Clinical Symptom Burden and Its Association With Echocardiographic Parameters and Comorbidities in Heart Failure With Preserved Ejection Fraction: A Retrospective Study

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome in which substantial symptoms may occur despite preserved left ventricular ejection fraction (LVEF). Echocardiographic abnormalities involving ventricular filling, left atrial remodeling, diastolic function, and pulmonary pressures may contribute to symptom burden. This study evaluated the association between clinical symptom severity, echocardiographic parameters, and comorbidities in patients with HFpEF.

This retrospective observational cross-sectional study was conducted at the Government Peripheral Hospital, Periyar Nagar, Chennai, Tamil Nadu, from March 2025 to March 2026. A total of 216 patients aged ≥18 years with HFpEF and LVEF ≥50% were included. Clinical symptom burden was assessed using New York Heart Association (NYHA) functional class and categorized as I-II or III-IV. Demographic characteristics, comorbidities, and echocardiographic parameters, including LVEF, left ventricular mass, left atrial volume index (LAVI), E/e' ratio, diastolic dysfunction grade, and estimated pulmonary artery systolic pressure (PASP), were evaluated. Multivariable logistic regression identified factors independently associated with NYHA III-IV symptoms.

The mean age was 67.8 ± 10.4 years, and 53.7% were female. Hypertension was the most prevalent comorbidity (80.6%), while 76.9% had ≥2 major comorbidities. Fifty-five patients (25.5%) had NYHA III-IV symptoms. Compared with NYHA I-II, the severe symptom group had higher E/e' (17.4 ± 5.0 vs. 12.6 ± 4.0), LAVI (44.5 ± 12.1 vs. 34.2 ± 9.1 mL/m²), LV mass, and PASP (43.9 ± 12.4 vs. 36.8 ± 8.7 mmHg), with significantly more advanced diastolic dysfunction. On multivariable analysis, E/e' (adjusted OR 1.18), LAVI (adjusted OR 1.05), and PASP (adjusted OR 1.04) were independently associated with severe symptoms.

Symptom severity in HFpEF was associated more strongly with abnormal filling pressures, left atrial remodeling, and pulmonary hemodynamics than with preserved systolic function alone. E/e', LAVI, and PASP may provide useful complementary markers of symptomatic burden and support a multidimensional echocardiographic assessment of HFpEF.