Cardiac Pacing in Patients with Heart Failure with Preserved Ejection Fraction

Purpose of Review Heart failure with preserved ejection fraction (HFpEF) is the most prevalent heart failure phenotype and carries substantial morbidity and mortality, yet effective device-based therapies are lacking. Sinus node dysfunction and atrioventricular block are common in this population and contribute to impaired cardiac reserve and exercise intolerance, providing a pathophysiologic rationale for cardiac pacing as a therapeutic strategy. This review examines the physiologic rationale, current evidence, and clinical decision-making for contemporary and emerging pacing strategies in HFpEF. Recent Findings A range of contemporary pacing approaches — including personalized accelerated pacing and conduction system pacing — is under investigation, each aiming to optimize cardiac output and loading conditions while avoiding the adverse effects of non-physiologic pacing. Conventional right ventricular pacing is independently associated with worse outcomes in HFpEF, reinforcing the rationale for physiologic alternatives. Summary Contemporary and emerging pacing strategies show promise for HFpEF, but prospective randomized clinical trials are needed to define their role.