HFpEF under the 2026 ESC classification — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 69-year-old woman with hypertension, permanent atrial fibrillation and BMI 34 kg/m² has 6 months of exertional breathlessness. Echocardiography: LVEF 59% (no previous echo), LA volume index 44 mL/m², E/e′ 11 at rest, TR velocity 3.0 m/s, LV mass index 90 g/m², relative wall thickness 0.45. NT-proBNP 210 pg/mL. ^[1]

1. State the three criteria that must all be present for HFpEF under the 2026 ESC guideline. (3)
2. Which ESC Table 10 echocardiographic criteria does she meet? Justify each with its threshold. (4)
3. Interpret her NT-proBNP. (2)
4. Name the gold-standard confirmatory test and one diagnostic threshold. (1) ^[1]

Model answers

1. Current or prior symptoms and/or signs of HF; LVEF of 50% or more that has never previously been under 50%; and objective evidence of structural and/or functional abnormality consistent with LV diastolic dysfunction or raised filling pressures, supported by raised natriuretic peptides.^[1]
2. LA dilatation: 44 mL/m² exceeds the AF threshold of 40 mL/m². Filling pressure: E/e′ 11 is above 9 at rest. PA pressure: TR velocity 3.0 m/s is above the resting threshold of 2.8 m/s. LV hypertrophy: relative wall thickness 0.45 is above 0.42, although LV mass index 90 g/m² is below the female threshold of 95 g/m². The more parameters in the pathological range, the higher the probability of HFpEF.^[1]
3. The suggested outpatient age-adjusted level (HFA-ESC consensus) above which HF is likely is 250 pg/mL or more between 50 and 75 years, so 210 pg/mL is below it. Obesity may lower natriuretic peptide levels, so HFpEF thresholds need critical evaluation, while AF raises them. Interpret the value with the clinical and echo findings rather than as a rule-out.^[1]
4. Invasive haemodynamic exercise testing: PCWP of 15 mmHg or more at rest, 25 mmHg or more with exercise, or LVEDP of 16 mmHg or more at rest is generally diagnostic.^[1]

SAQ 2 (10 marks)

Practice scenario. Her HFpEF is confirmed. She is euvolaemic on a loop diuretic, eGFR 58 mL/min/1.73 m², potassium 4.5 mmol/L, BMI 34 kg/m², no diabetes, NYHA class II–III. ^[1]

1. Name her foundational medical therapy with class, level and ESC Table 11 doses. (4)
2. A colleague suggests sacubitril–valsartan. State the ESC position and the PARAGON-HF result. (2)
3. What does the 2026 ESC recommend for her weight, and what did the trials show? (2)
4. Outline potassium and kidney monitoring after the MRA starts. (2) ^{[1] [9] [10] [12]}

Model answers

1. SGLT2 inhibitor and MRA, each Class I, level A, for symptomatic HF independent of LVEF, to reduce the risk of HF hospitalisation or CV death.^[1] Dapagliflozin or empagliflozin 10 mg once daily (start and target). For the MRA in HFpEF, use spironolactone (12.5–25 mg once daily, with 12.5 mg an optional start where kidney status or hyperkalaemia warrant caution; target 50 mg) or finerenone, whose eGFR-guided dose is 10–20 mg when eGFR is 60 mL/min/1.73 m² or below.^[1]
2. ACE-I/ARB/ARNI may be considered in symptomatic HFpEF to reduce HF hospitalisation (Class IIb, level C); the ESC adds that ARNIs may be considered especially at lower LVEF ranges.^[1] PARAGON-HF (4822 patients with NYHA class II–IV HF, LVEF of 45% or more, elevated natriuretic peptides and structural heart disease, randomised to sacubitril–valsartan or valsartan) missed its primary endpoint: rate ratio 0.87 (95% CI 0.75–1.01; P=0.06).^[9]
3. Semaglutide or tirzepatide 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).^[1] In STEP-HFpEF, semaglutide 2.4 mg weekly gave a placebo-adjusted KCCQ-CSS difference of 7.8 points (mean change 16.6 vs 8.7 at 52 weeks) and a placebo-adjusted body-weight difference of −10.7 percentage points (mean change −13.3% vs −2.6%).^[10] In SUMMIT (731 patients with HF, LVEF of at least 50% and BMI of at least 30, randomised 1:1 versus placebo), tirzepatide up to 15 mg weekly reduced CV death or worsening HF (HR 0.62).^[12]
4. Take care starting an MRA at potassium of 5.0 mmol/L or more or with impaired kidney function. If potassium exceeds 5.5 mEq/L, recheck first; there might then be an indication for dose reduction or temporary discontinuation, restarting if hyperkalaemia resolves. A creatinine rise under 50% above baseline, with eGFR above 15 mL/min/1.73 m², is acceptable.^[1]