Cleveland Panel Weighs New HFpEF Pathway, Access to Finerenone

On August 18, 2026, 11 heart failure clinicians, pharmacists, and internists from Cleveland Clinic, University Hospitals, and MetroHealth gathered for a Population Health Roundtable discussion hosted by The American Journal of Managed Care^® (AJMC^®) on the diagnosis and management of heart failure with mildly reduced and preserved ejection fraction (HFmrEF/HFpEF). Moderated by Trejeeve Martyn, MD, a heart failure cardiologist at Cleveland Clinic, the discussion moved through 3 themes: the shifting classification landscape, the newly published consensus pathway for drug therapy, and the systems-level barriers—from prior authorization to fragmented medical records—that keep patients off guideline-recommended care.

The discussion came weeks after 2 major updates to how heart failure is classified and treated: the Second Universal Definition of Heart Failure, jointly issued in June 2026 by the American Heart Association, American College of Cardiology (ACC), European Society of Cardiology, and World Heart Federation, and an updated 2026 ACC expert consensus decision pathway for HFpEF that elevates the nonsteroidal mineralocorticoid receptor antagonist (MRA) finerenone alongside sodium-glucose co-transporter 2 (SGLT2) inhibitors as first-line therapy for patients with an EF of 50% or higher.^1,2

A Moving Target for Classification

Martyn opened by asking whether the new universal definition was changing practice. Nancy Albert, PhD, associate chief nurse for research and innovation at Cleveland Clinic and a coauthor of the original 2020 mildly reduced–EF paper, said the evidence base has moved past her own earlier conclusions.

“That paper came out in 2020, and I'm an author on that, and it was back in a time when we thought patients with mildly reduced EF resembled more HFpEF than HFrEF,” Albert said. “Since then, much newer literature came out showing that they're really resembling more HFrEF, and so the 2022 guidelines really made the distinction for the 3 instead of trying to group the 2 together. I almost feel like the universal definition is a little bit outdated already.”

Arianne Clare Agdamag, MD, heart failure cardiologist, Cleveland Clinic, said the problem is less any one document than how many came out at once.

“They basically just classified more than 50%, less than 50%, basically everything else from that standpoint,” Agdamag said of the new definition. “Then it became confusing because [other groups] just published their own statement around the same time...they all came out shortly after each other, so that's the problem.”

Phoo Pwint Nandar, MD, a cardiologist at MetroHealth, argued phenotype should drive classification more than EF alone. “If you have the EF of 45% with an amyloid patient, the underlying pathophysiology and the medication that they're going to tolerate vs [a patient with] chemo cardiomyopathy is going to be different,” Nandar said. “I think the most important thing is phenotype first, and then categorize.”

Screening Gaps Outside Cardiology

Albert described routinely ordering N-terminal pro-B-type natriuretic peptide (NT-proBNP) and urine albumin-to-creatinine ratio (UACR) on new HFpEF referrals regardless of EF.

“I started about a couple years ago—I was part of a KDIGO work group in Vancouver, and ever since then I started doing it,” she said. “I'm amazed at [how] sometimes the eGFR [estimated glomerular filtration rate] isn't that bad, but the UACR is above 30 and sometimes even above 100 or 200.”

Anindita Ghosh, MD, an internist and medical director of value-based operations at Cleveland Clinic, said her health system's electronic prompts don't extend the same attention to heart failure.

“The only disease-specific health maintenance we have is for diabetes, and nothing else, which is very frustrating,” Ghosh said. “Because we don't have a health maintenance trigger for CKD [chronic kidney disease], heart failure, or none of that.”

Kyia Mountain, NP, University Hospitals, said screening in her cardiometabolic clinic remains symptom-based.

“Within our team, it's not standard actually that we are evaluating for that,” Mountain said.

Albert cited her own internal research study to illustrate how inconsistent referral patterns are.

“When people are diagnosed with heart failure, we send them back to internal medicine, and I'd say out of the cases we've diagnosed so far, half of them stay with internal medicine and the other half refer to cardiology—not heart failure specialty, just a cardiologist in our system,” Albert said. “I think it's very physician-dependent.”

New Pathway Puts Finerenone Alongside SGLT2 Inhibitors

The updated ACC pathway prioritizes finerenone over spironolactone based largely on the FINEARTS-HF (NCT04435626) trial, which showed a roughly 16% reduction in cardiovascular death or worsening heart failure events with lower hyperkalemia risk than seen with spironolactone in the earlier TOPCAT (NCT00094302) trial.^2-4 Brad Williams, PharmD, clinical pharmacy coordinator and heart failure specialist at Cleveland Clinic, came to the discussion with same-day chart-review data.

“I just pulled a handful of patients today and ran price checks—I looked at 8 patients at one hospital, specifically for EF above 50 with a HFpEF diagnosis,” Williams said. “One patient didn't have insurance, so obviously it wasn't covered. Five patients required PAs [prior authorizations], and 2 had it covered without a PA—one at $0 and one at $47. So, 25% had it covered.”

Albert said she was surprised the pathway named a specific drug rather than endorsing the MRA class broadly.

