Purpose of Review <p>To conduct a systematic review and meta-analysis of the prevalence, diagnostic accuracy of natriuretic peptides, prognosis, treatment response, and pathophysiological mechanisms of heart failure with preserved ejection fraction (HFpEF) in patients with chronic obstructive pulmonary disease (COPD).</p> Recent Findings <p>Diastolic dysfunction was highly prevalent in COPD, with a pooled prevalence of 43.4% (95% CI 32.5–54.9%). Among studies reporting severity, dysfunction was mild in 42.1%, moderate in 16.5%, and severe in 3.2%. HFpEF was rarely reported (<i>n</i> = 5 studies) with prevalence ranging from 18% to 50%. Natriuretic peptides showed high negative predictive value (0.80–0.93) but low positive predictive value (0.12–0.41) for HFpEF diagnosis (<i>n</i> = 2 studies). Prognosis was worse in patients with both COPD and HFpEF. Three large trials (PARAGON-HF, DELIVER, FINEARTS-HF) showed consistent relative treatment effects in patients with and without COPD, with greater absolute benefit in those with COPD due to higher event rates. The pathophysiology of HFpEF in COPD is multifactorial, involving hyperinflation, cardiac remodeling, vascular stiffness, and inflammation.</p> Summary <p>HFpEF is common in patients with COPD, associated with worse prognosis, and driven by multifactorial mechanisms. Despite diagnostic challenges, evidence supports use of guideline-directed therapies in this population.</p>