Recommendation 46: We suggest candesartan be considered to reduce heart failure hospitalizations in patients with HFpEF (Weak Recommendation, Moderate Quality Evidence).

Recommendation 47: We recommend systolic/diastolic hypertension be controlled according to current CHEP hypertension guidelines (guidelines.hypertension.ca) (2017) to prevent and treat HFpEF (Strong Recommendation, High Quality Evidence).

Recommendation 48: We recommend loop diuretics be used to control symptoms of congestion and peripheral edema (Strong Recommendation, Moderate Quality Evidence).

Recommendation 49: We suggest that in individuals with HFpEF, serum potassium < 5.0 mmol/L, and an estimated glomerular filtration rate (eGFR) > 30 mL/min, a MRA like spironolactone should be considered, with close surveillance of serum potassium and creatinine (Weak Recommendation, Moderate Quality Evidence).

• These recommendations place a high value on the known etiologic factors for HFpEF and less on known outcome-modifying treatments which, unlike in HFrEF, are still limited.
• The MRA recommendation is based on the post-hoc geographic subgroup analyses of the TOPCAT trial conducted within North and South America mentioned above.

• Excessive diuretic use can lead to decreased cardiac output and compromise of renal function. Every attempt should be made to use the lowest possible dose of diuretic to achieve and maintain euvolemia.
• There is insufficient quality of data to provide strong recommendations regarding statin therapy in HFpEF, so the decision to treat should be customized and based on existing guidelines for primary and secondary prevention of cardiovascular disease.
• After an MRA or ARB is initiated 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.