Background: Current guidelines recommend indexing left atrial volume (LAV) by body surface area (BSA). However, in overweight and obese individuals this may result in the underestimation of left atrial enlargement (LAE). The aim of our study was to assess whether alternative LAV indexing to height and/or height-squared better identifies individuals with LAE among those who are overweight and/or obese. Methods: LAV was indexed to BSA (LAVI), height (LAVh), and height-squared (LAVh2) in 127 individuals with a mean age of 45.7 years and a mean body mass index (BMI) of 34.9 kg/m2 who underwent outpatient echocardiography at the University clinic of cardiology in Skopje. Results: LAVI, LAVh, and LAVh2 showed a progressive increase of respective values with the extent of BMI showing the most enlarged LA size in individuals with Class III obesity. There was a progressive significant increase in the prevalence of LAEh and LAEh2 in obese groups with the highest prevalence among those with class III obesity (p=0.002, p=0.002, respectively), on the contrary of LAEBSA where we could not find any significance in its distribution among obese classes. The greatest degree of reclassification occurred when indexing for height-squared, having relatively less reclassification when indexing for height (p=0.0001). The degree of reclassification varied depending on BMI with the greatest impact among the Class III obese patients, where as many as 76.5% and 88.2% of individuals were reclassified according to height or height-squared, respectively. Conclusions: The use of height, and especially height-squared, in comparison to BSA-based indexing methods are more successful in identifying the LAE prevalence in each class of obesity. Using allometric indexation leads to the significant reclassification of LA size from normal to dilated, especially in women and those with severe obesity, thereby providing an opportunity to identify more individuals at increased risk of adverse events.

Obesity-related atrial cardiomyopathy is a clinical entity characterized by a variety of functional and structural abnormalities in the atria's myocardium. This study aimed to investigate the morphological and functional alterations of the left atrium (LA) in overweight and obese subjects.The study included 56 subjects aged 47+9.6 years, categorized into 4 groups according to their body mass index (BMI): group 1 -overweight (BMI 25-29.9 kg/m 2 ); group 2 -class I obesity (BMI 30-34.9 kg/m2); group 3 -class II obesity (BMI 35-39.9 kg/m 2 ) and group 4 -class III obesity (BMI >40 kg/m 2 ). All subjects underwent two-dimensional (2D) conventional echocardiography and speckle tracking myocardial deformation assessment. Left atrial enlargement (LAE) was registered in all four groups, with an average value of LA diameter 40.0±4.9 mm and LA volume (LAV) indexed to height (LAVh) 35.0 +7.8 ml. Global longitudinal strain (GLS%) and circumferential strain (GCS%) of LA were lower than reference normal values in all groups. LAV indexed to body surface area (LAVI) correlated with hip circumference (r=0.264; p=0.049), whereas LAVh correlated with waist and hip circumference (r=0.378; p=0.004). Linear regression analysis showed that hip circumference was a predictive factor for increasing LAVI (B=0.114; p=0.049; 95%CI 0.000-0.227) and LAVh (B=0.266; p =0.0001; 95%CI 0.129-0.403).LAVh is a clinically useful echocardiographic parameter to assess LA size in obese population. A sensitive method for detecting subclinical functional alterations of LA is assessment of its speckle tracking longitudinal strain.

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