The illusion of difference: do remodeling patterns truly distinguish HF phenotypes?

Background Left ventricular (LV) remodeling plays a central role in heart failure (HF) pathophysiology. Although hypertrophy patterns are traditionally associated with specific hemodynamic phenotypes, it remains unclear whether LV remodeling differs significantly between heart failure with preserved ejection fraction (HFpEF) and mildly reduced ejection fraction (HFmrEF). We aimed to assess the association between LV remodeling patterns and HF phenotype and to evaluate independent predictors of HFpEF. Methods A total of 160 patients with LVEF ≥40% were included and classified as HFmrEF (40–50%) or HFpEF (>50%). LV remodeling was categorized into three stable patterns: normal geometry, concentric pattern (concentric remodeling and concentric hypertrophy), and eccentric hypertrophy. Multivariable logistic regression was performed with HF phenotype as the dependent variable and remodeling pattern, sex, indexed LV mass (LVMI), and relative wall thickness (RWT) as covariates. Interaction terms between remodeling pattern and RWT were tested. Post-hoc power analysis was conducted for hypertrophy subtype comparisons. Results LV remodeling distribution did not significantly differ between HF phenotypes. In adjusted analysis, remodeling pattern was not independently associated with HFpEF (eccentric hypertrophy vs concentric pattern: OR 1.68, 95% CI 0.40–7.07, p=0.48; normal vs concentric pattern: OR 0.96, 95% CI 0.19–4.72, p=0.96). Male sex was associated with lower odds of HFpEF (OR 0.23, 95% CI 0.08–0.63, p=0.0047). Higher relative wall thickness independently predicted HFpEF (OR 1.93 per SD increase, 95% CI 1.04–3.58, p=0.038). Adding interaction terms between remodeling pattern and RWT did not improve model fit. Post-hoc power for detecting differences in hypertrophy subtype between HF groups was low (~12%, effect size w=0.10), indicating limited ability to detect small between-group differences. Conclusions In this cohort of patients with LVEF ≥40%, LV remodeling pattern was not independently associated with HF phenotype after multivariable adjustment. Relative wall thickness, rather than hypertrophy subtype or LV mass index, emerged as a significant structural correlate of HFpEF. These findings suggest that concentric remodeling characteristics may be more relevant than hypertrophy subtype in distinguishing HF phenotypes, although larger cohorts are required to confirm small effect sizes.