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p=0.017) over a median follow-up of 36.6 months.84) However, these findings were not validated in the I-PRESERVE trial, which showed no impact of irbesartan on the primary composite endpoint of cardiovascular death or cardiovascular hospitalisation in 4,128 patients with symptomatic HF and EF 45% over a mean follow-up of 49.5 months.85) Accordingly, renin-angiotensin system inhibitors have no specific indication for HFpEF in the latest ESC guidelines, whereas the 2022 AHA/ACC/HFSA guidelines support consideration of ARBs (class IIb B-R) to reduce hospitalisations, particularly among patients with EF closer to the lower limit of the preserved range.20, 72) MRAs The steroidal MRAs spironolactone and eplerenone constitute a key pharmacological therapy in HFrEF, based on landmark trials such as RALES and EMPHASIS-HF.86, 87) They have received respective class I A treatment recommendations by the ESC and the AHA/ACC/HFSA guidelines on the treatment of HF.53, 72) The role of steroidal MRAs in HFpEF remains uncertain and subject to ongoing debate

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