We show in 43 patients with 31P MRS, 1H CMR and a novel proton-density mapping sequence that a gradient of myocardial energetic impairment exists across a spectrum of HFpEF phenotypes of increasing clinical severity and worsening diastolic function. A greater degree of myocardial energetic deficit is linked to impaired LV systolic and diastolic functional reserve, to altered RV reserve and RV-PA coupling, and to exercise-induced pulmonary congestion assessed using novel proton density magnetic resonance imaging. A subgroup of HFpEF patients demonstrate transient pulmonary congestion during exercise which can be non-invasively assessed using exercise CMR and proton density mapping.
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