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cardio.hfpef.core.v1PRODUCTION
cardio.hfpef.core.v1

Heart failure with preserved EF (HFpEF, LVEF ≥50)

cardiologychronicadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm chronic HFpEF — exclude acute decompensation routing to cardio.acute-hf.core.v1

Inputs
1
Actions
0
Advance rule
Set
Advance when

patient hemodynamically stable

Patient inputs (20)

Age + frailty informs target dose + tolerability

HTN is dominant driver; titration target

AF rate-control coexists in ~60%

BMI gates GLP-1 / tirzepatide; weight diary for congestion

BMI ≥30 unlocks semaglutide / tirzepatide as disease-modifying

eGFR for SGLT2i (≥20) and finerenone (≥25)

Finerenone contraindicated K >5.0

Dominant HFpEF driver; uncontrolled HTN must be addressed

HFpEF gate (LVEF ≥50); HFmrEF (41–49) routes to HFrEF dossier

NYHA II–IV drives advanced therapy thresholds

ATTR-CM red flags (carpal tunnel, lumbar stenosis, low-flow low-gradient AS, autonomic features) → PYP scan

Comorbid DM + HFpEF strengthens SGLT2i + GLP-1 indication

AF ablation may improve HFpEF symptoms (CABANA subgroups)

OSA is reversible HFpEF aggravator

Detect existing HF meds; flag NSAIDs / non-DHP CCB / negative inotropes

Diagnostic confirmation; H2FPEF / HFA-PEFF score input

DM dose-modifier for SGLT2i + GLP-1 selection

IV iron for symptom benefit in HFpEF + iron deficiency

Hyper/hypothyroidism reversible aggravator

AF + LVH detection; LBBB ≥150 ms is uncommon in HFpEF

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningsevere_HTN_with_end_organ
    BP >=180/120 with new CP, dyspnea, neuro deficit, vision change (ACC/AHA 2022 HF)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverek_above_5_5_on_finerenone
    K >=5.5 on finerenone or steroidal MRA (FINEARTS-HF Solomon NEJM 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaki_on_disease_modifying
    Cr rise >0.3 mg/dL or 50% on SGLT2i / finerenone / ARB (KDIGO 2024 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateorthopnea_or_pnd
    New orthopnea or PND in known HFpEF (ACC/AHA 2022 HF)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateattr_red_flags
    ATTR-CM red flags - bilateral carpal tunnel, lumbar stenosis, low-flow low-gradient AS, autonomic dysfunction, family history (ACC/AHA 2022 HF; ATTR-ACT Maurer NEJM 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenew_atrial_fibrillation
    New AF on ECG / Holter / wearable (ESC 2021 HF)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildweight_gain_2kg_3d
    Home weight gain >=2 kg in 3 days OR >=2.5 kg in 1 week (ACC/AHA 2022 HF; HFSA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

HFpEF disease-modifying stepwise ladder (LVEF ≥50) (2022 AHA/ACC/HFSA; 2023 ESC Focused Update)
axis: hfpef_stepwisestep 1 - Step 1 — SGLT2i first-line for ALL HFpEF (DM-independent) per 2023 ESC FU Class I
Selected step "Step 1 — SGLT2i first-line for ALL HFpEF (DM-independent) per 2023 ESC FU Class I" — Confirmed HFpEF (LVEF ≥50), eGFR ≥20, amyloid screen negative or in progress (2022 AHA/ACC/HFSA)
  • empagliflozin
    first line
    SGLT2i
    10 mg • PO • once daily
    triggers: LVEF>=50, eGFR>=20
    EMPEROR-Preserved (PMID 34449189): CV death/HHF HR 0.79 (0.69–0.90), total HHF HR 0.73 (0.61–0.88); event-curve separation ~2–3 wk; benefit consistent ±DM. 2023 ESC FU Class I
    rxcui 1545653
  • dapagliflozin
    first line
    SGLT2i
    10 mg • PO • once daily
    triggers: LVEF>=50, eGFR>=20
    DELIVER (PMID 36027570): primary worsening-HF/CV-death HR 0.82 (0.73–0.92), worsening HF HR 0.79 (0.69–0.91); consistent LVEF ≥/<60; event separation ~3–4 wk. 2023 ESC FU Class I
    rxcui 1488564

outpatient playbook — drug actions (6)

