Conditions

Treatment options for

Heart Failure with Preserved Ejection Fraction

Heart failure is a common complex clinical syndrome of symptoms and signs caused by impairment of the heart’s action as a pump supporting the circulation.

Heart Failure with Preserved Ejection Fraction (HF-PEF), previously known as “diastolic” heart failure, is characterised by normal left ventricular ejection fraction (≥50%) despite symptoms and signs of heart failure.

It is poorly understood compared to Heart Failure with Reduced Ejection Fraction (HF-REF), more challenging to diagnose and has more limited treatment options available.

There is no single diagnostic test for Heart Failure.

NICE (2025) emphasise that someone must be symptomatic of heart failure.

Diagnosis may be confirmed by a combination of:

symptoms or signs
raised serum NT-proBNP levels
echocardiography
specialist assessment
see here for a visual summary from NICE and here for detailed guidance

HF-PEF accounts for roughly half of all cases of heart failure. It is more common in older patients, women and those with multiple co-morbidities.

The diagnosis is easy to miss. Chronic symptoms such as fatigue and reduced exercise tolerance may not be readily attributed to heart failure, especially in the context of multi-morbidities and/or a normal echocardiogram.

Heart failure may be classified by the degree of impairment of left ventricular ejection fraction (LVEF)¹ or degree of functional impairment².

	Left Ventricular Ejection Fraction
Heart Failure with Reduced Ejection Fraction (HF-REF)	≤40%
Heart Failure with Moderately Reduced Ejection Fraction (HFmrEF)	41%-49%
Heart Failure with Preserved Ejection Fraction (HF-PEF)	≥50%

New York Heart Association (NYHA) Functional Classification:

Class		Description
I	No limitation of physical activity	Ordinary physical activity does not cause undue fatigue, palpitation, shortness of breath
II	Slight limitation of physical activity	Ordinary physical activity results in fatigue, palpitation, shortness of breath
III	Marked limitation of physical activity	Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or shortness of breath
IV	Unable to carry on any physical activity without discomfort	Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases

References

1)National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management 2025 [Internet]. [London]: NICE; 2025. (NICE guideline [NG106])

2)Dolgin M, Association NYH, Fox AC, Gorlin R, Levin RI, New York Heart Association. Criteria Committee. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Lippincott Williams and Wilkins; March 1, 1994

Untreated, heart failure is progressive and carries a poor prognosis:

before modern treatments, 5-year survival rates were 30-40%¹
prognosis is complex, and depends on age, setting, sex and other factors

These selected figures are a guide, though there is significant uncertainty:

survival rates in the context of standard care at the time
they combine data on both HF-REF (reduced) and HF-PEF (preserved) ejection fraction

Overall survival rates

Survival rates at:	1 year	5 years	10 years	15 years
	81%	48%	26%	13%
Year of initial diagnosis*	2016	2012	2007	2000

* Defined by first recorded clinical code

Source: UK Primary Care database study 2019²

Survival rates by age at diagnosis

HF-PEF and HF-REF combined

Survival rates at:	1 year	5 years	10 years	15 years
Age: 45-54 years	90%	79%	65%	54%
55-64	88%	71%	52%	38%%
65-74	84%	59%	35%	17%
75-84	77%	43%	18%	6%
85-94	63%	22%	4%	0.2%
≥95	44%	6%	–	–

Source: UK Primary Care database study 2019²

Survival rates for HF-REF v HF-PEF v LVSD without HF

HF-REF carries a worse prognosis than HF-PEF

Survival rate at:	5 years	10 years
HF-REF	53%	27%
HF-PEF	62%	26%
LVSD* ≤40% but no HF	69%	38%

* LVSD, left ventricular systolic dysfunction

Source: UK Primary Care cohort study 2014³

patients identified from UK primary care lists and pro-actively screened to assess for heart failure and asymptomatic LVSD
diagnosed between: 1995 and 1999, followed up until 2009

Similar differences are seen in studies around the world over time:

Survival rate at:	5 years
HF-REF	63%
HF-PEF	70%

Source: Systematic review 2019¹(pools data from studies 1987-2017)

Survival rates by NT-proBNP level

HF-PEF and HF-REF combined

Survival rate at:	1 year	5 years	10 years
NT-proBNP*: <400	79%	54%	30%
400-1999	81%	50%	24%
≥2000	73%	38%	18%

* NT-proBNP measured at time of diagnosis, pg/ml.

