HFpEF
Symptom
Dyspnea
Cardiovascular disease
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Cardiomyopathy
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Coronary artery disease
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Valvular heart disease
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Pericardial disease
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Arrhythmia
Pulmonary disease
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Obstructive lung disease
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Restrictive lung disease
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Pleural disease
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Pulmonary embolism
Others
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Anemia
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Neuromuscular
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Deconditioning
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Obesity
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Anxiety
Edema
Increase hydrostatic pressure
Cardiovascular disease
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Cardiomyopathy
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Valvular heart disease
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Pericardial disease
Cirrhosis
Kidney disease
Venous insifficiency, obstruction, thrombosis
Pregnancy
Drugs: NSIADs, steriods, CCB
Decrease capillary oncotic pressure
Decrease protein intake
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malnutrition
Decrease protein production
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cirrhosis
Protein loss
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malabsorption
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nephrotic syndrome
HFpEF Diagnostic Scores
Three algorithms—H2FPEF, HFpEF-ABA, and HFA-PEFF—can help assess the probability that HFpEF is the root cause in a person experiencing dyspnea or edema.
The HFA-PEFF Score has a strong physiologic basis. Still, it is more complex, often requiring diastolic stress testing, invasive hemodynamic measurements, and natriuretic peptide assessment (which is less accurate in HFpEF and obesity) that aren't always feasible in routine practice. It's best suited for specialist cardiology settings.
The H2FPEF Score was derived and validated using invasive exercise hemodynamics, is easy to calculate from readily accessible clinical variables, and achieves greater accuracy despite using fewer inputs. Its limitations are that it may not distinguish obesity-related symptoms from true HFpEF, that many patients fall into an "intermediate" nondiagnostic category, and that its diagnostic value depends on pretest probability. It works across inpatient/outpatient, primary care, general cardiology, and specialist settings.
The HFpEF-ABA Score is the easiest to implement in primary care and for population screening, as it requires no echocardiographic data. Its main drawback is the need for an online calculator to compute probability, with no established thresholds to guide further workup. It suits inpatient/outpatient, primary care, and EMR-based population screening use.
Starting and Target Doses of Optimal Medical Therapy Options for HFpEF
Drug Class
Starting Dose
Target Dose
SGLT2 inhibitors (oral)
Dapagliflozin
10 mg daily
10 mg daily
Empagliflozin
10 mg daily
10 mg daily
Sotagliflozin*
200 mg daily
400 mg daily
Aldosterone antagonists† (oral)
Spironolactone
25 mg daily
50 mg daily
Finerenone
10 mg daily (eGFR ≥25 to <60 mL/min/1.73 m²)
20 mg daily (eGFR ≥60 mL/min/1.73 m²)
20 mg daily (eGFR ≥25 to <60 mL/min/1.73 m²)
40 mg daily (eGFR ≥60 mL/min/1.73 m²)
Incretin-based therapies‡ (subcutaneous)
Semaglutide
0.25 mg weekly
2.4 mg weekly
Tirzepatide
2.5 mg weekly
15 mg weekly
ARNIs (oral)
Sacubitril/valsartan
24 mg/26 mg twice daily, respectively
97 mg/103 mg twice daily, respectively
ARBs (oral)
Candesartan
4–8 mg daily
32 mg daily
*Sotagliflozin has demonstrated benefit in only individuals with type 2 diabetes recently hospitalized with HF regardless of ejection fraction.
†Eplerenone has no demonstrated clinical trial benefit in HFpEF but may be used as an alternative to spironolactone of gynecomastia.
‡FDA-approved dose titration schedule for semaglutide for weight loss: increase every 4 wks as tolerated (prescribed once weekly): 0.25 mg, 0.5 mg, 1.0 mg, 1.7 mg, 2.4 mg; and tirzepatide: increase every 4 wks as tolerated (prescribed once weekly): 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg,15 mg.
References
1) Kittleson MM, Panjrath GS, Bates K, Breathett KK, Dixon DL, Januzzi JL Jr, Mohammed SF. Management of Heart Failure With Preserved Ejection Fraction: 2026 ACC Expert Consensus Decision Pathway: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2026 Jul 23:S0735-1097(26)06875-0. doi: 10.1016/j.jacc.2026.06.018. Epub ahead of print. PMID: 42494134.