Global Convergence and Divergence in Clinical Practice Guidelines for Heart Failure With Preserved Ejection Fraction: A Systematic Comparative Review

Heart failure with preserved ejection fraction (HFpEF) is a growing global health challenge, yet international clinical guidance remains heterogeneous.This review synthesizes HFpEF recommendations from major national and international guidelines published between 2014 and March 2026.A systematic, PRISMA-informed search of bibliographic databases, guideline repositories, and professional society websites identified 1,061 records.Following deduplication and two-stage screening, 15 distinct documents met the eligibility criteria, spanning Europe, North America, South America, Asia, and Oceania.Data were extracted on diagnostic criteria, natriuretic peptide thresholds, scoring systems, pharmacological and nonpharmacological management, comorbidity strategies, and follow-up recommendations.Methodological quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, and findings were synthesized narratively.Regional endorsement and adaptation frameworks, specifically those from the Pan-African Society of Cardiology (PASCAR), were integrated via qualitative synthesis.There was strong global consensus on the core diagnostic definition of HFpEF, the role of natriuretic peptides and echocardiography, the use of diuretics for congestion, and sodium-glucose cotransporter 2 (SGLT2) inhibitors as foundational disease-modifying therapy.Variation persisted in diagnostic scoring systems (HFA-PEFF vs. H₂FPEF vs. none), natriuretic peptide thresholds (particularly those recommended by the National Institute for Health and Care Excellence (NICE)), use of advanced diagnostic testing, and phenotype-specific recommendations.The 2023 Saudi Heart Association update strengthened representation from the Middle East, with regional emphasis on diabetes, obesity, and metabolic syndrome.No sub-Saharan African guideline was identified; the PASCAR provides capacity-building frameworks rather than formal recommendation-based guidance.This review provides a comprehensive comparative analysis of contemporary HFpEF guidelines.Findings highlight increasing international convergence, particularly following recent Japanese and Saudi updates, alongside persistent diagnostic and therapeutic divergence that may influence clinical practice and equity of care.The absence of region-specific HFpEF guidance in Africa represents a key gap.Greater harmonization of diagnostic pathways, wider adoption of validated scoring systems, and improved contextualization of management across diverse health systems are needed.