Left atrial disease and left atrial reverse remodelling across different stages of heart failure development and progression: a new target for prevention and treatment

Abstract

The left atrium is a dynamic chamber with peculiar characteristics. Stressors and disease mechanisms may deeply modify its structure and function, leading to left atrial remodelling and disease. Left atrial disease is a predictor of poor outcomes. It may be a consequence of left ventricular systolic and diastolic dysfunction and neurohormonal and inflammatory activation and/or actively contribute to the progression and clinical course of heart failure through multiple mechanisms such as left ventricular filling and development of atrial fibrillation and subsequent embolic events. There is growing evidence that therapy may improve left atrial function and reverse left atrial remodelling. Whether this translates into changes in patient's prognosis is still unknown. In this review we report current data about changes in left atrial size and function across different stages of development and progression of heart failure. At each stage, drug therapies, lifestyle interventions and procedures have been associated with improvement in left atrial structure and function, namely a reduction in left atrial volume and/or an improvement in left atrial strain function, a process that can be defined as left atrial reverse remodelling and, in some cases, this has been associated with improvement in clinical outcomes. Further evidence is still needed mainly with respect of the possible role of left atrial reverse remodelling as an independent mechanism affecting the patient's clinical course and as regards better standardization of clinically meaningful changes in left atrial measurements. Summarizing current evidence, this review may be the basis for further studies.

Clinical implications of left atrial changes after optimization of medical therapy in patients with heart failure

“…Although our analysis cannot provide a pathological evidence of fibrosis reduction among those who did not experience adverse remodelling, and the reverse structural effect after HF therapy may be also related to a passive process due to an improvement of overall cardiac haemodynamics and filling pressure, it is possible that treatment response relies upon the burden of myocardial fibrosis, as observed for LV reverse remodelling 9,10 . Therefore, patients with less fibrosis and at an early stage of atrial disease may respond more quickly with a decrease in overall chamber compliance and a resultant decrease in LA dimension 24,34,35 . On the other hand, LA assessment may be less sensitive to capture the effect of HF treatment in patients with advanced atrial disease, as those with a history of AF 8…”

“…9,10 Therefore, patients with less fibrosis and at an early stage of atrial disease may respond more quickly with a decrease in overall chamber compliance and a resultant decrease in LA dimension. 24,34,35 On the other hand, LA assessment may be less sensitive to capture the effect of HF treatment in patients with advanced atrial disease, as those with a history of AF. 8 The current data show the importance of routine assessment of the left atrium and its change over time may represent per se a surrogate of HF treatment response identifying patients with reduced risk of CV events.…”

June 2022 at a glance: prevention, outcomes and treatment

“…The role of left atrial function has also been recently pointed out 16,17 . Left atrial remodelling across different stages of HF development, its clinical implications and therapeutic options are also reviewed in this issue 18 …”

Epicardial adipose tissue in heart failure: risk factor or mediator?

“…If dysfunctional epicardial fat leads to inflammation of both the atrial and ventricular myocardium, then one may speculate that interventions aimed at ameliorating this abnormality might exert favourable effects on HFpEF progression. From this perspective, the current analysis highlights the potential importance of using LA/LV measures as a marker of treatment response 15 . Statins reduce the quantity of EAT and promote a decrease of its proinflammatory characteristics 16 .…”

“…From this perspective, the current analysis highlights the potential importance of using LA/LV measures as a marker of treatment response. 15 Statins reduce the quantity of EAT and promote a decrease of its proinflammatory characteristics. 16 Metformin and sodium-glucose cotransporter 2 inhibitors have been shown to reduce the quantity of EAT and to ameliorate the related inflammatory burden.…”