  1. 1. dapagliflozin OR empagliflozin
    10 mg • PO • daily
    trigger: LVEF ≥50, eGFR ≥20 (ACC/AHA 2022 HF)
    DELIVER Solomon NEJM 2022 / EMPEROR-Preserved Anker NEJM 2021
  2. 2. finerenone
    10 → 20 mg • PO • daily
    trigger: LVEF ≥40, K <5.0, eGFR ≥25 (FINEARTS-HF Solomon NEJM 2024)
    FINEARTS-HF Solomon NEJM 2024
  3. 3. semaglutide
    0.25 → 2.4 mg weekly • SC • weekly
    trigger: BMI ≥30 (STEP-HFpEF Kosiborod NEJM 2023)
    STEP-HFpEF / STEP-HFpEF-DM Kosiborod NEJM 2023
  4. 4. tirzepatide
    2.5 → 15 mg weekly • SC • weekly
    trigger: BMI ≥30 (alternative to semaglutide) (SUMMIT Packer NEJM 2024)
    SUMMIT Packer NEJM 2024
  5. 5. furosemide
    20–40 mg • PO • daily–BID
    trigger: Volume overload (ACC/AHA 2022 HF)
    Symptom + congestion control (ACC/AHA 2022 HF)
  6. 6. losartan or amlodipine or chlorthalidone
    per HTN regimen • PO • daily
    trigger: BP >130/80 despite SGLT2i + finerenone (ACC/AHA 2022 HF)
    BP control to <130/80 — most impactful HFpEF intervention (ACC/AHA 2022 HF; ESC 2021)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Echo LVEF ≥50 with diastolic dysfunction; NT-proBNP elevated with preserved LVEF; Exertional dyspnea / orthopnea / fatigue.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Heart failure with preserved EF (HFpEF, LVEF ≥50)** (cardio.hfpef.core.v1).
Phenotype framing: Confirm HFpEF (LVEF ≥50) vs HFmrEF / HCM / amyloid / constrictive (ACC/AHA 2022 HF §3; ESC 2021)
Scope: Confirm chronic HFpEF — exclude acute decompensation routing to cardio.acute-hf.core.v1

No severity triggers fired against current inputs.

Plan

Regimen axis: **HFpEF disease-modifying stepwise ladder (LVEF ≥50) (2022 AHA/ACC/HFSA; 2023 ESC Focused Update)** — step "Step 1 — SGLT2i first-line for ALL HFpEF (DM-independent) per 2023 ESC FU Class I".
1. empagliflozin 10 mg PO once daily (SGLT2i, first line) — EMPEROR-Preserved (PMID 34449189): CV death/HHF HR 0.79 (0.69–0.90), total HHF HR 0.73 (0.61–0.88); event-curve separation ~2–3 wk; benefit consistent ±DM. 2023 ESC FU Class I
2. dapagliflozin 10 mg PO once daily (SGLT2i, first line) — DELIVER (PMID 36027570): primary worsening-HF/CV-death HR 0.82 (0.73–0.92), worsening HF HR 0.79 (0.69–0.91); consistent LVEF ≥/<60; event separation ~3–4 wk. 2023 ESC FU Class I

Setting playbook (outpatient) — Initiate disease-modifying therapy (SGLT2i + finerenone ± GLP-1/tirzepatide), achieve BP <130/80, treat AF + OSA + obesity (ACC/AHA 2022 HF; ESC 2021)
3. dapagliflozin OR empagliflozin 10 mg PO daily — LVEF ≥50, eGFR ≥20 (ACC/AHA 2022 HF) (DELIVER Solomon NEJM 2022 / EMPEROR-Preserved Anker NEJM 2021)
4. finerenone 10 → 20 mg PO daily — LVEF ≥40, K <5.0, eGFR ≥25 (FINEARTS-HF Solomon NEJM 2024) (FINEARTS-HF Solomon NEJM 2024)
5. semaglutide 0.25 → 2.4 mg weekly SC weekly — BMI ≥30 (STEP-HFpEF Kosiborod NEJM 2023) (STEP-HFpEF / STEP-HFpEF-DM Kosiborod NEJM 2023)
6. tirzepatide 2.5 → 15 mg weekly SC weekly — BMI ≥30 (alternative to semaglutide) (SUMMIT Packer NEJM 2024) (SUMMIT Packer NEJM 2024)
7. furosemide 20–40 mg PO daily–BID — Volume overload (ACC/AHA 2022 HF) (Symptom + congestion control (ACC/AHA 2022 HF))
8. losartan or amlodipine or chlorthalidone per HTN regimen PO daily — BP >130/80 despite SGLT2i + finerenone (ACC/AHA 2022 HF) (BP control to <130/80 — most impactful HFpEF intervention (ACC/AHA 2022 HF; ESC 2021))

