Left atrial-left ventricular indexed volume ratio: a potential predictor for adverse outcomes in patients with heart failure and preserved left ventricular ejection fraction

Abstract Background Heart failure with preserved left ventricular ejection fraction (HFpEF) is a complex syndrome associated with high morbidity and mortality. Left ventricular ejection fraction (LVEF), left atrial (LA) and left ventricular (LV) dimensions, as well as estimated pulmonary artery systolic pressure have been proposed as markers of cardiac dysfunction with prognostic implications. More recently, the ratio (LA/LV) between LA indexed volume (LAVi) and LV end-diastolic indexed volume (LVEDVi) has been suggested as a novel predictor of adverse events in the population with HFpEF. Aims To assess the association between LA/LV ratio with other markers and determine its prognostic cohort of patients with a diagnosis of HFpEF and acutely admitted for worsening heart failure. Methods In this single-centre, observational study, data from patients with HFpEF who were acutely admitted to our hospital between 1st January 2015 and 31st December 2023 were retrospectively collected. HFpEF was diagnosed according to the updated European Society of Cardiology guidelines. Demographics, blood tests, comorbidities, medications, echocardiographic data were recorded and stratified by quartiles of LA/LV ratio. Independent predictors of LA/LV ratio were identified using linear regression analysis and the association between LA/LV ratio and outcomes was assessed using Cox’s proportional hazard analysis. Our primary outcome was the composite of all-cause mortality or readmission due to heart failure (HF), assessed at 90 days after discharge. Results 1,424 patients, aged 81 years, of whom 47% men, were enrolled. Participants with higher LA/LV ratio were older, more likely men, with an increased prevalence of diabetes (p=0.001), hypertension (p=0.001) and with greater N-terminal pro-brain natriuretic peptide measurements (p=0.001). Compared to both LAVi (HR: 1.21; 95% CI: 1.09-1.32) and LVEDVi (HR: 1.12; 95% CI: 1.03-1.18), LA/LV ratio resulted as independent and stronger predictor of the composite of death for any cause or rehospitalization due to HF (HR: 1.32; 95% CI: 1.13-1.52). Using the lower LA/LV ratio quartile as reference, higher quartiles of LA/LV ratio identified a cohort of inpatients at increased risk to develop adverse events, both in the univariate and multivariate analysis. Conclusions LA/LV ratio is frequently elevated in patients with a diagnosis of HFpEF and acutely admitted due to worsening HF. LA/LV ratio independently predicts adverse events and higher quartiles identify patients with an increased risk to develop adverse outcomes.