Why the study?
Major advances in diagnosis and therapy of HFpEF prompted an update to the 2023 American College of Cardiology Expert Consensus Decision Pathway to guide perioperative clinicians.
Answers are grounded in this paper and cite their sources.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“I would argue that underdiagnosis is probably more of a concern than overdiagnosis, given the fact that a person who has dyspnea, atrial fibrillation, and obesity, even before we start off with diagnostic testing, most likely has heart failure with preserved ejection fraction. Clinicians therefore really need to have a high index of suspicion for the presence of heart failure because treatment in that situation can improve quality of life and functional capacity and can potentially reduce mortality and hospitalization risk.”
“HFpEF is often under-recognized and results in substantial resource utilization. Historically, treatment options were limited to managing comorbidities; however, revolutionary advances in the past decade regarding the pathophysiology of HFpEF, improved methods of diagnosis, and insights into prognostic predictions now yield novel, effective management strategies. With recent favorable clinical trial results, there is increasing urgency for accurate diagnosis and timely implementation of GDMT.”
“the evidence is no longer the main obstacle; prior authorizations, formulary restrictions, and access are.”
This review translates the updated 2026 ACC Expert Consensus Decision Pathway for HFpEF into actionable implications for perioperative assessment and anesthesia management.
Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous, multisystem syndrome frequently encountered by perioperative clinicians. The 2026 American College of Cardiology Expert Consensus Decision Pathway (ECDP) updates the 2023 pathway in response to major advances in diagnosis and therapy. It emphasizes probability-based diagnosis, recognition that normal natriuretic peptide concentrations do not exclude HFpEF, and systematic exclusion of cardiac and noncardiac mimics. The revised ECDP incorporates the HFpEF-ABA screening score, expands sex-specific considerations, and frames HFpEF within a cardiovascular-kidney-metabolic construct. Sodium-glucose cotransporter 2 inhibition and nonsteroidal mineralocorticoid receptor antagonism are positioned as foundational therapy when not contraindicated. Finerenone is favored over steroidal mineralocorticoid receptor antagonists, incretin-based therapy is incorporated for obesity-related HFpEF, and angiotensin receptor-neprilysin inhibition is selectively considered in women and in patients with a left ventricular ejection fraction below approximately 55% to 60%. The evidence remains nuanced because several pivotal trials enrolled patients with ejection fractions beginning at 40% or 45%, and benefits were often driven by fewer worsening heart failure events rather than cardiovascular mortality. This review summarizes the principal 2026 changes to the ECDP, critically appraises their evidentiary limits, and translates the pathway into implications for preoperative assessment, medication management, hemodynamic planning, and postoperative surveillance.
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Ripoll et al. (2026) conducted a review in Heart failure with preserved ejection fraction (HFpEF). 2026 ACC Expert Consensus Decision Pathway was evaluated. The 2026 ACC Expert Consensus Decision Pathway for HFpEF positions SGLT2 inhibitors and nonsteroidal mineralocorticoid receptor antagonists as foundational therapies.
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