Heart failure with preserved ejection fraction: From pathophysiology to a practical approach to diagnosis and treatment

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome with increasing prevalence, driven by aging and cardiometabolic comorbidities. It is better understood as a disorder of elevated filling pressures, impaired cardiovascular reserve, recurrent congestion, and systemic multiorgan dysfunction than as heart failure with normal systolic function. Diagnosis remains probabilistic and requires integration of symptoms, natriuretic peptides, echocardiographic structural and functional abnormalities, and, when resting findings are inconclusive, exercise or invasive hemodynamic testing. Treatment has evolved from symptom control toward phenotype-oriented care. Sodium-glucose cotransporter 2 inhibitors are foundational therapy, finerenone expands options for selected patients, and obesity is now a modifiable therapeutic target. This review summarizes current mechanisms, diagnostic pathways, and treatment strategies, with emphasis on practical clinical decision-making.