Confronting the "Urgency Gap" Between HFrEF and HFpEF Care

On August 6, 2026, 10 clinicians from across Chicago's major health systems gathered for a roundtable discussion titled "Beyond the Ejection Fraction: Transforming HFpEF and HFmrEF Management Across the Continuum." Moderated by Mark Belkin, MD, director of the hemodynamic laboratory and an advanced heart failure cardiologist at the University of Chicago Pritzker School of Medicine, the discussion moved through 3 themes: differentiating heart failure subtypes and their clinical impact, addressing heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF) across the care continuum, and leveraging multidisciplinary teams to optimize outcomes.

More than half of patients with heart failure now have an ejection fraction above 40%, split between HFmrEF and HFpEF.¹ Yet across a 5-year horizon, mortality and readmission rates are essentially identical regardless of phenotype.² That disconnect—equivalent risk, unequal urgency—became the throughline of the evening.

A Diagnosis Without the Same Urgency

Panelists agreed that HFpEF is frequently under-recognized at the point of referral.

“[In] HFpEF, we're missing a lot of patients, and those are the patients who have dyspnea—they're just chalking it up to older age or obesity, or they're deconditioned," said Quentin Youmans, MD, assistant professor of medicine, Northwestern Medicine. "If we don't look, then we're probably likely missing them."

Harsha Gondi, MD, a cardiologist at Mount Sinai Hospital, pointed to a documentation habit that compounds the problem.

"Especially when you're dealing with the fellows or residents on the clinic side, they just look at the first summary line of the echo, and it only gives the EF [ejection fraction] part, and that's the end of it,” said Gondi. “I believe you lose a lot of patients if you don't pay attention to the diastolic function."

That diagnostic lag translates into a triage gap. Paul Silverman, MD, director of the National Cardiovascular Service Line of Advocate Health Care, contrasted the 2 populations.

"If somebody shows up with dyspnea and an ejection fraction of 35%, they get referred immediately, and they go into the whole heart failure, 4 pillars of medication pathway… It’s more subtle with HFpEF, and so they get referred later, or they don’t get referred,” he said.

At the system level, Charlene Hope, PharmD, chief pharmacy quality and medication safety officer at the University of Chicago, said the calculus is less about ejection fraction and more about utilization.

"The meetings that I'm in are all about re-admissions and our ability to manage that patient population. They're usually at the top of the list for readmitting patients,” she said.

Once patients are identified, deciding who should manage them remains unsettled. Kerry Shanklin, APP, director of advanced practice providers (APP) and lead APP for the LVAD/Advanced Heart Failure Program at Rush, described routing patients into an APP-led heart failure clinic after a readmission "regardless of HFpEF [or] HFrEF.” Silverman argued that specialty bandwidth makes generalist management a necessity.

"Heart failure fellowships aren't filling; there's a shortage of heart failure docs… it behooves the system for the rest of us to be able to manage HFpEF," he countered.

Clyde Yancy, MD, professor and chief of cardiology at Northwestern Medicine, reframed the urgency question itself, cautioning against over-indexing on hospital-level statistics.

"For someone who's breathless and persistently living with lower extremity edema, that person is perpetually urgent,” he said. “I think the urgency may not be in administration or within the confines of the practice of medicine, but for that patient, it's an urgent scenario.”

Guidelines Racing to Catch Up With the Evidence

The panel's second segment turned to therapy selection, where the evidence base has shifted faster than formal guidance. Under the 2022 American Heart Association/American College of Cardiology (ACC)/Heart Failure Society of America guideline, diuretics remained the only class 1 recommendation for HFpEF, with sodium-glucose cotransporter 2 inhibitors (SGLT2is) earning a class 2a indication and renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists (MRAs), and beta-blockers relegated to class 2b.³ A 2026 ACC expert consensus decision pathway has since positioned SGLT2is alongside nonsteroidal MRAs as the backbone of optimal medical therapy for HFpEF.⁴

"The dilemma we have is when we have new evidence, how quickly are we able to see the effect of that evidence in everyday clinical practice?" said Yancy, a senior author on both the 2022 guideline and a related 2023 consensus statement. “There is a challenge with HFpEF. How do you stay aligned not with the guidelines anymore but aligned with the science, because the science is moving so quickly?"

MRA selection generated the sharpest debate. Silverman said he has been slow to adopt nonsteroidal MRAs like finerenone, citing cost and lingering skepticism about the evidence base for the drug class.

"Given the flaws with the [TOPCAT] study, I wonder… if there was ever a head-to-head comparison, whether or not there's any absolute benefit of a nonsteroidal MRA compared to spironolactone,” he said.