“I was actually surprised that the MRA was specific to the non-steroidal and not all MRAs,” she said. “Only because we have TOPCAT in the American part of the trial design, and the drug worked well in that group—and for patients who can't afford finerenone, it makes sense to have both, and a lot of our patients are already on spironolactone anyway.”

Nandar said her team increasingly leans on comorbidities to justify coverage for incretin-based therapies, since a standalone HFpEF diagnosis alone often isn't enough to satisfy payers.

Pharmacists Building the Bridge to Primary Care

Megan Valente, PharmD, heart failure clinical specialist at MetroHealth, described a pilot in which primary care pharmacists are trained to manage guideline-directed therapy for stable patients with HFpEF who don't have a clear reason to see cardiology.

“We have a small pilot group of our primary care pharmacists [among whom] we're trying to capture some of our HFpEF patients who are not necessarily consistently followed by cardiology but have a clear diagnosis,” Valente said. “We've been able to identify patients that do clearly have HFpEF, are without GDMT [guideline-directed medical therapy], and are probably for the most part stable—they haven't had a recent hospitalization, and they haven't been sort of on our radar from a cardiology standpoint, but yet could be soon.”

Jacalyn Rogers, PharmD, senior director of pharmacy at University Hospitals Cleveland Medical Center, said the system's 340B drug pricing program funds both its primary care pharmacist positions and a transitions-of-care service.

“We are getting the transitions-of-care program going, which is really merging that specialized pharmacy over to the primary care,” Rogers said. “The patient is getting a call from a pharmacist when they leave. They are getting those follow-up calls, and they're getting that all set up to make that less of like the swim lanes and more a continuity.”

Martin credited Williams with a parallel effort on the acute care side: a Cleveland Clinic virtual pharmacist consult service now running across several regional hospitals. “I think over 70% of recommendations are accepted by running hospitalists,” Martin said.

Variability, Adherence, and the Limits of the EHR

Multiple panelists said care still varies enormously by which physician a patient happens to see, particularly above an EF of 40%. Rob Montgomery, advanced heart failure and transplant cardiology specialist at University Hospitals, said the electronic health record (EHR) hasn't kept pace.

“Epic is like—if you want to actually have a heart failure registry, it's a systolic heart failure registry,” Montgomery said. “It's based on guidelines that they opened up in 2012.”

Albert said a more advanced build hasn't solved the problem at Cleveland Clinic either. “We have a sophisticated Epic, and we still have the same problem with variability,” she said. “So, I don't think Epic is just the only answer.”

Rogers said medication adherence remains underaddressed.

“It'll be a new diagnosis, and they'll get a 30-day supply and appointment to cardiology, and they don't make it to the cardiology appointment, but they feel much better,” she said. “They don't really have good understanding that this is chronic and they need to be taking this all the time.”

Rogers also pointed to fragmentation across competing systems. “We do have 3 strong health systems in this city,” she said. “Patients jump between them, and they're getting disjointed care.”

Nandar agreed, describing the practical result for medication reconciliation: “It would be nice to have a pathway, like a med rec that goes into one pathway system,” Nandar said. “I may see this patient today, and then next week the patient gets admitted to Cleveland Clinic or UH [University Hospitals] and gets some med changes and gets discharged, and I see them again in like 2 weeks later, and all the medications are different.”

Chantal Elamm, MD, advanced heart failure and transplant cardiology specialist and associate chief medical officer of University Hospitals, said her system had a better handle on this when heart failure care was consolidated into 1 service. “It was better when we had our dedicated floor service, where we saw HFpEF and HFrEF, not just the advanced population,” Elamm said.

Final Thoughts: Making the Financial Case for Pharmacy

Closing the session, Martyn asked how panelists justify additional pharmacist staffing to health system leadership. “It's all just hammering on data, right?” Martyn said. “But then I think the bigger part of it from a health system perspective is, yes, it's good, it's beneficial for patients, but is it cost-effective? How do you recoup this? Tying it into more prescription capture, this gives us a margin there. It offsets the cost of this additional FTE [full-time equivalent].”

Williams put a figure on that margin. “Up until last year, a margin we'd get on a fill was like $700 a fill,” he said. “If you're seeing a pharmacist and they're starting an SGLT2 and they're sending it across the street and they do that 4 times a day, you can justify the cost by something like that.”

Rogers said the strongest case combines that financial argument with the clinical story: “The impact on what we're able to do, and being able to tell that story behind it, as well as how it goes back to our retail operations in terms of script volume and script capture and ensuring that those readmission numbers are staying down.”

References

1. Walsh MN, Kober L, Sliwa K, et al. AHA/ACC/ESC/WHF expert consensus document: second universal definition of heart failure (2026). J Am Coll Cardiol. 2026:S0735-1097(26)06703-3. doi:10.1016/j.jacc.2026.05.036
2. Kittleson MM, Panjrath GS, Bates K, et al. 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. J Am Coll Cardiol. 2026:S0735-1097(26)06875-0. doi:10.1016/j.jacc.2026.06.018
3. Solomon SD, McMurray JJV, Vaduganathan M, et al. Finerenone in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2024;391(16):1475-1485. doi:10.1056/NEJMoa2407107
4. Pitt B, Pfeffer MA, Assmann SF, et al. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med. 2014;370(15):1383-1392. doi:10.1056/NEJMoa1313731