Coronary artery disease is associated with impaired atrial function regardless of left ventricular filling pressure

https://doi.org/10.1016/j.ijcard.2023.05.052Get rights and content

Highlights

  • LA strain and function are impaired in CAD regardless of LVEDP.

  • LA function may be affected by coexistent CAD severity, medications and loading conditions.

  • LA strain alone may be insufficient to accurately predict LVEDP in patients with CAD.

Abstract

Background

Left atrial (LA) strain is impaired in left ventricular (LV) diastolic dysfunction, associated with increased LV end diastolic pressure (LVEDP). In patients with preserved LV ejection fraction (LVEF), coronary artery disease (CAD) is known to impair LV diastolic function. The relationship of LVEDP with CAD and impact on LA strain is not well studied.

Methods and results

Patients with LVEF >50% (n = 37, age 61 ± 7 years) underwent coronary angiography, high-fidelity LV pressure measurements and cardiac magnetic resonance imaging. LA volumes, LA emptying fraction (LAEF), LA reservoir strain (LARS) and LA long-axis shortening (LALAS) were measured. By coronary angiography, patients were assigned into 3 groups: severe-CAD (n = 19, with obstruction of major coronary arteries >70% and/or history of coronary revascularization), mild-to-moderate-CAD (n = 10, obstruction of major coronary arteries 30–60%), and no-CAD (n = 8, obstruction of major coronary arteries and branches <30%). Overall, LVEF was 65 ± 8% and LVEDP was 14.4 ± 5.6 mmHg. Clinical characteristics, LVEDP and LV function measurements were similar in 3 groups. Severe-CAD group had lower LAEF, LALAS and LARS than those in no-CAD group (P < 0.05 all). In regression analysis, LARS and LALAS were associated with CAD severity and treatment with Nitrates, whereas LAEF and LAEFactive were associated with CAD severity, treatment with Nitrates and LA minimum volume (P < 0.05 all). LAEFpassive was associated with LVED volume (P < 0.05).

Conclusions

LA functional impairment may be affected by coexistent CAD severity, medications, in particular, Nitrates, and loading conditions, which should be considered when assessing LA function and LA-LV interaction. Our findings inspire exploration in a larger cohort.

Introduction

Assessment of left atrial (LA) function including LA strain is a promising tool for evaluation of left ventricular (LV) diastolic function in patients with preserved LV ejection fraction (LVEF). [1] Echocardiographic studies showed that the magnitude of LA longitudinal strain progressively diminishes with increasing LV filling pressure and severity of LV diastolic dysfunction (LVDD). [[2], [3], [4], [5]] LA strain was markedly reduced in LVDD subjects without heart failure clinical symptoms, [6] and lower LA strain was associated with worse outcomes. [7] In echocardiography, LA strain has recently been studied as a single diagnostic tool for LVDD or as an integral part of the existing diagnostic algorithms. [[8], [9], [10]] Cardiovascular magnetic resonance (CMR) can accurately measure cardiac structure and function. [11,12] CMR-measured LA strain metrics (e.g., LA reservoir strain (LARS), LA conduit strain and conduit strain rate) and volumetric metrics (e.g., LA minimum and maximum volume indexes, LA emptying fraction (LAEF)) differ in patients with heart failure with preserved LVEF (HFpEF) when compared to controls and revealed a strong prognostic value for incident HF admission and death. [[13], [14], [15], [16]] Moreover, CMR-derived LA metrics have been used for assessment of LV filling pressure for LVDD diagnostics. [17] Yet, the applicability of LA strain in early stages of LVDD or subclinical heart failure with preserved LVEF has not been extensively studied or validated, especially in the presence of coronary artery disease (CAD). It has been shown that CAD can influence the relationship between echocardiographic and hemodynamic indices. [1,18] LV systolic function measured as LVEF plays an important role in this relationship. [19] Importantly, it has been noted that LA longitudinal strain is impaired in CAD patients compared to those without CAD before changes in other LA and LV measurements, which prompted tests of 2D and 3D LA strain metrics as non-invasive tools for CAD diagnostics or its severity. [[20], [21], [22], [23]] Since LA strain impairment has been found to occur in both CAD patients and non-CAD patients with LVDD, it is unclear whether the altered LA strains reflect elevation in LV filling pressure as CAD progresses. We sought to investigate this in a small but well-characterized patient cohort.

