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HFpEF comorbidity lens

Which drug classes help which of the conditions this patient has, rebuilt from the 2026 ACC HFpEF pathway's cardiovascular-kidney-metabolic benefit matrix. Cell labels follow the figure; every cell cites its source.

The same values as in the patient editor in the header and on the other pages: change one here and it changes there.

Sex

Calculated 84 (CKD-EPI 2021)

Kidney stage: G2 (eGFR 60–89).

Conditions to cover
↓ HF events↓ CV death + HF eventsweight loss + ↑ quality of life↓ MACE↓ CKD progression
Drug classHFpEF
SGLT2 inhibitor
↓ CV death + HF events
Non-steroidal MRA (finerenone)
↓ CV death + HF events
Incretin-based therapy (semaglutide, tirzepatide)
↓ HF eventsweight loss + ↑ quality of lifesmall number of HF events
ARNI (sacubitril/valsartan)
↓ HF eventsif female or LVEF <55–60%
ARB (candesartan)
↓ HF eventsinconsistent benefit
ACE inhibitornot drawn
SGLT2 inhibitor
Non-steroidal MRA (finerenone)
Incretin-based therapy (semaglutide, tirzepatide)
ARNI (sacubitril/valsartan)
ARB (candesartan)
ACE inhibitor

HFpEF: No demonstrated benefit in HFpEF (PEP-CHF); not a substitute for an ARB or ARNI here.

Source: p. 22, Figure 8 (cell labels as printed: “if female or LVEF<55–60”, “inconsistent benefit”, “if existing CKD”, “if proteinuria”, “small number of HF events”).

2026 ACC HFpEF pathway, Figure 6

Figure 6 (narrated): SGLT2 inhibitor and a non-steroidal MRA for everyone (finerenone preferred; steroidal MRA if cost or tolerance prohibit); add an incretin-based therapy at BMI ≥30; titrate diuretics with fluid retention; add sacubitril/valsartan for women at any EF, men with LVEF <55–60% or with hypertension; candesartan when an ARNI is contraindicated or not tolerated; avoid beta-blockers without a specific indication. Early initiation and titration reduce HF hospitalizations and death.

LVEF 30% (below the 57% median in PARAGON-HF): sacubitril/valsartan “may be a reasonable choice for women or those with LVEF of <57%, particularly if additional blood pressure control is warranted”. The ESC 2026 guideline rates ACE-I/ARB/ARNI Class IIb for symptomatic HFpEF.