Divergent Left Ventricular Remodeling by Sex in Adults With Overweight and Obesity: An Echocardiographic Geometry...

Sex-specific differences in left ventricular (LV) geometry are poorly characterized across the obesity severity spectrum in real-world echocardiographic cohorts, and standard LVMI cut-offs derived from male or mixed-sex populations may systematically underclassify LVH in women.

Routine transthoracic echocardiography was performed in 205 adults with overweight or obesity (BMI ≥ 25 kg/m²). LV geometry was classified into four mutually exclusive patterns: normal geometry, concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH) using sex-specific LVMI thresholds (>95 g/m² females; >115 g/m² males) and a relative wall thickness (RWT) cut-off of 0.42. Binary logistic regression evaluated sex as an independent predictor of LV geometry outcomes, adjusting for age and obesity class.

Despite higher BMI in females (35.1 vs. 29.7 kg/m²; p < 0.001), mean LVMI was paradoxically lower (87.0 vs. 93.0 g/m²; p = 0.042), yet female sex independently predicted LVH by LVMI (OR 2.11, 95% CI 1.01-4.41; p = 0.047), a finding visible only with sex-specific thresholds. Overall concentric burden was similar (CR + CH: 47.6% vs. 46.9%), but pattern distribution differed: females more often showed CH (17.7% vs. 11.1%) and EH (15.3% vs. 7.4%), while males more frequently had normal geometry (42.0%) or CR (35.8%). The divergence was greatest in the overweight subgroup: CH was nearly threefold higher in females (34.8% vs. 12.8%), and RWT was significantly greater (0.470 vs. 0.385; p = 0.020).

Female sex independently predicts LVH by LVMI despite lower mean LVMI, a paradox visible only when sex-specific echocardiographic thresholds are applied. Females and males carry similar overall concentric burdens but follow divergent geometric remodeling paths, a difference detectable at the overweight threshold. These findings underscore the necessity of sex-specific LVMI reference values in echocardiographic practice.