OBJECTIVE: Heart failure with preserved ejection fraction (HFpEF) is a growing concern among the elderly population, significantly impacting morbidity and mortality rates. This study aimed to screen and investigate the characteristics and prognosis of early-stage HFpEF in the elderly. METHODS: A total of 1789 community-dwelling individuals aged over 65 from northern Shanghai were enrolled. According to American Heart Association (AHA) guidelines, participants were classified into four groups: HFpEF stage 0, HFpEF stage A, HFpEF stage B and HFpEF stage C. Major endpoints included major adverse cardiovascular events (MACEs), all-cause death and cardiovascular death. RESULTS: After a mean follow-up period of 7.10 ± 1.27 years, 1623 elderly subjects were included [HFpEF stage 0 (10.3%), HFpEF stage A (16.3%), HFpEF stage B (60.6%) and HFpEF stage C (12.8%)]. Patients with HFpEF stage A, HFpEF stage B and HFpEF stage C exhibited more MACEs than those in HFpEF stage 0 (P < 0.01). Patients with HFpEF stage C had a significantly higher cardiovascular (P < 0.001) and all-cause death ratio (P < 0.01). With HFpEF stage 0 as a reference, the increases in MACEs were significantly associated with HFpEF stage A [hazard ratio (HR): 2.97, 95% confidence interval (CI) (1.13, 7.82), P < 0.05], HFpEF stage B [HR: 2.69, 95% CI (1.09, 6.64), P < 0.05] and HFpEF stage C [HR: 4.86, 95% CI (1.88, 12.59), P < 0.01] in the Cox regression analysis. Our finding remains unaltered in the sensitivity analysis, with no interaction for effectiveness. CONCLUSIONS: Compared with those with HFpEF stage 0, patients with HFpEF, whether in stage B or C, exhibit significantly higher cardiovascular and all-cause mortality in the elderly. This study underscores the importance of early-stage HFpEF screening, particularly in older, asymptomatic stage B individuals.