The Role of Cardiovascular Magnetic Resonance in Heart Failure with Preserved Ejection Fraction

Ping Chai
National University Heart Centre Singapore


Heart failure with preserved ejection fraction (HFpEF) is a burgeoning healthcare problem with high morbidity and mortality. There is currently no proven medical therapy to improve outcomes for HFpEF population. Diagnosis is often challenging; HFpEF may be confused with other clinical conditions that present similarly and patients with HFpEF often suffer from multiple comorbid medical conditions. Current guidelines propose diagnostic criteria that include demonstration of cardiac structural and functional abnormalities besides symptoms/signs and ejection fraction criteria. The basic pathophysiology in HFpEF is presumed to be impaired diastolic function and/or increased afterload resulting in high filling pressures and reduction in cardiac output. Cardiovascular magnetic resonance (CMR) is well suited for the comprehensive evaluation of patients with suspected HFpEF. CMR is the gold standard modality for accurate non-invasive measurement of ventricular volumes, mass, ejection fraction, cardiac output and atrial volumes and function. Emerging CMR techniques for evaluation of ventricular diastolic function and filling pressures may help with diagnosis and understanding of the condition. An important utility unique to CMR is its ability to demonstrate the presence of discrete myocardial fibrosis (MF) using the late gadolinium enhancement (LGE) technique. The presence of LGE is a powerful independent predictor of adverse prognosis. CMR is also able to quantitate diffuse MF with T1 mapping and extracellular volume (ECV) measurement. Increased ECV has been recently shown to correlate with HFpEF and ventricular stiffness and is a potential therapeutic target. CMR is able to accurately detect presence of myocardial ischaemia and abnormal myocardial perfusion reserve that contribute to the development of HFpEF. However, CMR is not without limitations. HFpEF is often associated with atrial fibrillation causing gating issues during CMR. Significant kidney impairment is common in HFpEF, precluding the use of gadolinium contrast. Advances in CMR and contrast technology may overcome these limitations in the future.