In heart failure with preserved ejection fraction (HFpEF), the heart’s pumping function is largely maintained, yet the heart is unable to fill adequately with blood. A multicentre study by the German Centre for Cardiovascular Research (DZHK) now shows that advanced MRI techniques can detect changes in myocardial tissue associated with different mechanisms of impaired cardiac filling. The findings from the DECIPHER HFpEF study have been published in JACC: Cardiovascular Imaging.
HFpEF is a complex form of heart failure. Elevated left ventricular filling pressure plays an important role in its diagnosis. However, this primarily indicates that cardiac filling is impaired and does not directly reveal the mechanisms responsible.
Diastolic dysfunction can arise, for example, when the heart muscle does not relax sufficiently after contraction. Another cause is increased passive myocardial stiffness. Both mechanisms can lead to elevated filling pressures but may require different therapeutic approaches.
MRI reveals changes in the myocardium
In the prospective DECIPHER HFpEF study, researchers led by Professor Eike Nagel and Professor Andreas Zeiher from the DZHK Rhine-Main partner site and University Hospital Frankfurt investigated patients with suspected HFpEF at seven centres across Germany. They combined cardiovascular magnetic resonance (CMR) with invasive pressure-volume measurements of the heart.
For the current analysis, data were available from 52 patients with invasively confirmed HFpEF. The researchers also studied 32 age- and sex-matched controls and 18 healthy volunteers.
The researchers used T1 and T2 mapping, specialised CMR techniques that provide quantitative information about the composition of myocardial tissue. T1 mapping can detect changes associated with an increase in connective tissue, or fibrosis. T2 mapping is particularly sensitive to increased tissue water content, as can occur with oedema and inflammatory changes.
Both T1 and T2 values were significantly higher in people with HFpEF than in the control group. More importantly, the two measures were associated with different aspects of diastolic dysfunction: T1 values correlated primarily with passive myocardial stiffness, whereas T2 values correlated with impaired active relaxation. These associations remained after statistical adjustment for filling pressure and clinical factors including age, sex, body mass index, hypertension and diabetes. By contrast, the CMR parameters themselves were not significantly associated with filling pressure.
“Filling pressure provides important information about the state of the heart, but tells us relatively little about the mechanism underlying it,” says Professor Eike Nagel of University Hospital Frankfurt. “Our findings show that tissue characterisation by CMR can provide additional information about the underlying diastolic dysfunction.”
Abnormalities detectable despite normal resting filling pressure
Another part of the study suggests that CMR tissue parameters may also be relevant in patients whose filling pressure is not yet elevated at rest.
Eighteen symptomatic patients with normal resting filling pressure underwent a handgrip test during invasive assessment. In 12 of them, filling pressure increased to at least 16 mmHg during the test. The higher the T1 and T2 values measured by CMR at rest, the greater the rise in filling pressure during stress.
These findings suggest that CMR tissue characterisation can capture changes that are not fully reflected by a single measurement of resting filling pressure.
In the longer term, CMR tissue characterisation could help to define the heterogeneous condition of HFpEF more precisely. Further studies are needed, however, before the findings can be used for clinical stratification or treatment decisions. In particular, researchers need to establish whether the differences detected by CMR can predict different responses to treatment. The authors emphasise that the current study does not yet establish a clinical application for the approach.
Original publication: Eike Nagel et al.: Myocardial Tissue Characterization by CMR Captures Mechanistic Severity Beyond Filling Pressure in HFpEF. The Multicenter DECIPHER HFpEF Study. JACC: Cardiovascular Imaging, 2026. DOI: 10.1016/j.jcmg.2026.07.012.
