Acute Heart Failure in Heart Failure with Preserved Ejection Fraction: A State-of-the-art Review from an International Expert Group.

Acute heart failure with preserved ejection fraction (acute heart failure-heart failure with preserved ejection fraction) is increasingly prevalent, resulting from the interaction between a dysfunctional ventricle, the patient's comorbidity burden and acute triggers. Patients are typically older, commonly female and have cardiometabolic, renal, arrhythmic, ischaemic and inflammatory comorbidities that produce vulnerability to decompensation. Acute episodes manifest with pulmonary and/or systemic congestion, from abrupt rises in left-sided filling pressures due to cardiac and arterial stiffness driven by neurohormonal activation and inflammation. Congestion and elevated blood pressure are common, but clinical presentation is more heterogeneous, reflecting the haemodynamic abnormalities, severity of triggers and comorbidity load. Diagnosis relies on integrating clinical context, echocardiography, adjusted thresholds of natriuretic peptides, and invasive and/or stress haemodynamics when diagnosis is uncertain. Management requires individualised decongestion, alongside treatment of precipitants. Early initiation of disease-modifying therapies after haemodynamic stability, including sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists, improves outcomes. Acute heart failure-heart failure with preserved ejection fraction follows a relapsing-remitting trajectory, underscoring the importance of comorbidity management, structured follow-up and preventive strategies.