Introduction
Heart Failure with preserved ejection fraction (HFpEF) is a complex clinical entity associated with significant morbidity and mortality. HFpEF is responsible for approximately half of all heart failure hospitalizations, with mean survival similar to those with heart failure with reduced ejection fraction1. HFpEF typically begins with risk factor exposure, which promotes abnormal cardiac mechanics and preclinical myocardial dysfunction. Preclinical diastolic dysfunction is present in approximately ΒΌ of the adult population2. A significant proportion of patients with diastolic dysfunction go on to develop frank clinical heart failure.
The exact biologic links responsible for diastolic dysfunction and heart failure are not clearly apparent, but can be attributed to a complex interplay of various pathological conditions on background aging3. Until recently, myocardial determinants of HFpEF were thought primarily related to impairments in left ventricular relaxation and chamber stiffness. However, contemporary studies recognize the contribution of subtle left and right ventricular systolic dysfunction, as well as the impact of left atrial function and pericardial compliance. Furthermore, myocardial dysfunction may initially occur only during exercise and the static resting evaluation may not fully characterize potential dynamic changes. Therefore, assessment of cardiac mechanics during rest and exercise plays an important role in diagnosis and prognostication 4. This review focuses on the changes in cardiac mechanics that occur through the spectrum of preclinical myocardial dysfunction into clinically apparent HFpEF.