Left Atrial Strain as a Predictor of Left Ventricular Diastolic Dysfunction in Patients with Arterial Hypertension

Diagnostic and prognostic potential of left atrial strain in cardiovascular disease: a narrative review

Left atrial strain (LAS) was recently introduced as a parameter that reflects on left atrial function. Consequently, changes in LAS can inform the development of cardiovascular diseases, hence providing a window for non-invasive and cost-effective testing of these diseases and their complications at early stages of development, potentially offering a segway towards preventive interventions. LAS has yet to be implemented into standard practice. Therefore, we aimed to synthesize the current evidence on the diagnostic and prognostic potentials of LAS in a variety of cardiovascular diseases. We attempted to elucidate sufficient evidence to support uptake into clinical practice. A systematic search of four databases (Medline, PubMed, Embase, CINAHL) was performed for articles published within the last 5 years, for inclusion in this narrative review. A total of 3921 articles were identified, among which only 43 articles were included. LAS showed diagnostic potential in detecting (1) paroxysmal atrial fibrillation in stroke patients, (2) left atrial appendage dysfunction in patients with nonvalvular atrial fibrillation and heart failure with reduced ejection fraction, and finally (3) diastolic dysfunction in patients with arrhythmias, valvulopathies, acute coronary syndrome, primary arterial hypertension, and heart failure. LAS was also prognostic for the development of (1) atrial fibrillation in hypertensive patients, cardiovascular events in patients with (2) valvular diseases and (3) ischemic heart diseases, and (4) heart failure in patients with and without diastolic dysfunction. This review highlights the potential of LAS in identifying certain cardiac pathologies and their repercussions on patient prognosis, which should prompt courageous integration into the clinical workup while emphasizing areas for future research to guarantee successful and safe implementation into clinical practice.

Relationship Between Left Atrial Strain and Atrial Fibrillation: The Role of Stress Echocardiography

Interest in advanced echocardiographic imaging methods is growing. Left atrial strain (LAS) is among recently developed echocardiographic parameters. LAS represents an index of tissue deformation of the left atrium (LA). This parameter is an expression of LA function. Several arrhythmias are caused by impaired LA function. LAS can be assessed with a resting echocardiogram. The evaluation of LAS during stress echocardiography represents another model for assessing LA function. The development of altered LAS during physical or pharmacological stress is a predictor of early LA disease. Our review aims to evaluate the relationship between alterations in LAS and the development of atrial fibrillation (AF), and the diagnostic and prognostic roles of the stress echocardiogram in clinical practice.

Interpreting Diastolic Dynamics and Evaluation through Echocardiography

In patients with heart failure, evaluating left ventricular (LV) diastolic function is vital, offering crucial insights into hemodynamic impact and prognostic accuracy. Echocardiography remains the primary imaging modality for diastolic function assessment, and using it effectively requires a profound understanding of the underlying pathology. This review covers four main topics: first, the fundamental driving forces behind each phase of normal diastolic dynamics, along with the physiological basis of two widely used echocardiographic assessment parameters, E/e' and mitral annulus early diastolic velocity (e'); second, the intricate functional relationship between the left atrium and LV in patients with varying degrees of LV diastolic dysfunction (LVDD); third, the role of stress echocardiography in diagnosing LVDD and the significance of echocardiographic parameter changes; and fourth, the clinical utility of evaluating diastolic function from echocardiography images across diverse cardiovascular care areas.

Left atrial stiffness index - an early marker of left ventricular diastolic dysfunction in patients with coronary heart disease

AIMS

To evaluate the correlation between left atrial stiffness index (LASI) and left ventricular diastolic function in patients with coronary heart disease (CHD) by Autostrain LA technique.

METHODS

This was a retrospective analysis that included a total of 82 CHD patients who had suitable image quality for left atrial strain measurement. According to the 2016 ASE/EACVI guidelines for the echocardiographic assessment of diastolic dysfunction, the patients were divided into three groups: normal left ventricular diastolic function group (n = 26), indeterminate left ventricular diastolic function (n = 36), and left ventricular diastolic dysfunction (LVDD) (n = 20). The left atrial conduit strain (LAScd), Left atrial contractile strain (LASct), left atrial reservoir strain (LASr) and its derived parameters, including LASI and left atrial filling index (LAFI), were compared among the three groups. Furthermore, we conduct a correlation analysis between LASI and left ventricular diastolic function in patients with CHD.

