New ACC HFpEF guidance elevates SGLT2 inhibitors, finerenone, and GLP-1 therapies

Clinical takeaway: For most patients with confirmed HFpEF, early initiation of an SGLT2 inhibitor and consideration of finerenone should form the foundation of therapy, while obesity and other CKM comorbidities should be actively treated, including with GLP-1–based therapies when appropriate.

The 2026 ACC Expert Consensus Decision Pathway (ECDP) updates the 2023 guidance with a markedly different view of HFpEF, recognizing the condition as a complex, multisystem syndrome rather than a single disease entity. The document underscores that accurate diagnosis is critical because symptoms such as dyspnea and edema are often caused by alternative cardiac and noncardiac conditions.

Among pharmacologic therapies, SGLT2 inhibitors remain the best-supported treatment option and are described as the cornerstone of HFpEF management. Evidence continues to show reductions in the composite of HF hospitalization and cardiovascular death, along with improvements in health status. The pathway also highlights the expanding role of finerenone, whose benefits in FINEARTS-HF were driven mainly by reductions in worsening HF events. If finerenone is not feasible because of cost or tolerance, spironolactone remains a reasonable alternative.

A major addition is the incorporation of incretin-based therapies. In patients with HFpEF and obesity, semaglutide and tirzepatide improved symptoms, exercise capacity, quality of life, and weight loss, with emerging evidence suggesting reductions in worsening HF events.

Sacubitril/valsartan may be considered in selected patients, particularly women and those with LVEF below approximately 55% to 60%, while ARBs remain an option when ARNIs are not suitable. The pathway also cautions that beta-blockers lack proven benefit in HFpEF and should generally be reserved for specific indications such as angina or atrial fibrillation rate control.

Nonpharmacologic strategies, including exercise and caloric restriction, are strongly encouraged, especially in obesity-related HFpEF.

“As science evolves and further discoveries and developments occur, some of these recommendations may need to be altered to reflect those advances,” the writing committee states. “In the interim, this ECDP addresses contemporary management of HFpEF” and provides practical guidance for implementing the latest pharmacologic and nonpharmacologic therapies.

What's changed

• HFpEF is no longer viewed primarily as a cardiac disorder. The update emphasizes HFpEF as a heterogeneous, multisystem syndrome driven by visceral adiposity, inflammation, and metabolic dysfunction, requiring phenotype-specific care.
• SGLT2 inhibitors are elevated as cornerstone therapy for HFpEF, supported by robust evidence for reducing heart failure hospitalizations and improving quality of life.
• Nonsteroidal mineralocorticoid receptor antagonists (MRAs), particularly finerenone, are newly prioritized. The pathway states finerenone should be considered the preferred MRA based on recent trial data and FDA approval in HF with LVEF ≥40%.
• Incretin-based therapies enter the HFpEF treatment framework. Semaglutide and tirzepatide are recommended for patients with HFpEF and obesity to improve symptoms, functional capacity, weight loss, and potentially reduce worsening HF events.
• Greater emphasis is placed on cardiovascular-kidney-metabolic (CKM) syndrome and aggressive management of obesity, diabetes, CKD, hypertension, CAD, and atrial fibrillation.
• The document adds a more structured diagnostic approach, including use of H2FPEF, HFA-PEFF, and HFpEF-ABA scoring tools, evaluation of HFpEF mimics, and sex-specific diagnostic considerations.

Source: Kittleson MM, et al. (2026 July 23) J Am Coll Cardiol. Management of Heart Failure With Preserved Ejection Fraction: 2026 ACC Expert Consensus Decision Pathway: A Report of the American College of Cardiology Solution Set Oversight Committee