The purpose of this study is to find out if additional images taken during a stress echocardiogram study and risk score calculation will help the doctor determine if shortness of breath or chest pain are caused by stiff heart (heart failure with preserved ejection fraction or HFpEF).

Inclusion Criteria:

• Clinically indicated exercise stress echo for the evaluation of exertional dyspnea or chest pain
• Age ≥50 years

Exclusion Criteria:

• Known history of HFpEF
• LVEF <50% on baseline echo study
• History of hypertrophic cardiomyopathy, amyloidosis, or pulmonary arterial hypertension, severe right ventricular dysfunction and severe valvular disease based on chart review or baseline echo study
• History of organ transplant (heart, kidney, liver, lungs)
• Severe pulmonary disease requiring ambulatory oxygen therapy
• End-stage renal disease requiring long-term renal replacement therapy
• Decompensated liver disease
• Conditions that prevent accurate assessment of E/e' ratio (mitral prosthetic valve, severe mitral annular calcification)
• Plan to use echo contrast agent during stress study (i.e. contrast agent needed for baseline study)
• Patients from outside Duke health system with no plan for long-term care at Duke