ACC Expert Consensus Decision Pathway Updates HFpEF Definition, Diagnosis & Treatment

Released on July 23, 2026, the most recent update to the American College of Cardiology (ACC) Expert Consensus Decision Pathway (EDCP) aims to redefine, recategorize, and reestablish treatment criteria for heart failure with preserved ejection fraction (HFpEF).1,2

In an interview with HCPLive at the Heart Failure Society of America (HFSA) Annual Scientific Meeting 2026, James Januzzi, MD, chief scientific officer and C. Michael Gibson Chair in Medicine at the Baim Institute for Clinical Research and Adolph Hutter Professor of Medicine at Harvard Medical School and co-author of the new guidelines, discusses their implications for HFpEF care moving forward.

“In the document, we acknowledge that heart failure with preserved ejection fraction is unique compared to other forms of heart failure, such as reduced ejection fraction,” Januzzi told HCPLive. “We argued that clinicians need to take a very careful look at each patient on an individual level before deciding on specific therapeutic interventions.”

The original EDCP was published in 2023 – the present update shifts the definition of HFpEF from an individual cardiac condition to a multisystem syndrome driven by inflammatory pathways, visceral adiposity, and metabolic dysfunction. Additionally, the document highlights the distinct patient phenotypes prevalent in HFpEF and the individualized care required for these groups.1

Among the key components of the new guideline is the critical importance of accurate diagnoses. Januzzi and colleagues provide a structured approach to evaluating patients, composed of 3 main steps: identifying patients with possible HFpEF based on characteristic signs and symptoms, assessing for HFpEF noncardiac and cardiac mimics, and implementing an HFpEF management plan incorporating comorbidities and nonpharmacologic management in addition to optimal medical therapy.1,2

Additionally, the document provides an extensive list of potential cardiac and noncardiac mimics, recommending a diagnostic evaluation for each potential confounder to eliminate the possibility of HFpEF. These mimics can range from kidney disease, obesity, and pulmonary disease on the noncardiac side to aortic stenosis, ischemic heart disease, and cardiac amyloidosis.1

Following diagnosis, the document offers a variety of guidelines regarding treatment and medication. Part of the impetus for the update was additional research conducted in the years following the 2023 release – this includes positive trial data supporting the use of SGLT2 inhibitors, nonsteroidal mineralocorticoid receptor agonists, and incretin-based therapies like GLP-1 receptor agonists. The new guidelines recommend dosing and titration strategies for a wide range of medications in each of these classes.1,2

However, Januzzi places a significant amount of importance on the diagnostic process itself. Given the long list of potential causes of HFpEF, he stresses that underdiagnosis is a prevalent threat as components of HFpEF are addressed individually rather than seeing the bigger picture.

“I would argue that underdiagnosis is probably more of a concern than overdiagnosis, given the fact that a person who has dyspnea, atrial fibrillation, and obesity, even before we start off with diagnostic testing, most likely has heart failure with preserved ejection fraction,” Januzzi said. “Clinicians therefore really need to have a high index of suspicion for the presence of heart failure because treatment in that situation can improve quality of life and functional capacity and can potentially reduce mortality and hospitalization risk.”

Editors’ Note: Januzzi reports disclosures with Abbott Laboratories, AbbVie, Inc., Eli Lilly, AstraZeneca Pharmaceuticals, Jana Care, Siemens, and others.

References

1. Kittleson MM, Panjrath GS, Bates K, et al. Management of heart failure with preserved ejection fraction: 2026 ACC expert consensus decision pathway. JACC. 2026;88(15):1817-1846. doi:10.1016/j.jacc.2026.06.018

2. American College of Cardiology. Updated ACC Expert Consensus Decision Pathway Addresses Management of HFpEF. ACC. July 23, 2026. Accessed October 14, 2026. https://www.acc.org/latest-in-cardiology/journal-scans/2026/07/22/17/25/updated-acc-ecdp-addresses-management-of-hfpef