IIb B The use of ARBs might be considered to decrease hospitalizations for patients with HFpEF.169 2013 recommendation remains current. III: No Benefit B-R Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QoL in patients with HFpEF is ineffective.171,172 NEW: Current recommendation reflects new data from RCTs. See Online Data Supplement C. Nitrate therapy can reduce pulmonary congestion and improve exercise tolerance in patients with HFrEF. However, the NEAT-HFpEF (Nitrate s Effect on Activity Tolerance in Heart Failure With Preserved Ejection Fraction) trial171 randomized 110 patients with EF 50% on stable HF therapy, not including nitrates, and with activity limited by dyspnea, fatigue, or chest pain, to either isosorbide mononitrate or placebo and found no beneficial effects on activity levels, QoL, exercise tolerance, or NT-proBNP levels. On the basis of this trial, routine use of nitrates in patients with HFpEF is not recommended. This recommendation does not apply to patients with HFpEF and symptomatic CAD for whom nitrates may provide symptomatic relief. Phosphodiesterase-5 inhibition augments the nitric oxide system by upregulating cGMP activity. The RELAX (Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Heart Failure with Preserved Ejection randomized 216 patients with EF 50% on stable HF therapy and with reduced exercise tolerance (peak observed Vo2 <60% of predicted) to phosphodiesterase-5 inhibition with sildenafil or placebo. This study did not show improvement in oxygen consumption or exercise tolerance. III: No Benefit C Routine use of nutritional supplements is not recommended for patients with HFpEF. 2013 recommendation remains current. 9. IMPORTANT COMORBIDITIES IN HF 9.2. 