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The number of patients developing heart failure is increasing dramatically, and will likely continue to do so for the next few decades. At least half of the patients with symptoms and signs of heart failure have a normal left ventricular ejection fraction on echocardiography [heart failure with preserved ejection fraction (HFPEF)]. This review updates the current management of patients with HFPEF and summarizes what is in development.Many different pathophysiologies may result in HFPEF. No single imaging measure may reliably identify cardiac dysfunction, but plasma concentrations of natriuretic peptides, reflecting the final pathway of congestion, appear to. Natriuretic peptides are now an essential part of the diagnostic process and are increasingly used to select patients to be enrolled in clinical trials. No therapeutic intervention has unequivocally been shown to modify the natural history of HFPEF, although several improve symptoms and functional capacity, which are important targets in this population. The failure of many clinical trials may reflect the inclusion of patients who are at low risk of cardiovascular events or the diverse pathophysiology of HFPEF. When patients are congested (i.e. have elevated plasma concentrations of natriuretic peptides) a diagnosis of HFPEF can be made with some confidence, the patients will be at increased cardiovascular risk and treatments aimed at correcting congestion will probably be effective. Selection of treatment to target a specific underlying pathophysiology is an alternative, relatively untried approach.Further clinical trials will provide new insights into the pathophysiology of this complex disease and, hopefully, identify therapies that also improve outcome.