Heart failure with preserved ejection fraction in older adults

Heart failure with preserved ejection fraction (HFpEF) is the most common form of heart failure in older adults, particularly in women. It is associated with high morbidity and mortality and poor quality of life. Initially viewed as a disorder of left ventricular diastolic function, our understanding of HFpEF has evolved, and we now appreciate HFpEF as a systemic syndrome involving multiple organ systems influenced by aging, lifestyle factors, genetic predisposition, and multiple comorbidities. Treatment strategies include pharmacologic therapy, nonpharmacologic therapy, and management of multimorbidity. Pharmacologic therapy includes the use of loop diuretics, sodium-glucose cotransporter 2 inhibitors, and mineralocorticoid antagonists for most, and angiotensin receptor blockers/angiotensin receptor–neprilysin inhibitors and glucagon-like peptide 1 receptor agonists as add-on therapies for some. However, the risk of geriatric conditions such as falls, malnutrition, and/or sarcopenia must be considered. Nonpharmacologic therapy may include exercise training and caloric restriction. The concurrence of geriatric conditions should impact care and treatment priorities. Explicit integration of shared decision-making, multidisciplinary team use, and palliative care principles is applicable across the disease spectrum, starting as early as the diagnosis is made.