This 2026 ACC Expert Consensus Decision Pathway (ECDP) updates the 2023 version, providing practical guidance on the diagnosis and management of HFpEF, including optimal medical therapy (SGLT2 inhibitors, nonsteroidal MRAs, incretin-based therapies, ARNIs, ARBs), nonpharmacologic strategies, device therapy, and comorbidity management.
Key updates emphasize SGLT2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists, and incretin-based therapies (GLP-1 receptor agonists) as central pillars of optimal medical therapy in HFpEF, reflecting recent favorable trial data; HFpEF now accounts for >50% of all HF cases with outcomes comparable to HFrEF.
This is a consensus/expert opinion document, not a systematic review or RCT; recommendations are derived from committee deliberation and may lag behind the most recent published trials. The pathway is primarily focused on the ambulatory setting and may not fully apply to acute inpatient care.
Clinicians should prioritize SGLT2 inhibitors, nonsteroidal MRAs, and incretin-based therapies in eligible HFpEF patients, while also screening for and managing key comorbidities (obesity, diabetes, CKD, hypertension, atrial fibrillation, CAD). Use structured diagnostic scoring tools (HFA-PEFF, H2FPEF, HFpEF-ABA) to confirm diagnosis and exclude mimics before initiating therapy.
