Implementation of guideline-directed medical therapy in patients with heart failure and obesity: European Journal of Heart Failure expert consensus document

Obesity is prevalent among patients with heart failure (HF), especially in those with preserved ejection fraction (HFpEF), and complicates diagnosis, therapy, and monitoring. It alters haemodynamics, biomarker interpretation, and drug pharmacokinetics, potentially influencing treatment response. Evidence from subgroup analyses of major HF trials suggests that renin-angiotensin system inhibitors (mainly sacubitril-valsartan), mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors provide consistent benefits across body mass index (BMI) categories, with no major obesity-specific safety concerns. In contrast, data on beta-blockers in obese HF patients remains limited, largely reflecting the older design of pivotal trials. Management should include careful assessment of congestion, acknowledging the limitations of physical examination, and integrate natriuretic peptides measurement and imaging evaluation to guide individualised diuretic strategies. This expert consensus provides a comprehensive and pragmatic framework for the use of guideline-directed medical therapy in patients with HF and obesity, exploring the available evidence for each drug class and addressing efficacy, patient selection, safety, and monitoring.