HFpEF and Precapillary Pulmonary Hypertension: The Role of COPD

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome primarily characterized by exercise intolerance and exertional dyspnea due to exercise‐induced elevation of filling pressures. This hemodynamic profile alone may be insufficient to produce overt acute congestion or the sustained pulmonary pressure burden required for precapillary pulmonary vascular remodeling, which is more readily expected with persistent hemodynamic abnormalities such as long‐standing uncorrected valvular heart disease. Garcia‐Arango et al. show that an unfavorable pulmonary vascular resistance response to exercise in HFpEF is associated particularly with chronic obstructive pulmonary disease (COPD) and atrial fibrillation (AF). Importantly, most patients with this phenotype already had combined pre‐ and postcapillary pulmonary hypertension at rest, raising the possibility that, particularly in patients with COPD, the precapillary component reflects concomitant pulmonary vascular disease rather than HFpEF itself. Conversely, the association with AF, greater left atrial remodeling, and impaired atrial function suggests an atrial–pulmonary vascular interaction. The same atrial substrate may predispose to dynamic functional mitral and tricuspid regurgitation, providing an additional hemodynamic mechanism for acute congestion. These findings reinforce HFpEF as a heterogeneous syndrome of exercise intolerance in which pulmonary and atrial mechanisms may coexist with abnormal filling pressures, contributing differently to exertional symptoms and overt acute heart failure.