The article reviews the pathophysiology, diagnosis, and treatment of heart failure with preserved ejection fraction (HFrEF). HFrEF, which accounts for 50% of heart failure cases, is characterized by normal left ventricular ejection fraction but similar morbidity and mortality to heart failure with reduced ejection fraction (HFrEF). The pathophysiology of HFrEF involves multiple non-diastolic abnormalities, including systolic dysfunction, impaired ventricular-vascular coupling, abnormal vasodilation, chronotropic incompetence, and pulmonary arterial hypertension. Diagnosis is challenging and relies on clinical evaluation, echocardiography, and invasive hemodynamic assessment. Recent studies have highlighted the importance of diastolic left ventricular dysfunction, which is often non-specific for HFrEF. Treatment options are limited, and no effective therapies have been identified. The article discusses novel treatment strategies, including agents that enhance cGMP signaling, PDE5 inhibitors, and aldosterone antagonists, which show promise in preclinical studies. Despite advancements in understanding and diagnosis, effective treatments for HFrEF remain elusive, and further research is needed to reduce the burden of morbidity and mortality associated with this condition.The article reviews the pathophysiology, diagnosis, and treatment of heart failure with preserved ejection fraction (HFrEF). HFrEF, which accounts for 50% of heart failure cases, is characterized by normal left ventricular ejection fraction but similar morbidity and mortality to heart failure with reduced ejection fraction (HFrEF). The pathophysiology of HFrEF involves multiple non-diastolic abnormalities, including systolic dysfunction, impaired ventricular-vascular coupling, abnormal vasodilation, chronotropic incompetence, and pulmonary arterial hypertension. Diagnosis is challenging and relies on clinical evaluation, echocardiography, and invasive hemodynamic assessment. Recent studies have highlighted the importance of diastolic left ventricular dysfunction, which is often non-specific for HFrEF. Treatment options are limited, and no effective therapies have been identified. The article discusses novel treatment strategies, including agents that enhance cGMP signaling, PDE5 inhibitors, and aldosterone antagonists, which show promise in preclinical studies. Despite advancements in understanding and diagnosis, effective treatments for HFrEF remain elusive, and further research is needed to reduce the burden of morbidity and mortality associated with this condition.