HFpEF : The Forgotten Heart Failure

HFpEF : The Forgotten Heart Failure represents one of the most challenging and increasingly prevalent cardiovascular syndromes in contemporary clinical practice. Heart failure with preserved ejection fraction accounts for nearly half of all heart failure cases worldwide, yet it remains underrecognized, frequently misdiagnosed, and historically undertreated. Unlike heart failure with reduced ejection fraction, HFpEF does not present with impaired systolic function, making its identification more complex and its management less straightforward. HFpEF is characterized by impaired ventricular relaxation, increased myocardial stiffness, and abnormal diastolic filling, resulting in elevated cardiac filling pressures despite a normal or near-normal ejection fraction. These physiological changes lead to hallmark symptoms such as exertional dyspnea, fatigue, exercise intolerance, and fluid retention symptoms that often overlap with other cardiopulmonary or systemic conditions. This overlap contributes significantly to diagnostic delays and therapeutic uncertainty. The pathophysiology of HFpEF is multifactorial and extends beyond the myocardium itself. It is closely associated with aging, hypertension, obesity, diabetes mellitus, chronic kidney disease, atrial fibrillation, and systemic inflammation. These comorbidities drive structural remodeling, microvascular dysfunction, and endothelial impairment, transforming HFpEF into a systemic syndrome rather than a purely cardiac disorder. As a result, disease progression and symptom burden vary widely among individuals. Historically, HFpEF has been referred to as the “forgotten” or “neglected” form of heart failure due to limited evidence-based therapies demonstrating clear mortality benefit. This therapeutic gap has contributed to inconsistent management strategies and frustration among clinicians and patients alike. However, recent advances in clinical research have begun to reshape understanding of HFpEF, highlighting the importance of individualized care, comorbidity management, and targeted therapeutic approaches. Accurate diagnosis of HFpEF requires careful clinical evaluation supported by imaging, biomarkers, and hemodynamic assessment. Echocardiography plays a central role, particularly in assessing diastolic function, left atrial size, and ventricular stiffness. Biomarkers such as natriuretic peptides provide additional diagnostic and prognostic value, though interpretation may be influenced by obesity and renal function. The global burden of HFpEF continues to rise, driven largely by population aging and the growing prevalence of cardiometabolic disease. Patients with HFpEF experience frequent hospitalizations, reduced quality of life, and substantial healthcare utilization. Recognizing HFpEF as a distinct and serious form of heart failure is essential for improving patient outcomes and advancing cardiovascular care. HFpEF is no longer a condition that can be overlooked or minimized. As research continues to evolve, a deeper understanding of its complex mechanisms is redefining heart failure management and reinforcing the need for early recognition, comprehensive assessment, and multidisciplinary care strategies.