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To characterize geographic differences in clinical characteristics and care of patients hospitalized with heart failure and preserved ejection fraction (HF-PEF).Using data on 61 182 admissions in 307 US hospitals from March 2004 to March 2006 from the Acute Decompensated Heart Failure National Registry (ADHERE)-United States (US) database and 10 904 admissions in 70 hospitals from 10 countries from March 2005 to January 2009 from the ADHERE-International (I) database composed of countries in Asia-Pacific and Latin-American regions, we compared characteristics, treatments, length of stay, and in-hospital mortality between patients with PEF (left ventricular EF ≥ 40%). There were 26 258 (49.6%) admissions with HF-PEF in the ADHERE-US and 4206 (45.7%) in ADHERE-I. The USA cohort was older [median 77.2 years (25th, 75th, 66.5, and 84.4) vs. 71.0 (59.0, 79.0), P< 0.001] and more likely to be female (61.8 vs. 54.7%, P< 0.001). The international cohort had a longer length of stay [median 6.0 days (4.0, 10.0)] vs. 4.0 days [3.0, 7.0], P< 0.001) and higher use of inotropes (12.5 vs. 4.8%, P< 0.001). At discharge, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and diuretics were prescribed more in the USA (57.6 vs. 54.4%, P< 0.001; 63.0 vs. 35.5%, P< 0.001; 78.2 vs. 76.2%, P< 0.001); digoxin was prescribed more outside the USA (26.0 vs. 17.7%, P< 0.001). After adjusting for baseline characteristics, 7-day inpatient mortality was similar between the international and the USA cohorts [hazard ratio 0.80, 95% CI (0.61–1.05); P= 0.11].Clinical characteristics, inpatient interventions, discharge therapies, and length of stay vary significantly for HF-PEF patients across geographic regions. This has important implications for global clinical trials and outcome studies in HF.