Echo and CMR Evaluation in HFpEF

Study Questions:

What is the utility of a comprehensive imaging protocol, including echocardiography and cardiac magnetic resonance (CMR), in the diagnosis and differentiation of hypertensive heart disease and heart failure with preserved ejection fraction (HFpEF)?


The investigators conducted a prospective cross-sectional study of 112 well-characterized patients (62 with HFpEF, 22 with hypertension, and 28 healthy control subjects). All patients underwent cardiopulmonary exercise and biomarker testing and an imaging protocol including echocardiography with speckle-tracking analysis and CMR including T1 mapping pre- and post-contrast. Logistic regression analysis was performed to determine the relationship between significant echocardiographic and CMR variables and the diagnosis of HFpEF.


Echocardiographic global longitudinal strain (GLS) and extracellular volume (ECV) measured by CMR were the only variables able to independently stratify among the 3 groups of patients. ECV was the best technique for differentiation between hypertensive heart disease and HFpEF (ECV area under the curve: 0.88; GLS area under the curve: 0.78; p < 0.001 for both). Using ECV, an optimal cutoff of 31.2% gave 100% sensitivity and 75% specificity. ECV was significantly higher and GLS was significantly reduced in subjects with reduced exercise capacity (lower peak oxygen consumption and higher minute ventilation-carbon dioxide production) (p < 0.001 for both ECV and GLS).


The authors concluded that both GLS and ECV measured by CMR are able to independently discriminate between hypertensive heart disease and HFpEF and identify patients with prognostically significant functional limitation.


This study reports that an advanced imaging protocol including echocardiographic speckle tracking and T1 mapping can differentiate among patients with HFpEF, patients with hypertensive heart disease, and control subjects. Furthermore, both GLS and ECV correlate strongly and are significantly different in patients with objective functional limitation based on peak oxygen consumption and ventilation–carbon dioxide production, which are established markers of prognosis in HFpEF. If validated in additional prospective studies, CMR-derived ECV could be considered a noninvasive imaging biomarker of HFpEF, providing improved diagnostic clarity and potentially serving as a surrogate endpoint in clinical trials.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Acute Heart Failure, Chronic Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Hypertension

Keywords: Biological Markers, Diagnostic Imaging, Echocardiography, Exercise Test, Heart Failure, Heart Failure, Diastolic, Hypertension, Magnetic Resonance Imaging, Oxygen Consumption, Secondary Prevention, Stroke Volume

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