How is HFpEF typically managed, and why is it more challenging?

• A. Treat comorbidities (HTN, obesity, DM), diuretics for congestion, and address symptoms; limited proven mortality benefits from GDMT; SGLT2 inhibitors show benefit.
• B. Aggressive GDMT with RAAS inhibitors reduces mortality significantly.
• C. Only diuretics are used, no other treatments.
• D. CRT is standard therapy in all HFpEF.

Answer: (A)

The key idea is that HFpEF is managed by addressing the patient’s comorbid conditions and relieving congestion, rather than relying on a single therapy that clearly improves survival. Controlling hypertension, obesity, and diabetes helps reduce episodes of decompensation and symptom burden. Diuretics are used to relieve fluid overload and improve edema and shortness of breath. Recent evidence supports using SGLT2 inhibitors in HFpEF to reduce heart-failure hospitalizations, so they have become part of many treatment plans even in patients without diabetes.

What makes HFpEF more challenging is that therapies proven to improve survival in HFrEF don’t consistently show mortality benefits in HFpEF. This, combined with the wide variety of patient phenotypes and comorbidity patterns, means treatment must be individualized and focused on symptom relief, risk factor control, and therapies with demonstrated benefits like SGLT2 inhibitors, rather than a single GDMT approach that lowers mortality. Cardiac resynchronization therapy is not a standard treatment for HFpEF and is mainly considered for selected HFrEF cases with specific conduction issues.