Yancy countered that finerenone's trial data stand apart. "That's why the FINEARTS data are so compelling, because it says that for the nonsteroidal MRA, we have definitive prospective randomized controlled data, once again demonstrating a morbidity advantage,” he said.

In the FINEARTS-HF trial (NCT04435626), finerenone significantly reduced total worsening heart failure events and cardiovascular death compared with placebo (HR, 0.82; 95% CI, 0.71-0.94; P = .006), while the earlier TOPCAT (NCT00094302) trial's spironolactone results were less conclusive.⁵

Christine Cunningham, PharmD, cardiology pharmacist, Northwestern Medicine, credited pharmacy-led access support with accelerating adoption in her clinics.

"We're starting to see more and more uptake of the nonsteroidal MRAs,” she said. “I think one of the biggest pieces of that is our med access pathways… that access pathway has made it a lot easier to spread the word and get more patients on it."

Rachel Lavelle, PharmD, outpatient heart failure and heart transplant pharmacist, University of Chicago, added that formal cost-effectiveness data—costs run meaningfully higher for HFpEF than HFrEF across inpatient, outpatient, and pharmacy settings⁶—would help justify further staffing.

"Those analyses are helpful too, just getting buy-in from administrators…that it is worth staffing another pharmacist or building up these teams,” she added.

From Standing Orders to Systems of Care

The final segment addressed whether the multidisciplinary infrastructure built for HFrEF—recommended at a class 1 level in the 2022 guideline for implementing guideline-directed medical therapy (GDMT), addressing self-care barriers, and reducing readmissions⁷—can simply be extended to HFpEF and HFmrEF. Silverman described an Epic-embedded care pathway at Advocate designed to prompt GDMT initiation before discharge.

"The goal of it is exactly this,” he said. “It's basically to try and get people on all 4 [pillars]… before they leave the hospital or have documentation why they can't."

Youmans described a parallel infrastructure at Northwestern built around a heart failure navigator team and remote monitoring devices, including a low-cost wearable patch used alongside implantable pulmonary artery sensors: "We have a really robust heart failure navigator system… the heart failure patients who are on other wards… get kind of like auto-consulted to go see them."

But Anjan Tibrewala, MD, heart failure cardiologist, Northwestern Medicine, warned that scale is the limiting factor for HFpEF specifically.

"Northwestern has a heart failure registry… we have about 27,000 heart failure patients across our health system, and over 70% of those are HFpEF,” he said. “If you start implementing all these things and putting in all these resources for many patients, you start seeing where it just may not be sustainable."

Yancy pushed the caution further, noting that layering therapies quickly—standard practice in HFrEF—hasn't been proven safe or effective in HFpEF. “It requires a lot of resources from system leaders to build these operations without clear evidence that the rapidity with which you layer multiple therapies is beneficial and not harmful,” he said.

Even with dedicated navigator programs, follow-up remains inconsistent. Shanklin said tracking at Rush revealed a persistent blind spot.

"What we do find issues with is when we're not consulted,” she said. “I've been running reports, and 50% of our patients, even when they have consults, are not getting those hospital follow-ups.” The finding echoes evidence that early post-discharge follow-up and structured post-discharge contact can meaningfully cut readmissions.⁸

Final Thoughts: AI, Incretins, and Advocacy

Closing the session, panelists were asked what they would bring back to their organizations. Lavelle said the evidence base finally justifies expanding pharmacy-led titration services to HFpEF.

"Until very recently, we didn't have good algorithms… for HFpEF… I think that more and more we have justification to expand our reach there,” said Lavelle.

Gondi pointed to incretin-based therapies as the next inflection point, echoing an earlier comment from Yancy that the field hasn't fully reckoned with their potential: "These weight loss pills, I think they're going to change the game for HFpEF."

Yancy elaborated that emerging incretin data could rival existing pillars of therapy: "We have evidence that is inferential with semaglutide, more definitive with tirzepatide… we should not overlook the fact that these may be ultimately as beneficial, if not more so, than the SGLT2 inhibitors and even the nonsteroidal MRAs."

Hope closed with a call to apply population health infrastructure already built for other metrics—such as hypertension telemonitoring—to HFpEF and to bring artificial intelligence (AI) into patient identification rather than administrative tasks: "How can we leverage AI to identify these patients, to prioritize and make sure that they're getting to the right patients? How do we then tie in the telemonitoring and the wearables into all of that so that we can really start to advance care into 2026?"

References

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