Optimizing the Use of N-terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) in the Diagnosis of Heart Failure With Preserved Ejection Fraction (HFpEF): A Clinical Pathway Approach to an Underdiagnosed Entity

Heart failure (HF) with preserved ejection fraction (HFpEF) constitutes approximately 50% of all global HF cases and remains one of the most underdiagnosed and undertreated cardiovascular conditions. Diagnosis is often delayed because its symptoms overlap with comorbidities in older adults and the inadequate validation of diagnostic tools for HFpEF. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a recognized biomarker indicative of myocardial wall stress; however, its ideal diagnostic utility in HFpEF is hindered by physiological and comorbid factors, including age, obesity, atrial fibrillation, and renal dysfunction. This review aimed to critically analyze the changing role of NT-proBNP in diagnosing HFpEF, compile recent evidence (2022-2025), and suggest a structured clinical pathway that incorporates adjusted thresholds, clinical scoring systems, and multimodal imaging. By using a step-by-step approach, doctors can improve the diagnostic yield of NT-proBNP, avoid missing or misdiagnosing patients, and speed up the delivery of the right treatment for this complex condition.