Experts Debate How to Scale Multidisciplinary Care for HFpEF and HFmrEF

Heart failure affects an estimated 6.7 million Americans, with a 1 in 4 lifetime risk of developing the condition, according to a 2025 report from the Heart Failure Society of America.¹ Two subtypes of the disease—heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF)—together account for up to 75% of that burden, yet both remain comparatively underrecognized and undertreated relative to heart failure with reduced ejection fraction (HFrEF).² These gaps were the focus of a recent Population Health Roundtable hosted by The American Journal of Managed Care^® in Boston, which convened heart failure cardiologists, advanced practice providers, and pharmacists from Brigham and Women's Hospital, Massachusetts General Hospital, Tufts Medical Center, Beth Israel Deaconess Medical Center, and Lahey Hospital & Medical Center.

Rethinking How Ejection Fraction Should Guide Care

Moderator Scott Solomon, MD, senior physician at Brigham and Women's Hospital, opened by noting that the disease's nomenclature is a relatively recent, and somewhat arbitrary, construct: the term "preserved" ejection fraction dates to the CHARM-PRESERVED trial (NCT00634712) roughly 20 years ago, when investigators needed a label for patients with an ejection fraction over 40%. Current guidelines classify 41% to 49% as mildly reduced and 50% and above as preserved, but panelists agreed the cutoffs reflect clinical trial design more than underlying biology.

"It turns out that this is a relatively arbitrary number that is, in a standard echocardiography lab, plus or minus 5, maybe even 7," said Solomon, adding that the only reason such cutoffs exist is that clinical trials had to have inclusion criteria.

James Udelson, MD, chief of cardiology at Tufts Medical Center, defended the categories' clinical usefulness despite their arbitrary origins.

“It's a useful simple construct that has served us and patients well," he said. "I think the main purpose of the categories is to help people think about the treatments.”

David Venesy, MD, director of the Lahey Advanced Heart Failure and Cardiomyopathy Program, described a community-based population that skews older and sicker than academic-center cohorts often assume. A survey at his center put the average patient age at 84, he said, with 20% of heart failure admissions occurring in patients older than 90—patients who arrive with kidney disease, sleep apnea, and obesity layered on top of their cardiac diagnosis.

Diagnostic Blind Spots Persist Outside Cardiology

Panelists agreed that HFpEF and HFmrEF are disproportionately missed by clinicians outside heart failure subspecialty practice. Udelson said hospitalists are generally attuned to natriuretic peptide testing, "but the problem is that a third of the people don't have that" elevated biomarker despite having the disease, leaving many patients undiagnosed in the community.

Jonathan Cunningham, MD, MPH, a heart failure cardiologist at Mass General Brigham, pointed to atrial fibrillation (AF) as an underused case-finding opportunity, since AF and HFpEF frequently coexist.

"Many patients and cardiologists are used to accepting a certain level of dyspnea on exertion in patients with symptomatic AF," he said, noting that such patients may be treated for rhythm control alone while an underlying, treatable case of heart failure goes unaddressed.

Gregory Lewis, MD, director of heart failure at Mass General Brigham, cautioned against attributing symptoms too readily to the heart alone. "A lot of the patients that we diagnose with this have 5 or 6 different reasons that they may be short of breath," he said, arguing that more sophisticated testing helps clinicians establish "some type of a rank order" of a patient's limitations.

Erica Woodcome, ANP-BC, a nurse practitioner at Mass General Brigham, described leaning on clinical gestalt when biomarkers are ambiguous. "I always think of it as putting pieces together in this puzzle," she said, describing how she weighs exam findings against a patient's comorbidity profile—AF, an enlarged left atrium, and hypertension—even when natriuretic peptide levels are only mildly elevated.

Amyloid cardiomyopathy, a frequent HFpEF mimic, was cited as an area where structured referral pathways have improved detection. Venesy described a partnership in which every carpal tunnel release biopsy at his center, roughly 1500 cases a year, is screened for amyloid, yielding a positive rate of 20% to 25%. Cunningham described early efforts to apply artificial intelligence (AI) to the electronic health record to flag patients who meet testing criteria for amyloidosis or hypertrophic cardiomyopathy but have never been screened, calling centralized, technology-assisted diagnosis programs a scalable complement to that kind of multidisciplinary referral network.

Affordability, Not Evidence, Limits Use of Newer Therapies

On treatment, panelists converged on sodium-glucose cotransporter 2 (SGLT2) inhibitors as foundational therapy.

"There is absolutely no heterogeneity in the clinical benefit of SGLT2 inhibitors regardless of ejection fraction," Solomon said, citing pooled results from the DELIVER (NCT03619213) and EMPEROR-Preserved (NCT03057951) trials. Sacubitril/valsartan showed benefit concentrated in the mildly reduced range in the PARAGON-HF (NCT01920711) trial, supporting an FDA indication that Solomon said remains underused in practice.

