Left ventricular diastolic volume on cardiac magnetic resonance and risk of incident heart failure

Aims We explored the association between indexed left ventricular end-diastolic volume (iLVEDV) on cardiac magnetic resonance (CMR) and the risk of incident heart failure (HF) (stage C) in patients with suspected coronary heart disease without overt HF (stages A and B). We also examined the risk-modifying effect of left ventricular ejection fraction (LVEF) and sex. Methods and results We retrospectively included 5471 patients who underwent vasodilator stress CMR for suspected coronary artery disease and without a history of HF. Multivariate Cox proportional hazards regression adapted for competing events models assessed the relationship between iLVEDV and new-onset HF (stage C), considering LVEF status as a potential modifier. The mean age was 651 ± 11.6 years, and 2123 (38.8%) were women. The medians of CMR-iLVEDV and CMR-LVEF were 67 mL/m² (55–80) and 66% (58–72), respectively. At a median (p25% to p75%) follow-up of 5.1 years (2.3–8.2), we registered 287 new-onset HF diagnosis. iLVEDV was associated with a U-shaped risk of incident HF. The risk was most pronounced with an iLVEDV > 100 mL/m² and <45 mL/m². Notably, the association between iLVEDV and HF risk was influenced by LVEF status. In patients with LVEF < 50%, a higher risk was found in those with larger iLVEDV. On the contrary, LVEF > 60%, lower iLVEDV identified those at increased risk. Conclusion In subjects with higher LVEF, smaller left ventricle volumes identified a subset of patients with an increased risk of incident HF. These findings reveal a need for a better understanding of the pathophysiological mechanisms of HF with supranormal ejection fraction.