Background/Objectives: Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all heart failure cases and remains challenging to diagnose and manage due to its complex, multifactorial nature. Increasing evidence highlights the significance of arterial stiffness, assessed by pulse wave velocity (PWV), and autonomic dysfunction, reflected by impaired heart rate recovery (HRR) after exercise, as relevant markers in HFpEF. This review aims to synthesize current knowledge on the diagnostic and prognostic value of PWV and HRR in HFpEF. Methods: A narrative literature review was conducted using PubMed to identify studies published between 2009 and 2025 that investigated PWV and HRR in patients with HFpEF or populations at risk. Included studies ranged from invasive hemodynamic measurements and cardiopulmonary exercise tests to large cohort analyses such as IDENTIFY-HF and MESA. Key findings were summarized in comparative tables. Results: Patients with HFpEF consistently show higher PWV than age-matched controls, supporting the concept of HFpEF as a systemic vascular disorder. Elevated PWV has been linked to increased risk of HFpEF onset and poorer outcomes. Likewise, blunted HRR indicates autonomic imbalance and is strongly associated with higher morbidity and mortality. Interventions including structured exercise training and optimized risk factor management may help improve PWV and HRR. Conclusions: PWV and HRR offer valuable, complementary insights for risk stratification and individualized care in HFpEF. Further research should focus on integrating these parameters into diagnostic algorithms and evaluating targeted therapies that address vascular stiffness and autonomic dysfunction.

Background: The Heart Rate Recovery Index (HRRI), derived from post-exercise heart rate recovery (HRR), reflects autonomic function and cardiovascular performance. Whether HRRI reflects early myocardial dysfunction and left atrial remodelling in heart failure with preserved ejection fraction (HFpEF) has not been previously examined. The H₂FPEF score, which integrates clinical and echocardiographic parameters, is used to assess the likelihood of HFpEF. This study investigates the relationship between HRRI, H₂FPEF score, and echocardiographic markers of longitudinal systolic function, including mitral annular plane systolic excursion (MAPSE), as well as left atrial volume index (LAVI), in patients with preserved left ventricular ejection fraction. Methods: A prospective observational study included 241 patients referred for cardiac exercise testing at the Institute of Cardiovascular Diseases Timisoara and the Clinical County Hospital of Sibiu. HRRI was calculated as the ratio of heart rate acceleration time (AT) to deceleration time (DT) during exercise testing. A comprehensive echocardiographic assessment was performed on all patients. Statistical analysis involved univariate testing and multivariable logistic regression with stepwise selection. Results: HRRI was significantly lower in HFpEF patients compared with those without heart failure (1.97 ± 0.66 vs. 2.73 ± 1.08, p < 0.01). HRRI correlated significantly with exercise performance, age, H₂FPEF score, and echocardiographic markers of diastolic and longitudinal systolic dysfunction. ROC analysis identified an HRRI cut-off value of 2.25 for HFpEF detection (AUC = 0.748), while HRRI remained significantly associated with HFpEF after adjustment for the covariates included in the model. The combined HRRI–H₂FPEF score improved diagnostic discrimination compared with the H₂FPEF score alone (AUC 0.897 vs. 0.858), achieving an overall classification accuracy of 82.2%. Conclusions: In our study, HRRI is significantly reduced in HFpEF and distinguishes patients with and without heart failure. It shows associations with echocardiographic markers of diastolic and longitudinal systolic dysfunction, exercise capacity, and H₂FPEF score.

Background/Objectives: Heart failure with preserved ejection fraction (HFpEF) remains challenging to diagnose, and established algorithms such as HFA-PEFF and H2FPEF frequently classify patients within intermediate probability categories requiring additional testing. Arterial stiffness and cardiac autonomic dysfunction are increasingly recognized as relevant components of HFpEF pathophysiology, yet the combined discriminatory value of pulse wave velocity (PWV) and heart rate recovery index (HRRI) has not been well established. This study aimed to evaluate the individual and combined discriminatory performance of PWV and HRRI for HFpEF and to assess their incremental contribution beyond established clinical risk factors. Methods: In this prospective, single-center, cross-sectional study, 180 participants were included, comprising 86 patients with HFpEF and 94 participants without heart failure. Group allocation was clinically assigned by the treating cardiologist with access to PWV and HRRI results. PWV was assessed non-invasively using an oscillometric device, and HRRI was derived from standardized cycle ergometer exercise testing. Univariable and multivariable logistic regression, receiver operating characteristic (ROC) curve analysis, and likelihood-ratio testing were performed to assess independent associations and incremental model contribution. Sensitivity analyses evaluated the influence of age modelling and beta-blocker use. Results: Both PWV and HRRI were independently associated with clinically assigned HFpEF status after adjustment for age, sex, body mass index, hypertension, diabetes mellitus, dyslipidemia, and atrial fibrillation (adjusted OR 1.330 per 1 m/s increase in PWV and 0.857 per 0.1-unit increase in HRRI; both p ≤ 0.023). PWV and HRRI demonstrated AUCs of 0.770 and 0.792, respectively, with Youden index-derived cutoff values of ≥9.60 m/s and ≤1.97. Their combination significantly improved discrimination compared with either marker alone (AUC 0.833). Adding both markers to the clinical model improved model fit, but the AUC increase from 0.865 to 0.896 was not statistically significant after Holm adjustment (adjusted p = 0.132). The associations of both markers with HFpEF remained essentially unchanged after adjustment for beta-blocker therapy. Conclusions: PWV and HRRI were associated with clinically assigned HFpEF status; the observed discrimination does not establish independently validated diagnostic accuracy. Incremental discrimination beyond clinical characteristics and clinical usefulness remain to be established. The cutoff values are exploratory and should not be used as clinical decision thresholds without formal measurement reliability assessment and independent prospective validation.