1. We suggest that in individuals with HFpEF, an increased NP level, serum potassium < 5.0 mmol/L and an estimated glomerular filtration rate (eGFR) ≥ 30 ml/min, a mineralocorticoid receptor antagonist like spironolactone should be considered, with close surveillance of serum potassium and creatinine. (Weak Recommendation, Low-Quality Evidence).

Values and Preferences: This recommendation is based on a prespecified subgroup analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, which includes analysis of the predefined outcomes according to admission NT-proBNP level, and the corroborating portion of the trial conducted within North and South America.

Practical Tip: After spironolactone is started and with a change in dose, serum potassium and creatinine should be monitored in the first week, fourth week, and then fourth month, and whenever clinically indicated. In practice, spironolactone is available in 25-mg tablets. The dose to use will therefore be 25-50 mg per day.