Elsevier

The American Journal of Cardiology

Volume 187, 15 January 2023, Pages 30-37
The American Journal of Cardiology

Prevalence, Determinants, and Prognostic Value of Left Atrial Dysfunction in Patients With Chronic Coronary Syndrome and Normal Left Ventricular Ejection Fraction

https://doi.org/10.1016/j.amjcard.2022.10.030Get rights and content

Patients with chronic coronary syndrome (CCS), even when they have complete revascularization and normal left ventricular (LV) systolic function, experience subsequent cardiovascular disease (CVD), highlighting the importance of surrogate markers to prevent adverse consequences. Speckle-tracking echocardiography-derived left atrial (LA) reservoir strain has emerged as a sensitive marker for CVD in various clinical settings. The present study investigated the prevalence, determinants, and prognostic value of LA dysfunction in CCS. We included 278 consecutive patients with CCS with completed percutaneous coronary intervention and preserved LV ejection fraction who underwent follow-up echocardiography. Speckle-tracking analysis was performed to assess LA reservoir strain, and LA dysfunction was defined as LA reservoir strain ≤24%. The primary outcome comprised new-onset atrial fibrillation, heart failure hospitalization, acute coronary syndrome, stroke, or all-cause death. At baseline, 28 patients (10.1%) had LA dysfunction. Multivariable analysis identified age, hypertension, LV ejection fraction, and multivessel disease as independent determinants of LA reservoir strain (all p <0.05). During a median follow-up of 4.8 years, the primary outcome occurred in 60 patients (21.6%). LA dysfunction carried a significant risk for primary outcome independent of traditional risk factors, LV parameters, and LA size (adjusted hazard ratio 3.10, p = 0.003); the risk increase remained significant even after excluding atrial fibrillation from the primary outcome (adjusted hazard ratio 2.27, p = 0.043). In conclusion, approximately 10% of patients with CCS with normal LV ejection fraction had LA dysfunction associated with adverse cardiovascular outcomes. Further studies are needed to explore whether therapeutic interventions affecting LA remodeling may help prevent CVD events.

Introduction

Coronary artery disease (CAD) is a leading cause of death, affecting approximately 200 million people worldwide.1 Recent European Society of Cardiology guidelines have provided the new concept of “chronic coronary syndromes (CCS),” which covers a broad spectrum of clinical presentations in patients with CAD.2 Despite the technical advances of revascularization and optimal medical therapy over the past decades, patients with CCS experience an increased frequency of various forms of cardiovascular disease, including atrial fibrillation (AF), heart failure (HF), acute coronary syndrome (ACS), and stroke,3, 4, 5 highlighting the need for early detection of patients at higher risk for cardiovascular events. Left atrial (LA) enlargement is an established marker for cardiovascular events in various clinical settings;6,7 it represents advanced and partially irreversible structural remodeling.8 Recently, speckle-tracking echocardiography has emerged as a sensitive tool for early identification of myocardial dysfunction,8 and LA reservoir strain serves as a robust predictor for adverse cardiovascular outcomes in various patient populations.9, 10, 11 Nevertheless, limited data are available regarding the frequency and prognostic value of LA functional remodeling in patients with CCS. The aim of the present study was to investigate the prevalence, determinants, and prognostic value of LA dysfunction in patients with CCS with previous complete percutaneous coronary intervention (PCI) and normal left ventricular (LV) systolic function, namely, stable ischemic heart disease.

Section snippets

Methods

We retrospectively recruited 476 consecutive patients with CCS who had completed nonemergent coronary revascularization and follow-up echocardiography at the University of Tokyo Hospital between August 2014 and July 2016. Patients with a history of myocardial infarction (n = 62), coronary artery bypass grafting surgery (n = 16), AF or atrial flutter (n = 34), congenital heart disease (n = 2), moderate or severe valvular heart disease (n = 13), LV ejection fraction <50% (n = 21), lacking

Results

Patient clinical characteristics are exhibited in Table 1. The mean age was 71 ± 9 years and 218 patients (78.4%) were men. A total of 28 patients (10.1%) exhibited LA dysfunction (LA reservoir strain ≤24%). There was no significant statistical difference in age, gender, body mass index, and traditional cardiovascular risk factors in patients with and without LA dysfunction. Patients with LA dysfunction had more advanced CAD. Only 16 patients (5.8%) experienced angina, with a Canadian

Discussion

The main findings of the present study are as follows: (1) approximately 10% of patients with CCS with previous complete PCI and normal LV systolic function had LA dysfunction; (2) age, hypertension, and CAD severity were the key determinants of LA function in CCS; (3) patients with CCS with LA dysfunction had unfavorable cardiovascular outcomes; and (4) LA functional impairment was associated with subsequent CVD, independent of relevant risk factors, and LV and LA structural remodeling.

Disclosures

The authors have no conflicts of interest to declare.

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    This work was partially supported by Kaken (Japan) 19K20707.

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