Exercise Cardiovascular Magnetic Resonance for the Diagnosis and Phenotyping of Heart Failure with Preserved Ejection Fraction: A Comprehensive Review

In heart failure with preserved ejection fraction (HFpEF), functional abnormalities may emerge mainly during exercise. Resting investigations may therefore explain exertional symptoms only partly. Exercise cardiovascular magnetic resonance (Ex-CMR) measures chamber volumes, deformation and blood flow during physiological stress to assess cardiovascular reserve. This review examines the technical foundations of Ex-CMR and its applications in HFpEF diagnosis, physiological phenotyping and treatment monitoring. It considers the physiological interpretation and clinical evidence for atrial, biventricular and vascular reserve indices, with attention to standardised acquisition, multiparametric assessment and clinical translation.