How to Use Imaging: Cardiac Magnetic Resonance Imaging in Heart Failure With Preserved Ejection Fraction: a Stepwise Differential Diagnosis Approach

Heart failure with preserved ejection fraction (HFpEF) is a multifaceted syndrome that often presents diagnostic challenges due to its diverse causes and overlapping symptoms with other conditions. Its prevalence is increasing, driven by an aging population and rising associated comorbidities including obesity, diabetes, and hypertension. Echocardiography is a cornerstone in the screening and diagnosis of HFpEF due to its noninvasive nature, accessibility, and ability to provide a comprehensive cardiac assessment. Cardiac magnetic resonance can further enhance diagnostic accuracy and be a useful tool in follow-up. Cardiac magnetic resonance tissue characterization by parametric mapping sequences (T1/T2 mapping, late gadolinium enhancement, extracellular volume quantification, myocardial flow reserve, and myocardial strain) is also helpful in evaluating specific conditions that can lead to symptoms of heart failure in the setting of normal ejection fraction. The role of cardiac magnetic resonance has become increasingly important with the emergence of new therapies, as distinguishing HFpEF causes is essential for precise therapy selection. In this review, we describe the diagnostic imaging features associated with HFpEF, along with the potential role of imaging in follow-up. We also propose a diagnostic workflow for suspected HFpEF cases in clinical practice.