Role of left atrial remodeling in confirmed heart failure with preserved ejection fraction: focus on timely diagnosis

Aim. To study the heart structural and functional state in confirmed heart failure with preserved ejection fraction (HFpEF) depending on the severity of left ventricle (LV) diastolic dysfunction.

Material and methods. Data from 303 patients with LV diastolic dysfunction (men 45,2%, mean age 66,3±6,0 years) were analyzed. The diastolic stress test (DST) was performed when the criteria for HFpEF according to resting echocardiography data was insufficient (n=251). The study included 153 patients with confirmed HFpEF (men 35,3%, mean age 67,0±5,6 years). Group I (n=101) included patients with decreased LV diastolic reserve in DST (E/e’ >14), while group II (n=52) — patients with significant LV diastolic dysfunction at rest who do not require DST to verify HFpEF. The speckle-tracking echocardiography was used to assess left atrial reservoir strain (LASr).

Results. Significant differences were found in the 6-min walk test (400,0 [360,0;440,0] m in group I vs 365,5 [310,5;401,5] m in group II, respectively; p<0,001) and N-terminal pro-brain natriuretic peptide (NT-proBNP) level (257,7 [100,0;443,3] pg/ml and 412,0 [191,4;780,2] pg/ml; p=0,002). Resting echocardiography revealed significant differences in the left atrium (LA) volume index (VI) (33,5 [29,2;40,1] ml/m² vs 40,8 [37,3; 47,6] ml/m²; p<0,001), E/e’ ratio (11,3 [10,1;12,6] and 16,3 [14,9;19,2]; p<0,001), LASr (21,3 [19,5;24,7]% and 15,0 [12,5;17,3]%; p<0,001). Following moderate correlations were found in patients with HFpEF: LASr and E/e’ (r=-0,538; p<0,001), LASr and LAVI (r=-0,443; p<0,001). There was no correlation between LASr and NT-proBNP (r=-0,157; p=0,060). When analyzing the DST, significant differences were found in all characteristics in group I.

Conclusion. Patients with confirmed HFpEF with an increase in LV filling pressure are characterized by LA reservoir dysfunction and LA dilation. Phase analysis of LA strain and DST allows for timely diagnosis of HFpEF.

1. Ovchinnikov AG, Potekhina AV, Filatova AYu, et al. The Role of the Left Atrium in the Pathogenesis of Heart Failure With Preserved Ejection Fraction. Kardiologiia. 2024;64(11):13247. (In Russ.) doi:10.18087/cardio.2024.11.n2799.

2. Reddy YNV, Tada A, Obokata M, et al. Evidence-¬Based Application of Natriuretic Peptides in the Evaluation of Chronic Heart Failure With Preserved Ejection Fraction in the Ambulatory Outpatient Setting. Circulation. 2025;151(14):976-989. doi:10.1161/CIRCULATIONAHA.124.072156.

3. Nikorowitsch J, Bei der Kellen R, Kirchhof P, et al. Applying the ESC 2016, H2FPEF, and HFAPEFF diagnostic algorithms for heart failure with preserved ejection fraction to the general population. ESC Heart Fail. 2021;8(5):3603-12. doi:10.1002/ehf2.13532.

4. Selvaraj S, Myhre PL, Vaduganathan M, et al. Application of Diagnostic Algorithms for Heart Failure With Preserved Ejection Fraction to the Community. JACC Heart Fail. 2020;8(8):64053. doi:10.1016/j.jchf.2020.03.013.

5. Li S, Zhu X, Zhang Y, et al. Validation of heart failure algorithm for diagnosing heart failure with preserved ejection fraction: a meta-analysis. ESC Heart Fail. 2023;10(4):2225-35. doi:10.1002/ehf2.14421.

6. Galyavich AS, Tereshchenko SN, Uskach TM, et al. 2024 Clinical practice guidelines for Chronic heart failure. Russian Journal of Cardiology. 2024;29(11):6162. (In Russ.) doi:10.15829/1560-4071-2024-6162.

7. Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. European Heart Journal — Cardiovascular Imaging. 2016;17(12):1321-60. doi:10.1093/ehjci/jew082.

8. Lancellotti P, Pellikka PA, Budts W, et al. The Clinical Use of Stress Echocardiography in Non-Ischaemic Heart Disease: Recommendations from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Journal of the American Society of Echocardiography. 2017;30(2):101-38. doi:10.1016/j.echo.2016.10.016.

9. Matskeplishvili ST, Saidova MA, Mironenko MYu, et al. Standard transthoracic echocardiography. Guidelines 2024. Russian Journal of Cardiology. 2025;30(2):6271. (In Russ.) doi:10.15829/1560-4071-2025-6271.

10. Tani Y, Reddy YNV, Verbrugge FH, et al. Variability in approach to exercise stress echocardiography for diagnosis of heart failure with preserved ejection fraction: an international survey on real-world practice. Eur Heart J Imaging Methods Pract. 2024;2(1):qyae059. doi:10.1093/ehjimp/qyae059.

11. Obokata M, Kane GC, Reddy YN, et al. Role of Diastolic Stress Testing in the Evaluation for Heart Failure With Preserved Ejection Fraction: A Simultaneous Invasive-¬Echocardiographic Study. Circulation. 2017;135(9):825-38. doi:10.1161/CIRCULATIONAHA.116.024822.

12. Robinson S, Ring L, Oxborough D, et al. The assessment of left ventricular diastolic function: Guidance and recommendations from the British Society of Echocardiography. Echo Res Pract. 2024;11(1):16. doi:10.1186/s44156-024-00051-2.

13. Dal Canto E, Remmelzwaal S, van Ballegooijen AJ, et al. Diagnostic value of echocardiographic markers for diastolic dysfunction and heart failure with preserved ejection fraction. Heart Fail Rev. 2022;27(1):207-18. doi:10.1007/s10741-020-09985-1.

14. Shirokov NE, Yaroslavskaya EI, Krinochkin DV, et al. Diagnostic value of left atrial compliance in determining heart failure with preserved ejection fraction. Russian Open Medical Journal. 2024;13:e0409. doi:10.15275/rusomj.2024.0409.