Breathless with a normal ejection fraction — HFpEF case discussion

Objectives

1. Classify and diagnose HFpEF with the 2026 ESC criteria. ^[1]
2. Start foundational therapy with correct doses. ^[1]
3. Add weight-directed therapy within its recommendation. ^[1]
4. Plan safety monitoring. ^[1]

Candidate brief

You are the cardiologist in a general clinic. In twenty minutes, take the case from diagnosis through treatment and follow-up, quoting guideline classes and trial evidence. ^[1]

Expected actions

• Confirm HFpEF: current or prior symptoms and/or signs, LVEF of 50% or more with no previous value under 50%, and objective structural and/or functional abnormalities consistent with LV diastolic dysfunction/raised LV filling pressures, supported by raised natriuretic peptides. LA volume index 39 mL/m² exceeds 34 mL/m² in sinus rhythm, and E/e′ 12 at rest exceeds the threshold of above 9 at rest.^[1]
• Note that NT-proBNP 280 pg/mL exceeds the suggested 250 pg/mL outpatient age-adjusted level (HFA-ESC consensus) for 50–75 years, while obesity may lower peptide levels.^[1]
• Exclude mimics such as amyloidosis when wall thickness and red flags suggest it.^[1]
• Start an SGLT2 inhibitor (dapagliflozin or empagliflozin 10 mg once daily) and an MRA (sMRA/nsMRA for HFpEF), each Class I, level A in symptomatic HF, to reduce the risk of HF hospitalisation or CV death.^[1] Quote DELIVER HR 0.82 and EMPEROR-Preserved HR 0.79 (both LVEF >40%).^[3][4]
• If finerenone is chosen at eGFR above 60, the ESC dose range is 20–40 mg once daily; FINEARTS-HF (LVEF ≥40%) rate ratio 0.84.^[1][6]
• Consider semaglutide or tirzepatide, which should be considered in symptomatic HF with LVEF of 45% or more and BMI of 30 kg/m² or more, regardless of diabetes, to reduce body weight and improve exercise capacity and QoL (Class IIa, level B1). Lifestyle measures are recommended in all HF. Personalised exercise training within multidisciplinary exercise-based cardiac rehabilitation is recommended for all stable patients unless there are specific contraindications, to improve exercise capacity and QoL and reduce all-cause hospitalisation (Class I, level B1).^[1] Quote the STEP-HFpEF placebo-adjusted KCCQ-CSS difference of 7.8 points and SUMMIT HR 0.62.^[10][12]
• Monitor potassium and kidney function: take care when starting an MRA at potassium of 5.0 mmol/L or more (or with impaired kidney function); on treatment, above 5.5 mEq/L recheck, then consider dose reduction or temporary discontinuation; accept a creatinine rise under 50% above baseline as long as eGFR stays above 15 mL/min/1.73 m².^[1]

Marking

Pass:

• applies the three-part 2026 ESC definition and at least two Table 10 thresholds correctly.
• interprets NT-proBNP with age and obesity.
• starts SGLT2 inhibitor plus MRA with ESC doses and class.
• places incretin therapy within its recommendation.
• states potassium and creatinine rules.

Fail:

• uses the retired HFmrEF category or the 40% cut-off as the ESC classification.
• dismisses HF because of low peptides in an obese patient.
• omits the MRA from foundational therapy.
• claims a proven CV death reduction from SGLT2 inhibitors in HFpEF without the ESC position that individual CV mortality fell only in HFrEF (the pooled DELIVER + EMPEROR-Preserved analysis in LVEF >40% reported CV death HR 0.88, 95% CI 0.77–1.00).
• gives no potassium monitoring plan.