Exercise left atrial compliance: One more tool in the heart failure with preserved ejection fraction assistance toolbox?

This article refers to ‘Diagnostic value of reduced left atrial compliance during ergometry exercise in heart failure with preserved ejection fraction’ by T. Harada et al. , published in this issue on pages 1 293– 1 303. Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of all heart failure cases; however, the exact clinical diagnosis of HFpEF remains challenging. According to the 202 1 European Society of Cardiology guidelines, exercise invasive haemodynamic cardiac catheterization remains the gold standard to unequivocally confirm the diagnosis of HFpEF for those with inconclusive results from diagnostic criteria. 1 Typical haemodynamic presentations in HFpEF patients may include elevations in left ventricular end-diastolic pressure (LVEDP), pulmonary capillary wedge pressure (PCWP), and pulmonary artery pressure, which occur in parallel to each other. Provoked haemodynamics during exercise is crucial for patients with HFpEF, as some patients with HFpEF may show normal PCWP at rest under scenarios of decon-gestive or euvolaemic status (masked) and manifest a steep rise of PCWP during exercise from increased venous return into a more stiff left ventricle. 2 In this case, abnormal haemodynamic responses during exercise, yet maintained within normal range at rest, reflects impaired diastolic functional reserve in HFpEF, and may lead to limited exercise capacity presenting with exertional dyspnoea and effort intolerance ( Figure 1 A ). 3 This emphasizes the role of