Prognostic impact of left atrial strain, GLS LV and atrial mitral regurgitation in patients with HFpEF and atrial fibrillation

Background

Atrial myopathy is considered a key pathophysiological mechanism underlying atrial mitral regurgitation (AMR) in patients with atrial fibrillation (AF). Impaired left ventricular global longitudinal strain (GLS LV) has previously been associated with clinically significant AMR; however, the prognostic role of left atrial strain (LAS), GLS LV and AMR in patients with heart failure with preserved ejection fraction (HFpEF) and AF remains insufficiently investigated.

Aim

To evaluate the prognostic impact of left atrial reservoir strain, GLS LV and atrial mitral regurgitation in patients with HFpEF and atrial fibrillation.

Methods

This prospective study included 84 patients with HFpEF, AF and AMR (median age 78 [74–86] years). All patients underwent speckle-tracking echocardiography with assessment of left atrial reservoir strain (pathological ≤16%) and GLS LV (pathological ≥ −16%).

AMR was diagnosed in the presence of preserved left ventricular ejection fraction, biatrial enlargement and absence of organic mitral valve disease.

The median follow-up was 198 (143–232) days. Study endpoints included heart failure rehospitalization, cardiovascular mortality (CVM) and a combined endpoint (CE).

Results

Women accounted for 67% of the cohort. Hypertension was present in 98%, type 2 diabetes mellitus in 39%, and chronic kidney disease in 41% of patients. Pathological GLS LV was observed in 71% of patients, while reduced left atrial strain was detected in 75%. Moderate and severe AMR were present in 47% and 43% of patients, respectively.

During follow-up, the combined endpoint occurred in 38.1% of patients, including HF rehospitalization in 35.7% and cardiovascular mortality in 19.0%.

Pathological GLS LV was associated with a significantly higher risk of HF rehospitalization (log-rank = 4.06; p = 0.044). Reduced left atrial strain and moderate-to-severe AMR were significantly associated with an increased risk of rehospitalization and the combined endpoint (log-rank = 5.17; p = 0.023 and log-rank = 8.53; p = 0.014, respectively).

Patients with concomitant impairment of left atrial strain, abnormal GLS LV and severe AMR exhibited the worst prognosis, with significantly earlier occurrence of adverse events compared with patients with isolated abnormalities (84 ± 32 days; log-rank = 8.9; p = 0.012).

Kaplan–Meier analysis demonstrated a significantly shorter time to HF rehospitalization in patients with pathological GLS LV (238 ± 12 days, 95% CI 214–262) compared with those with preserved GLS LV (327 ± 13 days, 95% CI 300–353).

Conclusions

In patients with HFpEF and AF, reduced left atrial reservoir strain (≤16%) and impaired GLS LV (≥ −16%) are significant predictors of adverse cardiovascular outcomes. Moderate and severe atrial mitral regurgitation further increase the risk of unfavorable events. The combination of atrial and ventricular mechanical dysfunction with severe AMR identifies a high-risk HFpEF phenotype with the poorest prognosis.Fig. 1.For image description, please refer to the figure legend and surrounding text.Fig. 2.For image description, please refer to the figure legend and surrounding text.