Commentary on ‘What services are currently provided to people with HFpEF in the UK’

This invited commentary refers to ‘What services are currently provided to people with Heart Failure with preserved Ejection Fraction in the UK and what are their components? A systematic scoping review’, by F. Forsyth et al., https://doi.org/10.1093/eurjcn/zvaf143 The systematic scoping review by Forsyth et al.1 represents a timely and significant contribution to the fields of cardiovascular nursing and heart failure service design. This work offers the first comprehensive mapping of how care for patients with heart failure with preserved ejection fraction (HFpEF) is structured across the UK, a particularly important focus given the rising prevalence, clinical complexity, and demographic profile of this patient population. The review is methodologically rigorous,2 adhering to PRISMA Extension for Scoping Review guidelines and incorporating a broad, inclusive search strategy that spans both published literature and grey documents sourced through clinical networks and professional outreach. This approach yields a grounded, real-world view of HFpEF service delivery. Notably, the inclusion of patient and public involvement enhances the relevance of findings by integrating patient perspectives. Forsyth et al. reveal marked heterogeneity in HFpEF service provision. While many clinics are guided by broader heart failure frameworks aligned with NICE recommendations, the implementation of HFpEF-specific adaptations is inconsistent.1 Services are typically consultant-led, with variable engagement from specialist nurses, pharmacists, geriatricians, and rehabilitation professionals. The authors identify critical omissions in service components essential for managing HFpEF effectively: Frailty assessments, included in only one service, are notably absent despite robust evidence linking frailty with adverse outcomes in this predominantly older population. Cognitive screening is rarely described, even though cognitive impairment affects up to 40% of individuals with HFpEF and independently predicts hospitalization and mortality. Functional testing and cardiac rehabilitation referrals, cornerstones of improving quality of life and physical capacity are underutilized, despite strong evidence for exercise interventions.3 Primary–secondary care integration remains weak, despite the high multimorbidity burden and need for coordinated chronic disease management. These findings raise an important question: Why, despite the known burden and rising prevalence of HFpEF, has a well-structured care model not emerged? One major reason is the historical lack of evidence-based pharmacological treatments for HFpEF, which has hindered the development of disease-specific care pathways. Until recently, HFpEF lacked therapies proven to improve mortality, leading to therapeutic inertia and a reliance on generalized heart failure services designed primarily for heart failure with reduced ejection fraction (HFrEF). The recent inclusion of SGLT2 inhibitors in treatment guidelines has begun to shift this paradigm, but clinical inertia and service models have yet to catch up. In addition, the distinct demographic profile of HFpEF patients may contribute to service fragmentation. HFpEF disproportionately affects older adults and women, populations often underrepresented in cardiovascular trials and underserved in cardiology-focused service models.4,5 The predominance of women with HFpEF may also introduce sex-specific challenges in symptom recognition, referral patterns, and care preferences that remain unaddressed by standard heart failure services. Moreover, the overlap with geriatric syndromes, frailty, cognitive decline, and polypharmacy demands a multidisciplinary approach that extends beyond traditional cardiology and nursing dyads. Yet, as this review shows, such integrated models are rare. While the UK faces these challenges, similar issues are evident globally. In the USA, HFpEF represents approximately half of all heart failure cases, yet services remain fragmented.6 However, there are promising models emerging. For example, dedicated HFpEF clinics at US academic centres increasingly adopt a ‘domain management’ approach that integrates frailty and cognitive assessments, social risk screening, and personalized rehabilitation strategies.7,8 These programmes often include structured follow-up and guideline-based pharmacotherapy, including SGLT2 inhibitors, reflecting a more holistic approach. Conversely, the UK’s experience with national audits and guideline-based care offers a strong foundation on which to build standardized, scalable HFpEF service models. The opportunity for trans-national learning is substantial. The UK could lead the way by developing a national HFpEF framework, informed by international best practices and tailored to local population needs. Forsyth et al.’s scoping review is a wake-up call. It illuminates not only the current variability in HFpEF service provision but also the broader structural challenges that have impeded the development of robust, tailored care pathways. As HFpEF continues to grow in prevalence, especially among older adults and women, there is an urgent need to move beyond the HFrEF template and create care models that reflect the unique needs of this population. A national approach, grounded in multidisciplinary collaboration, patient-centred design, and integration across care settings, could significantly improve outcomes, reduce hospitalizations, and enhance quality of life for people with HFpEF. This review sets the stage for that transformation. Mulubrhan F. Mogos (Writing—original draft [lead], Writing—review & editing [lead])]