• Diuretics for signs of fluid retention.
• Since 2023, there has been a class IA recommendation for initiating SGLT2 inhibitors in patients with heart failure regardless of LVEF, including in patients with HFpEF.
• Classic neurohormonal blockers (ACE inhibitors, ARB, beta blockers) could not demonstrate a prognostic benefit in patients with HFpEF in contrast to HFrEF in previous studies. Therefore, there is no indication to start these drugs as heart failure therapy in HFpEF, unless as an antihypertensive or in the case of beta-blockers to calm a tachycardia.
• Patients with HFpEF often have comorbidities, such as obesity, sleep apnea, arterial hypertension, diabetes mellitus, AF and others. These are also a triggering factor for this clinical picture of heart failure and must therefore be treated optimally.

Efforts should be made to:

• Normotension (with an ACE inhibitor, sartane or other antihypertensives if necessary).
• Physical activity and cardiac rehabilitation.
• (if applicable).
• Optimal control of diabetes mellitus (if applicable).
• Optimal treatment of atrial fibrillation (if applicable).
• …

• But sometimes HFpEF can also be the result of a specific etiology that sometimes requires targeted treatment to prevent further deterioration.
  For example: aortic valve stenosis, cardiac amyloidosis , pericarditis constrictiva, cardiac iron overload,...
  It is very important to exclude or demonstrate these specific causes of HFpEF and to provide specific treatment if necessary.
  
  
• For HFpEF patients, there has only been a clear class IA recommendation for SGLT2 inhibitors since 2023. However, many sub- and meta-analyses also show a benefit of mineralocorticoid receptor antagonists (MRA) in this form of heart failure. It is therefore common for patients with HFpEF to be started with spironolactone by a cardiologist, even though no clear recommendation for this has been given in the guidelines.
  
  
• Patients with HFpEF often also have chronotropic incompetence. The heart rate then does not increase sufficiently during exercise. This can sometimes be a factor that contributes to a lower exercise capacity. Sometimes this is facilitated by therapy with a beta blocker. This is therefore sometimes reduced or stopped or switched to nebivolol by the treating cardiologist.
  
  
• If applicable:aim to lose weight. There are recent, promising results from the STEP-HFpEF trial with therapy with the GLP 1 receptor agonist, semaglutide, in patients with HFpEF and obesity. There was a significant reduction in weight, heart failure complaints, physical limitations with an improvement in exercise capacity. Studies investigating the longer term effects on mortality and heart failure endpoints are expected in the near future.