Prognostic value of left atrial reservoir strain for new-onset atrial fibrillation: a systematic review and meta-analysis of 26,189 participants
J Kirigaya, H Hayama, Y Katayama, T Negishi, K Ozawa, K NegishiAbstract
Background
Prediction of new-onset atrial fibrillation (NOAF) remains a major clinical challenge. Left atrial reservoir strain (LASr) by two-dimensional speckle-tracking echocardiography has emerged as a sensitive marker of left atrial dysfunction, potentially preceding structural remodeling. While numerous observational studies have assessed its prognostic utility, results vary across different clinical settings and populations. This meta-analysis aimed to assess the prognostic value of LASr for predicting NOAF and identify potential effect modifiers among various cardiac conditions.
Methods
We systematically searched MEDLINE, Embase, and CENTRAL from inception through November 2025. Studies reporting adjusted hazard ratios (aHR) for NOAF were included for the quantitative synthesis. The primary measure of effect was the aHR per 1% absolute increase in LASr. Pooled estimates were calculated using a random-effects model. To explore sources of heterogeneity, we performed subgroup analyses and meta-regression analysis.
Results
A total of 32 studies comprising 26,189 participants were included. Since three studies reported results from two separate populations each, a total of 35 cohorts (k=35) were analyzed. Based on pooled adjusted estimates, higher LASr was independently associated with a reduced risk of NOAF (pooled adjusted HR 0.94 [95% CI: 0.93–0.95] per 1 percentage point increase, P<0.001). (Figure A). Subgroup analyses confirmed the consistent prognostic utility of LASr across diverse clinical settings, including the general population, ischemic stroke, heart failure, and various cardiomyopathies. The predictive value remained significant regardless of left ventricular ejection fraction (LVEF >= 50% vs. < 50%), ultrasound vendor, or the number of echocardiographic views. Univariable meta-regression analysis demonstrated that the prognostic value of LASr was significantly modified by heart rate (P=0.047) and LV mass index (P=0.012) (Figure B). In contrast, no significant modification was observed for age, sex, body mass index, LA volume index, E/e', LVEF, LV global longitudinal strain, or follow-up period. While Egger's test suggested potential publication bias (P<0.05), the trim-and-fill method confirmed the results with a corrected aHR of 0.96 (95% CI: 0.94–0.97).
Conclusions
LASr is still a significant and independent predictor of NOAF across a broad spectrum of patients. While its predictive strength is modified by heart rate and LV mass index, these findings support the clinical utility of LASr for refining risk stratification among various cardiovascular conditions.Figure AFigure B