HFpEF in 2026: diagnose the syndrome, search for mimics, treat the whole phenotype

The practical shift

The 2026 ACC Expert Consensus Decision Pathway presents HFpEF as more than a preserved ejection fraction. It emphasizes a careful assessment of symptoms, congestion, structural or functional cardiac abnormalities, and the wider clinical context.

Start with diagnosis, not an assumption

Dyspnoea and oedema can reflect HFpEF, but they can also arise from pulmonary disease, kidney disease, obesity, frailty, valvular or infiltrative heart disease, pericardial disease, or other conditions. The pathway highlights the need to search for cardiac and noncardiac mimics rather than treating a preserved ejection fraction as a final answer.

Scores support judgement

H₂FPEF, HFA-PEFF, and HFpEF-ABA may support diagnostic evaluation, but none replaces pre-test probability, imaging, biomarkers, differential diagnosis, or clinical judgement. The intermediate range remains a signal to investigate further.

Treat the phenotype, not a label

The pathway links optimal care to comorbidity management, nonpharmacologic care, and evidence-based therapies where appropriate. Its focus is multidisciplinary and ambulatory, while recognizing that individual choices depend on clinical context and patient priorities.

Source

2026 ACC Expert Consensus Decision Pathway on Management of HFpEF.