Left Atrial Stiffness Index for Refining Diastolic Stress Test Selection in Suspected Heart Failure With Preserved Ejection Fraction.

Incremental Value of Left Atrial Strain in HFA-PEFF for Heart Failure With Preserved Ejection Fraction.

BACKGROUND Because exercise testing is not feasible for a substantial subset of patients with suspected heart failure with preserved ejection fraction (HFpEF), the Heart Failure Association-Pre-test assessment, Echocardiography and natriuretic peptide score, Functional testing in cases of uncertainty, Final etiology (HFA-PEFF) score often leaves many patients in an indeterminate diagnostic category. OBJECTIVES The authors aimed to assess whether resting left atrial strain provides incremental diagnostic value beyond the HFA-PEFF score in patients undergoing exercise right heart catheterization. METHODS This prospective study enrolled 77 patients with confirmed HFpEF and 37 patients with noncardiac dyspnea (NCD). HFpEF was diagnosed by exercise right heart catheterization demonstrating elevated pulmonary capillary wedge pressure at rest or during exercise. Patients who did not meet HFpEF criteria were classified as NCD. The median HFA-PEFF score was 4 in patients with HFpEF and 2 in those with NCD (P = 0.007). RESULTS Left atrial reservoir strain (LARS) was significantly lower in patients with HFpEF compared with those with NCD (26.4% vs 34.7%; P < 0.001). LARS was significantly correlated with exercise mean pulmonary capillary wedge pressure and peak oxygen consumption and declined progressively as more HFpEF criteria were met. The optimal cutoff of LARS for discriminating HFpEF from NCD was 32% (OR: 5.26; 95% CI: 2.30-12.58; P < 0.001). Adding LARS to the HFA-PEFF score improved the area under the curve from 0.65 (0.56-0.74) to 0.75 (0.65-0.85) (P = 0.019) when LARS was analyzed as a continuous variable and to 0.73 (0.63-0.83) (P = 0.026) when using the 32% cutoff. CONCLUSIONS LARS provides additive diagnostic value beyond the HFA-PEFF score and may reduce the need for noninvasive and invasive stress testing in patients with suspected HFpEF.

Exercise stress echocardiography for diagnosis of heart failure with preserved ejection fraction: a multicentre study.

Prognostic Implications of the 2025 ASE guidelines for the Evaluation of Left Ventricular Diastolic Function in Heart Failure with Preserved Ejection Fraction and Atrial Fibrillation.

BACKGROUND Non-invasive assessment of left atrial pressure (LAP) remains difficult in patients with atrial fibrillation (AF). The American Society of Echocardiography (ASE) updated the Recommendations for the Evaluation of Left Ventricular Diastolic Function and introduced a specific algorithm for LAP estimation in AF. We retrospectively investigated the prognostic value of the new algorithm-based LAP assessment in patients with heart failure with preserved ejection fraction (HFpEF) and persistent AF. METHODS This study included 363 patients hospitalized for acutely decompensated HFpEF who had persistent AF at discharge. LAP was categorized as normal, elevated, or indeterminate using echocardiography at discharge, according to the algorithm in the 2025 ASE guidelines. Multivariable Cox proportional hazards models were constructed to assess associations between LAP classification and clinical outcomes such as death, heart failure (HF) hospitalization and stroke during follow-up of 574 days. RESULTS LAP was classified as elevated in 93 patients (25.6%) and normal in 165 (45.5%), while it was indeterminate in 105 (28.9%) cases due to missing variables recommended in the 2025 guidelines. Elevated LAP was independently associated with HF hospitalization during follow-up period (HR 1.57, 95% CI 1.05-2.37, p=0.03), whereas it was not identified as an independent predictor for death or stroke after adjustment. This association remained significant after accounting for the competing risk of death and was largely preserved across multiple imputation and sensitivity analyses using different assumptions for indeterminate cases. The incremental value of LAP estimation for predicting HF hospitalization over natriuretic peptides was modest and not statistically significant. CONCLUSIONS In patients hospitalized for HFpEF with persistent AF, LAP classification was associated with HF hospitalization, implying clinical relevance of the 2025 algorithm-based approach in this challenging population.

