Send us a text🧠 Clinical ContextHeart failure with preserved ejection fraction (HFpEF) typically presents with orthopnea, dyspnea, edema, and often subtle signs like an S3 or elevated JVP—despite a normal EF (>50%). Diagnosing it requires nuance, and ruling out other causes of dyspnea is key.🧪 Rule Out FirstBefore calling it HFpEF, think differentials:AnemiaCirrhosisCOPD exacerbationRenal failureNSAID-induced fluid overloadMedication effectsGet a BNP (>100) or pro-BNP (>300), but remember these can be falsely low in obesity.🔍 Look for EtiologyConsider amyloidosis (found in 1 in 8 HFpEF cases)Assess for NSAID use, excessive dietary sodium/alcoholBe alert around holidays—fluid/salt overload is real!🚩 Inciting FactorsHigh-sodium and high-alcohol mealsHoliday binges (Super Bowl, Christmas, Thanksgiving)Poor adherence to fluid restriction or diuretics💊 Medications for HFpEF: Shelved SmartlyTop Shelf:SGLT2 Inhibitors (dapagliflozin, empagliflozin)Class-wide effectFirst-line for HFpEF with NYHA II–IV symptomsFinerenoneNew on the sceneEspecially promising in patients with diabetic kidney diseaseLower Shelf:SpironolactoneEvidence from the controversial TOPCAT trialUse with caution; monitor K+ and renal functionSacubitril/Valsartan (ARNI)Class IIb recommendationStronger benefit in women and men with EF <55–60%Limited by high costCandesartanA viable option for those who can't afford ARNIDiureticsNot disease-modifying but essential for symptom relief in volume-overloaded patients⚠️ Clinical ConsiderationsHFpEF is complex with limited effective therapiesMany benefits are modest, but SGLT2 inhibitors stand outEtiology and lifestyle often drive exacerbations—address these too🧩 Clinical TakeawayTreating HFpEF is less about one miracle drug and more about combining modestly effective meds with personalized care. Always rule out other causes, explore etiologies like amyloidosis, and be mindful of inciting factors—especially around festive seasons.SGLT2s lead the pharmacologic pack, but cost, side effects, and patient-specific factors still dictate the best plan. There's progress—but the heart of HFpEF still holds a few secrets.

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