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BackgroundA sex-based evaluation of prognosis in heart failure (HF) is lacking.Methods and resultsWe analyzed the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score registry, which includes HF with reduced ejection fraction (HFrEF) patients. A cross-validation procedure was performed to estimate weights separately for men and women of all MECKI score parameters: left ventricular ejection fraction (LVEF), hemoglobin, kidney function assessed by Modification of Diet in Renal Disease, blood sodium level, ventilation vs. carbon dioxide production slope, and peak oxygen consumption (peakVO2). The primary outcomes were the composite of all-cause mortality, urgent heart transplant, and implant of a left ventricle assist device. The difference in predictive ability between the native and sex recalibrated MECKI (S-MECKI) was calculated using a receiver operating characteristic (ROC) curve at 2 years and a calibration plot. We retrospectively analyzed 7,900 HFrEF patients included in the MECKI score registry (mean age 61 ± 13 years, 6,456 men/1,444 women, mean LVEF 33% ± 10%, mean peakVO2 56.2% ± 17.6% of predicted) with a median follow-up of 4.05 years (range 1.72–7.47). Our results revealed an unadjusted risk of events that was doubled in men compared to women (9.7 vs. 4.1) and a significant difference in weight between the sexes of most of the parameters included in the MECKI score. S-MECKI showed improved risk classification and accuracy (area under the ROC curve: 0.7893 vs. 0.7799, p = 0.02) due to prognostication improvement in the high-risk settings in both sexes (MECKI score >10 in men and >5 in women).ConclusionsS-MECKI, i.e., the recalibrated MECKI according to sex-specific differences, constitutes a further step in the prognostic assessment of patients with severe HFrEF.

The left atrium (LA) is emerging as a key element in the pathophysiology of several cardiac diseases due to having an active role in contrasting heart failure (HF) progression. Its morphological and functional remodeling occurs progressively according to pressure or volume overload generated by the underlying disease, and its ability of adaptation contributes to avoid pulmonary circulation congestion and to postpone HF symptoms. Moreover, early signs of LA dysfunction can anticipate and predict the clinical course of HF diseases before the symptom onset which, particularly, also applies to patients with increased risk of HF with still normal cardiac structure (stage A HF). The study of LA mechanics (chamber morphology and function) is moving from a research interest to a clinical application thanks to a great clinical, prognostic, and pathophysiological significance. This process is promoted by the technological progress of cardiac imaging which increases the availability of easy-to-use tools for clinicians and HF specialists. Two-dimensional (2D) speckle tracking echocardiography and feature tracking cardiac magnetic resonance are becoming essential for daily practice. In this context, a deep understanding of LA mechanics, its prognostic significance, and the available approaches are essential to improve clinical practice. The present review will focus on LA mechanics, discussing atrial physiology and pathophysiology of main cardiac diseases across the HF stages with specific attention to the prognostic significance. Imaging techniques for LA mechanics assessment will be discussed with an overlook on the dynamic (under stress) evaluation of the chamber.