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: 16.5). 02/2012; 59(7):673-80. DOI: 10.1016/j.jacc.2011.11.012
Source: PubMed


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.

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Available from: Mintu P Turakhia, Mar 04, 2014
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    • "In particular, recent studies have shown the importance of the functional assessment of the left atrium (LA) to describe global cardiac function [2] and improve the diagnosis of diastolic dyssynchrony [3], as well as the risk stratification and prediction of adverse cardiovascular events in both general and referral populations (e.g. atrial fibrillation, cardiomyopathy, ischemic heart disease, valvular heart disease [4], and coronary heart disease [5]). "
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    ABSTRACT: Segmentation of the left atrium (LA) of the heart allows quantification of LA volume dynamics which can give insight into cardiac function. However, very little attention has been given to LA segmentation from 3D ultrasound (US), most efforts being focused on the segmentation of the left ventricle (LV). The B-spline explicit active surfaces (BEAS) framework has been shown to be a very robust and efficient methodology to perform LV segmentation. In this study, the BEAS framework was adapted to allow for semi-automatic segmentation of the LA endocardium, with little user input. The method was tested in 20 volumetric sequences of echocardiographic data from healthy subjects and the segmentation results were evaluated against manual reference delineations of the LA. Relevant LA morphological and functional parameters were derived from the segmented surfaces, in order to assess the performance of the proposed method on its clinical usage. The results showed that the modified BEAS framework is capable of accurate semi-automatic LA segmentation in 3D transthoracic US, providing reliable quantification of the LA morphology and function.
    Full-text · Conference Paper · Sep 2014
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    ABSTRACT: Left atrial (LA) function is an important contributor to cardiac function in a variety of disease states and especially with exercise. The purpose of this study was to assess the role of LA function in the left ventricular (LV) filling pressure (E/e') response to exercise and exercise tolerance in patients with preserved LV ejection fraction (LVEF). LA contractile function (LA strain peak negative), conduit function (LA strain peak positive), and reservoir function (LA strain total) were measured from speckle tracking in 486 patients with preserved LVEF and negative exercise echocardiography for ischaemia. Maximal exercise tolerance was expressed as the estimated metabolic equivalents (METs). Per cent predicted METs was calculated in accordance with described nomograms. Features associated with exercise capacity were sought in a multiple linear regression, and compared using standardised β. Patients with increased stress E/e' had significantly lower LA strain profiles and larger LA volume than the remainder. LA strain total was strongly associated with exercise capacity in multivariate analysis (ß=0.21, p<0.001). E/e' rest was also associated with exercise capacity (ß=-0.11, p=0.001). Other independent correlates of exercise capacity were age (ß=-0.36, p<0.001), male gender (ß=0.34, p<0.001) and body mass index (ß=-0.23, p<0.001). The best predictor of per cent predicted METs was total LA strain in multivariate analysis. The association of reduced LA function with impaired exercise capacity was similar to that of elevated LVE/e', emphasising the role of ventriculo-atrial coupling to cardiac dysfunction with preserved LVEF.
    No preview · Article · Jul 2012 · Heart (British Cardiac Society)
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    ABSTRACT: AimsLeft atrial (LA) structural and functional abnormalities may be subclinical phenotypes, which identify individuals at increased risk of adverse outcomes.Methods and resultsMaximum LA volume (LAmax) and LA emptying fraction (LAEF) were measured via cardiac magnetic resonance imaging in 1802 participants in the Dallas Heart Study. The associations of LAEF and LAmax indexed to body surface area (LAmax/BSA) with traditional risk factors, natriuretic peptide levels, and left ventricular (LV) structure [end-diastolic volume (EDV) and concentricity(0.67) (mass/EDV(0.67))] and function (ejection fraction) were assessed using linear regression analysis. The incremental prognostic value of LAmax/BSA and LAEF beyond traditional risk factors, LV ejection fraction, and LV mass was assessed using the Cox proportional-hazards model. Both increasing LAmax/BSA and decreasing LAEF were associated with hypertension and natriuretic peptide levels (P < 0.05 for all). In multivariable analysis, LAmax/BSA was most strongly associated with LV end-diastolic volume/BSA, while LAEF was strongly associated with LV ejection fraction and concentricity(0.67). During a median follow-up period of 8.1 years, there were 81 total deaths. Decreasing LAEF [hazard ratio (HR) per 1 standard deviation (SD) (8.0%): 1.56 (1.32-1.87)] but not increasing LAmax/BSA [HR per 1 SD (8.6 mL/m(2)): 1.14 (0.97-1.34)] was independently associated with mortality. Furthermore, the addition of LAEF to a model adjusting Framingham risk score, diabetes, race, LV mass, and ejection fraction improved the c-statistic (c-statistics: 0.78 vs. 0.77; P < 0.05, respectively), whereas the addition of LAmax/BSA did not (c-statistics: 0.76, P = 0.20).Conclusion In the general population, both LAmax/BSA and LAEF are important subclinical phenotypes but LAEF is superior and incremental to LAmax/BSA.
    Preview · Article · Jul 2012 · European Heart Journal
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