The American College of Cardiology (ACC) has published an updated 2026 Expert Consensus Decision Pathway (ECDP) for the management of heart failure with preserved ejection fraction (HFpEF), replacing the 2023 version.1
The document, chaired by Michelle M. Kittleson, MD, PhD, reframes HFpEF as a multisystem syndrome driven by visceral adiposity, inflammatory adipokines, and metabolic dysfunction rather than a single cardiac condition. The update incorporates new trial data on sodium-glucose cotransporter 2 (SGLT2) inhibitors, nonsteroidal mineralocorticoid receptor antagonists (MRAs), and incretin-based therapies.1
The revision responds to a rapidly evolving therapeutic landscape since 2023, when finerenone, semaglutide, and tirzepatide lacked HFpEF-specific outcomes data. According to the ACC, these agents now offer benefits extending beyond heart failure to broader cardiovascular, kidney, and metabolic health. The writing committee positions accurate diagnosis as a prerequisite for guideline-based therapy, given persistent underrecognition of HFpEF in practice.2
The ECDP outlines three validated scoring systems for establishing diagnostic probability in patients presenting with dyspnea or edema: H2FPEF, HFA-PEFF, and HFpEF-ABA. The writing committee recommends H2FPEF as an initial screening tool followed by HFA-PEFF for confirmation, noting that discordance between the two can prompt further advanced testing. Each carries distinct tradeoffs: H2FPEF offers greater accuracy with fewer input variables and higher sensitivity, while HFA-PEFF is more specific but often requires diastolic stress testing or invasive hemodynamics rarely feasible in routine practice.1
Beyond scoring, the pathway calls for systematic exclusion of noncardiac mimics, including pulmonary disease, kidney disease, high-output states, obesity, and frailty, along with cardiac mimics such as valvular disease, pericardial constriction, infiltrative cardiomyopathies, and ischemic heart disease, before confirming HFpEF as a diagnosis of exclusion. The document also details sex-specific differences in presentation. Women with HFpEF show lower natriuretic peptide levels, greater concentric left ventricular remodeling, and worse symptom burden compared with men.1
Optimal medical therapy and comorbidity management in HFpEF
For pharmacotherapy, the ECDP designates an SGLT2 inhibitor plus a nonsteroidal MRA as foundational treatment for most patients, unless contraindicated, based on evidence from DELIVER, EMPEROR-Preserved, and FINEARTS-HF. Finerenone, which received US Food and Drug Administration approval in July 2025 for patients with left ventricular ejection fraction of 40% or higher, is now favored over spironolactone as the mineralocorticoid antagonist of choice, given its improved hyperkalemia profile. For patients with a body mass index of 30 kg/m² or higher, the pathway recommends incretin-based therapy with semaglutide or tirzepatide, citing STEP-HFpEF and SUMMIT.1
Sacubitril-valsartan is positioned as a reasonable option in women and patients with an ejection fraction below 55% to 60%, based on subgroup findings from PARAGON-HF, while angiotensin receptor blockers serve as an alternative when angiotensin receptor-neprilysin inhibitors are unavailable or contraindicated. The committee advises against routine beta-blocker use absent angina or atrial fibrillation rate control, citing risk of chronotropic incompetence. Comorbidity management extends to coronary artery disease, atrial fibrillation, hypertension, chronic kidney disease, diabetes, and obesity, with a systolic blood pressure target of 120 to 129 mm Hg identified as optimal for HFpEF.1
“In the interim, this ECDP addresses contemporary management of HFpEF,” Kittleson and colleagues wrote. The authors add the pathway provides structure for clinical decision-making as pharmacologic and nonpharmacologic evidence continues to accumulate.1
The ECDP notes several device-based interventions, including atrial shunt devices, splanchnic nerve ablation, and permanent pacing, have not shown consistent benefit and remain under evaluation. The document operates within the framework of the 2022 AHA/ACC/HFSA heart failure guideline while incorporating trial evidence unavailable at that guideline's publication.1
References
Kittleson MM, Panjrath GS, Bates K, et al. Management of heart failure with preserved ejection fraction: 2026 ACC expert consensus decision pathway: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Published online July 23, 2026. doi:10.1016/j.jacc.2026.06.018
