Coronary Artery Disease in Heart Failure With Preserved Ejection Fraction

Coronary artery disease (CAD), including both obstructive epicardial coronary artery disease and coronary microvascular dysfunction (CMD), is a common and impactful contributor to heart failure with preserved ejection fraction (HFpEF). CAD is associated with worse outcomes, progressive myocardial remodeling, and transition to reduced ejection fraction. CMD, which is particularly prevalent in women, impairs myocardial perfusion and energetics. This leads to exercise intolerance and elevated filling pressures. Emerging treatments such as sodium-glucose co-transporter 2 (SGLT2) inhibitors and finerenone offer benefit across HFpEF phenotypes, including those with ischemia. Multimodal diagnostic approaches, such as positron emission tomography, cardiovascular magnetic resonance, Doppler echocardiography, and invasive coronary physiology, are essential to identify CMD and subclinical CAD in appropriate patients. In conclusion, recognizing ischemic phenotypes within HFpEF is critical for risk stratification and therapeutic decision-making. Future studies should focus on phenotype-specific strategies to improve outcomes in this heterogeneous syndrome.