Experts Sound Alarm on Underrecognized Heart Failure Subtype as Costs, Readmissions Soar

Am J Manag Care. 2026;32(Spec. No. 6):SP282-SP284. https://doi.org/10.37765/ajmc.2026.89970

Heart failure affects more than 64 million people worldwide,¹ yet a significant proportion of those patients carry a subtype that continues to be overlooked, undertreated, and misunderstood, even within cardiology itself.² These unmet needs were discussed at a recent population health roundtable hosted by The American Journal of Managed Care in Phoenix, Arizona, which brought together cardiologists, nurse practitioners, pharmacists, and other health system clinicians from the Phoenix area.

The discussion centered on heart failure with preserved ejection fraction (HFpEF)—a phenotype in which the heart’s pumping function appears normal despite significant dysfunction—and heart failure with mildly reduced ejection fraction (HFmrEF). Together, patients with these subtypes account for more than half of all heart failure cases, yet they remain largely underdiagnosed and undertreated.

A Disease Hidden in Plain Sight

The session opened with a stark set of statistics presented by moderator Ambar Andrade, MD, an advanced heart failure cardiologist at Banner University Medical Center. Heart failure carries a significant mortality risk, drives billions of dollars in costs, and saddles patients with similar hospitalization rates regardless of ejection fraction subtype. Yet the clinical recognition of HFpEF lags badly behind that of heart failure with reduced ejection fraction (HFrEF).

“HFrEF is more known and recognized and treated, and HFpEF is not, and [it is] not emphasized from a metric standpoint by a lot of institutions,” said Andrew Boshara, MD, an advanced heart failure and transplant cardiologist at St. Joseph’s Hospital and Medical Center. “And so, it tends to be put to the wayside, unfortunately, especially since these patients usually present with a lot of other comorbidities that on their own increase the patient’s mortality and risk of not doing too well, aside from the HFpEF scenario.”

The problem begins with how clinicians across specialties interpret diagnostic findings. When a patient presents with an ejection fraction of 20% or 30%, the alarm is immediate, the panelists agreed, but when the ejection fraction is 50% or higher, even in a symptomatic patient, many providers simply move on. Namit Rohant, MD, advanced heart failure and transplant cardiologist at Dignity Health, described the downstream effect: “Unless you’re really thinking about, ‘Hey, this patient has some shortness of breath, it could be the heart, it could be the lungs,’ you’re not necessarily going to [say], ‘Oh, I need to call cardiology to look for HFpEF.’ ”

Nurse practitioners (NPs) on the front lines described a pattern of vague presentations that can make earlier recognition especially challenging, but it is achievable for clinicians who know what to look for. An example, said Corie Rogers, NP, an inpatient cardiology NP at Banner, is a “reduction [in] their ability to exercise within the past 6 months; so they used to be able to walk 4 miles, and now they can only walk 2 miles with fatigue.”

Crysta Silas, MSN, FNP-C, also an inpatient NP at Banner, noted that jugular venous distension (JVD) is often a clue in patients with HFpEF: “They have very vague symptoms, but not excessively fluid overload on swelling and things like that, but their JVDs protrude.”

Patients Caught in a Revolving Door

Clinicians described patients who cycle repeatedly through hospitalization without receiving a clear diagnosis or appropriate therapy. Inpatient providers who are focused on decompensation rarely escalate to a cardiology consult unless the EF is dramatically reduced. Outpatient specialists, in turn, see patients who have already accumulated significant disease burden.

Jocelyn Wehner, AGACNP, an NP in Banner’s outpatient cardiomyopathy clinic, described an adherence disparity between the 2 populations, perhaps due to differing perceptions of immediacy: “My patients with HFrEF have more of a shock factor. I think that’s something that people can conceptualize. But I definitely see less [adherence] with the [patients with] HFpEF vs [those with] HFrEF. There’s less of an urgency.”

Suzanne Sewell, NP, lead nurse practitioner for Dignity Health’s cardiovascular medical group, identified a terminology problem contributing to patient confusion, saying, “I really wish that we had a different buzz term for HFpEF, because to tell a patient that they have heart failure when their ejection fraction is normal is really difficult.”

Rogers agreed. “I think also there’s a lack of education for them,” she said. “Nobody ever talks about the increase of HFpEF and sudden cardiac death…and there’s no really true understanding.”

[Editor’s note: This quote was updated after publication to align with current guidelines recommending implantable cardioverter-defibrillators for patients with EF less than 35%, reflecting higher sudden cardiac death risk in HFrEF.]

Guideline-Directed Therapy: Known but Not Applied

One consensus from the roundtable was that guidelines do recommend specific therapies for HFpEF and HFmrEF—including sodium-glucose cotransporter 2 (SGLT2) inhibitors, mineralocorticoid receptor antagonists (MRAs), and glucagon-like peptide-1 receptor agonists in some patients—yet the panel agreed these therapies remain dramatically underutilized, even among cardiologists.

“I would be surprised if even the vast majority of cardiologists knew that there were guideline-directed therapies for HFpEF in 2026,” Rohant said. “I think there’s a lot of education that needs to be done, even among the cardiologists who don’t necessarily manage HFpEF regularly.”

