Despite major improvements in outcome for patients with heart failure and a reduced ejection fraction (HFREF), the prognosis in heart failure with preserved ejection fraction (HFPEF) has remained unaltered during the past few decades. Moreover, the incidence of HFPEF has increased and currently HFPEF accounts for 50% of all heart failure cases. It therefore constitutes a considerable burden on health-care services. The pathophysiological mechanisms leading to HFPEF are still not clear. The HFPEF phenotype is thought to be the result of the interplay of diastolic left ventricular dysfunction, systolic left ventricular dysfunction, vascular stiffening and vasomotor or chronotropic insufficiency. The diagnosis of HFPEF has improved as a consequence of the 2007 ESC guidelines, but it is still a matter of debate. Echocardiography is a corner stone in the diagnosis, but unfortunately it has some shortcomings. With a better knowledge of the pathophysiological mechanisms, the diagnostic criteria can be refined and a more important role for biomarkers is likely. Therapeutic options in HFPEF have been disappointing with neutral outcomes of the large clinical trials with ACE-inhibitors, angiotensin receptor blockers and beta blockers. Better insight into the pathophysiology and improved diagnostic criteria will probably pave the way for future studies with drugs that tackle the mechanisms underlying HFPEF. The purpose of this review is to discuss the literature on pathophysiology, diagnosis and therapeutic interventions in HFPEF. © 2012, Nederlandse Vereniging voor Intensive Care.