The 2026 American College of Cardiology Expert Consensus Decision Pathway for Heart Failure with Preserved Ejection Fraction: Implications for Cardiothoracic and Vascular Anesthesia.

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.