Non-pharmacologic actions:
- Sodium <2 g/day, fluid <1.5-2 L/day if congestive (ACC/AHA 2022 HF)
- Aerobic + resistance exercise prescription (Ex-DHF 2011; ACC/AHA 2022 HF)
- Cardiac rehab referral for deconditioning (ACC/AHA 2022 HF)
- OSA evaluation + CPAP if AHI >=15 (ACC/AHA 2022 HF)
- AF rate or rhythm control per shared decision (CASTLE-AF subgroup; ESC 2021 HF)
- AVOID nitrates unless angina (NEAT-HFpEF NEJM 2015)
- Vaccinations (flu, pneumococcal, COVID, RSV) (ACC/AHA 2022 HF)

AVOID / contraindication checks:
- Sglt2i block if egfr lt 20 or active DKA (2023 ESC FU; DELIVER PMID 36027570)
- Finerenone block if K gt 5.0 or egfr lt 25 (FINEARTS HF PMID 39225278)
- MRA avoid K above 5 or eGFR below 30 (TOPCAT PMID 24716680 hyperK 18.7%)
- Glp1 caution if gastroparesis or pancreatitis history (STEP HFpEF PMID 37622681)
- Nitrates avoid in HFpEF unless angina (NEAT HFpEF — no benefit, ↑adverse)
- ARNi avoid pregnancy angioedema or with ACEi 36h washout (PARAGON HF PMID 31475794)
- Disease modifying axis gated OFF until amyloid screened (ATTR CM tafamidis PMID 30145929)

Monitoring

Regimen monitoring:
- BMP at 2wks after finerenone or spironolactone start (FINEARTS-HF PMID 39225278)
- BMP q1m during MRA titration (FINEARTS-HF PMID 39225278)
- BMP q3m at steady state (ACC/AHA 2022 HF)
- weight daily at home (ACC/AHA 2022 HF; HFSA 2022)
- A1c q3m if dm present (ADA 2026)
- GLP1 GI tolerability at 4wks during titration (STEP-HFpEF PMID 37622681)
- BP at each visit target lt 130 80 (ACC/AHA 2022 HF; 2025 AHA/ACC HBP)

Setting (outpatient) monitoring:
- BMP at 2 wks after finerenone start, then q1m during titration (FINEARTS-HF Solomon NEJM 2024)
- Daily home weight; alert if >2 kg gain in 3 days (ACC/AHA 2022 HF; HFSA 2022)
- BP home log (ACC/AHA 2022 HF)
- A1c q3 mo if DM (ADA 2026)
- GLP-1 GI tolerability check at 4 wks (STEP-HFpEF Kosiborod NEJM 2023)

Follow-up plan: Visit cadence by NYHA + recent titration; vaccinations; cardiac rehab
- Close-out criterion: follow-up scheduled

Monitoring phase: BMP within 2 wks of finerenone start; weight diary; A1c q3m if DM

Disposition

Current setting: outpatient — Initiate disease-modifying therapy (SGLT2i + finerenone ± GLP-1/tirzepatide), achieve BP <130/80, treat AF + OSA + obesity (ACC/AHA 2022 HF; ESC 2021)

Disposition criteria:
- Continue chronic management if controlled (ACC/AHA 2022 HF)
- Refer cardiac amyloid / advanced HF clinic if mimics confirmed (ACC/AHA 2022 HF)
- Annual echo + NT-proBNP for follow-up (ESC 2021 HF)

Escalation triggers (move to higher acuity):
- Weight gain >2 kg in 3 days + worsening symptoms -> diuretic up-titration or admit (ACC/AHA 2022 HF)
- New atrial fibrillation -> cardio.afib.core.v1 (ESC 2021 HF)
- Suspected ATTR amyloid (red flags) -> cardiac amyloid clinic + PYP scan (ACC/AHA 2022 HF)
- BP >=180/120 + end-organ -> ED + cardio.hypertensive-emergency.core.v1 (ACC/AHA 2022 HF)

Patient Action Plan

**HFpEF action plan (weight + dyspnea + BP zones)**
Personalised values: dry_weight_kg, home_diuretic, home_diuretic_rescue_dose, NYHA_baseline, BP_target.

