HEART FAILURE WITH PRESERVED EJECTION FRACTION: UNDERESTIMATED DIAGNOSIS AND RECENT THERAPEUTIC ADVANCES

Abstract

Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of heart failure cases, yet it is often recognized late because symptoms, biomarkers, and resting findings may be nonspecific. This critical narrative review aimed to examine the causes of underdiagnosis, organize diagnostic confirmation according to pretest probability, and interpret recent therapeutic advances without extending conclusions beyond demonstrated outcomes. PubMed/MEDLINE, SciELO, and LILACS were consulted, together with guidelines, consensus documents, and regulatory sources available through 2026. The evidence indicates that H2FPEF, HFA-PEFF, and HFpEF-ABA are complementary tools, whereas intermediate or discordant probabilities require functional testing, preferably during exercise. Sex-related differences, obesity, natriuretic peptide concentrations, and treatable causes such as transthyretin amyloid cardiomyopathy influence recognition. Sodium-glucose transporter 2 inhibitors provide the most consistent evidence for reducing worsening heart failure and hospitalization; finerenone reduces recurrent events, while semaglutide or tirzepatide improve symptoms and functional capacity in obesity-related HFpEF. A mortality benefit remains uncertain for the broad syndrome. The greatest clinical gain depends on combining early recognition, physiological confirmation, and treatment tailored to the dominant phenotype.