Heart failure with preserved ejection fraction (HF-PEF) is part of the 'heart-failure spectrum', but differs pathophysiologically from heart failure with reduced ejection fraction (HF-REF). Metabolic abnormalities in HF-PEF cause intrinsic stiffness of the cardiac myocyte and alternation of the collagen turn-over in the extracellular matrix of the heart. HF-PEF is most often present in elderly women with a history of hypertension, diabetes mellitus or metabolic syndrome, and obesity. Signs of fluid retention are often not present on physical examination in patients with HF-PEF. The most notable echocardiographic abnormalities seen in HF-PEF are an enlarged left atrium with hypertrophy, reduced left ventricular relaxation and elevated filling pressures. Co-morbidly and advanced age are largely determinant for mortality, which in HF-PEF is somewhat lower than in HF-REF. Evidence-based drug therapy for HF-PEF is currently lacking; ongoing studies are evaluating medications other than the well-established drugs used to treat HF-REF.