Diagnostic accuracy of cardiovascular magnetic resonance strain analysis and atrial size to identify heart failure with preserved ejection fraction

Abstract

Aims Heart failure with preserved ejection fraction (HFpEF) continues to be a diagnostic challenge. CMR atrial measurements, feature-tracking (CMR-FT), tagging have long been suggested to diagnose HFpEF and potentially complement echocardiography especially when echocardiography is indeterminate. Data supporting the use of atrial measurements, CMR-FT or tagging is absent. Our aim is to conduct a prospective case-control study assessing the diagnostic accuracy of CMR atrial volume/area, CMR-FT, and tagging to diagnose HFpEF amongst patients suspected of having HFpEF. Methods & Results 121 suspected HFpEF patients were prospectively recruited from four centres. Patients underwent echocardiography, CMR, NT-proBNP measurements within 24 hours to diagnose HFpEF. Patients without HFpEF diagnosis underwent catheter pressure measurements or stress echocardiography to confirm HFpEF or non-HFpEF. Area under the curve (AUC) were determined by comparing HFpEF with non-HFpEF patients. 53 HFpEF (median age 78yrs, interquartile range 74-82yrs) and 38 non-HFpEF (median age 70yrs, interquartile range 64-76yrs). CMR left atrial (LA) reservoir strain (ResS), LA area indexed (LAAi) and LA volume indexed (LAVi) had the highest diagnostic accuracy (AUCs 0.803, 0.815 and 0.776 respectively). LA ResS, LAAi and LAVi had significantly better diagnostic accuracy than CMR-FT left ventricle (LV)/right ventricle (RV) parameters and tagging (p < 0.01). Tagging circumferential and radial strain had poor diagnostic accuracy (AUC 0.644 and 0.541 respectively). Conclusion CMR LA ResS, LAAi and LAVi have the highest diagnostic accuracy to identify HFpEF patients from non-HFpEF patients amongst clinically suspected HFpEF patients. CMR-FT LV/RV parameters and tagging had low diagnostic accuracy to diagnose HFpEF.

Diagnostic Performance of Cardiovascular Magnetic Resonance Phase Contrast Analysis to Identify Heart Failure With Preserved Ejection Fraction

“…All other parameters showed no statistical significance (AUC: 0.509 to 0.601). Compared with the left atrial (LA) area indexed and LA reservoir strain AUC previously published 4 , other PC parameters were significantly lower apart from the PC S wave.…”

“…Indeterminate patients underwent catheter pressure measurements or stress echocardiography to further confirm HFpEF or non-HFpEF diagnosis. Specific study inclusion/exclusion criteria and recruitment protocol have been previously published 4 . CMR was performed on a 3T scanner, including mitral inflow, tissue velocity, and pulmonary vein flow PC images.…”

“…Mitral inflow and LV tissue velocity parameters by CMR showed poor diagnostic accuracy for HFpEF. Ng et al 4 suggested the best CMR parameters for independently diagnosing HFpEF among clinically suspected patients with HFpEF are LA reservoir strain (by CMR feature tracking), LA area index, and LA volume index (AUCs: 0.803, 0.815, and 0.776, respectively). Ramos et al 5 found CMR and echocardiography showed very good agreement in diastolic dysfunction grading.…”

Phenotyping heart failure by cardiac magnetic resonance imaging of cardiac macro- and microscopic structure: state of the art review

“… 53 Multiple studies have also used FT-CMR to correlate left atrial (LA) strain with diastolic dysfunction, invasive haemodynamics, and outcomes. 54–56 Other studies have suggested a link between CMR RV strain and elevated pulmonary arterial pressure. 57–59 Unique CMR methods for assessment of LV diastolic function are also emerging.…”

“… 60 , 89 In a prospective multi-centre cohort of 121 patients suspected of HFpEF, CMR measurements of left atrial volume index, left atrial reservoir strain, and left atrial area index were found to be the best discriminators between HFpEF and non-HFpEF (as per European Society of Cardiology 2021 guidelines, ± right heart catheterization). 36 , 54 Impaired LA function on CMR volumetric and FT-CMR has also been associated with exercise intolerance and adverse outcomes in HFpEF. 56 , 60 , 90 …”