Arterial Stiffness in HFpEF: From Clinical Insight to Bedside Action

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all heart failure cases and is increasing in prevalence due to aging populations and comorbidities such as hypertension and diabetes. While echocardiography remains the diagnostic cornerstone, many patients with preserved ejection fraction present with nonspecific symptoms and ambiguous diastolic indices, leading to diagnostic uncertainty and therapeutic delay. Arterial stiffness-quantified by pulse wave velocity, augmentation index, and cardio-ankle vascular index)-is emerging as a key contributor to HFpEF pathophysiology. Increased vascular stiffness elevates systolic blood pressure, impairs ventricular relaxation, and promotes adverse remodeling. These stiffness markers are preload-independent, reproducible, and readily measurable in outpatient settings. Clinical studies have demonstrated that elevated pulse wave velocity and cardio-ankle vascular index are associated with worse diastolic function, increased hospitalizations, and higher mortality. In patients with preserved ejection fraction and equivocal echocardiographic findings, arterial stiffness assessment offers additional diagnostic clarity, supports individualized therapy, and can serve as a modifiable target. Lifestyle changes and pharmacologic agents such as angiotensin converting enzyme inhibitors, mineralocorticoid receptor antagonists, and sodium - glucose cotransporter 2 inhibitors have shown promise in reducing stiffness and improving symptoms. As a practical and underutilized parameter, arterial stiffness bridges a critical gap in understanding and managing HFpEF. Incorporating it into routine clinical practice may enhance early detection, risk stratification, and treatment outcomes in this complex and often underdiagnosed population.