RESULTS

LASr and LAScd in normal group were higher than those in indeterminate group, LASr and LAScd in indeterminate group were higher than those in LVDD group, LASI in normal group was lower than that in indeterminate group, and LASI in indeterminate group was lower than that in LVDD group (P < 0.001). LASct in both normal and indeterminate groups was higher than that in LVDD group (P < 0.05). The LAFI of normal group was lower than that of indeterminate group and LVDD group (P < 0.001). LASI was positively correlated with E/e'(r = 0.822) (P < 0.001). LASr and E/e' were negatively correlated (r = -0.637) (P < 0.001).

CONCLUSION

LASI is closely related to the changes of left ventricular diastolic function in CHD patients.

Left Atrial Peak Systolic Strain as an Indicator Pathway of Diastolic Dysfunction of the Left Ventricle

BACKGROUND

Left atrial peak systolic strain (LA-PSS) imaging is an emerging index of left atrial function, and it was shown to be decreased in heart failure with preserved ejection fraction (EF). We aimed to determine whether LA-PSS could be used as an additional diagnostic parameter to current existing guidelines for the presence of left ventricle diastolic dysfunction (LVDD).

MATERIALS AND METHODS

A total of 190 consecutive adult patients with cardiovascular risk factors and normal left ventricle EF with no prior history of heart failure were included in the study. Speckle tracking software was used to study ventricular parietal deformity, left ventricle global longitudinal systolic strain, and LA-PSS.

RESULTS

The median left ventricle global longitudinal systolic strain was -19%, with a significant difference ( P < 0.001) between patients with normal diastolic function versus those with LVDD. The median LA-PSS was 33% (30% to 38%) ( P < 0.001). Most patients (61%) had grade 1 atrial dysfunction based on PSS (range 24%-35%). The analysis of the area under the receiver operating characteristic curve of the LA-PSS as a potential indicator pathway of LVDD was 67% [95% confidence interval (CI), 62-72], and 75% (95% CI, 70-80), when the indeterminate pattern was included. The decreased LA-PSS made it possible to reclassify patients with an indeterminate pattern of diastolic function in 96% of cases.

CONCLUSIONS

These results support the potential role of LA-PSS as an additional parameter for the diagnosis of LVDD in patients with normal EF, and may be integrated into the guidelines for routine evaluation of patients.

Evaluating left atrial function changes by speckle tracking echocardiography in type 2 diabetes patients in Central Vietnam: a cross-sectional comparative study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a metabolic disorder that detrimentally affects multiple systems in the body, with a particular emphasis on the vascular and nervous systems. Despite its significant impact, limited studies have explored the influence of this condition on the left atrial (LA) function. To address this gap, our study utilized speckle tracking echocardiography (STE) to assess LA function in patients with T2DM in Central Vietnam.

RESULTS

The cross-sectional comparative study enrolled 134 subjects involving 66 patients with T2DM and 68 healthy individuals meeting the selection and exclusion criteria of the study. In our study, healthy individuals demonstrated higher values for LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct), measuring 38.75% ± 5.43%, 19.58% ± 5.91%, and 19.16% ± 4.98%, respectively. In contrast, the T2DM group exhibited lower values for LASr, LAScd, and LASct, which measured 31.2% ± 4.56%, 14.77% ± 6.3%, and 16.36% ± 4.82%, respectively (p < 0.05). T2DM patients with normal LA volume index (LAVI) and normal left ventricular mass index (LVMI), LASr, LAScd, and LASct results were 32.07% ± 5.28%, 16.28% ± 6.95%, and 15.64% ± 5.32%. respectively.

CONCLUSIONS

STE of the LA reveals a noteworthy reduction in reservoir, conduit, and contractile functions within the T2DM group when compared to the control group (p < 0.05). Furthermore, these impaired functions persist in T2DM patients even in the absence of increased LAVI and LVMI.

Effects of Liraglutide, Empagliflozin and Their Combination on Left Atrial Strain and Arterial Function

