Hypertension: a missing piece in HFpEF?

As population aging accelerates and unhealthy lifestyle habits become increasingly prevalent, the burden of heart failure with preserved ejection fraction (HFpEF) continues to rise. Hypertension, obesity, and atrial fibrillation (AF) are major contributors to the development and progression of HFpEF. Among these risk factors, hypertension serves as a central hub linking cardiovascular and metabolic abnormalities. This review discusses the relationship between hypertension and HFpEF, focusing on sympathovagal imbalance as a common mechanism underlying hypertension, obesity, and AF. We summarize evidence regarding the contribution of autonomic dysregulation to HFpEF pathogenesis and examine the therapeutic potential of targeting autonomic function. Current evidence suggests that a systolic blood pressure target of <130 mmHg may be appropriate for patients with HFpEF. In addition to established pharmacological therapies, emerging neuromodulatory approaches, particularly low-level transcutaneous tragus stimulation, may represent promising adjunctive treatment strategies. Improved understanding of these interrelated mechanisms may facilitate more individualized management of HFpEF.