Left atrial structure and function and the risk of death or heart failure in atrial fibrillation

Abstract

AimsThe present study aimed to assess the association between left atrial (LA) structure and function and the risk for cardiovascular (CV) death or heart failure (HF) hospitalization in a population with atrial fibrillation (AF).Methods and resultsIn a prospective echocardiographic substudy of the Effective Anticoagulation with Factor Xa Next Generation in AF‐Thrombolysis in Myocardial Infarction 48 (ENGAGE AF‐TIMI 48) study, 971 patients underwent transthoracic echocardiography. The associations between LA structure (LA volume index [LAVi]) and function (LA emptying fraction [LAEF] and LA expansion index [LAEi]) and risk for the composite endpoint of CV death or HF hospitalization, and its components, were assessed. Over a median follow‐up of 2.5 years, 142 patients (14.6%) experienced CV death or HF hospitalization. Higher LAVi and lower LAEF and LAEi were each associated with a higher unadjusted risk for the composite outcome and its components. After adjustment for clinical and echocardiographic confounders, only measures of impaired LA function were predictive of the composite outcome (hazard ratio [HR] per 1 standard deviation [SD] decrease in LAEF: 1.35; 95% confidence interval [CI] 1.09–1.67 [P = 0.005]; HR per 1 SD decrease in LAEi: 1.34; 95% CI 1.06–1.69 [P = 0.012]). These findings were similar regardless of left ventricular ejection fraction, history of HF or whether patients were in AF or sinus rhythm at the time of the echocardiographic examination.ConclusionsIn patients with AF, LA dysfunction was significantly associated with an increased risk for CV death or HF hospitalization and was more predictive of these outcomes than LA size. These parameters may help to identify AF patients at greatest risk for the development of HF.Clinical Trial Registration: ClinicalTrials.gov, NCT00781391.

Central role of left atrial dynamics in limiting exercise cardiac output increase and oxygen uptake in heart failure: insights by cardiopulmonary imaging

“…Studies on the role of LA dynamics in HF of different LVEF have been performed in a rigorous format but the correlation of LA dynamics with indexes of physical performance at peak exercise has been addressed only measuring LA function at rest . However, none of these studies investigated the association with CO, especially looking at LA reserve during exercise.…”

Heart Failure in Atrial Fibrillation ― An Update on Clinical and Echocardiographic Implications ―

“…33 In the recent prospective substudy of the Effective Anticoagulation with Factor Xa Next Generation in AF-Thrombolysis in Myocardial Infarction 48 (ENGAGE AF-TIMI 48), which included 971 patients with a CHADS2 score ≥2 demonstrated that hospitalization for HF was more common than for thromboembolic events (9.6% vs. 4.9%), and cardiovascular death was the most common cause of death (71.9%) in AF patients. 35 Notably, the impact of AF and HF on death may differ according to their temporal association. In a recent study investigating patients with AF or HF, the subsequent development of the other was associated with increased risk of death, and, also, preexisting HF negatively affected survival in patients with AF; however, preexisting AF did not have an impact on survival in patients with HF.…”

“…It is suggested that LA dysfunction or LA fibrosis antedate LA enlargement, 64,65 and the prognostic utility of LA function has also been investigated. 35,40,66 In a substudy of the ENGAGE AF-TIMI 48 study, 35 LA dysfunction assessed by LA emptying fraction [100*(LA maximal volume−LA minimal volume)/LA maximal volume] and LA expansion index [(LA maximal volume−LA minimal volume)/LA minimal volume] were significantly associated with an increased risk for cardiovascular death, HF hospitalization, or both, with an intraobserver intraclass correlation coefficient of 0.95 (range: 0.91-0.99) and an interobserver intraclass correlation coefficient of 0.84 (range: 0.75-0.93). In that study, LA functional impairment was demonstrated as more predictive of these outcomes than LA size.…”

“…In that study, LA functional impairment was demonstrated as more predictive of these outcomes than LA size. 35 The usefulness of other myocardial functional assessments beyond LVEF to predict cardiovascular outcomes in AF patients has been also investigated, and the results are summarized in the Table. A cohort study of 190 persistent AF patients reported that a combination index using transmitral flow E and LA strain (E/LA strain) was a predictor of cardiovascular events including cardiovascular death, HF hospitalization, myocardial infarction, and stroke although they did not demonstrate intra-and interobserver reliability of E/LA strain. 66 Su et al also demonstrated that worsening global LV longitudinal strain was independently associated with an increased risk of cardiovascular events in AF, with intra-and interobserver mean percent errors for measurement of 5.3±3.5% and 6.2±3.8%, respectively.…”

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) . Khan et al .…”