Role of Cardiac Magnetic Resonance in Heart Failure with Preserved Ejection Fraction
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Purpose of Review
Approximately half of the patients presenting with heart failure have preserved ejection fraction. These patients usually have a combination of underlying etiologies and may profit from individualized treatment. Failure of clinical trials without adequate understanding of the underlying problem highlights the need for an in-depth assessment of this complex clinical syndrome. This review seeks to discuss the role of cardiovascular magnetic resonance imaging (CMR) in improving diagnosis and targeted management of heart failure with preserved ejection fraction (HFpEF).
Technical advances in tissue mapping techniques enable a virtual histopathological perspective to detect myocardial disease processes, such as inflammation, infiltration, and fibrosis. Myocardial perfusion imaging enables separation between regional ischemia due to epicardial coronary artery disease (CAD) and microvascular disease. Finally, computation of aortic pulse wave velocity (PWV) provides insight into the effects of the vascular stiffness on the efficiency of cardiac work.
A comprehensive CMR protocol enables identification of the underlying pathophysiology in patients with HFpEF, allows identification of important differential diagnoses in patients with specific diseases, and may lead to imaging-guided precision medicine in HFpEF.
KeywordsHFpEF Diastolic dysfunction Cardiovascular magnetic resonance T1/T2 mapping Aortic pulse wave velocity
Coronary artery disease
Coronary flow reserve
Cardiovascular magnetic resonance imaging
Heart failure with preserved ejection fraction
Heart failure with reduced ejection fraction
Late gadolinium enhancement
Pulse wave velocity
Right ventricular dysfunction
Compliance with Ethical Standards
Conflict of Interest
Faraz Pathan and Valentina O. Puntmann declare that they have no conflicts of interest.
Eike Nagel reports non-financial support from Bayer Healthcare, non-financial support from Siemens Healthcare, non-financial support from TOMTEC, non-financial support from CVI42, non-financial support from MEDIS, grants from Deutsches Zentrum für Herz- Kreislauf-Forschung e.V. (DZHK), and grants from German Research Foundation (DFG), during the conduct of the study. He also reports grants and personal fees from Bayer Healthcare and personal fees from Siemens Healthcare, outside the submitted work.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.• Dunlay SM, Roger VL, Redfield MM. Epidemiology of heart failure with preserved ejection fraction. Nat Rev Cardiol. 2017;14(10):591–602. Latest review on epidemiology of HFpEF highlights magnitude of problem and differences between population characteristics and sample characteristics in clinical trials. CrossRefPubMedGoogle Scholar
- 5.Lee DS, Gona P, Vasan RS, Larson MG, Benjamin EJ, Wang TJ, et al. Relation of disease pathogenesis and risk factors to heart failure with preserved or reduced ejection fraction: insights from the Framingham Heart Study of the National Heart, Lung, and Blood Institute. Circulation. 2009;119(24):3070–7.CrossRefPubMedPubMedCentralGoogle Scholar
- 13.•• Paulus WJ, Tschope C. A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. J Am Coll Cardiol. 2013;62(4):263–71. Key pathophysiological reviews providing insights into sub stratifying HFpEF. CrossRefPubMedGoogle Scholar
- 23.Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891–975.CrossRefPubMedGoogle Scholar
- 26.Anjan VY, Loftus TM, Burke MA, Akhter N, Fonarow GC, Gheorghiade M, et al. Prevalence, clinical phenotype, and outcomes associated with normal B-type natriuretic peptide levels in heart failure with preserved ejection fraction. Am J Cardiol. 2012;110(6):870–6.CrossRefPubMedPubMedCentralGoogle Scholar
- 29.Grothues F, Smith GC, Moon JCC, Bellenger NG, Collins P, Klein HU, et al. Comparison of interstudy reproducibility of cardiovascular magnetic resonance with two-dimensional echocardiography in normal subjects and in patients with heart failure or left ventricular hypertrophy. Am J Cardiol. 2002;90(1):29–34.CrossRefPubMedGoogle Scholar
- 31.• Mohammed SF, Hussain I, AbouEzzeddine OF, Takahama H, Kwon SH, Forfia P, et al. Right ventricular function in heart failure with preserved ejection fraction: a community-based study. Circulation. 2014;130(25):2310–20. Highlights the role of the right ventricle in HFpEF clinical syndrome. CrossRefPubMedPubMedCentralGoogle Scholar
- 34.•• Paelinck BP, de Roos A, Bax JJ, Bosmans JM, van Der Geest RJ, Dhondt D, et al. Feasibility of tissue magnetic resonance imaging: a pilot study in comparison with tissue Doppler imaging and invasive measurement. J Am Coll Cardiol. 2005;45(7):1109–16. Key manuscript comparing CMR derived diastolic indices to echocardiography and invasive assessment and a key reference for future CMR studies evaluating diastolic function. CrossRefPubMedGoogle Scholar
- 37.Ambale-Venkatesh B, Armstrong AC, Liu C-Y, Donekal S, Yoneyama K, Wu CO, et al. Diastolic function assessed from tagged MRI predicts heart failure and atrial fibrillation over an 8-year follow-up period: the multi-ethnic study of atherosclerosis. Eur Heart J Cardiovasc Imaging. 2014;15(4):442–9.CrossRefPubMedGoogle Scholar