Mineralocorticoid receptor antagonists (MRA) generated more debate. Finerenone, a nonsteroidal MRA, produced a roughly 16% reduction in cardiovascular death or total worsening heart failure events in the FINEARTS-HF (NCT04435626) trial, with a lower observed risk of hyperkalemia than spironolactone, according to Solomon. Lewis called the evidence for finerenone "certainly a lot stronger" than the subgroup data supporting spironolactone but said cost remains the primary obstacle to first-line use.

“And I think to ask someone to pay for one of the SGLT2s plus a GLP-1 [glucagon-like peptide-1] and then add this on, we've slowly started to adopt it, some of our physicians more than others, but its cost has been probably the biggest barrier,” said Jacqueline Ruckel, lead nurse practitioner at Mass General Brigham's Mass General campus.

Kelly Nguyen, PharmD, a clinical pharmacy specialist at Tufts Medical Center, described her team's efforts to navigate that landscape—drawing on cardiomyopathy grants, manufacturer co-pay cards, and income-based hospital assistance programs—and said roughly half of finerenone requests her team pursues are ultimately approved and started. Solomon noted that sacubitril/valsartan and dapagliflozin are now both generic and available for under $20 a month, yet uptake among eligible patients remains well below target even where cost is no longer the barrier.

Scaling Multidisciplinary Teams Beyond Academic Centers

Several institutions described pharmacist-led clinics, operating under collaborative practice agreements, that independently manage GLP-1 titration and guideline-directed medical therapy (GDMT) optimization. Sonia Kothari, PharmD, a pharmacist at Beth Israel Deaconess Medical Center, described a workflow in which a dedicated prior authorization team secures coverage before patients are enrolled in scheduled follow-up calls every 4 to 6 weeks. Marwa Sabe, MD, MPH, associate director of the Heart Failure Program and director of the LVAD Program at Beth Israel Deaconess, said the same model extends to specialty amyloid therapies. Venesy described a similar televisit-based cardiometabolic pharmacotherapy clinic at Lahey as fully billable and self-sustaining, adding that primary care physicians rarely initiate these conversations even when they recognize the need.

Linda Ordway, RN, MS, ACNP, CHFN, lead inpatient nurse practitioner for the Advanced Heart Failure Service at Tufts Medical Center, said her team absorbs much of this titration work when primary care declines to manage it but cautioned it still requires vigilance; she described a patient recently hospitalized for acute kidney injury after appetite suppression on a GLP-1 left him dehydrated.

Udelson framed the resulting access gap as the discussion's central takeaway.

“When we see a patient in clinic, it's very straightforward; just send them your way, and things are very taken care of, and it's great for everybody,” he said. “It's fabulous for the patients, but out in the community, either primary care physicians, hospitalists, or general cardiologists, they don't have these resources, and so there are tons of people out there who aren't getting Entresto, can't figure out the prior authorization for the SGLT2, GLP-1s. No way can super busy people do that.”

Christine Ko, PharmD, BCPS, BCCP, an ambulatory clinical pharmacist at Massachusetts General Hospital who splits her time between a cardiology GDMT clinic and a primary care clinic, said that gap is visible even within her own institution. Primary care providers "just don't have the education and the comfortability with our heart failure medications," she said, describing routine questions from colleagues about how to dose or switch patients onto sacubitril/valsartan—queries she read as a sign of willingness to engage rather than reluctance.

Remote monitoring devices such as CardioMEMS, Cordella, and HeartLogic were described as effective but resource-intensive. Cunningham argued that noninvasive remote monitoring paired with centralized, increasingly AI-assisted data review will be necessary to scale monitoring beyond the small share of patients who currently qualify for implantable devices. Lewis and Udelson drew a parallel to centralized anticoagulation management services, which faced early resistance before being widely adopted.

"I think most people recognize now that centralizing that management is better for patients and clinicians and quality overall," Cunningham said.

Closing Thoughts

Asked for the most pressing next step, Udelson returned to the access gap. "For a managed care journal, probably the biggest unmet need in the community is just kind of exporting what we all do," he said.

Lewis described a newly built cardiomyopathy program that books a patient's pharmacotherapy, nurse practitioner, physician, and echocardiogram appointments for the following 3 months at the time of hospital discharge, rather than scheduling one visit at a time.

Cunningham pointed to the financial structure of heart failure care as an underused lever.

"Heart failure hospitalization is so costly that all of these initiatives can be based around ways to keep our patients out of the hospital," he said, adding that bundled payments could support more organized, team-based programs going forward.

References

1. Fonarow GC, Ahmad FS, Ahmad T, et al. HF stats 2025: heart failure epidemiology and outcomes statistics. J Card Fail. Published online September 2025. doi:10.1016/j.cardfail.2025.07.007
2. New initiative launched to improve care for people with certain types of heart failure. News release. American Heart Association. September 15, 2025. Accessed August 3, 2026. https://newsroom.heart.org/news/new-initiative-launched-to-improve-care-for-people-with-certain-types-of-heart-failure