In heart failure with preserved ejection fraction not adequately controlled by furosemide, which drug would be recommended?

• A. Metoprolol
• B. Dapagliflozin
• C. Spironolactone
• D. Ramipril

Answer: (B)

In HFpEF, once diuretic therapy like furosemide no longer controls symptoms, therapies with proven heart-failure outcomes become the focus, not just symptom relief. Dapagliflozin, an SGLT2 inhibitor, has robust trial data showing a real reduction in heart-failure hospitalizations and cardiovascular risk in HFpEF, even in patients without diabetes. It helps alleviate congestion, provides renal benefits, and improves overall outcomes in this group, making it a strong, guideline-supported option when fluid overload remains.

Metoprolol can help with rhythm or rate control in some patients, but it hasn’t shown a clear, consistent outcome benefit in HFpEF as a disease-modifying therapy. Ramipril (an ACE inhibitor) and spironolactone have smaller or mixed evidence in HFpEF; spironolactone may be considered in select patients with symptoms and elevated natriuretic peptides, but the stronger, more consistent evidence in HFpEF recently comes from SGLT2 inhibitors like dapagliflozin.