Rethinking Left Ventricular Diastolic Dysfunction in Hypertension: The Interplay of Arterial Stiffness, Ventricular–Arterial Coupling, and Pulse Wave Velocity in HFpEF

Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of heart failure cases and is closely associated with hypertension and left ventricular diastolic dysfunction (LVDD). This narrative review examines the relationship between diastolic function, arterial stiffness, and ventricular-arterial coupling in hypertensive heart disease. We summarize ventricular relaxation and filling and discuss echocardiographic measures, including E/e', left atrial volume, and left atrial reservoir strain, for assessing diastolic function and filling pressures. We then examine how aortic stiffening may increase late systolic load and contribute to ventricular remodeling and impaired relaxation. This review addresses four central questions: whether arterial stiffness represents an independent component of hypertensive left ventricular diastolic dysfunction; whether pulse wave velocity (PWV) is primarily a marker of vascular aging, ventricular afterload, or HFpEF risk; whether PWV provides incremental information beyond established echocardiographic markers; and how arterial stiffness could be integrated into contemporary HFpEF assessment. The available evidence supports arterial stiffness as a biologically plausible contributor to hypertensive ventricular remodeling and impaired diastolic reserve. However, current evidence does not establish echocardiographic global PWV (PWVg) as an independent diagnostic criterion or validated prognostic marker of clinical HFpEF. We therefore propose PWVg as a complementary, hypothesis-generating measure for vascular and ventricular phenotyping, to be interpreted alongside clinical assessment, natriuretic peptides, multiparametric echocardiography, and exercise or invasive hemodynamic testing when indicated.