Background and Objectives: Glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are cardioprotective drugs. We investigated their effects on left atrial function, a major determinant of cardiac diastolic dysfunction in type 2 diabetes mellitus. We also explored the association of changes in arterial stiffness with those of the LA strain after treatment. Materials and Methods: A total of 200 patients (59.5 ± 9.1 year old, 151 male) with type 2 diabetes mellitus treated with metformin were randomized to insulin (n = 50 served as controls), liraglutide (n = 50), empagliflozin (n = 50) or their combination (liraglutide + empagliflozin) (n = 50). We measured at baseline and 6 months post-treatment: (a) left atrial and global left ventricular longitudinal strain by speckle tracking echocardiography; (b) pulse wave velocity (PWV) and central systolic blood pressure. Results: At baseline, there was a correlation of the LA reservoir strain with PWV (r = -0.209, p = 0.008), central SBP (r = -0.151, p = 0.030), EF (r = 0.214, p = 0.004) and GLS (r = -0.279, p = 0.009). The LA reservoir change 6 months post-treatment was correlated with the PWV change in all groups (r = -0.242, p = 0.028). The LA reservoir change 6 months post-treatment was correlated with the GLS change in all groups (r = -0.322, p = 0.004). Six months after intervention, patients treated with liraglutide, empagliflozin and their combination improved the left atrial reservoir strain (GLP1RA 30.7 ± 9.3 vs. 33.9 ± 9.7%, p = 0.011, SGLT2i 30 ± 8.3 vs. 32.3 ± 7.3%, p = 0.04, GLP1&SGLT2i 29.1 ± 8.7 vs. 31.3 ± 8.2, p = 0.007) compared to those treated with insulin (33 ± 8.3% vs. 32.8 ± 7.4, p = 0.829). Also, patients treated with liraglutide and the combination liraglutide and empagliflozin had improved left atrial conduction strain (p < 0.05). Empagliflozin or the combination liraglutide and empagliflozin showed a greater decrease of PWV and central and brachial systolic blood pressure than insulin or GLP-1RA. (p < 0.05). Conclusions: Impaired aortic elastic properties are associated with a decreased LA strain in type 2 diabetics. Treatment with liraglutide, empagliflozin and their combination for 6 months showed a greater improvement of left atrial function compared to insulin treatment in parallel with the improvement of arterial and myocardial functions.

Assessment of left atrial function in patients with metabolic syndrome by four-dimensional automatic left atrial quantification

OBJECTIVE

This study aimed at assessing the changes of left atrial (LA) volume and strain function in metabolic syndrome (MS) patients using four-dimensional automatic left atrial quantification (4D-LAQ) and exploring independent correlative factors for LA function.

METHODS

A total of 110 MS patients and 70 normal controls were selected and assigned into the MS group and the control group, respectively. Echocardiogram parameters were routinely examined and the thickness of epicardial adipose tissue (EAT) were measured with a parasternal long axis of left ventricle(LV). The LA volume and strain parameters were determined using 4D-LAQ. The independent correlation factors for LA strain parameters in MS patients were investigated through linear regression analysis.

RESULTS

Compared with the control group, LA volume parameters were increased in the MS group, LA strain parameters and LA emptying fraction (LAEF) were decreased (all P < 0.05). EAT thickness is associated with LA reservoir longitudinal strain (LASr), conduit longitudinal strain (LAScd), reservoir circumferential strain (LASr-c), and conduit circumferential strain (LAScd-c) (all P < 0.05). LA contraction longitudinal (LASct) and circumferential strain (LASct-c) were not statistically significant. Regression analysis results show that systolic blood pressure (SBP) and triglyceride (TG) are independent correlative factors. Intra-observer and inter-observer repeatability test showed that the LA parameters examined by 4D-LAQ had good agreement.

CONCLUSIONS

4D-LAQ is capable of effectively assessing the LA function in MS patients and providing a useful reference for clinical diagnosis. SBP and TG serve as the independent correlative factors for LA function.

Corrélation du strain atrial gauche avec les pressions de remplissage du ventricule gauche chez les patients suspects d’avoir une insuffisance cardiaque ayant une fraction d’éjection préservée

INTRODUCTION

Despite different ultrasound parameters, left ventricular filling pressures (LVFP) assessment remains inconclusive in some cases.

AIM

To determine the contribution of left atrial strain (LAS) in estimating LVFP in patients with exertional symptoms and preserved left ventricular ejection fraction.

METHODS

This was a monocentric study, carried out in the cardiology department of the Interior Security Forces Hospital, La Marsa, between October 2021 and March 2022. Patients with exertional symptoms had a physical examination, a biological assessment and an ultrasound examination at rest and, if necessary, during exercise. We investigated the performance of LAS components (Peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS) and conduit function (FnC) in predicting LVFP rising. Patients were categorized into two final groups according to LVFP: Group A= high LVFP at rest or during exercise (25 patients) and Group B= not-high LVFP at rest and during exercise (48 patients).

RESULTS

Seventy-three patients were enrolled in the study, with a mean age of 61±12 years and a majority being female (57%). The median PALS was 29.3% [21.4-32.4]. The mean PACS and FnC values were 13.4%±4.9 and 13.7%±4.7, respectively. Patients with high LVFP demonstrated lower LAS parameters and elevated NT-Pro BNP levels. LAS showed negative correlations with the E/e' ratio and NT-Pro BNP. PALS emerged as an independent predictor of LVFP elevation (HR=0.71; 95% CI: 0.513-0.986; p=0.041).

CONCLUSION

This study highlights that LAS, as a simple ultrasound parameter, can effectively predict high LVFP.

