How do management priorities differ between HFrEF and HFpEF?

• A. HFrEF has strong guideline-directed medical therapy proven to reduce mortality; HFpEF management focuses on comorbidities and symptoms.
• B. HFpEF has stronger mortality benefit from GDMT than HFrEF.
• C. There is no difference in management goals between HFrEF and HFpEF.
• D. HFpEF management relies exclusively on device therapy.

Answer: (A)

The main idea here is that treatment priorities differ because HFrEF and HFpEF have different responses to therapies and different drivers of outcomes. In HFrEF, guideline-directed medical therapy has repeatedly shown clear mortality and hospitalization benefits. Drugs such as those that block maladaptive neurohormonal activation (ACE inhibitors or ARBs or sacubitril/valsartan, beta-blockers, mineralocorticoid receptor antagonists) and newer options like SGLT2 inhibitors are used broadly to improve survival and reduce decompensation.

HFpEF, on the other hand, involves preserved pumping function but a stiff ventricle and a disease pattern driven largely by comorbid conditions (hypertension, obesity, diabetes, atrial fibrillation, sleep apnea, etc.). Large trials have not demonstrated a robust mortality benefit from the same guideline-directed therapies that help HFrEF, so the focus shifts to controlling symptoms and addressing these comorbidities to prevent decompensation. Diuretics are used for fluid relief, and aggressive management of blood pressure and associated conditions is prioritized, along with lifestyle and risk-factor modification. Device therapies that are helpful in HFrEF—such as certain ICDs or CRT—are not routinely indicated for HFpEF.

So, the best choice reflects a clear contrast: proven mortality-reducing GDMT in HFrEF, versus a HFpEF approach centered on comorbidity and symptom management.