Chlorthalidone as Secondary Treatment in HFpEF?

This review addresses important issues that face practitioners today concerning the treatment of heart failure with preserved ejection fraction (HFpEF). It points out how the accepted efficacy of HFpEF medication treatment has changed. Medications are now recommended for use in HFpEF that have diuretic properties and are significant because of a reduction in the frequency of the development of heart failure (not mortality). This heart failure incidence reduction appears predictable and is valuable, but it raises the question of the use of chlorthalidone in the treatment of HFpEF. Chlorthalidone has previously been demonstrated to reduce heart failure incidence in the treatment of hypertensive patients, which is a similar patient population. Chlorthalidone, possibly with a generic mineralocorticoid antagonist, could be an acceptable low-cost alternate therapy as secondary treatment for HFpEF. Of course, chlorthalidone does not have the other theoretic benefits of the sodium-glucose cotransporter 2 (SGLT2) inhibitors or finerenone. It would be helpful if this was discussed in the upcoming HFpEF guidelines, especially for use in patients who cannot afford or tolerate the new HFpEF medications.