New ACC Pathway Refines HFpEF Care

The American College of Cardiology (ACC) issued a revised expert consensus decision pathway for the management of heart failure with preserved ejection fraction (HFpEF), updating its 2023 document with recent evidence and revised treatment algorithms. Published in JACC, the pathway provides practical guidance on diagnosis, pharmacologic and nonpharmacologic therapy, and management of comorbidities.

ACC describes HFpEF as a complex, multisystem syndrome associated with visceral adiposity, inflammatory adipokines, metabolic dysfunction, and distinct phenotypic subgroups. The pathway advises clinicians to identify characteristic symptoms and signs, consider cardiac and noncardiac mimics, and use diagnostic scoring systems when appropriate. It also cautions that normal natriuretic peptide levels alone do not exclude HFpEF.

For medical therapy, the pathway identifies sodium-glucose cotransporter-2 (SGLT2) inhibitors as the cornerstone of HFpEF treatment. Randomized trials of dapagliflozin and empagliflozin showed reductions in the combined risk of heart failure hospitalization and cardiovascular death, along with improvements in health status and quality of life. The committee said finerenone should be considered the mineralocorticoid receptor antagonist of choice, with spironolactone a reasonable alternative when cost or tolerability is limiting.

For patients with HFpEF and a body mass index (BMI) of at least 30kg/m², the pathway states that semaglutide or tirzepatide may improve health status and exercise function and potentially reduce worsening heart failure events. The authors also recommend exercise and nutritional support with incretin-based therapy to reduce the risk of sarcopenic obesity and preserve or increase muscle mass and function.

The pathway emphasizes accurate diagnosis, early initiation and titration of therapy, and management of coronary artery disease, atrial fibrillation, hypertension, chronic kidney disease, diabetes, and obesity. The authors noted that the document does not replace clinical judgment and that its recommendations may change as evidence evolves.

Source: Kittleson MM, Panjrath GS, Bates K, et al. Management of heart failure with preserved ejection fraction: 2026 ACC expert consensus decision pathway. J Am Coll Cardiol. 2026. doi:10.1016/j.jacc.2026.06.018