Insights into the role of obesity in Heart Failure with Preserved Ejection Fraction pathophysiology and management.

Heart failure (HF) is a significant global health issue, categorized by left ventricular ejection fraction, being either reduced (HFrEF: <0.40) or preserved (HFpEF: >0.50), or in the middle of this range. While the overall incidence of HF remains stable, HFpEF cases are increasing, representing about 50% of all HF cases. Outcomes for HFpEF are similar to HFrEF, leading to substantial healthcare resource utilization. Despite extensive research over the past two decades, the prognosis and mortality rates for HFpEF remain high. A key feature of HFpEF is exercise intolerance, characterized by severe exertional dyspnea and fatigue, which significantly impacts quality of life. The underlying mechanisms of exercise intolerance are not fully understood due to the complex pathophysiology and multi-system involvement. Obesity is a common comorbidity in HFpEF, especially in North America, leading to worsening symptoms, hemodynamics, and mortality rates. Increased adiposity leads to inflammation, hypertension, dyslipidemia, and insulin resistance, and impairing cardiac, vascular, pulmonary, and skeletal muscle function. Therefore, managing obesity is crucial in treating HFpEF. This review explores the pathophysiologic mechanisms of HFpEF, emphasizing obesity's role, and discusses current management strategies while identifying areas needing further research.