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.
Key red flags
Rest dyspnoea, hypoxaemia, rapid oedema/weight change or hypoperfusion needs urgent acute-HF assessment despite preserved EF.
Investigation priorities
Triage suspected HF using the NICE chronic-HF route.
Management branches
Suspected HF with LVEF above 40%
- Use NT-proBNP to triage and obtain expert echo; assess structural/filling criteria rather than using EF alone.
- Exclude mimics and identify congestion, AF, BP, valve/coronary disease, renal disease, diabetes, obesity and pulmonary contributors.
Key medicines
Dapagliflozin10 mg orally once daily.
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.