HFpEF: diagnosis (H2FPEF, HFA-PEFF) and treatment

Applies the 2026 ESC definition of HFpEF (symptoms and signs, LVEF ≥ 50% and objective evidence of structural or functional abnormality or raised filling pressure, with AF-specific natriuretic peptide thresholds). Calculates the H2FPEF score and the HFA-PEFF step 2 score. Then lists treatment: the ESC 2026 foundational therapy of an SGLT2 inhibitor and an MRA (steroidal or finerenone), diuretics, comorbidity management, ACE inhibitor, ARB or ARNI, semaglutide or tirzepatide in obesity, exercise training, and screening for cardiac amyloidosis. ESC and ACC/AHA recommendations are shown side by side.

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Step 1 · Clinical picture and natriuretic peptide

ESC 2026: symptoms, LVEF ≥ 50% and objective evidence of diastolic dysfunction or raised filling pressure

LVEF

Natriuretic peptide

NT-proBNP

pg/mL

Tick AF in H2FPEF to apply AF thresholds

Step 2 · H2FPEF score

Reddy 2018, for unexplained dyspnoea with LVEF ≥ 50%

Step 2 · HFA-PEFF score

Pieske 2019. Each domain scores 0, 1 (minor) or 2 (major); points do not add within a domain

Functional

Morphological

Biomarker domain: enter the natriuretic peptide above

e′ thresholds are lower at age ≥ 75 (septal < 5, lateral < 7 cm/s). LVMI thresholds are men/women in g/m².

HFpEF · diagnosis and treatment

Enter the LVEF and natriuretic peptide, then score H2FPEF or HFA-PEFF.

References