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Heart failure with preserved ejection fraction: the missing pieces in diagnostic imaging

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Abstract

Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent phenotype affecting over half of today’s heart failure patients. With no proven therapy and no universally accepted diagnostic guideline, many HFpEF patients continue to be misdiagnosed or underdiagnosed at the early stages until the disease has progressed much further along. It is extremely difficult to diagnose the HFpEF patient, because they have a normal ejection fraction and present with non-specific symptoms such as dyspnea or exercise intolerance. To provide greater specificity, the current diagnostic criteria mandate the presence of diastolic dysfunction, where myocardial relaxation is impaired and ventricular filling pressure is elevated as a result of a hypertrophic and stiff heart. Unfortunately, diastolic dysfunction reflects late-stage structural and functional changes and offers a very narrow window, if at all, for successful intervention. In this article, we review the imaging modalities used in the current diagnostic workflow for assessing HFpEF. We also describe the most up-to-date insight into its pathophysiological basis, which attributes systemic inflammation driven by comorbidities as the initiator of disease. With this extramyocardial perspective, we provide our recommendation on new imaging targets that extend beyond the heart to enable early, accurate diagnosis of HFpEF and allow an opportunity for treating this fatal condition.

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Funding sources

This work was supported in part by grants from the Natural Sciences and Engineering Research Council of Canada (#355795) and the Ted Rogers Centre for Heart Research. S. L. is funded by a Heart & Stroke Richard Lewar Centre of Excellence Studentship.

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Authors and Affiliations

  1. Institute of Biomaterials & Biomedical Engineering, University of Toronto, 164 College Street, RS407, Toronto, Ontario, M5S 3G9, Canada

    Sadi Loai & Hai-Ling Margaret Cheng

  2. Translational Biology & Engineering Program, Ted Rogers Centre for Heart Research, 661 University Avenue, Room 1433, Toronto, Ontario, M5G 1M1, Canada

    Sadi Loai & Hai-Ling Margaret Cheng

  3. The Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, 10 King′s College Road, Room SFB540, Toronto, Ontario, M5S 3G4, Canada

    Hai-Ling Margaret Cheng

  4. Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, 6 Queens Park Crescent West, Room 202, Toronto, Ontario, M5S 3H2, Canada

    Hai-Ling Margaret Cheng

  5. Ontario Institute for Regenerative Medicine, 661 University Avenue, Suite 510, Toronto, Ontario, M5G 0A3, Canada

    Hai-Ling Margaret Cheng

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  1. Sadi Loai
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Loai, S., Cheng, HL.M. Heart failure with preserved ejection fraction: the missing pieces in diagnostic imaging. Heart Fail Rev 25, 305–319 (2020). https://doi.org/10.1007/s10741-019-09836-8

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