The updated 2026 ACC Expert Consensus Decision Pathway (ECDP) for the Management of Heart Failure With Preserved Ejection Fraction (HFpEF) reflects a significant evolution in how HFpEF is understood and treated. The document recognizes that HFpEF is no longer viewed as a single cardiac condition, but rather as a complex, multisystem syndrome driven by visceral adiposity, inflammatory pathways, and metabolic dysfunction, with distinct patient phenotypes requiring individualized care. Read the full document in JACC.

New Evidence
Prompted by major advances in the field since the original ECDP published in 2023, the new document includes positive clinical trial data supporting SGLT2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists (MRAs), and incretin-based therapies. Importantly, these therapies offer benefits that extend beyond heart failure to broader cardiovascular, kidney, and metabolic health, underscoring the need for earlier recognition and treatment of HFpEF.

Accurate Diagnosis
A central theme of the ECDP is the critical importance of accurate diagnosis. The document provides a structured approach to evaluating patients with symptoms such as dyspnea and edema, incorporating differential diagnosis, diagnostic scoring systems, assessment of HFpEF mimics, and sex-specific considerations. The goal is to ensure patients are correctly identified and receive evidence- and guideline-based therapies as early as possible.

Comprehensive Management
On the management side, the ECDP offers practical guidance on implementing optimal medical therapy, including the use and titration of SGLT2 inhibitors, MRAs, incretin-based therapies, angiotensin receptor-neprilysin inhibitors, angiotensin receptor blockers, diuretics, and beta-blockers. It also highlights the importance of nonpharmacologic interventions, including exercise and caloric restriction, and provides a framework for addressing common HFpEF-related comorbidities. Additionally, it emphasizes comprehensive management of conditions frequently associated with HFpEF, including coronary artery disease, atrial fibrillation, hypertension, chronic kidney disease, diabetes mellitus and obesity.

"As science evolves and further discoveries and developments occur, some of these recommendations may need to be altered to reflect those advances," write the authors, led by Chair Michelle M. Kittleson, MD, PhD, FACC, and Vice Chair Gurusher S. Panjrath, MBBS, FACC. "In the interim, this ECDP addresses contemporary management-of HFpEF. It provides practical tips and structure on clinical decision-making, implementation of the latest advancements in pharmacologic and nonpharmacologic therapy, and management of comorbidities."