Current concepts and challenges in pediatric diastolic dysfunction and heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) has transitioned from an underrecognized and poorly characterized condition to a recognized, increasingly prevalent form of heart failure in the adult population, accounting for approximately half of all heart failure cases. Improved diagnostic capabilities and the growing burden of risk factors, including aging, hypertension, diabetes, and obesity, drive this rise. In contrast, pediatric HFpEF remains largely under-characterized, arising in a heterogeneous context that includes congenital heart disease and restrictive cardiomyopathies. The true incidence and prevalence of pediatric HFpEF remain difficult to establish due to challenges such as the absence of standardized diagnostic criteria, limited sensitivity of conventional diastolic function parameters, a lack of age-specific reference ranges for imaging and biomarker thresholds, and nonspecific symptoms that complicate early detection. While recent pharmacological advances in adult HFpEF, such as sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 (GLP-1) receptor agonists, have demonstrated incremental benefits, there is a notable absence of evidence-based treatments for pediatric HFpEF. This review provides an up-to-date overview of pediatric HFpEF, highlighting key diagnostic challenges and therapeutic gaps, discussing recent advancements in diagnostics and emerging therapeutic strategies with potential relevance for pediatric care. IMPACT: This article addresses pediatric heart failure with preserved ejection fraction (HFpEF), a condition that is emerging in the pediatric population. While HFpEF is a well-established and prevalent condition in adults, its prevalence in children remains underrecognized and poorly understood. This article highlights key challenges in diagnosing and managing pediatric HFpEF, including the absence of standardized diagnostic criteria, limited sensitivity of traditional diastolic function measures, and a lack of age-specific imaging biomarkers. In this up-to-date review, we discuss those limitations, emphasizing the need for greater research into its pathophysiology and therapeutic strategies.