Unfortunately, clinical trials in HFpEF to date have not identified any specific treatment to improve prognosis. The aim of treatment is to control the patient’s symptoms of heart failure and ensure good management of co-morbidities that may co-exist, such as hypertension, atrial fibrillation, chronic kidney disease or diabetes.

Diuretics are commonly prescribed to manage fluid overload. This is usually a loop diuretic such as furosemide or bumetanide, with the dose titrated to the minimum dose required to control symptoms and careful monitoring of renal function and electrolytes. They may be stopped or the dose reduced as the congestion resolves. However, in resistant cases where diuresis is difficult, more specialist management may involve adding a thiazide diuretic such as bendroflumethiazide 2.5mg every day, or perhaps only on alternate days, for a short period. 

It is always worth checking patient adherence as diuretics can have significant effects on quality of life and patients may choose to omit doses if they are interfering with their daily activities or causing nocturnal symptoms.

Daily weights are a good measure of fluid loss and patients should aim for a weight loss of no more than 0.5-1.0kg a day as rapid diuresis may result in acute kidney injury. 

Electrolyte loss is also common, which can limit their use. Failure to respond to combinations of loop and thiazide diuretics, hyponatraemia, worsening renal impairment or ongoing weight gain (indicating further fluid retention) would warrant specialist input and may require admission to hospital or a day care unit for intravenous diuretics.