In HFpEF, which comorbidity often drives symptom burden and treatment decisions?

• A. Hypertension alone.
• B. Atrial fibrillation alone.
• C. Hypertension and atrial fibrillation, with obesity/metabolic syndrome also contributing.
• D. Diabetes mellitus alone.

Answer: (C)

In HFpEF, symptoms and treatment decisions are driven largely by this cluster of comorbidities that shape diastolic function and filling pressures, not by systolic weakness. Hypertension pushes the heart to thicken and stiffen, so the ventricle becomes less compliant and filling pressures rise, which directly worsens shortness of breath and exercise intolerance. Atrial fibrillation adds another layer: the loss of organized atrial contraction reduces the volume that can fill the noncompliant ventricle, and rapid rates shorten diastole, both of which amplify congestion and symptoms and steer decisions toward rhythm or rate control. Obesity and metabolic syndrome further contribute by promoting inflammation, endothelial dysfunction, and often sleep apnea, all of which worsen diastolic dysfunction and increase filling pressures.

Together, these interrelated conditions commonly co-occur and collectively drive symptom burden in HFpEF, guiding key management choices such as aggressive blood pressure control, addressing rate or rhythm in AF, and implementing weight management and metabolic interventions. That's why this option—hypertension and atrial fibrillation, with obesity/metabolic syndrome also contributing—is the best fit for what typically drives symptoms and treatment in HFpEF.