Diagnostic value of reduced left atrial compliance during ergometry exercise in heart failure with preserved ejection fraction

Abstract

AimsDiagnosis of heart failure with preserved ejection fraction (HFpEF) remains challenging in patients presenting with chronic dyspnoea. We sought to determine the diagnostic value of reduced left atrial (LA) compliance during exercise to diagnose HFpEF.Methods and resultsErgometry exercise stress echocardiography was performed in 225 patients with HFpEF and 262 non‐heart failure controls (non‐cardiac dyspnoea [NCD]) in Protocol 1, where the diagnosis of HFpEF was defined by the HFA‐PEFF algorithm. In Protocol 2, the diagnosis of HFpEF was ascertained by exercise right heart catheterization in 67 participants (49 HFpEF and 18 NCD). Speckle‐tracking echocardiography was performed at rest and during exercise to determine LA compliance (ratio of LA reservoir strain to E/e'). As compared with NCD, patients with HFpEF demonstrated decreased LA reservoir strain and compliance at rest, and these differences further increased during exercise in Protocol 1. Exercise LA compliance discriminated HFpEF from NCD (area under the curve 0.87, p < 0.0001), with a superior diagnostic ability to exercise E/e' ratio (DeLong p = 0.005). Exercise LA compliance demonstrated incremental diagnostic value over clinical factors (age, systemic hypertension, and atrial fibrillation) and resting LA compliance (χ2 212.4 vs. 166.2, p < 0.0001). These findings were confirmed in Protocol 2.ConclusionLeft atrial compliance during exercise demonstrated superior diagnostic ability to exercise E/e' ratio, with incremental diagnostic value over the resting LA compliance. Exercise LA compliance may enhance the diagnosis of HFpEF among patients with dyspnoea.

Exercise left atrial compliance: One more tool in the heart failure with preserved ejection fraction assistance toolbox?

“…According to the HFA-PEFF score, LAVi along with other echo-based parameters (including E/e', LV mass index, relative wall thickness) are essential and integral components in the diagnosis of HFpEF. 13 In the current issue of the Journal, Harada et al 14 It is not surprising that integrating information of LA reservoir strain and LVEDP during exercise (as LA compliance) would likely serve as a better surrogate marker compared with each of them alone. Findings from this study also shed light on the possibility of refining HFpEF diagnostic algorithm in the future by incorporating the concept of 'stiff LA syndrome' featured by reduced LA compliance at rest and particularly during exercise stress condition (Figure 1B).…”

“…While the findings from Harada et al 14 are inspiring for exploring the new imaging modality and may encourage the utilization of non-invasive stress test for HFpEF diagnosis, the clinical generalizability for such a novel tool remains to be determined. Second, there might exist a proportion of HFpEF patients presenting with exercise intolerance yet unable to complete a stress test from limited physical strength (such as sarcopenic patients).…”

“…In the current issue of the Journal, Harada et al 14 . determined LA compliance with the ratio of LA reservoir strain to E/e'.…”

“…While the findings from Harada et al 14 . are inspiring for exploring the new imaging modality and may encourage the utilization of non‐invasive stress test for HFpEF diagnosis, the clinical generalizability for such a novel tool remains to be determined.…”

August 2023 at a glance: Focus on epidemiology and medical therapy

“…20 The diagnosis of HF with preserved ejection fraction (HFpEF) remains challenging. 3,21,22 Harada et al 23 examined 225 patients with HFpEF and 262 controls with non-cardiac dyspnoea (NCD) who underwent exercise stress echocardiography. As compared with NCD, patients with HFpEF demonstrated decreased left atrial (LA) reservoir strain and compliance at rest; these differences further increased during exercise.…”