A 74-year-old woman with HFpEF and multiple comorbidities has been optimising treatment. Which addition would be most appropriate?

• A. Empagliflozin 10mg daily
• B. Lisinopril 20mg daily
• C. Spironolactone 25mg daily
• D. Hydrochlorothiazide 25mg daily

Answer: (A)

In HFpEF, drugs that consistently improve long-term outcomes across diverse patients are SGLT2 inhibitors. Empagliflozin has shown a clear reduction in the composite of cardiovascular death and heart failure hospitalization in HFpEF, and importantly this benefit occurs regardless of diabetes status. For an older patient with multiple comorbidities, this means not only better symptom management but a real prognostic improvement with a well-tolerated safety profile when monitored appropriately.

ACE inhibitors like lisinopril are useful for blood pressure and some patients with HFpEF, but the strongest mortality and hospitalization benefits proven in trials are not as robust for HFpEF as for HFrEF. Spironolactone has some signals in HFpEF but the overall results are inconsistent, so it’s not as reliably beneficial in this setting. A thiazide diuretic can help with edema but does not offer the cardiovascular outcome improvements that an SGLT2 inhibitor provides.

So, starting an SGLT2 inhibitor such as empagliflozin is the most appropriate addition for this patient.