HFpEF, HFmrEF Care Still Lags Behind the Evidence, Experts Say

In 2026, The American Journal of Managed Care (AJMC) convened 3 separate Population Health Roundtables—in Philadelphia, Pennsylvania; Boston, Massachusetts; and Chicago, Illinois. Each event drew a different bench of heart failure cardiologists, advanced practice providers, and pharmacists from major academic and health-system programs, yet the 3 conversations converged on strikingly similar conclusions. Taken together, they paint a picture of a health care system whose care pathways and infrastructure have historically been built around heart failure with reduced ejection fraction (HFrEF), even as heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF) have become increasingly prominent, and the evidence base for their treatment has expanded.

A Problem at Scale

HFpEF and HFmrEF now account for a substantial and growing share of heart failure cases. Panelists in Philadelphia estimate that the 2 subtypes together account for approximately 60% of heart failure cases nationally.¹ In Boston, panelists put the combined burden even higher, at up to 75% of the estimated 6.7 million individuals in the US with heart failure.² In Chicago, panelists cite Northwestern Medicine’s registry of 27,000 patients with heart failure, more than 70% of whom have an HFpEF diagnosis.³

Despite that shift, outcomes have not sorted themselves neatly by phenotype. Across all discussions, panelists cite data showing that mortality, hospitalization, quality-of-life impact, and cost of care are essentially indistinguishable across the ejection fraction spectrum. The Chicago panel described this as an “urgency gap,” clinical risk that is equivalent between HFrEF and HFpEF, paired with care pathways, referral patterns, and administrative attention that remain unequal.

Why HFpEF Gets Missed

A theme running through all 3 cities was how easily HFpEF can be overlooked, particularly outside specialty heart failure practices. In Philadelphia, Eman Hamad, MD, MHA, director of the Advanced Heart Failure & Transplant Program at Temple University Hospital, described the core misconception directly: that a “preserved” ejection fraction implies a milder disease course.¹ Brandie Camp, CRNP, of Thomas Jefferson University Hospital in Philadelphia, added a human dimension to that gap, describing older, often obese patients who are told their breathlessness is simply a consequence of weight or age and are not evaluated for
heart failure.

“I’ve talked to a lot of my patients who 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,” Camp said. “I think that perception really influences a lot of the patients who we end up seeing.”

Boston panelists identify biomarker limitations as another diagnostic challenge.² James Udelson, MD, chief of cardiology at Tufts Medical Center, noted that a substantial subset of patients with HFpEF may not have elevated natriuretic peptide levels, potentially leaving cases undiagnosed when clinicians rely heavily on biomarkers. Jonathan Cunningham, MD, MPH, a heart failure cardiologist at Mass General Brigham, highlighted atrial fibrillation (AF) as an underused case-finding opportunity, noting that clinicians and patients alike may accept exertional dyspnea as a baseline in patients with AF without further investigation. Erica Woodcome, ANP-BC, a nurse practitioner at Mass General Brigham, described relying on clinical gestalt—considering examination findings, comorbidities, and imaging together—when biomarkers alone are ambiguous.

Chicago panelists identify a more procedural failure point: incomplete review of echocardiogram reports.³ Harsha Gondi, MD, a cardiologist at Sinai Chicago, said trainees frequently read only the ejection fraction line of an echo summary and stop there, potentially missing diastolic function data that could support an HFpEF evaluation. Paul Silverman, MD, director of the National Service Line of Advocate Health Care, contrasted the fast-tracked referral pathway often triggered by a low ejection fraction with the slower, less certain route HFpEF patients may travel.

“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,” Silverman said.

Amyloid Cardiomyopathy as a Structured Detection Opportunity

The Boston discussion offered a specific example of how a structured diagnostic process can help close a potential gap.² David Venesy, MD, director of the Lahey Advanced Heart Failure and Cardiomyopathy Program, describes a partnership that screens every carpal tunnel release biopsy performed at his center—approximately
1500 cases annually—for transthyretin amyloidosis, a potential cause or mimic of HFpEF. Venesy noted a 20% to 25% positive rate in his center’s experience.

Carpal tunnel syndrome is increasingly recognized as a potential early manifestation of transthyretin amyloidosis, and screening tissue obtained during carpal tunnel surgery can identify otherwise unrecognized disease. Cunningham described early efforts to use artificial intelligence within the electronic health record to flag patients who meet testing criteria for amyloidosis or hypertrophic cardiomyopathy but have never been referred for screening, framing centralized, technology-assisted detection as a potential complement to clinician-driven referral.

Treatment Guidelines and Evidence Are Rapidly Evolving

All 3 roundtables converged on sodium-glucose cotransporter 2 (SGLT2) inhibitors and mineralocorticoid receptor antagonists (MRAs) as increasingly important components of HFpEF and HFmrEF treatment, while discussion continued over how best to sequence, implement, and finance those therapies.

In Boston, Scott Solomon, MD, a senior physician at Brigham and Women’s Hospital and Edward D. Frohlich Distinguished Chair and a professor of medicine at Harvard Medical School, cited pooled data from the phase 3 DELIVER (NCT03619213) and EMPEROR-Preserved (NCT03057951) trials showing consistent SGLT2 inhibitor benefit across the ejection fraction range.

