Session 2 · Frame 1 of 10

The swelling improved. The treatment decision remains.

67 years old; confirmed HFpEF; EF 58%
Obesity and hypertension; no diabetes
Stable after congestion treatment; renal function and medicines under review

Fictional Angela case scene — Fictional AI-generated scene; not patient testimony.

Facilitator notes

Open with Angela in her modern kitchen if the brief scene adds context. Her question is practical: if she does not have diabetes, why is a medicine commonly associated with diabetes being discussed? Ask learners to separate symptom relief from treatment intended to reduce HF events. Do not present a brand as the inevitable conclusion. Allow the panel to articulate the patient priorities, treatment burden and affordability questions.

Sources: ACC summary of the 2026 HFpEF consensus update.

Session 2 · Frame 2 of 10

Three opening decisions

HF therapy without diabetes
What a positive trial actually proves
Starting dose, target dose and monitoring

Angela has confirmed symptomatic HFpEF, no diabetes, adequate renal function and stable volume status. Which plan is best supported?A. Wait for diabetes before considering an SGLT2 inhibitor.B. Discuss an eligible SGLT2 inhibitor with product-specific safety and access review.C. Increase diuretic therapy despite euvolemia as the only treatment.D. Use a beta-blocker solely to reproduce HFrEF therapy.

Angela asks whether SUMMIT proves tirzepatide prevents cardiovascular death in HFpEF. Which answer is most accurate?A. Yes; every component of a positive composite must improve.B. It proves superiority over semaglutide.C. The composite improved, driven by fewer worsening-HF events; isolated mortality reduction was not demonstrated.D. The study assessed weight only.

For the HF indication, a stable patient has EF 55%, eGFR 45 mL/min/1.73 m² and potassium 4.8 mEq/L, without a contraindicated interaction. Which initial plan matches the label?A. Start 40 mg and check labs at the annual visit.B. Start 10 mg daily and arrange potassium/eGFR review at four weeks.C. Start the 20 mg target immediately for every patient.D. Use only the CKD dose-adjustment table.

Facilitator notes

Collect the three independent pre responses before presenting efficacy data. Do not disclose correct choices through slide titles or sponsor logos. This activity compares decision quality, not willingness to prescribe. The accredited host must retain first responses, time stamps and item versions. The faculty will revisit all three concepts using new patients after discussion.

Sources: ACC HFpEF consensus: practical diagnostic and management framework.

Session 2 · Frame 3 of 10

Use the evidence for the question it answered

EMPEROR-Preserved and DELIVER: HF event composites
Benefits did not require diabetes
Separate trials do not establish a drug ranking

Facilitator notes

Explain why a patient without diabetes can still be eligible for an appropriate SGLT2 inhibitor. Describe the study populations and outcomes without implying that every composite component showed the same effect. Ask the pharmacist to distinguish expected benefit from a guarantee. Do not rank empagliflozin and dapagliflozin using their separate hazard ratios. Present the decision within the complete HF and comorbidity plan.

Sources: DELIVER primary report.

Session 2 · Frame 4 of 10

Make initiation a usable plan

Review renal function and volume status
Check product-specific eligibility, safety and access
Teach illness and procedure instructions

Facilitator notes

Walk through what must happen before the first prescription: actual renal function, volume status, concurrent therapies, affordability and a realistic follow-up. Discuss genital or urinary symptoms and ketoacidosis warning symptoms. Product-specific renal instructions differ. Both labels include withholding at least three days before surgery or prolonged fasting when possible, and resuming after stability and oral intake return. Invite questions that clarify implementation rather than rehearsing a promotional benefit statement.

Sources: Dapagliflozin US prescribing information, June 2026.

Session 2 · Frame 5 of 10

Obesity therapy: population and endpoint matter

STEP-HFpEF: symptoms, function and weight
SUMMIT: composite benefit driven by worsening-HF events
Neither is a head-to-head comparison

Facilitator notes

Ask Angela’s question: does this mean I am less likely to die? Faculty should explain what was and was not demonstrated. Review symptom/function improvement and the difference between a composite and mortality alone. Discuss labeled obesity indications, tolerability, nutrition and physical function. The absence of an HFpEF indication in the current US obesity-product labels must remain clear when discussing the trial evidence.

Sources: SUMMIT primary report.

