The following are key points to remember from this state-of-the-art review on cardiac magnetic resonance (CMR) imaging in the evaluation of diastolic dysfunction and phenotyping of heart failure with preserved ejection fraction (HFpEF):

1. HFpEF presents a challenging diagnosis due to a heterogeneous patient population and limited treatment options.
2. Diagnosing HFpEF is critically important because of its high prevalence (∼50% of HF cases) and association with adverse prognosis.
3. Diastolic function assessment using echocardiography has been the cornerstone in the workup of HFpEF and is as important as systolic functional assessment.
4. There has been increased awareness of the potential utility of CMR imaging over the past decade as a promising, radiation-free, robust imaging modality providing an unrestricted field of view and high-resolution images for global and regional (systolic and diastolic) functional assessment of the left ventricle.
5. CMR provides early markers for detecting myocardial disease using tissue characterization imaging, which might prove useful to improve diagnosis and management of HFpEF.
6. Over the years, several studies have examined CMR-derived diastolic functional indices, including transmitral and pulmonary venous velocities, left ventricular (LV) and left atrial strain using myocardial tagging, and, more recently, feature tracking.
7. The relevance of imaging-based diastolic function indices and their clinical application across different modalities is increasingly being recognized.
8. It is important to recognize other alternative pathologies in patients diagnosed with HFpEF, and CMR can add value to the diagnostic workup of HFpEF unmasking alternative pathologies, which may have prognostic and therapeutic implications. Feature-tracking CMR (FT-CMR) has been studied to evaluate LV rotational indices of torsion (calculated as the difference between apical and basal rotation), and reveal a particular pattern of rotation in cardiac amyloidosis and hypertrophic cardiomyopathy.
9. Diastolic function assessment by CMR is feasible, but it is yet to be used routinely in clinical practice.
10. There is an ongoing need for more standardized post-processing software to permit widespread application of this relatively new technology. While there are gaps, there are many potential opportunities with this robust technology for the management of HFpEF.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging

Keywords: Amyloidosis, Cardiomyopathies, Cardiomyopathy, Hypertrophic, Diagnostic Imaging, Diastole, Echocardiography, Heart Failure, Magnetic Resonance Imaging, Multimodal Imaging, Stroke Volume, Systole, Ventricular Function

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