Left atrial function in heart failure with preserved ejection fraction: a systematic review and meta‐analysis

Abstract

Aims Left atrial (LA) mechanical function may play a significant role in the development and progression of heart failure with preserved ejection fraction (HFpEF). We performed a systematic review and meta‐analysis to evaluate association of impaired LA function with outcomes in HFpEF. Methods and results Multiple databases were searched for original studies measuring different phases of LA function in HFpEF patients. Comparative LA function between HFpEF patients and healthy controls was assessed by pooling weighted mean differences (WMD). Adjusted hazard ratios (HRs) with 95% confidence intervals were pooled to evaluate the prognostic utility of LA function. Twenty‐two studies (2 trials, 20 observational) comprising 1974 HFpEF patients and 751 healthy controls were included. HFpEF patients had decreased LA reservoir [WMD = −12.21% (−15.47, −8.95); P < 0.001], LA conduit [WMD = −5.68% (−8.56, −2.79); P < 0.001], and pump [WMD = −11.07% (−14.81, −7.34); P < 0.001] emptying fractions compared with controls. LA reservoir [WMD = −13.38% (−16.07, −10.68); P < 0.001], conduit [WMD = −4.09% (−6.77, −1.42); P = 0.003], and pump [WMD = −3.53% (−4.47, −2.59); P < 0.001] strains were also significantly lower in HFpEF patients. Decreased LA reservoir strain [HR 1.24 (1.02, 1.50); P = 0.03] was significantly associated with risk of composite all‐cause mortality or heart failure hospitalization. Conclusions Impaired LA function appears to have diagnostic and prognostic value in HFpEF, but whether indices of LA function truly refine discrimination for diagnosis or prognosis remains to be fully determined. Larger studies are needed to better evaluate associations between LA function and clinical outcomes and the role of LA function as a target for novel HFpEF therapies.

March 2020 at a glance: heart failure with preserved ejection fraction, left atrial myopathy, atrial fibrillation and cardiac amyloidosis

“…Left atrial (LA) function is associated with an increased risk of HF in patients with atrial fibrillation (AF). 7 Khan et al 8 HFpEF patients compared to controls. Decreased LA reservoir strain was associated with more clinical events.…”

Left atrial myopathy in heart failure with preserved ejection fraction

“…LA functional parameters were pooled using weighted mean differences across studies in a random effects model, and then linked to mortality and HF hospitalization when available. 10 The authors identified 22 studies fitting the inclusion criteria, of which 16 included a control group. 10 The final pooled data included 1974 HFpEF patients and 751 controls.…”

“…10 The authors identified 22 studies fitting the inclusion criteria, of which 16 included a control group. 10 The final pooled data included 1974 HFpEF patients and 751 controls. Almost all studies used echocardiography for LA function assessment, with only three using magnetic resonance imaging.…”

“…Importantly, LA reservoir strain was associated with the composite of mortality and HF hospitalization, although this analysis included data from only two studies. 10 In this meticulously performed meta-analysis, Khan et al 10 provide the most comprehensive, contemporary summary of LA dysfunction in HFpEF. While these data pooled from nearly 2000 patients add greatly to current understandings, there are a few important caveats to consider.…”

“…the specificity by which HFpEF was defined in the included studies, as well as differences in imaging techniques. 10 Despite these limitations, the study by Khan et al 10 points to the potentially important role for greater use of LA function in the evaluation and management of HFpEF. Current echocardiographic guidelines emphasize annular relaxation velocity (an index of LV myocardial relaxation) and mitral inflow profiles in the assessment of diastolic dysfunction, 11 but recent studies have suggested poor sensitivity of these indices in the diagnosis of HFpEF.…”