Hfpef latest guidelines
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"heart failure with preserved ejection fraction" AND "guidelines"
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HFpEF latest guidelines 2024 2025 AHA ACC ESC treatment recommendations
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PMID: 38918060
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PMID: 41953528
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Here is a comprehensive, up-to-date summary of HFpEF guidelines incorporating the latest evidence through mid-2026.
HFpEF: Latest Guidelines and Evidence (2024-2026)
Definition and Diagnosis
HFpEF is defined as heart failure with LVEF ≥50%, supported by signs/symptoms of HF, elevated natriuretic peptides, and evidence of structural/functional diastolic abnormalities.
- NT-proBNP: ESC/AHA cut-off ≥125 ng/L; NICE uses higher thresholds (400-2000 ng/L: 6-week specialist referral; >2000 ng/L: urgent)
- Echocardiography: A 2025 update from the American Society of Echocardiography (PMID 40617625) revised recommendations for evaluating diastolic function and HFpEF diagnosis
- Scoring systems: HFA-PEFF and H2FPEF scores are used to guide diagnosis, though guideline uptake remains inconsistent
Pharmacological Treatment - Guideline Recommendations
1. SGLT2 Inhibitors (Cornerstone Therapy) - CLASS I / IIa
The most evidence-based treatment for HFpEF:
| Drug | Trial | Key Result | Guideline Class |
|---|---|---|---|
| Empagliflozin | EMPEROR-Preserved | 21% reduction in CV death/HF hospitalization (HR 0.79) | Class IIa B-R (AHA/ACC/HFSA 2022); Class I A (ESC 2023 Focused Update) |
| Dapagliflozin | DELIVER | ~20% RRR in CV death/HF hospitalization | Incorporated in ESC Class I |
The ESC 2023 Focused Update elevated SGLT2i to Class I, Level A after pooled evidence from both EMPEROR-Preserved and DELIVER. The AHA/ACC/HFSA 2022 guidelines list them as Class IIa B-R. SGLT2i should be considered in ALL HFpEF patients unless contraindicated. - Fuster and Hurst's The Heart, 15th ed.
2. Finerenone (Non-Steroidal MRA) - FDA Approved July 2025
The FINEARTS-HF trial (2024) showed finerenone significantly reduced total worsening HF events and CV death in HFmrEF/HFpEF with favorable hyperkalemia risk. The FDA approved finerenone for HFmrEF and HFpEF in July 2025. Incorporation into formal ESC guidelines (expected 2026) and AHA/ACC updates is anticipated. The ongoing REDEFINE-HF and CONFIRMATION-HF (finerenone + dapagliflozin) trials will refine its role further.
3. MRA (Spironolactone/Eplerenone) - CLASS IIb
- Spironolactone reduced HF hospitalization in HFpEF (TOPCAT trial) but did NOT reduce mortality
- AHA/ACC/HFSA 2022: Class IIb B-R (with caution given post-hoc nature of evidence)
- ESC guidelines: No formal recommendation
- Subanalysis of TOPCAT supports IIb for patients at the lower EF spectrum (45-55%), informing HFmrEF overlap
- Awaiting SPIRRIT-HFpEF trial results
4. RAAS Inhibition (ACEi / ARB / ARNI)
- ACEi, ARBs, and beta-blockers are reasonable and may reduce HF hospitalizations modestly but no mortality benefit is confirmed in HFpEF
- Sacubitril/valsartan (ARNI): PARAGON-HF did not meet its primary endpoint vs. valsartan, but FDA approved it for HFpEF based on benefit seen in patients with LVEF <normal (borderline/mildly reduced). ARNI is preferred over ACEi/ARB if LVEF is less than "normal" (see flowchart below)
- All three major guidelines (NICE, ESC, AHA) recommend ACEi/ARB/ARNI for symptom and hospitalization benefit
5. GLP-1/GIP Receptor Agonists (Emerging - Obesity-Phenotype HFpEF)
A major new therapeutic frontier, particularly for the obese HFpEF phenotype (which makes up ~80% of HFpEF cases in some cohorts):
| Drug | Trial | Key Findings |
|---|---|---|
| Semaglutide | STEP-HFpEF program | Improved symptoms, physical function, exercise capacity, weight and inflammation; reduced CV death/HF hospitalization composite in pooled analyses |
| Tirzepatide | SUMMIT trial | Clinically meaningful improvements in symptoms, exercise capacity, and composite HF/CV outcomes in obesity-related HFpEF |
These are not yet in formal HF guidelines but are strongly anticipated in the forthcoming 2026 ESC HF Guidelines update. Per the 2026 systematic review (PMID 41953528), they represent a "promising extension beyond SGLT2 inhibitors" in cardiometabolic HFpEF.
