Of the millions of heart failure heart failure patients worldwide, approximately half present with preserved left ventricular ejection fraction (HFPEF). HFPEF has high rates of morbidity and mortality, yet therapy remains empirical due to incomplete understanding of disease pathophysiology. Systemic hypertension is the most prominent risk factor for HFPEF. Patients often have multiple other comorbid conditions, which may contribute to symptom burden and the HFPEF syndrome itself. The classic paradigm of ventricular diastolic dysfunction has expanded, and vascular dysfunction likely contributes to HFPEF in many patients. Pressure-volume loop analysis identifies three distinct hemodynamic phenotypes for HFPEF, a finding which may have significant implications for clinical trial enrollment and individual patient treatment.