Revista Clinica Espanola · Nov 2026
SEMI 2026 Guidelines for the diagnosis and treatment of heart failure with preserved ejection fraction. Developed by the Heart Failure and Atrial Fibrillation Working Group of the Spanish Society of Internal Medicine (SEMI)
By Quirós-López R, Formiga F, González-Franco A et al.
This clinical practice guideline (CPG) from the Spanish Society of Internal Medicine provides a comprehensive approach to the diagnosis and treatment of heart failure with preserved ejection fraction (HFpEF) in adults. Developed using GRADE methodology, it is intended for use across levels of care, with particular attention to older people, people with frailty and those with multimorbidity. The diagnosis of HFpEF requires an integrated assessment of clinical, laboratory and imaging findings. Algorithms such as H₂FPEF and HFA-PEFF may facilitate this process, but do not replace clinical judgement. Patient assessment must be multidimensional, with particular attention to congestion, comorbidities, nutritional status, cognition, frailty, sarcopenia, functional capacity and social determinants. This CPG recommends diuretics to control congestion and SGLT2 inhibitors as the pharmacological treatment with the most consistent supporting evidence. It also recommends finerenone to reduce worsening heart failure events and reserves sacubitril/valsartan for selected patients. Semaglutide and tirzepatide are particularly relevant to the HFpEF-obesity phenotype. For non-pharmacological management, the CPG provides recommendations on supervised exercise, weight reduction, vaccination, self-care and palliative care. It also highlights the appropriate identification of patients with cardiac amyloidosis and initiation of specific treatment when indicated. Comprehensive management of comorbidities is a central component and requires a multidisciplinary, person-centred approach. Appropriate management of HFpEF requires the active involvement of nursing staff, whose role is fundamental in health education, promotion of self-care, treatment adherence and clinical follow-up. Overall, this CPG aims to provide a practical, comprehensive framework to improve care for people with HFpEF.