6. Loop Diuretics
- Used for fluid overload/congestion - mainstay for symptom relief
- No mortality benefit; titrate to euvolemia
- Does not modify disease course
Non-Pharmacological and Comorbidity Management
This is the backbone of HFpEF therapy given the high comorbidity burden:
| Comorbidity | Intervention |
|---|---|
| Hypertension | Treat aggressively; BP target <130/80 mmHg (both AHA/ACC and ESC). A 2025 meta-analysis (PMID 40410293) found SBP <130 mmHg associated with better outcomes in HFpEF |
| Atrial fibrillation | Rate or rhythm control; catheter ablation IIa for HFpEF + AF (2023 ACC/AHA/ACCP/HRS AF guidelines) |
| Obesity | Weight loss, GLP-1 RA (emerging) |
| T2DM | SGLT2i serve dual purpose (glucose + HF outcomes) |
| OSA | Screen and treat; CPAP |
| CAD | Revascularization per standard guidelines |
| Iron deficiency | FAIR-HFpEF trial (2024): ferric carboxymaltose improved exercise capacity; IV iron may be considered |
| Exercise/Rehab | Structured exercise training improves quality of life and exercise capacity (Class IIa) |
Treatment Algorithm Summary
The Washington Manual of Medical Therapeutics flowchart:
All patients: MRA + SGLT2i + Loop diuretic (if fluid overloaded) + ARNI (or ACEi/ARB if LVEF near normal)
Special cases: Persistent HTN → add antihypertensives; Recent hospitalization on maximal therapy with LVEF <45% → consider Vericiguat; Treat comorbidities (AF, CAD, DM, obesity, OSA)
Key Differences Between Major Guidelines (2022-2025)
| Recommendation | AHA/ACC/HFSA 2022 | ESC 2023 Focused Update |
|---|---|---|
| SGLT2i | Class IIa B-R | Class I A |
| MRA (spironolactone) | Class IIb B-R | No recommendation |
| Finerenone (HFpEF) | Not yet included | Expected in 2026 update |
| ARNI | Consider if LVEF < normal | Class IIb |
| Diuretics for congestion | Class I | Class I |
What's Coming: The 2026 ESC HF Guidelines
The 2026 ESC HF Guidelines are expected to include:
- Finerenone recommendation (following FINEARTS-HF and FDA approval)
- Possible GLP-1 RA recommendations for obese HFpEF phenotype
- Updated diagnostic criteria for diastolic function (ASE 2025 update)
- Phenotype-specific treatment pathways (obese, atrial fibrillation, CKD-driven HFpEF)
The iCARDIO 2025 Global Implementation Guidelines also provide a practical global framework incorporating these advances.
Key Bottom Line: No therapy has proven mortality benefit in HFpEF - the field is shifting toward HF hospitalization reduction and symptom improvement. SGLT2 inhibitors are the closest to a disease-modifying pillar (Class I per ESC). Finerenone (FDA-approved July 2025) is the next major addition. GLP-1/GIP agonists are highly promising for the obese phenotype. Aggressive comorbidity management remains essential for all patients.
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