Regis Fernandes, MD, a preventive cardiologist at Mayo Clinic Arizona, added that even nonpharmacological services can be difficult to access due to coverage policies. “There [are] plenty of data on the benefits of cardiac rehabilitation for HFpEF;it’s just that it’s not paid [for],” he said. “There is no gap in evidence. There is an issue with managed care and paying for that.”

The newer nonsteroidal MRA finerenone also drew attention, particularly following the results of the phase 3 FINEARTS-HF trial (NCT04435626),³ with participants noting an increase in uptake across specialties. “It really was the nephrologists that started pushing finerenone initially, and cardiologists are slowly gaining momentum as well,” Wehner said. “We really want to make sure, with insurance barriers and prior authorizations, that that is all in place.”

Michael Campbell, PharmD, BCACP, an ambulatory care clinical pharmacist at Mayo Clinic Arizona, embedded in family medicine, framed the access gap in systemic terms: “As pharmacists, we can’t monitor or titrate therapy or even determine what’s [guideline-directed medical therapy] for that patient if they haven’t been diagnosed with the appropriate type of heart failure. So, then it just falls by the wayside, and we treat things that aren’t necessarily putting the patient most at risk from a hospitalization or, worse, mortality.”

The Case for Interdisciplinary Overhaul

Much of the roundtable’s energy coalesced around the need for a fundamental restructuring of how multidisciplinary teams manage this population. Campbell argued that the time and skills of cardiologists and advanced practice providers are being misallocated.

“You all are the best diagnosticians in the room,” he said. “If you’re spending time getting your patients access to medications, which takes you hours or days to do, there are pharmacists who can do that in 3 minutes. We need better diagnostic clarity, and we need to partner with interdisciplinary care better so that everybody focuses on the top of their licensure to take care of the patient.”

Janelle Duran, PharmD, system pharmacy manager at CommonSpirit Health, agreed, noting that even well-intentioned efforts to embed pharmacists in multidisciplinary rounds run into hard structural limits. Inconsistent staffing models mean that pharmacist presence during rounds cannot be guaranteed across every hospital, making systematic HFpEF medication review an aspiration rather than a standard of care.

Looking beyond the point of diagnosis and acute treatment, Rogers discussed room for improvement in the coordination of therapy that will be sustainable beyond discharge. “If you’re going to put a patient on a medication, then you need to educate them. You need to make sure that they can afford it in the outpatient setting and then set them up with outpatient discharge,” she said. “And I feel like this is very much lacking throughout the consensus of the [providers] caring for them.”

Prevention as the Long Game

Fernandes offered that when it comes to HFpEF, the cardiology community is intervening too late and in the wrong direction. Rather than treating end-stage HFpEF with a cascade of medications, he called for targeting the upstream conditions—insulin resistance, obesity, hypertension, and chronic kidney disease—before structural heart disease develops.

“If you know that HFpEF comes from cardiometabolic syndrome, if we treat the kidney, we treat the heart. If we treat the heart, we treat the kidneys,” he said. “It’s not surprising that a good RAS [renin-angiotensin system] inhibitor, like finerenone in combination with SGLT2, will give you the best results in clinical trials.”

He recommended that the treatment of patients with stage A or B HFpEF—patients who have risk factors or early structural changes but no symptoms—become a priority focus for health systems, with GLP-1 agonists as a first tool to address obesity-driven cardiometabolic risk.

What Comes Next

As the session closed, panelists identified specific actions they planned to take back to their organizations. Boshara called for bringing readmission-reduction data directly to hospital administration. Rohant pledged to work toward cross-institutional collaboration in Phoenix so that patients discharged from one system could seamlessly connect with heart failure programs at another. Campbell announced plans to conduct a retrospective outcomes analysis comparing outcomes with finerenone, spironolactone, and no MRA.

Andrade closed the session on a note of measured optimism, describing how her Banner cardiomyopathy clinic had grown from the ground up: “Over the past year and a half, we’ve seen 750 unique [patients with] cardiomyopathy. We built it from nothing. And we’ve slowly asked and advocated for resources: a part-time PharmD, a medical assistant who knows how to leverage AI [artificial intelligence] to get prior authorizations, a nurse navigator who can do the 48-hour phone calls and help patients get plugged in.” The lesson, she suggested, was that change is possible, but it requires persistent advocacy within systems that are only beginning to recognize the scale of the problem.

References

1. Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: a comprehensive and updated review of epidemiology. Cardiovasc Res. 2023;118(17):3272-3287. doi:10.1093/cvr/cvac013

2. Focus on heart failure | HFpEF: where we stand in 2025. Cardiology. June 1, 2025. Accessed May 12, 2026. https://www.acc.org/latest-in-cardiology/articles/2025/06/01/01/focus-on-heart-failure-hfpef

3. Solomon SD, McMurray JJV, Vaduganathan M, et al; FINEARTS-HF Committees and Investigators. Finerenone in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2024;391(16):1475-1485. doi:10.1056/NEJMoa2407107