Body-size normalization materially changed apparent LA enlargement in this selected HFpEF population; BSA-normal/height2-enlarged classification was associated with higher E/e', a noninvasive filling-related marker, but was threshold-dependent, and the findings do not establish diagnostic superiority or prognostic benefit.
BMI was positively associated with absolute left atrial volume in HFpEF patients.
BMI was inversely associated with LA volume indexed to BSA.
BMI was positively associated with LA volume indexed to height squared.
About a quarter of participants were classified discordantly (BSA-normal but height2-enlarged).
Discordant classification was associated with higher adjusted E/e' compared with participants normal by both methods.
The reclassification proportion was threshold-dependent.
Body-size normalization materially changed apparent LA enlargement, but the findings do not establish diagnostic superiority or prognostic benefit.
This study looked at how doctors measure the size of the left atrium (an upper heart chamber) in people with heart failure who still have a normal pumping fraction (HFpEF). Because larger people naturally have larger hearts, atrial volume is usually adjusted for body size. The researchers compared three approaches in 1663 patients from a large hospital database: no adjustment, adjustment for body surface area, and adjustment for height squared. The approach changed the picture. Higher BMI was linked with a larger absolute atrial volume and with larger volume adjusted for height squared, but with a smaller volume when adjusted for body surface area. About 23% of patients had an atrium that looked normal by body surface area but enlarged by height squared. These patients tended to have higher E/e', an ultrasound-based measure related to heart filling pressure, than those normal by both methods (about 1.6 units higher). This research suggests that the way body size is accounted for can change whether a patient's atrium is labeled enlarged, especially in people with higher BMI. However, the share of patients reclassified fell to under 10% when a different published height-based cutoff was used, and the study could not show that one method is better for diagnosis or predicting outcomes. It was a retrospective analysis of a selected group, so the results point to a question for future study rather than a change in practice.
Wu X, Zhang H. (2026). Body-Size Indexation of Left Atrial Volume in Heart Failure with Preserved Ejection Fraction: Retrospective Reclassification and E/e' Concordance.. Echocardiography (Mount Kisco, N.Y.). https://doi.org/10.1111/echo.70660