HFpEF in perioperative medicine

Recent perioperative literature has increasingly questioned the central role of left ventricular ejection fraction (LVEF) in cardiovascular risk stratification. While patients with preserved LVEF may experience perioperative complications, acute heart failure (AHF) in appears uncommon in the absence of identifiable major structural or hemodynamic dysfunction, such as severe valvular disease, precapillary pulmonary hypertension with cor pulmonale, restrictive cardiomyopathies, or terminal renal disease. This distinction has important implications for the interpretation of perioperative risk in patients with heart failure with preserved ejection fraction (HFpEF).In the absence of these conditions, the HFpEF label may often identify a heterogeneous syndrome dominated by exertional dyspnoea, frequently with substantial extracardiac and peripheral contributors, rather than a cardiac phenotype intrinsically prone to acute decompensation. Perioperative vulnerability in these patients may therefore reflect advanced age, extracardiac comorbidity burden, pulmonary or renal disease, and generalized multisystem frailty, while cardiac systolic performance itself remains largely preserved. A physiology-guided perioperative approach integrating structural abnormalities, pulmonary pressures, congestion, and right ventricular function may therefore provide greater clinical relevance than LVEF-based categorization alone.