Harada T; Mayo Clinic, Minnesota, USA.
Naser JA; Ghanbari F; Borlaug BA

Jacc: Cardiovascular Imaging. 19(11):1381-1403, 2026

Heart failure with preserved ejection fraction (HFpEF) is a clinical
syndrome characterized by dyspnea caused by hemodynamic congestion, which
develops at rest or with exercise. Noninvasive diagnosis remains
challenging, because resting diastolic pressures may be normal, and even
when abnormal, currently applied noninvasive indices lack sensitivity. The
pathophysiology of HFpEF extends far beyond diastolic dysfunction, and
such complexity can be better understood through imaging. This
State-of-the-Art Review emphasizes echocardiography and other noninvasive
imaging approaches as the first-line tools for HFpEF evaluation, while
linking multimodality imaging to invasive hemodynamics as a physiologic
reference standard. The authors emphasize evidence-based, multiparametric
assessment, where combined cardiopulmonary exercise testing with exercise
stress echocardiography can quantify the diverse reserve limitations that
characterize HFpEF, including cardiac and extracardiac contributors,
atrial and right heart dysfunction, pulmonary vascular and ventilatory
limitation, dynamic atrioventricular regurgitation, extrinsic restraint,
pulmonary congestion, and peripheral impairments, acknowledging that such
phenotyping must be anchored to actionable findings and evidence-based
interventions. The authors describe the potential role of exercise cardiac
magnetic resonance and artificial intelligence-enabled imaging analysis
for phenotyping and risk stratification. Finally, the authors propose an
echo-first Bayesian pathway that updates pretest to posttest probability
and supports identification of patients in whom invasive hemodynamic
exercise testing may be required to confirm the diagnosis and validate
imaging markers against invasively measured congestion.