Routine cine cardiovascular magnetic resonance for clinical phenotyping and serial assessment of heart failure with preserved ejection fraction: a retrospective single-center clinical analysis

Background Heart failure with preserved ejection fraction (HFpEF) is difficult to confirm because symptoms are non-specific, comorbidities are prevalent, and left ventricular ejection fraction (LVEF) is normal by definition. We evaluated whether markers from routine cine cardiovascular magnetic resonance (CMR) improved phenotyping and diagnostic discrimination in HFpEF and whether they changed after treatment optimization. Methods In this retrospective single-center, observational analysis, 126 adults evaluated between January 2023 and December 2025 were included: 72 with adjudicated HFpEF, 27 hypertensive controls without heart failure, and 27 healthy volunteers. All had available 1.5-T cine CMR studies that underwent blinded analysis of LV volumes, LVEF, left ventricular mass index (LVMI), left atrial volume index (LAVI), right ventricular ejection fraction, and feature-tracking global longitudinal strain (GLS). Interobserver reproducibility was quantified. The primary analysis estimated the discrimination of LAVI, LVMI, and GLS for HFpEF; a multiparametric model was developed using Firth-penalized logistic regression with bootstrap optimism correction. Forty-six patients with HFpEF had repeat CMR available at approximately 6 months after individualized treatment optimization and were included in the serial analysis. Results LVEF was preserved and similar across groups. HFpEF was associated with higher LVMI, marked LAVI enlargement, and less negative GLS, with large effect sizes for LAVI and GLS. LAVI and GLS were the strongest single discriminators [apparent area under the curve (AUC) 0.83 and 0.85, respectively]; the multiparametric model achieved an apparent AUC of 0.87 that fell to 0.84 after optimism correction and did not exceed GLS alone. LAVI and less negative GLS remained independent predictors after adjustment. At 6 months, LAVI decreased (mean change −4.8 mL/m 2 ), and GLS became more negative (−1.3 percentage points), exceeding measurement variability, whereas LVEF was unchanged. Conclusions Routine cine CMR identified atrial remodeling, ventricular hypertrophy, and impaired longitudinal deformation despite preserved LVEF, and appeared capable of detecting selective short-term temporal changes rather than definitive treatment-induced reverse remodeling. It is a practical adjunct for phenotyping and hypothesis-generating serial assessment, pending external validation.