Heart failure with preserved ejection fraction (HFpEF) is becoming increasingly prevalent in aging societies. A recent multicenter cohort study in Japan demonstrated that cardiac rehabilitation (CR) significantly improves the prognosis of patients with HFpEF and frailty. The 2025 Japanese Heart Failure Guidelines recommend pharmacologic therapies for HFpEF. Recent international trials have led to the adoption of sodium-glucose transporter 2 inhibitors and angiotensin-receptor-neprilysin inhibitors in Japan, supported by evidence showing reduced rates of heart failure readmission. However, it should be noted that the majority of patients enrolled in those trials were in their early 70s. In real-world clinical practice, the number of patients in their 80s and 90s receiving treatment is increasing. This older population is more susceptible to adverse effects such as orthostatic hypotension, hyperkalemia, and urinary tract infections. Polypharmacy further complicates medication management. In such cases, CR plays a vital role in maintaining quality of life and supporting long-term prognosis. Furthermore, HFpEF is frequently accompanied by comorbidities such as atrial fibrillation, hypertension, and ischemic heart disease. It is important to note that elderly patients are also susceptible to additional conditions, including cerebrovascular disease, musculoskeletal disorders and malignancies. A multidisciplinary approach to CR, tailored to these complex health profiles, is essential to prevent the progression of functional decline and frailty.