Time to screen: rationale and roadmap for HFpEF screening in individuals with obesity

Obesity is a major risk factor for heart failure with preserved ejection fraction (HFpEF) and is associated with a distinct pathophysiological phenotype. Individuals with obesity develop HFpEF on average a decade earlier than individuals without obesity. Despite this, systematic screening for HFpEF in individuals with obesity is not currently recommended in clinical guidelines. This review discusses the rationale for screening individuals with obesity for HFpEF, highlighting the rising prevalence of obesity-related HFpEF, its earlier onset, and its often under-recognized clinical presentation. We describe the specific pathophysiological mechanisms linking obesity to HFpEF, including inflammation, adipose tissue distribution, and hemodynamic alterations. Furthermore, we review the limitations of current diagnostic approaches in this population, including the interpretation of natriuretic peptides, echocardiographic challenges, and indexing pitfalls. Current and emerging screening tools (e.g., HFpEF-ABA score) are critically appraised, with a proposal for a stepwise screening and diagnostic pathway tailored to individuals with obesity. Given the high burden and early onset of HFpEF in people with obesity, screening strategies may enable earlier detection and timely intervention. Prospective studies are needed to determine the prevalence of (early) HFpEF in populations with obesity and to evaluate the effectiveness of structured screening approaches in clinical practice.