Ophthalmic insights into systemic microvascular dysfunction for early detection of HFpEF: a narrative review

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome characterized by diastolic dysfunction in the context of elevated left ventricular filling pressures leading to clinical symptoms such as dyspnea, fluid retention and lethargy. Systemic microvascular dysfunction plays a key role in the pathophysiology of HFpEF, contributing to impaired tissue perfusion, endothelial dysfunction, and increased cardiovascular morbidity. Due to significant morbidity and mortality associated with the condition, there is a clear need for early detection and risk stratification. This narrative review aims to explore the use of retinal imaging as a non-invasive tool for detecting systemic microvascular dysfunction and its implications as a biomarker for HFpEF. A comprehensive search of the literature was performed, and relevant studies were identified for inclusion based on their relevance to microvascular dysfunction and retinal changes in HFpEF. While N-terminal pro-B-type natriuretic peptide (NT-proBNP) and transthoracic echocardiography remain the diagnostic gold standard, retinal vascular changes have shown potential for both diagnostic and prognostic applications in HFpEF. Retinal biomarkers provide unique insights into microvascular dysfunction. Early studies support integrating these biomarkers for detection and risk stratification in future clinical guidelines. However, further research is needed to validate their predictive value and feasibility as standardized biomarkers for HFpEF assessment.