New Scoping Review Offers Hospitals a Practical Roadmap for HFpEF

A new scoping review published in the Journal of Brown Hospital Medicine offers hospitalists a consolidated, practical framework for managing heart failure with preserved ejection fraction (HFpEF)—a condition that now accounts for roughly half of all heart failure cases and disproportionately affects older adults with multiple comorbidities.¹

“Recent advances in guideline-directed medical therapy (GDMT) have begun to shift the treatment paradigm for HFpEF, with emerging evidence supporting targeted pharmacologic therapies alongside comprehensive comorbidity management,” wrote the researchers of the study. “This review aims to synthesize current evidence on GDMT in HFpEF, focusing on clinically relevant pharmacologic interventions and their application in hospitalized patients.”

Why HFpEF Remains a Hospitalist Challenge

Unlike heart failure with reduced ejection fraction (HFrEF), which stems primarily from impaired systolic pumping, HFpEF is driven by diastolic dysfunction, ventricular stiffening, and diffuse myocardial fibrosis linked to systemic inflammation and endothelial dysfunction. Common comorbidities, including hypertension, type 2 diabetes, atrial fibrillation, chronic kidney disease, coronary artery disease, and excess adiposity, all contribute to and complicate the syndrome.

GDMT Landscape Continues to Shift

The review compares recommendations from the American Heart Association (AHA) 2022, European Society of Cardiology (ESC) 2021/2023, and the newer Japanese Circulation Society/Japanese Heart Failure Society (JCS/JHFS) 2025 guidelines.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors carry the strongest and most consistent endorsement, with JCS/JHFS and ESC now assigning them a Class Ia recommendation—stronger than the AHA’s current Class IIa—based on pooled data from the EMPEROR-Preserved (NCT03057951) and DELIVER (NCT03619213) trials. Finerenone (Kerendia; Bayer), a nonsteroidal mineralocorticoid receptor antagonist (MRA), earned a Class Ia recommendation in the JCS/JHFS and ESC guidelines following the FINEARTS-HF (NCT04435626) trial, while angiotensin receptor neprilysin inhibitors (ARNIs) and angiotensin II receptor blockers (ARBs) remain limited to a Class IIb designation across most societies.

Semaglutide has also entered the JCS/JHFS guideline with a Class IIa recommendation for patients with HFpEF and co-occurring type 2 diabetes and elevated body mass index, based on the STEP-HFpEF DM (NCT04916470) trial, which showed meaningful symptom and functional improvements alongside reductions in body weight.

A Framework Built for the Inpatient Setting

The authors emphasize that not every GDMT option is appropriate to start during hospitalization. SGLT2 inhibitors are positioned as the most practical inpatient-initiated therapy given their safety profile and minimal titration needs, while glucagon-like peptide-1 (GLP-1) receptor agonists and select MRAs are better suited to outpatient initiation with longitudinal follow-up. The review also outlines emerging device-based options, including interatrial shunt devices, and disease-specific pathways for secondary HFpEF causes such as hypertrophic cardiomyopathy and transthyretin amyloid cardiomyopathy.

For additional context, a 2025 American College of Cardiology clinical review notes that nearly 6.7 million Americans live with heart failure, more than half with HFpEF, and that the phenotype carries a 20% to 29% 1-year mortality rate along with a 21% 30-day readmission rate, underscoring the stakes of getting inpatient management right.²

Managed Care Implications

For payers and health systems, the review’s emphasis on comorbidity-driven care has direct cost implications: uncontrolled hypertension, atrial fibrillation, and renal dysfunction are recurrent drivers of HFpEF-related hospitalization and readmission. Formulary and care-management strategies that support timely SGLT2 inhibitor initiation, structured discharge planning, and outpatient follow-up may help reduce the high readmission burden associated with this population, particularly as GDMT options continue to expand and diverge across international guidelines.

“One of the most impactful roles of the hospitalist lies in ensuring a successful transition from inpatient to outpatient care,” wrote the researchers. “Early follow-up, medication optimization, patient education, and coordination with primary care and cardiology are essential to improving adherence and reducing readmissions. As the understanding of HFpEF continues to evolve, improving outcomes will depend not only on advancing pharmacologic therapies but also on strengthening continuity of care. A structured, hospitalist-driven approach that integrates inpatient management with outpatient follow-up represents a critical opportunity to enhance long-term outcomes in this increasingly prevalent condition.”

References

1. Northway J, Park J, Mankowitz K, Hoque F. Comprehensive framework of heart failure with preserved ejection fraction management for hospitalists: a scoping review. J Brown Hosp Med. 2026;5(3). doi:10.56305/001c.163599
2. Focus on heart failure: HFpEF—where we stand in 2025. American College of Cardiology. June 1, 2025. Accessed July 6, 2026. https://www.acc.org/latest-in-cardiology/articles/2025/06/01/01/focus-on-heart-failure-hfpef