Heart failure with preserved ejection fraction (HFpEF): diagnosis and management for the general physician

Abstract

Heart failure (HF) with preserved ejection fraction (HFpEF) is becoming the dominant HF phenotype in clinical practice, reflecting population aging and increasing cardiometabolic disease. Contemporary HFpEF is recognised as a complex, systemic syndrome with heterogeneous pathophysiology and substantial morbidity. It remains underdiagnosed, with many patients detected only during hospitalisation. Diagnosis requires a high index of suspicion and a structured approach integrating clinical assessment, natriuretic peptides, and echocardiography to demonstrate elevated left ventricular filling pressures and exclude alternative diagnoses. Recent randomised trials have demonstrated that sodium-glucose cotransporter-2 inhibitors and non-steroidal mineralocorticoid receptor antagonists reduce HF hospitalisations and improve quality of life. Additional strategies, including anti-obesity therapies, support phenotype-directed management, alongside core strategies of congestion relief, comorbidity optimisation, and multidisciplinary care. Early recognition and timely initiation of evidence-based therapy are essential to improve outcomes for this population. This review provides a practical, evidence-based framework for the contemporary diagnosis and management of HFpEF.