Heart Failure With Preserved Ejection Fraction: A Practical, Stepwise Guide to Evidence-Based Therapy in 2026

Heart failure with preserved ejection fraction (HFpEF) represents a large and growing share of the overall heart failure population and remains clinically challenging to manage. HFpEF has historically lacked effective therapies and a clear treatment algorithm accessible to non-specialists. Recent years have brought new pharmacologic options and expanded regulatory approvals, along with combination-therapy modeling suggesting meaningful projected lifetime benefit, yet translation of this evidence into everyday practice remains slow, particularly outside cardiology. Existing reviews synthesizing this evidence are predominantly specialist-oriented, lengthy, and organized by drug class rather than by clinical decision point, leaving a gap for the residents, hospitalists, internists, and primary care physicians who manage most patients with HFpEF. This technical report presents a concise, phenotype-guided, four-step treatment framework, informed by contemporary trial evidence and situated alongside current guideline pathways, together with a brief diagnostic checkpoint, a summary evidence table, and a discussion of common pitfalls, to facilitate rapid clinical application. This framework is an author-derived synthesis rather than a prospectively validated or guideline-endorsed treatment sequence.