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The role of imaging in health failure with preserved ejection fraction

Dr. M. Cikes, University Hospital Rebro, Zagreb, Croatia



“At first, it may seem cumbersome to diagnose health failure with preserved ejection fraction (HFpEF) by imaging, specifically echocardiography, as the typical features of heart failure, such as left ventricular (LV) cavity dilation and left ventricular ejection fraction (LVEF) impairment, are lacking. However, the main structural changes seen in HFpEF typically imply a certain grade of LV hypertrophy and left atrial dilation, which can be clearly observed and quantified by echocardiography.

Regarding cardiac function, preserved LVEF, in the recently published ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, implies a LVEF of ≥50%. However, this value is arbitrary: several trials included patients with a LVEF of 40%–49%, now labelled as heart failure with mid-range ejection fraction and recognized as a grey area.

More detailed analysis of cardiac function using deformation imaging shows that LV systolic function is not entirely normal in patients with HFpEF: a reduction in LV longitudinal strain has been confirmed by multiple studies. There are even data showing reduced circumferential function, which may further distinguish HFpEF patients from a similar group with hypertensive heart disease but without overt signs and symptoms of heart failure. Deformation imaging studies also demonstrate an important role of atrial function and its impairment in HFpEF.

Another functional alteration suggested in the diagnosis of HFpEF is an E/e’ ≥13, implying elevated LV filling pressures. However, all of these features should be interpreted within the context of possible etiological factors (typically: female sex, older age, hypertension, obesity etc), as well as the clinical presentation and elevation in biomarkers (NT-proBNP and BNP).

Finally, echocardiography provides the additional diagnostic option of performing a diastolic stress test, typically a bicycle stress echocardiogram. During this procedure, LV function is quantified as mentioned above, but also allowing for the noninvasive quantification of pulmonary artery pressures, stroke volume and cardiac output, and their changes with exercise.”