HFpEF in Asia: distinct phenotypes, shared mechanisms, and emerging insights

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous, comorbidity-driven syndrome of increasing global prevalence, with Asian patients displaying a distinctive and clinically relevant epidemiologic and biological profile. Compared with Western cohorts, Asian patients are often younger and less overtly obese based on body mass index. However, they carry substantial burdens related to diabetes, chronic kidney disease, anemia, and hypertension, resulting in adverse health outcomes that are disproportionate to chronological age. Asian HFpEF shows marked region-specific patterns: Northeast Asian cohorts exhibit an older, leaner, atrial fibrillation-related phenotype, whereas South and Southeast Asian cohorts exhibit earlier onset, greater metabolic-renal multimorbidity, and worse prognosis. Mechanistically, visceral adiposity, systemic inflammation, immunometabolic dysregulation, structural remodeling, and accelerated cardiac aging converge to drive HFpEF across Asian patients, often at lower body mass index thresholds than recognized in Western models. Current diagnostic frameworks require Asian-specific validation, and dedicated multiomics and phenotyping studies are essential to advance precision medicine for HFpEF globally.