# Heart Failure with Preserved Ejection Fraction > HFpEF for NEET-SS Cardiology: H2FPEF and HFA-PEFF diagnosis, SGLT2 inhibitor trials, spironolactone TOPCAT, PARAGON-HF and comorbidity-first care. - Canonical URL: https://prepelephant.com/topics/neet-ss/cardiology/heart-failure-preserved-ef - Exam / course: NEET-SS · Subject: Cardiology - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Heart Failure with Preserved Ejection Fraction", PrepElephant, https://prepelephant.com/topics/neet-ss/cardiology/heart-failure-preserved-ef ## Direct answer Half of all heart failure occurs with a normal or near-normal ejection fraction, and until recently almost nothing improved its outcomes. Heart failure with preserved ejection fraction (LVEF at or above 50 per cent; 41-49 per cent is HFmrEF) is diagnosed with weighted tools — the H2FPEF score and the HFA-PEFF algorithm — combining symptoms, natriuretic peptides, structural changes and diastolic dysfunction, because no single finding is decisive. Management now has one class with solid trial evidence: SGLT2 inhibitors (EMPEROR-Preserved and DELIVER each cut the composite of cardiovascular death or heart-failure hospitalisation by around 20 per cent across the LVEF spectrum above 40 per cent), plus spironolactone (TOPCAT was neutral overall but positive in the Americas subgroup), diuretics for congestion, and aggressive treatment of the drivers — obesity, hypertension, atrial fibrillation, sleep apnoea and iron deficiency. ## What you must remember - **Definition and classification:** LVEF at or above 50 per cent is HFpEF, 41-49 per cent HFmrEF, 40 per cent or less HFrEF — HFmrEF is managed largely along HFrEF lines, and EF is a spectrum, not three diseases. - **Diagnostic scores:** H2FPEF (obesity, hypertension, atrial fibrillation, pulmonary hypertension, age over 60, elevated filling pressures) and HFA-PEFF (pretest, echo, natriuretic peptides, functional testing) — quote one in any answer. - **SGLT2 inhibitors:** EMPEROR-Preserved and DELIVER reduced cardiovascular death or HF hospitalisation by roughly 20 per cent in LVEF above 40 — the first universally applicable therapy. - **Spironolactone:** TOPCAT neutral overall, positive in the Americas subgroup (with hyperkalaemia the practical limit) — a reasonable add-on for selected patients. - **Sacubitril-valsartan:** PARAGON-HF missed significance (hazard ratio 0.92), with signals of benefit in women and LVEF 41-57 per cent; not a routine indication. - **Comorbidity payload:** obesity (STEP-HFpEF showed semaglutide improved symptoms and weight), iron deficiency (intravenous ferric carboxymaltose — FAIR-HF), AF, hypertension and sleep apnoea each shift symptoms measurably. - **Decongestion:** loop diuretics remain the symptom-relief backbone; natriuretic peptides run lower in obese patients, so do not exclude HFpEF on a "normal" NT-proBNP in a 100 kg patient. - **Beta-blockers and ARNIs:** no consistent outcome benefit in HFpEF — reserve beta-blockers for rate control in AF or angina, not as disease-modifying therapy. ## Working through a suspected HFpEF case A 68-year-old woman with type 2 diabetes, obesity and hypertension reports two years of worsening exertional breathlessness; her EF is 60 per cent. The mistake is to stop at "echo normal". Apply the structured approach: her H2FPEF score is high (obese, hypertensive, older, echocardiographic E/e' of 15 with left atrial dilatation), NT-proBNP is mildly raised, and a diastolic stress echo confirms exercise-induced elevation of filling pressures. Diagnosis made, shift to treatment in sequence: start an SGLT2 inhibitor for outcomes and glycaemic benefit; use a loop diuretic for congestion symptoms and then down-titrate; verify blood pressure is at target; screen for atrial fibrillation with a 14-day patch if the ECG is inconclusive; check ferritin and TSAT and replete iron intravenously if deficient; and address weight, sedentary habit and sleep apnoea. Review in three months with a 6-minute walk or KCCQ symptom score — objective anchors, not "how do you feel". ## Where students slip Three recurring errors: labelling every breathless obese patient with a normal EF as HFpEF without applying scores (chronic lung disease, pulmonary hypertension and anaemia all mimic it — the work-up must exclude them); quoting TOPCAT as a positive trial (it was neutral overall — say "Americas subgroup"); and forgetting that natriuretic peptides are obesity-suppressed, so thresholds differ. A subtler slip is treating the diagnosis as a single disease: HFpEF is a syndrome where the dominant phenotype (obese and insulin-resistant in Indian clinics, elderly hypertensive in others) dictates which comorbidity therapy yields the biggest symptom dividend. The exam rewards that phenotyping instinct. ## Frequently asked questions ### How is HFpEF diagnosed when the ejection fraction is normal? By combining symptoms with elevated natriuretic peptides, structural heart disease (left atrial enlargement, hypertrophy) and diastolic dysfunction, formalised in the H2FPEF score or HFA-PEFF algorithm. ### Which drug class improves outcomes in HFpEF? SGLT2 inhibitors — empagliflozin and dapagliflozin each reduced cardiovascular death or heart-failure hospitalisation by about 20 per cent in LVEF above 40 per cent. ### What did TOPCAT show for spironolactone? No significant benefit overall, but the Americas subgroup showed fewer deaths and hospitalisations, supporting cautious use with potassium monitoring in selected patients. ### Why can natriuretic peptides mislead in HFpEF? Obesity suppresses NT-proBNP and BNP levels, so a modestly normal value does not exclude the diagnosis in heavy patients. ### Does exercise training help HFpEF? Yes — supervised exercise training improves functional capacity and quality of life and is a guideline-recommended component of management.