacotherapy/bariatric surgery | Improvement in peak VO2 in patients≥60 years47 No RCT evidence of benefit | – – |
| Pulmonary disease | No RCT evidence of benefit | – | |
| Sleep disordered breathing | No 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.