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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Heart failure with mildly reduced or preserved ejection fraction

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull

Synopsis

Confirm HFmrEF or HFpEF rather than diagnosing by EF alone, relieve congestion and apply the NICE 2025 phenotype-specific medicine combinations.

  • NICE defines HFmrEF as symptomatic HF with LVEF 41–49%; HFpEF requires symptomatic HF with LVEF at least 50% plus structural/functional evidence, not a normal EF alone.
  • For HFmrEF, consider an ACE inhibitor, beta-blocker, MRA and SGLT2 inhibitor; use an ARB instead of ACE inhibitor when ACE intolerance applies.
  • For HFpEF, consider an MRA plus an SGLT2 inhibitor under the NICE 2025 update.
  • Use diuretics for congestion in every EF phenotype and titrate to the lowest dose that relieves fluid retention.
  • Search actively for hypertension, AF, obesity, diabetes, CKD, coronary disease, valve disease, sleep-disordered breathing, lung disease and amyloidosis when clues exist.
  • Natriuretic peptides do not distinguish EF phenotype: echo is required, and obesity can produce deceptively low levels.
  • Do not routinely restrict salt or fluid; reserve fluid restriction for dilutional hyponatraemia or clearly excessive intake and review the need.
  • Clinical deterioration follows the same acute-HF pathway regardless of a preserved EF.

Key red flags

Acute decompensation

Rest dyspnoea, hypoxaemia, rapid oedema/weight change or hypoperfusion needs urgent acute-HF assessment despite preserved EF.

Investigation priorities

01
NT-proBNPFirst step

Triage suspected HF using the NICE chronic-HF route.

Management branches

First-lineConfirm phenotype

Suspected HF with LVEF above 40%

  1. Use NT-proBNP to triage and obtain expert echo; assess structural/filling criteria rather than using EF alone.
  2. Exclude mimics and identify congestion, AF, BP, valve/coronary disease, renal disease, diabetes, obesity and pulmonary contributors.
  3. Use a loop diuretic when congested, titrated to the lowest effective dose.
  4. Create a care plan with specialist HF and primary-care responsibilities and personalised rehabilitation.

Key medicines

Dapagliflozin10 mg orally once daily.Volume depletion, genital infection and rare euglycaemic DKA; interrupt for hospitalised major surgery or acute serious illness, monitor blood ketones and restart only once stable with normal ketones.
SpironolactoneA typical HF start is 25 mg orally once daily; use lower/alternate-day dosing or cautious titration according to renal function, potassium, BP and frailty.Hyperkalaemia, renal impairment and gynaecomastia; baseline and 1–2-week renal/potassium monitoring after initiation or increment is essential.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG106: Chronic heart failure in adultsSeptember 2025 definitions and treatment combinations.
  • NICE NG106 core treatments visual summaryHFmrEF/HFpEF medicine summary.
  • NICE TA902: Dapagliflozin for chronic HF with preserved or mildly reduced EFNHS technology-appraisal route.
  • NICE TA929: Empagliflozin for chronic HF with preserved or mildly reduced EFNHS technology-appraisal route.
  • ESC 2023 Focused update on heart failureCurrent European HFmrEF/HFpEF evidence context.
  • Dapagliflozin SmPCLicensed 10 mg once-daily HF dose.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom