6th May 2025

Pharmacological therapy

Heart failure with preserved ejection fraction (HFpEF) 

No pharmacological therapies have been shown to benefit HFpEF. Treatment is focused on managing comorbidities such as atrial fibrillation, hypertension, diabetes and ischemic heart disease and encouraging lifestyle modifications, including smoking cessation, moderate alcohol use, healthy dietary habits and maintaining an active lifestyle. Patients should also be offered a personalised exercise-based cardiac rehabilitation programme. 

Heart failure with reduced ejection fraction (HFrEF) 

Heart failure patients should be commenced on an ACE-inhibitor and a beta-blocker, which have both been shown to reduce mortality in heart failure. If the patient remains symptomatic following these medications, a mineralocorticoid receptor antagonist (MRA) can be added to the regime. If patients are unable to tolerate ACE-inhibitors or an ARB, they can be offered hydralazine and nitrates. 

If symptoms persist despite the medications above, the patient should be referred for specialist advice and can be commenced on one of the medications specified in Figure 1.

Sodium-glucose co-transporter-2 (SGLT-2) inhibitors

In 2019, a landmark trial on the use of dapagliflozin in patients with heart failure (DAPA-HF) showed that SGLT-2 inhibitors reduced cardiovascular morbidity and mortality in patients with heart failure independent of their diabetes status. This has been reflected in the NICE guidance for type 2 diabetes control where SGLT-2 inhibitors are preferentially selected in patients who are comorbid with diabetes and heart failure. Please note: the NICE guidance for heart failure in 2018 does not comment on the routine initiation of SGLT-2 inhibitors.

Table 6: Common side effects of heart failure medications and drug monitoring.