Heart failure with preserved ejection fraction (HFpEF) has become an emerging concern. The protective effect of bradycardia in patients with reduced ejection fraction using beta-blockers or ivabradine does not improve symptoms in HFpEF. This review aims to assess current data regarding the impact of anti-bradycardia pacing in patients with HFpEF. A search was conducted on PubMed, ScienceDirect, Springer, and Wiley Online Library, selecting studies from 2013 to 2023. Relevant and eligible prospective studies and randomized controlled trials were included. Functional status, quality of life, and echocardiographic parameters were assessed. Six studies conformed to the selection criteria. Four were prospective studies with a total of 90 patients analyzed. Two were randomized controlled trials with a total of 129 patients assessed. The 6-min walk test (6MWT) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score improved in all prospective studies. My-PACE trial showed improvements in MLHFQ score (p < 0.001), significant relative lowering in NT-proBNP levels (p = 0.02), and an increased mean daily activity in the personalized accelerated pacing group compared to usual care. RAPID-HF trial proved that pacemaker implantation to enhance exercise heart rate (HR) did not improve exercise capacity and was associated with increased adverse events. HFpEF requires a more individualized approach and quality of life management. This review demonstrates that higher resting HR by atrial pacing may improve symptoms and even outcomes in HFpEF, while a higher adaptive rate during exertion has not been proven beneficial. Graphical Abstract

Background: Residual systemic congestion is common after treatment for acute decompensated heart failure (ADHF) and remains difficult to assess non-invasively. We investigated internal jugular vein distensibility (DIJV) as a dynamic marker of residual congestion and its association with established congestion parameters and clinical outcomes. Methods: In this prospective single-center study, 112 patients hospitalized with ADHF underwent clinical, laboratory, echocardiographic, and venous ultrasound assessment at admission and after decongestive treatment. DIJV was calculated as the ratio of maximal internal jugular vein diameter during Valsalva to resting diameter, with DIJV ≥ 4 indicating preserved distensibility. Results: At the final in-hospital assessment, 59 patients (52.7%) had persistent DIJV < 4. These patients had higher NT-proBNP, larger inferior vena cava diameter, greater portal vein pulsatility, higher pulmonary artery systolic pressure, and lower TAPSE/PASP compared with patients with preserved DIJV. They also had longer hospital stays and higher rates of ADHF rehospitalization and six-month mortality. Higher admission DIJV remained associated with lower odds of six-month ADHF rehospitalization after multivariable adjustment (OR 0.31 per 1-unit increase, 95% CI 0.15–0.59; p < 0.001). Conclusions: DIJV improves with decongestive treatment, but frequently remains impaired. Persistent impairment is associated with a broader residual-congestion profile and adverse clinical outcomes, supporting DIJV as a simple, dynamic adjunct to multiparametric congestion assessment.