Obesity contributes to heart failure with preserved ejection fraction‚ HFpEF‚ by causing structural changes to the heart and other factors‚ including volume overload‚ high blood pressure‚ inflammation‚ and other metabolic disorders‚ but not low ejection fraction․   Hemodynamic consequences: Increased blood volume and cardiac output raise ventricular filling pressures and stress; sodium retention and decreased venous capacitance further expand plasma volume․ Hypertension and remodeling: Long-term pressure and volume overload can cause left ventricular hypertrophy and concentric chamber remodeling․ These conditions increase chamber stiffness․   Visceral and epicardial fat: Dysfunctional adipose tissue releases leptin‚ tumor necrosis factor-α‚ interleukin-6‚ and other adipokines․ Epicardial fat can affect the heart both mechanically and through inflammation․   Microvascular disease: Systemic inflammation impairs coronary endothelial nitric oxide signaling‚ resulting in microvascular disease‚ oxidative stress‚ cardiomyocyte hypertrophy‚ and interstitial fibrosis․   Diastolic dysfunction: Heart fibrosis and fat accumulation decrease left ventricular compliance and increase left ventricular pressure‚ even when left ventricular ejection fraction is normal․ Metabolic dysfunction: Insulin resistance and excess free fatty acids contribute to lipotoxicity and reduced energy reserves in the heart․   Comorbid conditions that increase risk include hypertension‚ type 2 diabetes‚ obstructive sleep apnea‚ chronic kidney disease‚ and atrial fibrillation․ Exercise intolerance: Obesity can impair other aspects of exercise ability‚ such as pulmonary vasculature function and skeletal muscle oxygen consumption and heart rate response‚ further limiting exercise tolerance․   Clinical finding: Obesity-related HFpEF is a cardiometabolic disorder with multiple health effects‚ including evidence of diastolic and other organ dysfunction in the presence of a normal ejection fraction․ In evaluating patients with obesity-related HFpEF‚ other signs and symptoms of HF and obesity-related disorders should be assessed in addition to ejection fraction․