Indexed left atrial volume enhances 3-month MACE risk prediction in chronic heart failure

Background Chronic heart failure (CHF) is a multifaceted clinical syndrome arising from structural or functional myocardial abnormalities. In CHF, transthoracic echocardiography is indispensable for detecting cardiac anomalies—such as chamber enlargement and impaired ventricular function—quantifying indexed left atrial volume (LAVi), and guiding management decisions. Complementarily, 24-hour Holter electrocardiography provides robust assessment of heart rate variability (HRV), reflecting autonomic nervous system influences on cardiac performance. Together with clinical, biological, treatment, and comorbidity data, these modalities offer a comprehensive foundation for risk stratification in CHF. Purpose The aim of this study was to develop and validate a 3-month risk score for predicting major adverse cardiovascular events (MACE) in patients with CHF that integrates LAVi with Holter-derived HRV measures, pharmacotherapy, and key clinical and biological variables. Methods In this prospective cohort study conducted from May 2023 to January 2024, we enrolled 140 consecutive patients with established CHF. Each participant underwent thorough clinical evaluation, biological testing, comprehensive echocardiography, 24-hour Holter ECG monitoring, as well as documentation of current treatments and relevant comorbidities. A multivariable logistic regression model was constructed to predict MACE—defined as heart failure hospitalization, myocardial infarction, or cardiovascular death—using three predictors: LAVi, triangular index, and beta-blocker therapy (coded 0 = no, 1 = yes). The resulting risk-score equation was: Risk score=−0.10869×(Triangular index)−1.83637×(Beta-blocker use)+0.03407×(LAVi). Results During the 3-month follow-up period, 28 patients (20.0%) experienced a MACE. Applying a decision threshold of 0.1915459, 34 patients (24.3%) were classified as high-risk. The event rate among high-risk patients was 44.1% (15/34) compared with 12.3% (13/106) in the low-risk group (p<0.001). At this cutoff, the risk score achieved a sensitivity of 83%, specificity of 78%, positive predictive value of 44%, and negative predictive value of 88%. Calibration analyses demonstrated close alignment between predicted and observed event rates across deciles of risk, and the Hosmer–Lemeshow test indicated adequate model fit (p = 0.45). The overall discriminative performance, as measured by the area under the receiver operating characteristic curve, was 0.8288 (82.9%). Conclusions Incorporation of indexed left atrial volume into a multifactorial risk score alongside HRV metrics, beta-blocker therapy, and comprehensive clinical and biological variables significantly enhances short-term prediction of MACE in CHF patients. This integrated tool enables effective stratification of patients into low- and high-risk categories, facilitating tailored therapeutic strategies and potentially improving clinical outcomes.