How Difficult Is the Diagnosis of Heart Failure with Preserved Ejection Fraction

Abstract Heart failure with preserved ejection fraction (HFpEF) is a systemic syndrome driven by inflammation, with a substantial contribution from comorbidities, ageing, lifestyle factors, and genetic predisposition. HFpEF accounts for approximately 50% of hospital admissions for heart failure. Mortality ranges from 15% at one year to up to 75% at 5-10 years. This paper provides an overview of heart failure with preserved ejection fraction, spanning epidemiological to therapeutic aspects, with particular focus on diagnostic challenges and strategies to overcome them. The diagnostic pathway leading to HFpEF requires extensive exclusion of potentially confounding conditions. Indeed, the identification of some of these conditions allows for targeted therapies that may improve survival. Diagnostic suspicion begins with the recognition of symptoms and signs of heart failure, followed by the assessment of natriuretic peptides and supported by scoring systems and instrumental investigations performed at rest or during exercise. HFpEF remains a challenging condition to diagnose due to the lack of uniform definitions in the literature, the presence of symptoms and signs shared with other diseases, and the absence of a universally recognised pathognomonic marker.