Source: UK Primary Care database study 2020⁴

Survival rates by diagnosis at hospital admission v community

HF-PEF and HF-REF combined

Survival rates are worse for those first diagnosed during acute hospital admission:

Survival rate at:	1 year	5 years	10 years	15 years
Diagnosed in community	81%	52%	29%	15%
Diagnosed at hospital admission	69%	37%	18%	8%

Source: UK Primary Care database study 2019²

Survival rates men v women

Age adjusted mortality rates are roughly the same for men and women.
However, women are diagnosed on average 5 years older than men, so have higher crude mortality rates⁵.

References

1)Jones NR, Roalfe AK, Adoki I et al. Survival of patients with chronic heart failure in the community: a systematic review and meta-analysis. Eur J Heart Fail 2019; 21: 1306-1325

2)Taylor CJ, Ordóñez-Mena JM, Roalfe AK et al. Trends in survival after a diagnosis of heart failure in the United Kingdom 2000-2017: population based cohort study. BMJ 2019; 364 :l223

3)Taylor CJ, Roalfe AK, Iles R, Hobbs FR. Ten-year prognosis of heart failure in the community: follow-up data from the Echocardiographic Heart of England Screening (ECHOES) study. Eur J Heart Fail 2012; 14: 176-184

4)Taylor CJ, Lay-Flurrie SL, Ordóñez-Mena JM et al. Natriuretic peptide level at heart failure diagnosis and risk of hospitalisation and death in England 2004–2018 Heart 2022 Apr; 108(7): 543-549

5)Taylor CJ, Ordóñez-Mena JM, Jones NR et al. National trends in heart failure mortality in men and women, United Kingdom, 2000–2017. Eur J Heart Fail 2021; 23: 3-12

Treatment options:

Diuretics

Loop diuretics reduce symptoms and signs of fluid overload.

Many patients may need to remain on a maintenance dose, though these do not need to be continued once fluid overload has resolved and if it does not recur.

Long-term therapies

SGLT2inhibitors and MRAs now have evidence of benefits on prognosis and are recommended as options to consider for those with HF-PEF in the 2025 NICE guideline
(ACE inhibitors and betablockers do not have evidence of benefit on long-term prognosis)

Managing co-morbidities

Optimising the management of general cardiovascular risk factors is advised, as this improves prognosis overall, though there is no evidence of a direct effect on the progression of HF-PEF itself.

Optimising management of other co-morbidities such respiratory disease or angina may improve general symptoms such as breathlessness and exercise tolerance.

NICE recommends SGLT2 inhibitors as an option for treating symptomatic chronic heart failure with preserved ejection fraction:

The data below describes evidence about empagliflozin, but dapagliflozin has an equal effect.

Patient characteristic

Reduce risk of:

No treatment

With treatment

ARR -- Absolute Risk Reduction

NNT -- Number Needed to Treat

RRR -- Relative Risk Reduction

No treatment

11.7 people are hospitalised for heart failure over 2 years

With treatment

8.6 people are hospitalised for heart failure over 2 years

ARR 3.1% Absolute Risk Reduction

NNT 32 Number Needed to Treat

RRR 26.5% Relative Risk Reduction

If 100 people like this take empagliflozin for 2 years, 3.1 will avoid hospitalisation for heart failure compared with those who do not take empagliflozin

No treatment

8.2 people have a cardiovascular death over 2 years

With treatment

7.3 people have a cardiovascular death over 2 years

ARR 0.9% Absolute Risk Reduction

NNT 118 Number Needed to Treat

RRR 10.4% Relative Risk Reduction

If 100 people like this take empagliflozin for 2 years, 0.9 will avoid a cardiovascular death compared with those who do not take empagliflozin

No treatment

17.1 people with have a HHF or cardiovascular death over 2 years

With treatment

13.8 people with have a HHF or cardiovascular death over 2 years

ARR 3.2% Absolute Risk Reduction

NNT 31 Number Needed to Treat

RRR 19% Relative Risk Reduction

If 100 people like this take empagliflozin for 2 years, 3.2 will avoid hospitalisation for heart failure or cardiovascular death compared with those who do not take empagliflozin

Evidence Source: NICE

Evidence Quality: HIGH

Study Population

SGLT2 inhibitors in CKD

SGLT2 inhibitors in T2DM

The EMPEROR-Preserved trial¹ (which provides the data on benefits here), showed no increase in the following adverse events with empagliflozin treatment:

renal adverse events
hypoglycaemia
diabetic ketoacidosis

Other harms were reported in this trial:

	Placebo	Empagliflozin	Absolute Risk Increase	Number Needed to Harm
Symptomatic hypotension	5.2%	6.6%	1.4%	71
Urinary tract infections	8.1%	9.1%	1%	100
Discontinuation of treatment due to side effects	18.4%	19.1%	0.7%	142

note: these are absolute figures and were not reported with any calculation of statistical significance

However, this was one trial in a particular population:

See the sections on SGLT2 inhibitors in CKD and T2DM for further information on harms in these populations.

Reference

1) EMPEROR-Preserved Trial Investigators. Empagliflozin in Heart Failure with a Preserved Ejection Fraction. N Engl J Med 2021; 385:1451-1461

MRAs have been shown to reduce hospital admissions in patients with HF-PEF

reductions in mortality of approximately 1% ARR were seen in the 2025 NICE evidence review, though these failed to reach statistical significance

Patient characteristic

Reduce risk of:

No treatment

12.1 people are hospitalised for heart failure over 3 years

With treatment

9.6 people are hospitalised for heart failure over 3 years

ARR 2.5% Absolute Risk Reduction

NNT 40 Number Needed to Treat

RRR 21% Relative Risk Reduction

If 100 people like this take an MRA for 3 years, 2.5 will avoid hospitalisation compared with those who do not take an MRA

Evidence Source: NICE

Evidence Quality: MODERATE

Study Populations

Stats explained

These three statistical terms offer three different ways of looking at the results of trial data.

ARR

Absolute Risk Reduction

This tells you how many people out of 100 who take a treatment have an adverse event prevented.

The value of the ARR changes with the baseline risk of the person (or population) taking the treatment. The higher the starting risk, the greater the absolute chance of benefit.

You need to think about over what time the trial data show this benefit, as it is usually assumed that more absolute risk reduction is gained over time.

Your patient might be taking the treatment for much longer than the length of a clinical trial (or, if life expectancy is limited, perhaps for less time).

NNT

Number Needed to Treat

This tells you how many people need to take the treatment in order for one person to avoid an adverse event.

The lower the number, the more effective the treatment.

The value of the NNT changes with the baseline risk of the person (or population) taking the treatment. The higher the starting risk, the smaller the NNT.

You need to think about over what time the trial data show benefit, as it is usually assumed that more benefit is gained over time and therefore the NNT will drop over time.

Your patient might be taking the treatment for much longer than the length of a clinical trial (or, if life expectancy is limited, perhaps for less time).

RRR

Relative Risk Reduction

This tells you the proportion of adverse events that are avoided if the entire population at risk is treated.

The value of the RRR is usually constant in people (or populations) at varying degrees of risk.

It is also usually assumed to stay constant over time.

This can be helpful, especially when thinking about population outcomes, but can be misleading for an individual person:

For example, a RRR of 25% in someone with a baseline risk of 40% would give them an ARR of 10% and an NNT of 10.

A RRR of 25% in someone with a baseline risk of 4% would give them an ARR or 1% and an NNT of 100.

Conditions

Heart Failure with Preserved Ejection Fraction

Treatment options:

If 100 people like this take empagliflozin for 2 years, 3.1 will avoid hospitalisation for heart failure compared with those who do not take empagliflozin

If 100 people like this take empagliflozin for 2 years, 0.9 will avoid a cardiovascular death compared with those who do not take empagliflozin

If 100 people like this take empagliflozin for 2 years, 3.2 will avoid hospitalisation for heart failure or cardiovascular death compared with those who do not take empagliflozin

Evidence Source: NICE

Evidence Quality: HIGH

Study Population

If 100 people like this take an MRA for 3 years, 2.5 will avoid hospitalisation compared with those who do not take an MRA

Evidence Source: NICE

Evidence Quality: MODERATE

Study Populations

Key

Stats explained

ARR

NNT

RRR

GP Evidence