Journal of cardiothoracic and vascular anesthesiaSep 18, 2026

Guidelines for Treating Heart Failure with Normal Pumping Strength and What They Mean for Heart and Blood Vessel Anesthesia

GLP-1 Therapies Weekly Brief ↗PubMed ↗DOI ↗

Updated Sep 19, 2026

Abstract

The 2026 updates to the American College of Cardiology Expert Consensus Decision Pathway for heart failure with preserved ejection fraction (HFpEF) reflect major advances in diagnosis and therapy.

Probability-based diagnosis is emphasized, with normal natriuretic peptide levels not excluding HFpEF.
The HFpEF-ABA screening score is incorporated, along with expanded sex-specific considerations.
HFpEF is framed within a cardiovascular-kidney-metabolic construct, highlighting its multisystem nature.
Foundational therapies include sodium-glucose cotransporter 2 inhibitors and nonsteroidal mineralocorticoid receptor antagonists when not contraindicated.
Finerenone is preferred over steroidal mineralocorticoid receptor antagonists, and incretin-based therapy is included for obesity-related HFpEF.
Angiotensin receptor-neprilysin inhibition is selectively recommended for women and patients with left ventricular ejection fractions below approximately 55% to 60%.

Simplified

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous, multisystem syndrome frequently encountered by perioperative clinicians. The 2026 American College of Cardiology Expert Consensus Decision Pathway (ECDP) updates the 2023 pathway in response to major advances in diagnosis and therapy. It emphasizes probability-based diagnosis, recognition that normal natriuretic peptide concentrations do not exclude HFpEF, and systematic exclusion of cardiac and noncardiac mimics. The revised ECDP incorporates the HFpEF-ABA screening score, expands sex-specific considerations, and frames HFpEF within a cardiovascular-kidney-metabolic construct. Sodium-glucose cotransporter 2 inhibition and nonsteroidal mineralocorticoid receptor antagonism are positioned as foundational therapy when not contraindicated. Finerenone is favored over steroidal mineralocorticoid receptor antagonists, incretin-based therapy is incorporated for obesity-related HFpEF, and angiotensin receptor-neprilysin inhibition is selectively considered in women and in patients with a left ventricular ejection fraction below approximately 55% to 60%. The evidence remains nuanced because several pivotal trials enrolled patients with ejection fractions beginning at 40% or 45%, and benefits were often driven by fewer worsening heart failure events rather than cardiovascular mortality. This review summarizes the principal 2026 changes to the ECDP, critically appraises their evidentiary limits, and translates the pathway into implications for preoperative assessment, medication management, hemodynamic planning, and postoperative surveillance.

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Guidelines for Treating Heart Failure with Normal Pumping Strength and What They Mean for Heart and Blood Vessel Anesthesia

Abstract

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