Obesity is a current pandemic that sets all affected individuals at risk of heart failure (HF), and the majority of them will develop the clinical syndrome of HF with preserved ejection fraction (HFpEF). The diagnosis of HFpEF is challenging as it is based on the detection of subtle functional and structural remodeling of the heart that leads to diastolic dysfunction with increased left ventricular (LV) filling pressures and raised natriuretic peptides (NPs). The accurate diagnosis of HFpEF is even more challenging in patients who are obese, since the echocardiographic imaging quality may be suboptimal, the parameters for the evaluation of cardiac structure are indexed to the body surface area (BSA) and thus may underestimate the severity of the remodeling, and the NPs in patients who are obese have a lower normal threshold. Moreover, patients who are obese are prone to atrial fibrillation (AF) and pulmonary hypertension (PH), making the evaluation of diastolic dysfunction more strenuous. The current review aims to offer insights on the accurate diagnosis of HFpEF in patients who are obese in different clinical scenarios—patients who are obese in different clinical scenarios—such as in sinus rhythm, in atrial fibrillation, and in the case of pulmonary hypertension—by applying multimodality imaging and clinical diagnostic algorithms.

Heart failure (HF) is increasingly recognized as a progressive syndrome that begins long before patients develop clinical signs or symptoms, during which conventional echocardiographic parameters may fail to detect early myocardial impairment. Atrial strain imaging by speckle-tracking echocardiography has emerged as a sensitive, non-invasive tool capable of identifying subtle functional abnormalities before symptoms or structural remodeling occur. Impaired left atrial (LA) reservoir strain (LASr) serves as a sensitive marker of left ventricular (LV) diastolic dysfunction with elevated filling pressures, exercise intolerance, and HF with preserved ejection fraction, with incremental diagnostic or prognostic value reported in selected studies. Reduced LA strain is also strongly associated with atrial fibrillation (AF), valvular heart disease progression, adverse outcomes following myocardial infarction, and pulmonary vascular involvement. Although comparatively less studied, right atrial (RA) reservoir strain (RASr) reflects the haemodynamic burden of the right heart, right ventricular–pulmonary arterial coupling, and early subclinical dysfunction in cardiometabolic disease, pulmonary hypertension, and established HF. Similarly, RA strain has demonstrated potential diagnostic and prognostic value across the HF spectrum. This review summarizes contemporary evidence regarding the pathophysiological, diagnostic, and prognostic significance of LASr and RASr in unveiling subclinical dysfunction in HF. Both LA and RA strain may provide complementary information on atrioventricular coupling and may identify functional impairment and increased haemodynamic burden before overt structural remodeling becomes evident. Atrial strain assessment may therefore complement conventional echocardiography in the early detection, phenotypic characterization, and risk stratification of patients across different stages of HF.

Background: Reliable quantification of systemic venous congestion in acute heart failure (HF) has become feasible with the advent of the venous excess ultrasound (VExUS) score, informing therapeutic management. Nevertheless, the determinants of the VExUS score trajectory during hospitalization and the prognostic implications of persistent subclinical congestion at discharge remain poorly defined. Methods: Consecutive patients admitted for acute HF were prospectively enrolled (n = 418, 73.3 ± 11.8 years old, 59.1% male). VExUS scores were assessed at admission and prior to discharge to categorize the patients into three groups: non-congested (persistent score of 0; n = 81), improved (score reduction of ≥1 point; n = 214), and non-improved (persistent congestion without score reduction; n = 123). Baseline clinical data were collected and all the patients had a transthoracic echocardiogram on admission. All patients were followed up post-discharge and the primary endpoint was a composite of all-cause mortality or HF hospitalization. Results: Patients with non-improved VExUS exhibited a higher burden of right-sided remodeling and dysfunction including larger right chambers, lower right ventricle (RV) systolic function indices, higher RV systolic pressures and a higher prevalence of severe tricuspid regurgitation (all p < 0.001). Severe tricuspid regurgitation was the sole independent predictor of VExUS non-improvement (OR 2.86, 95% CI 1.51–5.45, p = 0.001). Non-improved VExUS (HR 1.77; 95% CI 1.17–2.67; p = 0.007), severe tricuspid regurgitation (HR 1.88; 95% CI 1.16–3.02; p = 0.010) and intravenous furosemide dose (HR 1.00; 95% CI 1.00–1.01; p = 0.011) were independent predictors of the composite primary endpoint. Inclusion of non-improved VExUS provided incremental prognostic value over models including clinical, laboratory, and echocardiographic parameters (Δχ²= 9.22; p = 0.007). Conclusions: VExUS non-improvement throughout hospitalization marks patients with worse primary endpoint Severe tricuspid regurgitation emerges as an independent determinant of VExUS non-improvement which is independently associated with poor long-term outcomes.