Session 2 · Frame 6 of 10

Mineralocorticoid antagonism: distinguish the evidence

FINEARTS-HF enrolled EF at least 40%
Finerenone has a current US HF indication
Do not treat TOPCAT as a positive head-to-head comparison

Facilitator notes

Connect the biological rationale to the clinical evidence, then stop short of claiming interchangeable results across all MRAs. FINEARTS-HF and TOPCAT were different trials. Introduce finerenone only within a balanced review of appropriate HF treatment, comorbidities and safety. Ask the independent reviewer to confirm the current label and guideline interpretation before release, including differences between European guidance and US prescribing authority.

Sources: FINEARTS-HF primary report.

Session 2 · Frame 7 of 10

Reveal: eGFR 42, potassium 4.7

After full eligibility checks: HF start 10 mg daily
HF target for that baseline renal category: 20 mg when eligible
Potassium/eGFR at four weeks; use the complete HF adjustment table

Facilitator notes

Ask learners to distinguish starting dose from target dose. A participant who remembers a CKD regimen may choose the wrong monitoring or titration rule. Have the pharmacist explain the indication-specific table and contraindications. Name the clinician who will review the result. Do not assume that a target dose must be reached regardless of laboratory changes, tolerability or clinical circumstances.

Sources: Finerenone US prescribing information, September 2026.

Session 2 · Frame 8 of 10

Build a complete plan with Angela

HF therapy and congestion management have different purposes
Address BP, rhythm, kidney health, function and sleep
Decide together what is feasible and affordable

Facilitator notes

Invite the primary-care faculty member to explain how the plan fits into a typical visit and subsequent contact. Ask Angela’s fictional question about cost, pill burden or laboratory access, and have the panel work through a response. Do not imply that choosing a medication resolves food access, transportation or referral delays. Document the decision and the reason when treatment is deferred.

Sources: ACC HFpEF consensus: practical diagnostic and management framework.

Session 2 · Frame 9 of 10

Questions that test the evidence

Does a positive composite prove a mortality benefit?
Can obesity treatment replace all HF-directed care?
How does European guidance differ from a US indication?

Facilitator notes

Use ten minutes for audience discussion. Correct overstatements without implying that a therapy lacks value simply because one outcome was not established. Explain that sex subgroup evidence supports relevant female cases but not a universal claim of greater drug benefit in women. Note unanswered questions for source-checked faculty follow-up.

Sources: STEP-HFpEF prespecified pooled sex analysis.

Session 2 · Frame 10 of 10

Apply the evidence to a new patient

Three parallel post cases
Choose the next treatment and monitoring step
Explain the expected benefit and the limit

A woman without diabetes has confirmed HFpEF and asks why an SGLT2 inhibitor is being discussed. Which explanation is accurate?A. It is required only to prevent future diabetes.B. All SGLT2 agents have interchangeable HF labels.C. Trials support HF benefit beyond glucose lowering; select a suitable agent and monitoring plan.D. A standalone cardiovascular mortality benefit was proven in every HFpEF trial.

Which explanation best distinguishes STEP-HFpEF from an HF mortality trial?A. It demonstrated symptom, function and weight benefits; it was not designed to establish a mortality reduction.B. Its weight effect proves longer survival.C. Its findings establish superiority over tirzepatide.D. The result means all obesity drugs treat HFpEF identically.

A woman with EF 58%, eGFR 42 mL/min/1.73 m² and potassium 4.7 mEq/L is an appropriate finerenone HF candidate after full review. Which plan is correct?A. Start 20 mg because that is her target.B. Start 10 mg and check potassium only after symptoms develop.C. Start 10 mg, check potassium/eGFR at four weeks, and consider the 20 mg HF target when eligible.D. Start 40 mg because the HF label differs from CKD.

Facilitator notes

Collect the three first post responses and then debrief. Ask the audience to state one trial claim they would now explain more carefully. Finish with an action that can be implemented: connect every treatment choice to the patient, evidence, current label, safety plan and access. Complete the evaluation without an essay or a media-watching requirement.

Sources: ACC summary of the 2026 HFpEF consensus update.

Minutes	Teaching task
0–5	Three baseline decisions; first responses locked
5–15	Evidence framework
15–40	Progressive case reveal, polling and faculty reasoning
40–50	Audience questions and implementation barriers
50–55	Three parallel post-case decisions
55–60	Synthesis and evaluation