Left Atrial Function Predicts Heart Failure Hospitalization in Subjects With Preserved Ejection Fraction and Coronary Heart Disease Longitudinal Data From the Heart and Soul Study

Department of Medicine, University of California, San Francisco, California
Journal of the American College of Cardiology (Impact Factor: 15.34). 02/2012; 59(7):673-80. DOI: 10.1016/j.jacc.2011.11.012
Source: PubMed

ABSTRACT This study sought to determine whether left atrial (LA) dysfunction predicts heart failure (HF) hospitalization in subjects with preserved baseline ejection fraction (EF).
Among patients with preserved EF, factors leading to HF are not fully understood. Cross-sectional studies have demonstrated LA dysfunction at the time of HF, but longitudinal data on antecedent atrial function are lacking.
We performed resting transthoracic echocardiography in 855 subjects with coronary heart disease and EF ≥50%. Left atrial functional index (LAFI) was calculated as ([LA emptying fraction × left ventricular outflow tract-velocity time integral] / [indexed LA end-systolic volume]), where LA emptying fraction was defined as (LA end-systolic volume--LA end-diastolic volume) / LA end-systolic volume. We used Cox models to evaluate the association between LAFI and HF hospitalization.
Over a median follow-up of 7.9 years, 106 participants (12.4%) were hospitalized for HF. Rates of HF hospitalization were inversely proportional to quartile (Q) of LAFI: Q1, 47 per 1,000 person-years; Q2, 18.3; Q3, 9.6; and Q4, 5.3 (p < 0.001). Each standard deviation decrease in LAFI was associated with a 2.6-fold increased hazard of adverse cardiovascular outcomes (unadjusted hazard ratio: 2.6, 95% confidence interval: 2.1 to 3.3, p < 0.001), and the association persisted even after adjustment for clinical risk factors, N-terminal pro-B-type natriuretic peptide, and a wide range of echocardiographic parameters (adjusted hazard ratio: 1.5, 95% confidence interval: 1.0 to 2.1, p = 0.05).
Left atrial dysfunction independently predicts HF hospitalization in subjects with coronary heart disease and preserved baseline EF. The LAFI may be useful for HF risk stratification, and LA dysfunction may be a potential therapeutic target.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Heart failure (HF) may be accompanied by considerable alterations of left ventricular (LV) volume, depending on the particular phenotype. Two major types of HF have been identified, although heterogeneity within each category may be considerable. All variants of HF show substantially elevated LV filling pressures, which tend to induce changes in LV size and shape. Yet, one type of HF is characterized by near-normal values for LV end-diastolic volume (EDV) and even a smaller end-systolic volume (ESV) than in matched groups of persons without cardiac disease. Furthermore, accumulating evidence indicates that, both in terms of shape and size, in men and women, the heart reacts differently to adaptive stimuli as well as to certain pharmacological interventions. Adjustments of ESV and EDV such as in HF patients are associated with (reverse) remodeling mechanisms. Therefore, it is logical to analyze HF subtypes in a graphical representation that relates ESV to EDV. Following this route, one may expect that the two major phenotypes of HF are identified as distinct entities localized in different areas of the LV volume domain. The precise coordinates of this position imply unique characteristics in terms of the actual operating point for LV volume regulation. Evidently, ejection fraction (EF; equal to 1 minus the ratio of ESV and EDV) carries little information within the LV volume representation. Thus far, classification of HF is based on information regarding EF combined with EDV. Our analysis shows that ESV in the two HF groups follows different patterns in dependency of EDV. This observation suggests that a superior HF classification system should primarily be founded on information embodied by ESV.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Left atrial (LA) volume is an important marker of cardiac dysfunction and cardiovascular outcome in heart failure (HF), but LA function is rarely measured.
    European Heart Journal 10/2014; DOI:10.1093/eurheartj/ehu405 · 14.72 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background—Left atrial (LA) structure and function are altered in most heart failure (HF) patients, but there may be fundamental differences in LA properties between HF with preserved (HFpEF) and reduced ejection fraction (HFrEF). Methods and Results—198 HF patients (51% HFpEF, NYHA 3.1±0.7) and 40 HF-free controls underwent catheterization, echocardiography and follow-up. Compared to controls, HF patients had larger and more dysfunctional left atria. At identical mean LA pressure (20 vs 20 mmHg, p=0.9), HFrEF patients had larger LA volumes (LAVI 50 vs 41 ml.m-2 p<0.001), while HFpEF patients had higher LA peak pressures, lower LA minimal pressures, higher LA stiffness (0.79 vs 0.48, p<0.001), greater LA pulsatility (19 vs 13 mmHg, p<0.001) and higher wall stress variations. Despite smaller LA volumes, better function and less mitral regurgitation, HFpEF patients had more atrial fibrillation (AF: 42 vs 26%, p=0.02). LA dysfunction was associated with increased pulmonary vascular resistance and right ventricular dysfunction in both HF phenotypes. After a median follow-up of 350 days, 31 HFpEF and 28 HFrEF patients died. LA function (total LA EF) was associated with lower mortality in HFpEF (HR 0.43, 95% CI 0.2-0.9, p<0.05), but not in HFrEF. Conclusions—HFrEF is characterized by greater eccentric LA remodeling, while HFpEF by increased LA stiffness, which might contribute to greater AF burden. LA function is associated with pulmonary vascular disease and right heart failure in both HF phenotypes, but is associated with outcome more closely in HFpEF, supporting efforts to improve LA function in this cohort.
    Circulation Heart Failure 01/2015; DOI:10.1161/CIRCHEARTFAILURE.114.001667 · 6.68 Impact Factor

Full-text (2 Sources)

Available from
May 26, 2014