Американский колледж кардиологов обновил рекомендации по лечению сердечной недостаточности с сохраненной фракцией выброса

The American College of Cardiology (ACC) published a 2026 expert consensus decision pathway (ECDP) on the management of patients with heart failure with preserved ejection fraction (HFpEF) in the Journal of the American College of Cardiology. The report from the ACC Solution Set Oversight Committee is an update to the 2023 ECDP and addresses pivotal advances in HFpEF care, including recent favorable clinical trials with sodium glucose-cotransporter 2 (SGLT2) inhibitors, nonsteroidal mineralocorticoid receptor antagonists (MRAs), and incretin-based therapies, and evidence that these therapies have additional cardiovascular-kidney-metabolic (CKM) benefits. “This revised ECDP was written to provide timely, practical guidance based on emerging evidence on the diagnosis and management of HFpEF,” the ACC committee wrote. “This document aligns with and operates within the framework of the recommendations published in the ‘2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure,’ but provides a nuanced, updated approach to various aspects of HFpEF care based on emerging evidence.” Specifically, the goal of the ECDP is to identify and implement current best practices for therapy to improve outcomes in patients with HFpEF, and an accurate diagnosis is critical, according to the ACC committee. …this ECDP…provides practical tips and structure on clinical decision-making, implementation of the latest advancements in pharmacologic and nonpharmacologic therapy, and management of comorbidities [in patients with HFpEF]. Clinicians are advised to identify individuals with possible HFpEF based on characteristic symptoms and signs, evaluate for HFpEF noncardiac and cardiac mimics during a thorough differential diagnosis, and implement an HFpEF management plan that includes managing comorbidities, nonpharmacologic management, and optimal medical therapy. Diagnosing HFpEF The main challenge for diagnosing patients with HFpEF is the lack of a single test that definitively establishes the diagnosis. Therefore, a careful differential diagnosis is required, with use of HF scoring systems to assess the probability of the diagnosis. Also, potential noncardiac and cardiac mimics must be considered, which may present with symptoms of dyspnea, exercise intolerance, and edema, as well as signs of congestion and preserved ejection fraction, the committee noted. The H2FPEF, HFpEF-ABA, and HFA-PEFF diagnostic scoring systems may be used to assess the likelihood that HFpEF is the underlying cause in a patient with dyspnea or edema. “In clinical practice, the HFpEF-ABA score would function most readily as a screening tool in the primary care setting or in the electronic medical record, with the probability of HFpEF prompting further imaging, natriuretic peptide testing, cardiology referral, or all of these,” the committee wrote. “In cardiology practices where access to echocardiographic data is available, the H2FPEF score may be easily calculated and potentially more useful than the HFA-PEFF, given evidence of greater accuracy despite fewer input variables.” A systematic evaluation is essential to exclude noncardiac and cardiac mimics before a diagnosis of HFpEF can be confirmed. Noncardiac mimics include conditions such as pulmonary disease, kidney disease, high-output states (anemia and liver disease), obesity, and frailty or deconditioning. Some cardiac conditions that should be considered include valvular heart disease, pericardial disease, myocardial disease, and ischemic heart disease. Women who have HFpEF are frequently older than men and typically have a similar comorbidity burden, although an increased attributable risk for HFpEF occurs from traditional risk factors in women vs men, particularly hypertension, type 2 diabetes, and obesity. Women with HFpEF generally have more significant symptoms of dyspnea and a worse quality of life, and men have more epicardial coronary artery disease (CAD), with women more commonly having coronary microvascular dysfunction. Managing Patients With HFpEF Management of patients with HFpEF involves optimal medical therapy, which may include SGLT2 inhibitors, MRAs, incretin-based therapies, angiotensin receptor–neprilysin inhibitors, and angiotensin receptor blockers (ARBs); nonpharmacologic methods, such as exercise, weight loss, and wireless, implantable pulmonary artery monitors; and risk stratification and management of comorbidities, including hypertension, type 2 diabetes, obesity, atrial fibrillation (AF), CAD, chronic kidney disease (CKD), and obstructive sleep apnea. Optimal Medical Therapy Detailed guidance for optimal medical therapy is provided in the 2026 AHA/ACC/ADA/ASN Cardiovascular-Kidney-Metabolic Syndrome Guideline, and clinicians also should consider cautions and contraindications when prescribing these treatments. SGLT2 inhibitors are the foundation for HFpEF therapy, with research showing that SGLT2 inhibitors can significantly lower the risk for hospitalization for HF and cardiovascular death, as well as improve health status and quality of life. Trials with sotagliflozin and empagliflozin and a meta-analysis that also included dapagliflozin found that SGLT2 inhibitors may be safely initiated in the acute care setting. Spironolactone, a nonselective, steroidal MRA, can improve diastolic function in patients with HFpEF. Finerenone, a nonsteroidal MRA, is associated with improved selectivity for the mineralocorticoid receptor, balanced distribution in the heart and kidney, short half-life, minimal hormonal adverse effects, and decreased risk for hyperkalemia. “Finerenone should be considered the MRA of choice for individuals with HFpEF,” the committee wrote. “However, if cost or tolerance is prohibitive, spironolactone is a reasonable alternative.” Incretin-based therapies include semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1 RA), and tirzepatide, a dual GLP-1 RA and glucose-dependent insulinotropic polypeptide receptor agonist, which were originally approved in patients