Early Echocardiographic Markers in Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) represents nearly half of all heart failure cases and remains diagnostically challenging due to its heterogeneous pathophysiology and often subtle myocardial dysfunction. Conventional echocardiographic parameters, such as left ventricular ejection fraction (LVEF) and the left atrial volume index (LAVI), frequently fail to detect early functional changes. Advanced echocardiographic techniques have emerged as valuable tools for early diagnosis and risk stratification. Global Longitudinal Strain (GLS) allows for the identification of subclinical systolic dysfunction, even with preserved LVEF. Left Atrial Strain (LAS), particularly reservoir and pump strain, provides sensitive markers of diastolic function and elevated filling pressures, offering additional diagnostic and prognostic insights. Myocardial Work (MW), through non-invasive pressure-strain loops, enables load-independent assessment of contractility, while Right Ventricular Free Wall Longitudinal Strain (RVFWLS) captures early right heart involvement, often present in advanced HFpEF. The integration of these advanced parameters can enhance diagnostic precision and guide personalized treatment strategies. This review highlights the current evidence and clinical applications of strain-based imaging in HFpEF, underscoring the importance of a multiparametric, pathophysiology-oriented approach in heart failure evaluation.