Aortic Stenosis and Heart Failure With Preserved Ejection Fraction: A Cautionary Tale of Common Partners

Aortic stenosis (AS) is increasingly recognized as a disease of both the valve and the myocardium. Beyond valvular obstruction, many patients with aortic stenosis develop extra-valvular abnormalities, including left ventricular hypertrophy, diastolic dysfunction, and atrial and pulmonary vascular remodeling, which have emerged as major determinants of symptoms and prognosis. These abnormalities share many similarities with heart failure with preserved ejection fraction (HFpEF), a condition that is also prevalent in the same aging population. Emerging data suggest that AS and HFpEF frequently coexist and interact, compounded by shared cardiometabolic risk factors, producing convergent phenotypes that complicate diagnosis and influence treatment response. Residual HFpEF appears to underlie much of the persistent heart failure burden after aortic valve replacement, while even mild AS portends worse outcomes in patients with HFpEF. Recent studies have shown that HFpEF-directed therapies, such as sodium-glucose cotransporter 2 inhibitors, may benefit selected patients with AS. As both conditions increase in prevalence and valve interventions are offered to increasingly complex patients, a clearer understanding of the ways in which AS and HFpEF overlap and interact is essential. This review integrates epidemiological, pathophysiological, and clinical perspectives to synthesize emerging evidence on the AS-HFpEF overlap and outlines implications for diagnosis, prognosis, and management.