CMR to characterize myocardial structure and function in heart failure with preserved left ventricular ejection fraction

Despite remarkable progress in therapeutic drugs, morbidity, and mortality for heart failure (HF) remains high in developed countries. HF with preserved ejection fraction (HFpEF) now accounts for around half of all HF cases. It is a heterogeneous disease, with multiple aetiologies, and as such poses a significant diagnostic challenge. Cardiac magnetic resonance (CMR) has become a valuable non-invasive modality to assess cardiac morphology and function, but beyond that, the multi-parametric nature of CMR allows novel approaches to characterize haemodynamics and with magnetic resonance spectroscopy (MRS), the study of metabolism. Furthermore, exercise CMR, when combined with lung water imaging provides an in-depth understanding of the underlying pathophysiological and mechanistic processes in HFpEF. Thus, CMR provides a comprehensive phenotyping tool for HFpEF, which points towards a targeted and personalized therapy with improved diagnostics and prevention. Graphical Abstract The role of cardiovascular magnetic resonance in phenotyping heart failure with preserved ejection fraction (HFpEF). CMR to assess non-invasively for cardiac function, structure, haemodynamics, and energetics/metabolism in HFpEF. ATP, adenosine triphosphate; CMR, cardiovascular magnetic resonance; H, hydrogen; HFpEF, heart failure with preserved ejection fraction; MRI, magnetic resonance imaging; MRS, magnetic resonance spectroscopy; PCr, phosphocreatine; P, phosphorus; W, Watt. The graphical abstract features a panel adapted from Pan et al. (i), Lewis et al. (ii), Haaf et al. (iii), Ferreira et al. (iv), Burrage et al. (v), and Mahmod et al. (vi) under a Creative Commons License. Images created with BioRender.com.