Coronary artery disease is associated with impaired atrial function regardless of left ventricular filling pressure
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.
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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.
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This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.