Impact of cardiac rehabilitation on left atrial function in patients with heart failure reduced ejection fraction

Heart failure with reduced ejection fraction (HFrEF) involves impaired left ventricular systolic function and frequently affects left atrial (LA) performance, which plays a vital role in cardiac output and is an emerging prognostic marker. While cardiac rehabilitation (CR) improves overall cardiac function, its impact on LA function in HFrEF patients remains under-investigated. To evaluate the effect of a structured 12-week CR program on LA function in patients with HFrEF. This prospective observational cohort study included 40 patients with HFrEF (mean age 53.6 ± 10.2 years, 87.5% male), LVEF ≤ 40%, and NYHA class I–II. Participants underwent a 12-week supervised CR program comprising exercise and lifestyle modifications at Ain Shams University Hospitals. Two-dimensional speckle tracking echocardiography was used to assess LA reservoir, conduit, and contractile strain at baseline and post-rehabilitation. Patients with significant valvular disease, residual ischemia, non-sinus rhythm, or poor adherence were excluded. CR significantly improved LA strain parameters: reservoir strain increased from 20.5% ± 9.5 to 23.6% ± 8.0 (p = 0.004), conduit strain from –10.2% ± 6.0 to –11.6% ± 4.6 (p = 0.048), and contractile strain from –10.3% ± 5.8 to –12.0% ± 5.9 (p = 0.020). LVEF improved from 36.4% ± 3.5 to 40.7% ± 5.3 (p < 0.001), while changes in LA size and volume were minimal. A 12-week CR program significantly enhances LA function in HFrEF, indicating potential benefits in atrial mechanics and overall cardiac performance. Larger studies are needed to validate long-term outcomes.

Heart Rate Recovery Index as a Functional Marker in Heart Failure with Preserved Ejection Fraction: Associations with H2FPEF Score, Longitudinal Systolic Function and Left Atrial Remodelling

Background: The Heart Rate Recovery Index (HRRI), derived from post-exercise heart rate recovery (HRR), reflects autonomic function and cardiovascular performance. Whether HRRI reflects early myocardial dysfunction and left atrial remodelling in heart failure with preserved ejection fraction (HFpEF) has not been previously examined. The H2FPEF score, which integrates clinical and echocardiographic parameters, is used to assess the likelihood of HFpEF. This study investigates the relationship between HRRI, H2FPEF score, and echocardiographic markers of longitudinal systolic function, including mitral annular plane systolic excursion (MAPSE), as well as left atrial volume index (LAVI), in patients with preserved left ventricular ejection fraction. Methods: A prospective observational study included 241 patients referred for cardiac exercise testing at the Institute of Cardiovascular Diseases Timisoara and the Clinical County Hospital of Sibiu. HRRI was calculated as the ratio of heart rate acceleration time (AT) to deceleration time (DT) during exercise testing. A comprehensive echocardiographic assessment was performed on all patients. Statistical analysis involved univariate testing and multivariable logistic regression with stepwise selection. Results: HRRI was significantly lower in HFpEF patients compared with those without heart failure (1.97 ± 0.66 vs. 2.73 ± 1.08, p < 0.01). HRRI correlated significantly with exercise performance, age, H2FPEF score, and echocardiographic markers of diastolic and longitudinal systolic dysfunction. ROC analysis identified an HRRI cut-off value of 2.25 for HFpEF detection (AUC = 0.748), while HRRI remained significantly associated with HFpEF after adjustment for the covariates included in the model. The combined HRRI–H2FPEF score improved diagnostic discrimination compared with the H2FPEF score alone (AUC 0.897 vs. 0.858), achieving an overall classification accuracy of 82.2%. Conclusions: In our study, HRRI is significantly reduced in HFpEF and distinguishes patients with and without heart failure. It shows associations with echocardiographic markers of diastolic and longitudinal systolic dysfunction, exercise capacity, and H2FPEF score.

Association Between Left Atrial Stiffness Index and Clinical Outcomes in Chronic Heart Failure With Impaired Left Ventricular Systolic Function.

Left atrial (LA) stiffness integrates information related to LA mechanical properties and left ventricular (LV) filling dynamics and may provide a comprehensive assessment of cardiac hemodynamic burden in heart failure (HF). However, its clinical significance in patients with chronic HF and impaired LV systolic function remains unclear. We investigated the association between the LA stiffness index (LASI) and clinical outcomes in patients with chronic HF and impaired LV systolic function. We retrospectively analyzed 1,147 patients with chronic HF and left ventricular ejection fraction (LVEF) <50% who underwent comprehensive echocardiography between January 2018 and March 2023. LASI was calculated as the ratio of E/e' to LA reservoir strain and stratified into tertiles. The primary endpoint was a composite of cardiovascular death or HF hospitalization. Kaplan-Meier analysis and Cox proportional hazards models were used to evaluate the association between LASI and clinical outcomes. During a median follow-up of 34 months, 218 patients experienced the primary endpoint. Event-free survival progressively decreased across LASI tertiles (log-rank P < 0.01). After adjustment for age, sex, LVEF, LA volume index, and tricuspid regurgitation velocity, higher LASI remained independently associated with adverse outcomes (hazard ratio 2.41, 95% confidence interval 1.55-3.73, P < 0.01). This association was consistent across clinically relevant subgroups, including age, diabetes mellitus, LV geometry, and LA size. In conclusion, in patients with chronic HF and impaired LV systolic function, increased LASI was independently associated with cardiovascular death and HF hospitalization, suggesting that LASI may serve as a practical echocardiographic marker reflecting atrial dysfunction and hemodynamic burden.