with type 2 diabetes. Use of semaglutide and tirzepatide has since expanded to include obesity, a major risk factor and prevalent condition in HFpEF. A concern with incretin-based therapies is sarcopenic obesity, especially in older adults. ARBs have shown modest benefit for decreasing the risk for HF hospitalizations and should be considered when angiotensin receptor-neprilysin inhibitors are contraindicated or unaffordable, according to the committee. “Based on robust clinical trial evidence, optimal medical therapy for individuals with HFpEF includes an SGLT2 inhibitor and nonsteroidal MRA, unless otherwise contraindicated, to reduce cardiovascular death and HF hospitalization, and improve health status,” the committee advised. The ECDP recommends that loop diuretics be used judiciously and titrated as needed to alleviate congestion and associated symptoms. In addition, no benefit of β-blockers in patients with HFpEF has been established, and, therefore, use of β-blockers should be limited to specific indications, such as angina or rate control of AF, according to the committee. Nonpharmacologic Management Research has shown that 3 to 4 months of exercise is associated with improved exercise capacity and quality of life in patients with HFpEF, although some longer-term studies up to 12 months have been inconsistent. No evidence has shown that exercise is associated with a decrease in HF hospitalizations or death, but it should be encouraged in individuals with HFpEF owing to improvement in clinical and patient-centered outcomes, according to the committee. Caloric restriction with or without exercise has led to improvement in some clinical outcomes for patients with obesity-related HFpEF, although the benefits of interventions may not be sustained after the intervention is complete. Implantable pulmonary artery monitors have been effective for reducing HF hospitalizations and improving quality of life in some studies. Research has not found a consistent benefit for permanent pacing in patients with HFpEF, with results depending on the particular pacing strategy used. Comorbidities CKM syndrome provides a framework to prioritize comorbidity management for HFpEF, in which the cumulative burden and severity of CKM comorbidities are strongly associated with adverse clinical outcomes. Treatments such as SGLT2 inhibitors, MRAs, and GLP-1 RAs provide complementary CKM benefits in patients with HFpEF. Management for patients with HFpEF and comorbid CAD focuses on guideline-directed secondary prevention and symptom control with the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization and the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Observational studies have suggested that revascularization is associated with preserved cardiac function and improved survival in patients with HFpEF and CAD. Secondary prevention with high-intensity statins, antiplatelet therapy, and optimized blood pressure control are important for overall care, according to the committee. Patients with comorbid HFpEF and AF have worse symptoms, more cardiac dysfunction, and increased risk for hospitalizations and death compared with those in sinus rhythm. Research indicates that rhythm control, especially catheter ablation, is associated with a reduced mortality rate and fewer cardiovascular and HF events in patients with HFpEF and AF vs use of rate-control strategies, and SGLT2 inhibitors and GLP-1 RAs can reduce AF in those patient groups. Hypertension is highly prevalent among patients with HFpEF and is an important modifiable risk factor. The 2025 Multisociety Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults recommends that patients with type 2 diabetes, CKD, and HF warrant a target blood pressure of less than 130/80 mm Hg; however, evidence suggests that the optimal systolic blood pressure target is 120 to 129 mm Hg for patients with HFpEF. Among patients with HFpEF, angiotensin receptor-neprilysin inhibitors or ARBs may be a more effective antihypertensive option owing to the potential additional benefit of reduced HF hospitalizations. Comorbid CKD in individuals with HFpEF is associated with a significant increase in death and worsening HF events. Management of CKD focuses on use of renin-angiotensin system inhibitors, SGLT2 inhibitors, nonsteroidal MRAs, and GLP-1 RAs, which can reduce the progression of kidney dysfunction, including in patients with diabetic kidney disease. Patients with coexisting HF and type 2 diabetes have worse clinical outcomes compared with those without type 2 diabetes, including a higher risk of death and worse health-related quality of life. Treatment of type 2 diabetes for patients with HFpEF should follow the American Diabetes Association’s Standards of Care in Diabetes — 2026, the committee noted. A key component is the replacement of agents that provide only glucose control, such as sulfonylureas, with those that offer HF-specific benefit, and SGLT2 inhibitors are foundational treatment in patients with HFpEF, regardless of diabetic status. Obesity can be an HFpEF mimic, but it is also a common comorbidity, and higher degrees of obesity are associated with greater pulmonary capillary wedge pressures during exercise, more severe symptoms, and lower exercise capacity. The ACC developed recommendations for managing obesity in HF in a 2025 scientific statement. Successful treatment of patients with obesity involves a multidisciplinary approach with nutritional support, exercise, incretin-based therapies, and consideration of bariatric surgery, according to the committee. “As science evolves and further discoveries and developments occur, some of these recommendations may need to be altered to reflect those advances,” the ACC committee concluded. “In the interim, this ECDP addresses contemporary management of HFpEF. It provides practical tips and structure on clinical decision-making, implementation of the latest advancements in pharmacologic and nonpharmacologic therapy, and management of comorbidities.” Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. This article originally appeared on The Cardiology Advisor