Correlation between left atrial strain and left ventricular diastolic function in hypertensive patients

OBJECTIVES

Early detection of asymptomatic diastolic dysfunction is essential to prevent the development of heart failure in hypertensive patients. Current studies suggest that left atrial strain contributes to the evaluation of left ventricular diastolic function, but there are fewer studies on the correlation between left atrial strain and diastolic function in hypertensive patients. In this study, we applied a two-dimensional speckle tracking technique to evaluate the changes in left atrial strain in hypertensive patients, and to investigate the relationship between left atrial strain and left ventricular diastolic function.

METHODS

A total of 82 hypertensive patients who were visited the Department of Cardiology at the Third Xiangya Hospital of Central South University from July 2021 to January 2022, were enrolled for this study, and 59 healthy subjects served as a control group. According to the number of left ventricular diastolic function indexes recommended by the 2016 American Society of Echocardiography Diastolic Function Guidelines (mitral annular e´ velocity: Septal e´<7 cm/s, lateral e´<10 cm/s, E/e´ ratio>14, left atrial volume index>34 mL/m2, peak tricuspid regurgitation velocity>2.8 m/s), the hypertensive patients were divided into 3 groups: Group Ⅰ (0 index, n=36 ), Group Ⅱ (1 index, n=39), and Group Ⅲ (2 indexes, n=7). Two-dimensional speckle tracking technique was used to measure left atrial reservoir strain (LASr), conduit strain, and contraction strain, and to analyze the correlation between left atrial strain and left ventricular diastolic function in hypertensive patients.

RESULTS

The LASr, left atrial conduit strain (LAScd), and LASr/(E/septal e´) of the hypertension group were lower than those of the control group, and E/LASr was higher than that of the control group. There was no significant difference in left atrium volume index between the 2 groups (P>0.05). Compared with Group Ⅰ, LASr, LAScd, and LASr/(E/septal e´) were decreased in Group Ⅱ and Group Ⅲ, LASr/(E/septal e´) was also decreased in Group Ⅲ compared with Group Ⅱ (all P<0.05). Compared with Group Ⅰ, E/LASr was increased in Group Ⅲ. LASr was positively correlated with septal e´, lateral e´, E, and E/A, and negatively correlated with E/septal e´.

CONCLUSIONS

The changes of left atrial function in patients with early hypertension are earlier than those of left atrial structure. Left atrial strain and its combination with conventional ultrasonographic indices [LASr/(E/septal e´)] of diastolic function are potentially useful in assessing left ventricular diastolic function in hypertensive patients.

Significant Association between Subclinical Left Cardiac Dysfunction and Liver Stiffness in Metabolic Syndrome Patients with Diabetes Mellitus and Non-Alcoholic Fatty Liver Disease

Background and Objectives: Diabetes mellitus (DM) is connected to both cardiovascular disease and non-alcoholic fatty liver disease (NAFLD), and is an important component of metabolic syndrome (MetS). NAFLD can be detected and quantified using the vibration controlled transient elastography (VCTE) and the controlled attenuation parameter (CAP), whereas traditional and two-dimensional speckle tracking echocardiography (2D-STE) can reveal subclinical abnormalities in heart function. We sought to see if there was a link between left cardiac dysfunction and different levels of hepatic fibrosis in MetS patients with DM and NAFLD. Patients and Methods: We recruited successive adult subjects with MetS and a normal left ventricular ejection fraction, who were divided into two groups according to the presence or absence of DM. The presence of NAFLD was established by CAP and VCTE, while conventional and 2D-STE were used to assess left heart's systolic and diastolic function. The mean age of the MetS subjects was 62 ± 10 years, 82 (55%) were men. The distribution of liver steatosis severity was similar among diabetics and non-diabetics, while liver fibrosis grade 2 and 3 was significantly more frequent in diabetics (p = 0.02, respectively p = 0.001). LV diastolic dysfunction was found in 52% of diabetic and in 36% of non-diabetic MetS patients (p = 0.04). 2D-STE identified in the diabetic subjects increased LA stiffness (40% versus 24%, p = 0.03) and reduced global left ventricular longitudinal strain (47% versus 16%, p < 0.0001). Liver fibrosis grade ≥ 2 was identified as an independent predictor of both subclinical LV systolic dysfunction and of LA dysfunction in MetS patients with DM (p < 0.0001). Conclusions: The current investigation confirms the link between liver stiffness and subclinical cardiac dysfunction as detected by 2D-STE in MetS patients with DM. The novel parameters derived from LA and LV 2D-STE have demonstrated greater sensitivity compared to the older measurements, and a substantial connection with hepatic fibrosis.