Experts Call for Structured Pathways to Close Gaps in Heart Failure Care

Heart failure affects an estimated 56 million people worldwide, and in the US, the lifetime risk of developing it is 1 in 4—nearly 5 times the lifetime risk of breast cancer in women.¹ Yet a substantial share of those patients carry subtypes that remain underrecognized and undertreated even within cardiology: heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF). These unmet needs were the focus of a recent Population Health Roundtable hosted by The American Journal of Managed Care^® in Philadelphia, "Beyond the Ejection Fraction: Transforming HFpEF and HFmrEF Management Across the Continuum," which convened heart failure cardiologists, advanced practice providers, and pharmacists from Thomas Jefferson University Hospital, the University of Pennsylvania, Temple University Hospital, and Main Line Health.

Together, HFpEF and HFmrEF now account for roughly 60% of all heart failure cases nationally²—a reversal from decades ago, when reduced ejection fraction made up the majority, as noted during the discussion. Despite that shift, the panelists note that mortality, hospitalization rates, quality-of-life impact, and even cost of care are statistically indistinguishable across the ejection fraction spectrum.

Differentiating Heart Failure Subtypes and Their Clinical Impact

The session opened with moderator Susie Joseph, MD, professor of medicine and director of acute and chronic mechanical circulatory support, Toll Heart and Vascular Institute, Thomas Jefferson University Hospital, presenting epidemiologic data designed to challenge a persistent assumption: that a preserved ejection fraction implies a more benign disease course.

Eman Hamad, MD, MHA, director of advanced heart failure, Temple University Hospital, named the misconception directly. "I think that's the main problem, that people really think that patients who have HFpEF have a ‘normal’ EF, so that their mortality is actually not as bad, but it is the same mortality for HFrEF or HFpEF,” she said.

Lee Goldberg, MD, MPH, associate chief health information officer and vice chair of medicine, University of Pennsylvania, traced clinicians' and institutions' historic inattention to HFpEF to where investment has flowed.

“The money is in HFrEF,” he said. “Most institutions are investing a ton of money in HFrEF because there are procedures to do and diagnostics to do and all this other stuff. And up until recently, we barely had drugs for HFpEF.”

Brandie Camp, CRNP, certified nurse practitioner, Thomas Jefferson University Hospital, described the human cost of that inattention upstream, noting that patients with longstanding, profound shortness of breath are frequently discounted by referring providers.

“A lot of these patients are elderly and obese,” said Camp. “I've talked to a lot of my patients that just feel like they're brushed aside and their primary maybe doesn't recognize that this could be HFpEF and are just told that they're obese and they need to lose weight and fix these other things, and then they never really get the diagnosis to get adequate treatment. I think that perception really influences a lot of the patients that we end up seeing.”

Addressing HFpEF and HFmrEF Across the Care Continuum

On treatment selection, panelists converged on sodium-glucose cotransporter 2 (SGLT2) inhibitors and mineralocorticoid receptor antagonists (MRAs) as the backbone of guideline-supported therapy, while debating sequencing among spironolactone, eplerenone, and the newer nonsteroidal MRA finerenone.

Alicia Nordberg-Payne, PharmD, BCACP, clinical pharmacy specialist of cardiology, Hospital of the University of Pennsylvania, described the collaborative practice agreements that let pharmacists titrate therapy without waiting on physician visits, noting pharmacists can independently manage lab monitoring and dose titration once a regimen is established. Christina Ruggia-Check, PharmD, clinical pharmacy specialist of cardiology, Temple University Hospital, reported that her clinic's structured optimization protocol moved patients from suboptimal to optimal guideline-directed medical therapy (GDMT) in an average of 2.63 months.

Brandi Thoma, PharmD, BCCP, clinical pharmacist, Thomas Jefferson University Hospital, described the formulary fight required to expand access to newer agents, recounting her effort to add finerenone to Jefferson's enterprise formulary over cost objections from the pharmacy and therapeutics committee.

Monitoring treatment effectiveness in HFpEF, panelists agreed, relies less on a single biomarker than on functional status. Angela Nam, PharmD, transition of care CHF pharmacist, Main Line Health, working the discharge side, pointed to the practical access barriers that undercut even well-chosen therapies.

“I hate not having a pharmacist; it makes my job really hard,” she said, describing how thin staffing limits proactive medication access support for patients leaving the hospital.

Leveraging Multidisciplinary Teams to Optimize Heart Failure Outcomes

Discussion of hospital workflows surfaced a structural blind spot: Patients admitted to general medicine services are frequently over-diuresed, have GDMT discontinued as kidney function shifts, and are discharged without cardiology follow-up.

"They never plug them in to be followed by cardiology," Hamad said of this pattern, noting that even within her own health system, HFpEF "is still not recognized as that entity." Her response was operational—a dedicated HFpEF consult order in the electronic health record that routes any patient with unexplained dyspnea and a normal ejection fraction directly to the heart failure service.

Monique Tanna, MD, advanced heart failure and transplant cardiologist, University of Pennsylvania, described parallel work underway at Penn—newly built "Penn Pathways" focused on earlier inpatient GDMT initiation and incorporating quality-of-life instruments, including the Kansas City Cardiomyopathy Questionnaire, into routine visits, an effort still searching for systematic uptake.

The panel converged on a shared diagnosis of the underlying problem: HFrEF benefits from automated order sets, tracked metrics, and institutional infrastructure built around adherence to the "4 pillars" of therapy, while HFpEF has none of that scaffolding.

"We probably need a HFpEF pathway just like we have HFrEF," said Goldberg. "Because we're all over the place and we have no way of measuring it."

Closing Thoughts

Asked what they could realistically implement within 6, 12, or 18 months, panelists offered concrete, near-term commitments rather than aspirational goals: dedicated continuing education programming on HFpEF, expanded pharmacist-physician collaborative practice agreements, formal escalation pathways from general medicine to heart failure services, and renewed efforts to operationalize quality-of-life tracking at the point of care.

J. Eduardo Rame, MPhil, FAHA, FESC, professor of clinical cardiology and enterprise chief of advanced cardiac and pulmonary vascular disease programs at Thomas Jefferson University Hospitals, framed the longer-term ambition as understanding heart failure's local variation—by population, comorbidity profile, and geography—well enough to move past one-size-fits-all treatment algorithms.

References

1. Bozkurt B, Ahmad T, Alexander KM, et al. Heart failure epidemiology and outcomes statistics: a report of the Heart Failure Society of America. J Card Fail. 2023;29(10):1412-1451. doi: 10.1016/j.cardfail.2023.07.006
2. New initiative launched to improve care for people with certain types of heart failure. American Heart Association. September 15, 2025. Accessed June 25, 2026. https://newsroom.heart.org/news/new-initiative-launched-to-improve-care-for-people-with-certain-types-of-heart-failure