Left atrial strain and compliance in the diagnostic evaluation of heart failure with preserved ejection fraction

Abstract

Aims Left atrial (LA) function is impaired in heart failure with preserved ejection fraction (HFpEF) and predicts disease severity and risk of adverse outcome. We sought to evaluate whether LA strain could enhance diagnosis of HFpEF. Methods and results Consecutive patients with unexplained exertional dyspnoea and image quality suitable for measuring LA strain underwent invasive cardiopulmonary exercise testing to ascertain the presence of HFpEF or non‐cardiac causes of dyspnoea (NCD). LA reservoir strain was measured in all patients, while LA conduit and booster strain were measured in patients with sinus rhythm. LA strain was measurable in 363 of 378 examinations (96.5%; HFpEF: 238, NCD: 125). LA reservoir strain (29 ± 16% vs. 40 ± 13%, P < 0.0001) and conduit strain (18 ± 10% vs. 22 ± 10%, P = 0.0001) were significantly impaired in HFpEF compared to NCD. Of all echocardiographic indices, LA reservoir strain best discriminated HFpEF from NCD [area under the curve (AUC) 0.719, P < 0.0001], outperforming E/e' (AUC difference +0.117, P < 0.0001), LA enlargement (+0.090, P = 0.001), tricuspid regurgitation velocity > 2.8 m/s (+0.082, P = 0.0085), left ventricular hypertrophy (+0.0159, P < 0.0001) and left ventricular global longitudinal strain (+0.0198, P < 0.0001). Indexing LA reservoir strain to estimated LA pressure (E/e') as a surrogate for LA compliance further improved diagnostic performance (AUC 0.772, P < 0.0001; +0.053 compared to LA reservoir strain alone, P = 0.003). Conclusion Left atrial reservoir strain may provide enhanced diagnostic accuracy beyond conventional echocardiographic measures to discriminate HFpEF from NCD. Further study is required to verify the diagnostic utility of LA strain.

Left atrial function in heart failure with preserved ejection fraction: a systematic review and meta‐analysis

“…Most studies ( n = 19) set a LVEF cut‐off for HFpEF diagnosis of ≥ 50% while the remaining used ≥ 45% as their cut‐off. Study characteristics and patient demographics of included studies are summarized in Table . Methodological quality assessment showed low to moderate risk of bias among trials (online supplementary ) and observational studies (online supplementary ).…”

Cardiotoxicity in breast cancer treatment: What about left ventricular diastolic function and left atrial function?

“…With senescence, LA contraction augments as a compensatory mechanism with a late decrease with further aging . The same changes are reported with LV diastolic dysfunction . In early stages, LA reservoir and conduit strain decreases and an increase in its booster function can compensate filling.…”

Left atrial myopathy in heart failure with preserved ejection fraction

“…Most patients included were in sinus rhythm: 7 studies completely excluded patients with history of AF, and only 3 of the 22 studies included patients in AF at the time of evaluation. This is important because patients with AF often display the most profound impairments in LA function . Despite irregular heart rhythm and loss of atrioventricular synchrony, LA reservoir strain can still be measured with good reproducibility in AF, though conduit and booster strain are not measurable due to the absence of atrial contraction ( Figure ).…”

“…This is important because patients with AF often display the most profound impairments in LA function . Despite irregular heart rhythm and loss of atrioventricular synchrony, LA reservoir strain can still be measured with good reproducibility in AF, though conduit and booster strain are not measurable due to the absence of atrial contraction ( Figure ). The general exclusion of AF patients in many studies may have underestimated the true burden of adverse LA reservoir function in HFpEF.…”

“…There are also technical limitations to Doppler‐based assessments of filling pressure in HFpEF, particularly in the presence of AF, mitral annular calcification, wall motion abnormalities and ventricular pacing . In contrast, the assessment of LA reservoir strain is not subject to any of these limitations and may contribute greater accuracy beyond conventional measures in HFpEF …”