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.
Proven in trialsTrials counted real events, like heart attacks, strokes, or deaths, and this changed them.
An SGLT2 inhibitor (dapagliflozin or empagliflozin) is the one drug class with clear benefit here, reducing heart failure hospitalizations. A mineralocorticoid receptor antagonist, an ARB, or an ARNI may be considered in selected people, particularly toward the lower end of the preserved range. 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.
ACC/AHA (US)
The SGLT2 inhibitor recommendation is Class 2a, Level B-R.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Cir… · Recommendation behind this rule · class and level read from the guideline tables on 2026-09-30
MRA, ARB or ARNi in selected patients (may be considered)
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Cir… · Graded separately within the same recommendation · class and level read from the guideline tables on 2026-09-30
Titrating blood pressure medication to target in HFpEF with hypertension
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Cir… · Graded separately within the same recommendation · class and level read from the guideline tables on 2026-09-30
Routine nitrates or PDE-5 inhibitors to raise activity or quality of life (ineffective)
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Cir… · Graded separately within the same recommendation · class and level read from the guideline tables on 2026-09-30
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Circulation) · Class 2a · Level B-R
Promising, but not in the guidelines yet.
Two newer options for preserved-EF heart failure are worth asking about: finerenone, and — if obesity is part of the picture — semaglutide.
Proven in trialsTrials counted real events, like heart attacks, strokes, or deaths, and this changed them.
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.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Circulation) · Level B-R
“Heart failure, preserved” — an illustrative profile, not a real user.
Asked after: Heart failure
Cited by the recommendations above.
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Runs in lib/engine/heartFailurePathway.ts as hf-pef.