Solomon also noted that the availability of generic versions of some heart failure therapies has substantially reduced medication costs, although affordability and access remain important considerations for some patients. For instance, sacubitril/valsartan and dapagliflozin are now generic and available for less than $20 a month, yet uptake remains well below target even where cost is no longer a barrier—suggesting inertia, not just affordability, is limiting adoption.

The sharpest disagreement across the conversations centered on finerenone, a nonsteroidal MRA. In Chicago, Silverman said he has been slow to adopt the drug, citing its cost and lingering skepticism about the MRA class more broadly; he said his doubt is rooted in the mixed results of the older phase 3 TOPCAT trial (NCT00094302) of spironolactone.³ Clyde Yancy, MD, Magerstadt Professor at the Northwestern University Feinberg School of Medicine and chief of cardiology at Northwestern Medicine, pushed back, pointing to the phase 3 FINEARTS-HF (NCT04435626) trial’s finding of a statistically significant reduction in the composite of total worsening heart failure events and cardiovascular death.

“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,” Yancy said.

Gregory Lewis, MD, medical director of the MGH Heart Transplant Program at Mass General Brigham, said the evidence for finerenone is considerably stronger than the subgroup data historically cited for spironolactone, but noted that cost remains the primary obstacle to first-line use—particularly for patients already paying out of pocket for an SGLT2 inhibitor and a glucagon-like peptide-1 (GLP-1) receptor agonist.²

Pharmacists across all 3 events describe active efforts to close that access gap, including a structured medication optimization protocol that moves patients to optimal guideline-directed therapy in an average of 2.63 months, cardiomyopathy grants, manufacturer co-pay cards, income-based hospital assistance programs, and a dedicated medication access pathway accelerating nonsteroidal MRA uptake.^1,2,3

Guideline lag was a specific concern in Chicago.³ Yancy, a senior author on the 2022 American Heart Association/American College of Cardiology (ACC)/Heart Failure Society of America guideline,⁴ noted that diuretics remain the only class 1 recommendation for HFpEF under that document, with SGLT2 inhibitors relegated to class 2a and MRAs to class 2b—even though a 2026 ACC expert consensus pathway⁵ has since repositioned SGLT2 inhibitors and nonsteroidal MRAs as backbone therapy.

“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?” Yancy said. “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?”

Scaling Multidisciplinary Care

Each roundtable spent significant time on whether the multidisciplinary infrastructure built for HFrEF—pharmacist-led titration clinics, standing order sets, dedicated navigator teams—can simply be extended to HFpEF. The consensus was cautious optimism paired with real capacity constraints.

Philadelphia and Boston panelists highlighted pharmacist-led clinics operating under collaborative practice agreements that independently manage lab monitoring, dose titration, and GLP-1 initiation without requiring a physician visit for every adjustment. Alicia Nordberg-Payne, PharmD, BCACP, clinical pharmacy specialist of cardiology at Hospital of the University of Pennsylvania, and Sonia Kothari, PharmD, a pharmacist at Beth Israel Deaconess Medical Center in Boston, described similar models, with Kothari’s team pairing a dedicated prior authorization service with scheduled follow-up calls every 4 to 6 weeks.^1,2

But Chicago’s panelists were most explicit about the limits of scale.³ Anjan Tibrewala, MD, heart failure cardiologist at Northwestern Medicine and associate professor at Feinberg School of Medicine, warned that with over 70% of the health system’s heart failure registry classified as HFpEF, resource-intensive interventions built for a smaller HFrEF population may not be sustainable if applied uniformly. Additionally, rapid, layered medication titration, considered standard in HFrEF, has not been proven safe or effective in HFpEF, Tibrewala noted, urging caution before building expensive infrastructure around an unproven approach. Moreover, even where navigator programs exist, follow-up gaps persist.

Across cities, panelists agree that responsibility for HFpEF management cannot rest solely with heart failure subspecialists, given workforce shortages.

“The money is in HFrEF,” said Lee Goldberg, MD, MPH, associate chief health information officer and medical director for the heart failure and cardiac transplant program at the University of Pennsylvania Health System.¹ “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.” /

References

1. Steinzor P. Experts call for structured pathways to close gaps in heart failure care. AJMC. June 26, 2026. Accessed August 20, 2026. https://www.ajmc.com/view/experts-call-for-structured-pathways-to-close-gaps-in-heart-failure-care
2. Steinzor P. Experts debate how to scale multidisciplinary care for HFpEF and HFmrEF. AJMC. August 4, 2026. Accessed August 20, 2026. https://www.ajmc.com/view/experts-debate-how-to-scale-multidisciplinary-care-for-hfpef-and-hfmref
3. Steinzor P. Confronting the “urgency gap” between HFrEF and HFpEF care. AJMC. August 18, 2026. Accessed August 20, 2026. https://www.ajmc.com/view/confronting-the-urgency-gap-between-hfref-and-hfpef-care
4. Heidenreich PA, Bozkurt C, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure. J Card Fail. 2022;28(5):e1-e167. doi:10.1016/j.cardfail.2022.02.010
5. 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