Imaging in heart failure with preserved ejection fraction: insights into echocardiography and cardiac magnetic resonance imaging

Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent and represents more than half of all heart failure cases. It is defined by the presence of heart failure signs and symptoms, identification of cardiac structural abnormalities leading to high left ventricular filling pressures, and an EF > 50%. Common imaging findings in HFpEF include left ventricular hypertrophy, diastolic dysfunction, left atrial enlargement, and elevated pulmonary artery pressure (> 35 mm Hg). Echocardiography is the primary imaging modality for diagnosing HFpEF. It can be complemented by cardiac magnetic resonance (CMR) when further characterization is needed. Advances like real-time 3-dimensional echocardiography and speckle-tracking derived strain, as well as tissue characterization by CMR, have furthered our understanding of the mechanisms and aided in making the diagnosis of a diverse group of conditions that can present as HFpEF. This review aims to touch upon the imaging methods of characterizing HFpEF and discuss their role in specific disease entities.