Heart Failure and Atrial Fibrillation: Diastolic Function Differences Depending on Left Ventricle Ejection Fraction

Abstract

Background: Heart failure (HF) and atrial fibrillation (AF) are prevalent cardiovascular diseases, and their association is common. Diastolic dysfunction may be present in patients with AF and all types of HF, leading to elevated intracardiac pressures. The objective of this study was to analyze diastolic dysfunction in patients with HF and AF depending on left ventricle ejection fraction (LVEF). Material and methods: This prospective study included 324 patients with chronic HF and AF (paroxysmal, persistent, or permanent) hospitalized between January 2018 and March 2021. The inclusion criteria were age older than 18 years, diagnosis of chronic HF and AF, and available echocardiographic data. The exclusion criteria were a suboptimal echocardiographic view, other cardiac rhythms than AF, congenital heart disease, or coronavirus 2 infection. Patients were divided into three subgroups according to LVEF: subgroup 1 included 203 patients with HF with reduced ejection fraction (HFrEF) and AF (62.65%), subgroup 2 included 42 patients with HF with mildly reduced ejection fraction (HFmrEF) and AF (12.96%), and subgroup 3 included 79 patients with HF with preserved ejection fraction (HFpEF) and AF (24.38%). We performed 2D transthoracic echocardiography in all patients. Statistical analysis was performed using R software. Results: The E/e′ ratio (p = 0.0352, OR 1.9) and left atrial volume index (56.4 mL/m2 vs. 53.6 mL/m2) were higher in patients with HFrEF than in those with HFpEF. Conclusions: Patients with HFrEF and AF had more severe diastolic dysfunction and higher left ventricular filling pressures than those with HFpEF and AF.

Left ventricular diastolic function in atrial fibrillation: Methodological implications and clinical considerations

“…6 However, it is not a reliable indicator of diastolic dysfunction in AF, where frequently LA is dilated regardless of LVDD. 16 Despite these limitations, LAVi remains the unique recommended LA anatomical parameter to analyze changes caused by LVDDin LA (Figure 5). 53 All criteria are present in a Flow Chart.…”

“…In such patients, high-heart rate atrial fibrillation and LVDD can contribute to symptoms, since AF and HFpEF are prevalent cardiovascular diseases, and their association is frequent. 16 The presence of diastolic dysfunction could cause worse clinical conditions in patients with atrial fibrillation. Echocardiographic evaluation of LVDD during atrial fibrillation is controversial, and to better understand this key point is necessary to explain the electrophysiological and pathophysiological mechanism underlying atrial fibrillation.…”

“…The assessment of diastolic dysfunction is challenging and crucial in patients with atrial fibrillation, particularly in those with AF and symptoms and signs of congestive heart failure in the absence of systolic dysfunction. In such patients, high‐heart rate atrial fibrillation and LVDD can contribute to symptoms, since AF and HFpEF are prevalent cardiovascular diseases, and their association is frequent 16 . The presence of diastolic dysfunction could cause worse clinical conditions in patients with atrial fibrillation.…”

“…In AF the ineffective atrial contraction results in the absence of A wave in Pulsed‐wave Derived–Doppler transmitral inflow (Figure 1). 16 Even if in AF it is not possible to calculate the E/A ratio, this parameter alone is not sufficient in sinus rhythm for diastolic function assessment. For this reason, in AF patients, methods for assessing diastolic dysfunction are mitral deceleration time (DT), DT of pulmonary venous flow (≤220 ms), IVRT (≤65 ms), E/e′ ratio (Figure 2) (≥11), 39 peak acceleration rate of mitral E velocity (≥1900 cm/s 2 ), and E/Vp ratio (≥1.4) 2 .…”

“…LAVi is another echocardiographic parameter, reflecting atrial changes caused by LV dysfunction, 53 but it is related to chronic and longstanding hemodynamic changes caused by LV diastolic dysfunction and increased LV filling pressures 6 . However, it is not a reliable indicator of diastolic dysfunction in AF, where frequently LA is dilated regardless of LVDD 16 . Despite these limitations, LAVi remains the unique recommended LA anatomical parameter to analyze changes caused by LVDDin LA (Figure 5).…”