**All clear — at dry weight, BP at goal, baseline activity** (green):
Triggers:
- Weight at or within 1 kg of dry weight (ACC/AHA 2022 HF)
- No new dyspnea, orthopnea, or edema (ACC/AHA 2022 HF)
- BP at goal (<130/80) (ACC/AHA 2022 HF)
- Usual exercise tolerance (ACC/AHA 2022 HF)
Actions:
- Take all HFpEF meds as prescribed every day (ACC/AHA 2022 HF)
- Sodium <2 g/day (ACC/AHA 2022 HF)
- Daily weight at the same time, after voiding, in same clothing (ACC/AHA 2022 HF; HFSA 2022)
- Walk / exercise per plan (Ex-DHF 2011; ACC/AHA 2022 HF)
- Keep follow-up appointments (ACC/AHA 2022 HF)

**Caution — early congestion, BP drift, or new symptoms** (yellow):
Triggers:
- Weight up 2 kg in 3 days OR 2.5 kg in a week (ACC/AHA 2022 HF; HFSA 2022)
- New ankle / leg swelling (ACC/AHA 2022 HF)
- Need extra pillow at night, or breathlessness on stairs you previously tolerated (ACC/AHA 2022 HF)
- BP persistently >=140/90 on home monitor (ACC/AHA 2022 HF)
- Increased fatigue or new palpitations (possible AF) (ESC 2021 HF)
Actions:
- Take prescribed rescue diuretic dose per action plan (ACC/AHA 2022 HF)
- Tighten sodium intake and hold extra fluids (ACC/AHA 2022 HF)
- Recheck BP and weight in 24 h (ACC/AHA 2022 HF)
- Call HF clinic / PCP within 24-48 h (ACC/AHA 2022 HF)
Contact provider when:
- No improvement after 48 h of rescue diuretic (ACC/AHA 2022 HF; HFSA 2022)
- New irregular pulse or palpitations (ESC 2021 HF; ACC/AHA 2022 HF)
- BP ≥160/100 on repeat (ACC/AHA 2022 HF)

**Medical alert — severe decompensation** (red):
Triggers:
- Severe shortness of breath at rest (ACC/AHA 2022 HF)
- Cannot lie flat / sleep due to breathlessness (ACC/AHA 2022 HF)
- New chest pain or pressure (ACC/AHA 2022 HF)
- Confusion, fainting, or near-fainting (ACC/AHA 2022 HF)
- BP >=180/120 with headache, vision change, weakness, or chest pain (ACC/AHA 2022 HF)
Actions:
- Call 911 / emergency services immediately (ACC/AHA 2022 HF)
- Sit upright (ACC/AHA 2022 HF)
- Do not drive yourself - call EMS (ACC/AHA 2022 HF)
- Bring medication list + weight diary (ACC/AHA 2022 HF)
Contact provider when:
- Any red zone symptom — go to ED now, do not wait (ACC/AHA 2022 HF)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] BP >=180/120 with new CP, dyspnea, neuro deficit, vision change (ACC/AHA 2022 HF)
- [SEVERE] K >=5.5 on finerenone or steroidal MRA (FINEARTS-HF Solomon NEJM 2024)
- [SEVERE] Cr rise >0.3 mg/dL or 50% on SGLT2i / finerenone / ARB (KDIGO 2024 AKI)

Citations

- 2022 AHA/ACC/HFSA HF Guideline (PMID 35363499/35379503) + 2023 ESC Focused Update (PMID 37622666) + EMPEROR-Preserved + DELIVER + FINEARTS-HF + TOPCAT(-Americas) + STEP-HFpEF(+DM pooled) + SUMMIT + PARAGON-HF [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 35379503) [PMID:35379503](https://pubmed.ncbi.nlm.nih.gov/35379503/)
- Cited evidence (PMID 37622666) [PMID:37622666](https://pubmed.ncbi.nlm.nih.gov/37622666/)
- Cited evidence (PMID 34449189) [PMID:34449189](https://pubmed.ncbi.nlm.nih.gov/34449189/)
- Cited evidence (PMID 36027570) [PMID:36027570](https://pubmed.ncbi.nlm.nih.gov/36027570/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2022 AHA/ACC/HFSA HF Guideline (PMID 35363499/35379503) + 2023 ESC Focused Update (PMID 37622666) + EMPEROR-Preserved + DELIVER + FINEARTS-HF + TOPCAT(-Americas) + STEP-HFpEF(+DM pooled) + SUMMIT + PARAGON-HF — PMID:35363499
  • Cited evidence (PMID 35379503) — PMID:35379503
  • Cited evidence (PMID 37622666) — PMID:37622666
  • Cited evidence (PMID 34449189) — PMID:34449189
  • Cited evidence (PMID 36027570) — PMID:36027570