In a patient with heart failure and preserved ejection fraction whose A1C is well-controlled, what would be the most appropriate additional therapy?

In patients with heart failure and preserved ejection fraction (HFpEF), it is essential to manage both the heart failure symptoms and any comorbid conditions, such as diabetes. In this scenario, where the patient's A1C is well-controlled, the addition of sacubitril/valsartan is considered the most appropriate therapy due to its efficacy in managing heart failure symptoms.

Sacubitril/valsartan is a combination of an angiotensin receptor blocker (valsartan) and a neprilysin inhibitor (sacubitril). This combination has been shown to significantly reduce hospitalization rates and mortality in patients with heart failure with reduced ejection fraction, and while its primary benefits are established in that population, there may be nuances in treating HFpEF. Emerging data suggest that beyond traditional therapies, neprilysin inhibition may contribute beneficial effects in patients with HFpEF as well, especially related to symptom management and functional capacity improvement.

The addition of spironolactone is valid in heart failure management, particularly in cases with fluid retention or those with significant blood pressure issues; however, its role is more aligned with certain types of heart failure rather than with patients whose ejection fraction is preserved. Likewise, while beta-blockers are beneficial