Small left ventricle in patients with heart failure with preserved ejection fraction is associated with higher mortality

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Abstract Background Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome rather than a single entity. Left ventricular (LV) remodeling patterns may be associated with this heterogeneity. Population-based studies have shown that LV volume decreases with aging, a key factor for HFpEF development. HFpEF associated with small LV may represent a distinctive phenotype characterized by older age and unique clinical features. Purpose This study aims to investigate the characteristics and clinical outcomes of HFpEF wih small LV. Methods We analyzed 1,140 patients from PURSUIT-HFpEF registry, a multicenter prospective observational registry of acute decompensated HFpEF patients. Clinical data were collected during the compensated phase, after stabilization following acute decompensated HF treatment. The study population was divided into groups with small, normal, and large LV based on LV end-diastolic dimension per the American Society of Echocardiography references. We examined the impact of LV size on all-cause mortality. Results Of 1,140 patients, 161 (14.1%) patients were identified with small LV, and 71 (6.2%) patients were identified with large LV. Patients with small LV were older and had higher heart rates, lower systolic blood pressure, lower body mass index, higher hemoglobin levels, higher estimated glomerular filtration rate, and elevated NT pro-BNP levels. The Kaplan-Meier analysis revealed that LV size was significantly associated with mortality (Log-rank p< 0.001). After adjusting for covariates, small LV remained independently associated with mortality compared with the normal LV group (adjusted hazard ratio: 0.64 [95% confidence interval: 0.49-0.83], p<0.001). Conclusions HFpEF with small LV represents a distinct phenotype characterized by older age, elevated NT-proBNP, fewer comorbidities, and higher mortality. These findings highlight the need for tailored management strategies for this subgroup.

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