Section snippets

Study population

This study included 37 participants (age 61 ± 7 years) that underwent coronary angiography for chest pain and/or dyspnea evaluation and were subjects of a prospective research study that included left heart catheterization for clinical indications and CMR. [24] Clinical characteristics are described in Table 1. Major exclusion criteria included reduced LVEF (<50%), acute myocardial infarction, coronary intervention during cardiac catheterization, abnormal segmental wall motion, atrial

Basic clinical characteristics, LV function and LVEDP in groups

The study cohort included 37 patients (61 ± 7 yrs.) with primary complaints of chest pain and/or dyspnea (symptomatically, NYHA class I (58%) or II (42%)). Most patients had hypertension (86%), and almost half had diabetes mellitus (46%). By coronary angiography results and patient history, patients were assigned into 3 groups: 1) NO_CAD (n = 8); 2) MM_CAD (n = 10); and 3) SVR_CAD (n = 19). Between groups, there was no difference in demographics, clinical characteristics, and medications (Table

Discussion

Our study demonstrated that CAD is associated with LA functional impairment in patients with preserved LVEF, but LA volume and strain metrics may not necessary be related to LVEDP in those with CAD. The latter finding may be in part be related to certain load-dependent properties of LA strain and effects of medications, which should be considered when using LA strain parameters as a surrogate for the loading factors, particular in CAD patients.

Patients with CAD have abnormal LV diastolic

Conclusions

In conclusion, our study suggests that alterations in LA strain and related functional impairments are sensitive indicators of CAD regardless of measured LVEDP. Thus, LA function parameters may be markers of early impairment in LV diastolic function in CAD patients with preserved LVEF and could provide additional value for CMR evaluation of these patients. On the other hand, our data suggests that it would be unreliable to predict an instantaneous value of LVEDP based on LA strain in each

Funding

The study was supported by grant NIH NHLBI R01-HL104018.

Declaration of Competing Interest

Authors declare no potential conflicts of interest related to this study.

References (50)

  • L. Khedr et al.

    Assessment of left and right atrial geometrical changes in patients with stable coronary artery disease: left and right atrial strain and strain rate imaging study

    Egypt Heart J.

    (2018)
  • M. Zareian et al.

    Left atrial structure and functional quantitation using cardiovascular magnetic resonance and multimodality tissue tracking: validation and reproducibility assessment

    J. Cardiovasc. Magn. Reson.: Off. J. Soc. Cardiovasc. Magn. Reson.

    (2015)
  • A. Saltups et al.

    Left ventricular hemodynamics in patients with coronary artery disease and in normal subjects. Correlations with the extent of coronary artery lesions and the electrocardiogram

    Am. J. Med.

    (1971)
  • H. Ito et al.

    Cardiovascular magnetic resonance feature tracking for characterization of patients with heart failure with preserved ejection fraction: correlation of global longitudinal strain with invasive diastolic functional indices

    J. Cardiovasc. Magn. Reson.: Off. J. Soc. Cardiovasc. Magn. Reson.

    (2020)
  • D.C.J. Keulards et al.

    High microvascular resistance and reduced left atrial strain in patients with coronary microvascular dysfunction: the micro-strain study

    Int. J. Cardiol.

    (2021)
  • A. Manouras et al.

    The value of E/Em ratio in the estimation of left ventricular filling pressures: impact of acute load reduction: a comparative simultaneous echocardiographic and catheterization study

    Int. J. Cardiol.

    (2013)
  • T. Tsujimoto et al.

    Use of nitrates and risk of cardiovascular events in patients with heart failure with preserved ejection fraction

    Mayo Clin. Proc.

    (2019)
  • S.J. Hwang et al.

    Implications of coronary artery disease in heart failure with preserved ejection fraction

    J. Am. Coll. Cardiol.

    (2014)
  • M. Cameli et al.

    Correlation of left atrial strain and Doppler measurements with invasive measurement of left ventricular end-diastolic pressure in patients stratified for different values of ejection fraction

    Echocardiography (Mount Kisco, NY).

    (2016)
  • A. Lundberg et al.

    Left atrial strain improves estimation of filling pressures in heart failure: a simultaneous echocardiographic and invasive haemodynamic study

    Clin. Res. Cardiol.: Off. J. German Cardiac Soc.

    (2019)
  • A. Singh et al.

    Peak left atrial strain as a single measure for the non-invasive assessment of left ventricular filling pressures

    Intern. J. Cardiovasc. Imag.

    (2019)
  • B.H. Freed et al.

    Prognostic utility and clinical significance of cardiac mechanics in heart failure with preserved ejection fraction: importance of left atrial strain

    Circul. Cardiovasc. Imag.

    (2016)
  • J. Lin et al.

    Left atrial reservoir strain combined with E/E’ as a better single measure to predict elevated LV filling pressures in patients with coronary artery disease

    Cardiovasc. Ultrasound

    (2020)
  • J.L. Fan et al.

    Correlation of left atrial strain with left ventricular end-diastolic pressure in patients with normal left ventricular ejection fraction

    Intern. J. Cardiovasc. Imag.

    (2020)
  • C.G. Schiros et al.

    Mitral annular kinetics, left atrial, and left ventricular diastolic function post mitral valve repair in degenerative mitral regurgitation

    Front. Cardiovasc. Med.

    (2015)
  • 1

    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

    View full text