- 44.Hinojar R, Varma N, Child N, Goodman B, Jabbour A, Yu CY, et al. T1 Mapping in discrimination of hypertrophic phenotypes: hypertensive heart disease and hypertrophic cardiomyopathy: findings from the International T1 Multicenter Cardiovascular Magnetic Resonance Study. Circ Cardiovasc Imaging. 2015;8(12).Google Scholar
- 49.Falk RH, Alexander KM, Liao R, Dorbala S. AL (light-chain) cardiac amyloidosis. A review of diagnosis and therapy. Journal of the American College of Cardiology 2016;68(12):1323–1341.Google Scholar
- 51.Adler Y, Charron P, Imazio M, Badano L, Baron-Esquivias G, Bogaert J, et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: the task force for the diagnosis and management of pericardial diseases of the European Society of Cardiology (ESC) endorsed by: the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015;36(42):2921–64.CrossRefPubMedGoogle Scholar
- 54.Jaarsma C, Leiner T, Bekkers SC, Crijns HJ, Wildberger JE, Nagel E, et al. Diagnostic performance of noninvasive myocardial perfusion imaging using single-photon emission computed tomography, cardiac magnetic resonance, and positron emission tomography imaging for the detection of obstructive coronary artery disease: a meta-analysis. J Am Coll Cardiol. 2012;59(19):1719–28.CrossRefPubMedGoogle Scholar
- 57.Rieber J, Huber A, Erhard I, Mueller S, Schweyer M, Koenig A, et al. Cardiac magnetic resonance perfusion imaging for the functional assessment of coronary artery disease: a comparison with coronary angiography and fractional flow reserve. Eur Heart J. 2006;27(12):1465–71.CrossRefPubMedGoogle Scholar
- 58.Takx RA, Blomberg BA, El Aidi H, Habets J, de Jong PA, Nagel E, et al. Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis. Circ Cardiovasc Imaging. 2015;8(1).Google Scholar
- 60.Wei J, Mehta PK, Johnson BD, Samuels B, Kar S, Anderson RD, et al. Safety of coronary reactivity testing in women with no obstructive coronary artery disease: results from the NHLBI-sponsored WISE (Women’s Ischemia Syndrome Evaluation) study. JACC Cardiovasc Interv. 2012;5(6):646–53.CrossRefPubMedPubMedCentralGoogle Scholar
- 61.Thomson LE, Wei J, Agarwal M, Haft-Baradaran A, Shufelt C, Mehta PK, et al. Cardiac magnetic resonance myocardial perfusion reserve index is reduced in women with coronary microvascular dysfunction. A National Heart, Lung, and Blood Institute-sponsored study from the Women’s Ischemia Syndrome Evaluation. Circ Cardiovasc Imaging. 2015;8(4): https://doi.org/10.1161/CIRCIMAGING.114.002481 e.
- 63.Kato S, Saito N, Kirigaya H, Gyotoku D, Iinuma N, Kusakawa Y, et al. Impairment of coronary flow reserve evaluated by phase contrast cine-magnetic resonance imaging in patients with heart failure with preserved ejection fraction. J Am Heart Assoc. 2016;5(2).Google Scholar
- 64.Nagel E. MR-INFORM: stress perfusion imaging to guide the management of patients with stable coronary artery disease. Presentation Session. 2017:401–12.Google Scholar
- 66.Shah NR, Cheezum MK, Veeranna V, Horgan SJ, Taqueti VR, Murthy VL, et al. Ranolazine in symptomatic diabetic patients without obstructive coronary artery disease: impact on microvascular and diastolic function. J Am Heart Assoc. 2017;6(5).Google Scholar
- 73.Puntmann VO, Arroyo Ucar E, Hinojar Baydes R, Ngah NB, Kuo YS, Dabir D, et al. Aortic stiffness and interstitial myocardial fibrosis by native T1 are independently associated with left ventricular remodeling in patients with dilated cardiomyopathy. Hypertension. 2014;64(4):762–8.CrossRefPubMedGoogle Scholar
- 77.Child N, Suna G, Dabir D, Yap ML, Rogers T, Kathirgamanathan M, et al. Comparison of MOLLI, shMOLLLI, and SASHA in discrimination between health and disease and relationship with histologically derived collagen volume fraction. European heart journal cardiovascular Imaging. 2017:jex309-jex.Google Scholar
- 79.Coelho-Filho OR, Shah RV, Neilan TG, Mitchell R, Moreno H Jr, Kwong R, et al. Cardiac magnetic resonance assessment of interstitial myocardial fibrosis and cardiomyocyte hypertrophy in hypertensive mice treated with spironolactone. J Am Heart Assoc. 2014;3(3):e000790.CrossRefPubMedPubMedCentralGoogle Scholar
- 86.Bell V, McCabe EL, Larson MG, Rong J, Merz AA, Osypiuk E, et al. Relations between aortic stiffness and left ventricular mechanical function in the community. J Am Heart Assoc. 2017;6(1).Google Scholar
- 89.Weber T, Wassertheurer S, O'Rourke MF, Haiden A, Zweiker R, Rammer M, et al. Pulsatile hemodynamics in patients with exertional dyspnea: potentially of value in the diagnostic evaluation of suspected heart failure with preserved ejection fraction. J Am Coll Cardiol. 2013;61(18):1874–83.CrossRefPubMedGoogle Scholar
- 94.Melenovsky V, Borlaug BA, Rosen B, Hay I, Ferruci L, Morell CH, et al. Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction. J Am Coll Cardiol. 2007;49(2):198–207.CrossRefPubMedGoogle Scholar
- 96.Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29(4):277–314.CrossRefPubMedGoogle Scholar
- 97.Ather S, Chan W, Bozkurt B, Aguilar D, Ramasubbu K, Zachariah AA, et al. Impact of noncardiac comorbidities on morbidity and mortality in a predominantly male population with heart failure and preserved versus reduced ejection fraction. J Am Coll Cardiol. 2012;59(11):998–1005.CrossRefPubMedPubMedCentralGoogle Scholar