Ejection fraction — the number that decides the whole regimen 50% or above (preserved)
hf-pefNo one has reached this rule yetSGLT2 inhibitor, an MRA, and treat the drivers — blood pressure, atrial fibrillation, sleep apnea, weight
No clinician has signed off this rule yet. It reflects our reading of the guidelines cited below, which has not been independently checked.
Word for word, as generated for the example person below. Figures in the text are theirs.
Your ejection fraction is 58%, which is preserved. The pumping is fine — the problem is a stiff heart that doesn't fill well, and the treatment is different.
An SGLT2 inhibitor (dapagliflozin or empagliflozin) is the one drug class with clear benefit here, reducing heart failure hospitalizations. A mineralocorticoid receptor antagonist is reasonable to add. Beyond that, most of the gain comes from treating what's driving the stiffness: getting blood pressure to goal, controlling atrial fibrillation if you have it, treating sleep apnea, and losing weight if you carry excess. Diuretics relieve congestion and make you feel better but don't change the course of the disease — which is worth knowing so they don't get mistaken for the whole treatment.
Outcome-provenTested in randomised trials measuring heart attacks, strokes, or death, not a stand-in for them.· Class 2a· Level B-R· checked 2026-09-12
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Circulation) · Class 2a
Promising evidence that hasn't become standard care yet — worth knowing, not yet worth expecting.
Two newer options for preserved-EF heart failure are worth asking about: finerenone, and — if obesity is part of the picture — semaglutide.
Finerenone (a non-steroidal MRA) reduced heart failure events in preserved and mildly-reduced ejection fraction in FINEARTS-HF. Semaglutide improved symptoms, physical limitation, and weight in obesity-related preserved-EF heart failure in the STEP-HFpEF programme, which is notable because very little else has moved symptoms in this group. Both are newer than the guideline text above, so availability and insurance coverage vary — this is a question for a cardiologist rather than something to expect automatically.
Outcome-provenTested in randomised trials measuring heart attacks, strokes, or death, not a stand-in for them.· Level B-R· checked 2026-09-12
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Circulation) · Emerging evidence — beyond current guideline text
“Heart failure, preserved” — an illustrative profile, not a real user.
Asked after: Heart failure
Cited by the recommendations above.
For practising clinicians. Endorse it, propose a change, or dispute it. We verify every reviewer before a review is shown, and a review stays attached to the version of the rule you saw — if the rule changes, the page says so. You'll be asked to declare any relevant interests; they're shown with your review.
Log in or create an account to submit a review. An account is how we tie a review to a person we can verify.
Runs in lib/engine/heartFailurePathway.ts as hf-pef.