Original Research
Left Atrial Strain Impairment Precedes Geometric Remodeling as a Marker of Post-Myocardial Infarction Diastolic Dysfunction

https://doi.org/10.1016/j.jcmg.2020.05.041Get rights and content
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Abstract

Objectives

The aims of this study were to test the magnitude of agreement between echocardiography (echo)- and cardiac magnetic resonance (CMR)–derived left atrial (LA) strain and to study their relative diagnostic performance in discriminating diastolic dysfunction (DD) and predicting atrial fibrillation (AF).

Backgrounds

Peak atrial longitudinal strain (PALS) is a novel performance index. Utility of echo-quantified LA strain has yet to be prospectively tested in relation to current DD guidelines or compared to CMR.

Methods

The study population comprised 257 post-myocardial infarction (MI) patients undergoing echo and CMR, including prospective derivation (n = 157) and clinical validation (n = 100) cohorts. DD was graded on echo using established consensus guidelines blinded to strain results.

Results

PALS on both echo and CMR was nearly 2-fold lower among patients with versus no DD (p < 0.001) and was significantly different in those with mild versus no DD (p < 0.01). In contrast, LA geometric parameters including echo- and CMR-derived volumes were significantly different between advanced versus no DD groups (p < 0.001) but not between groups with mild versus no DD (all p > 0.05). Echo and CMR PALS yielded small differences irrespective of orientation and similar diagnostic performance for DD in the derivation (area under the curve [AUC]: 0.70 to 0.78) and validation (AUC: 0.75 to 0.78) cohorts. Impaired PALS on both modalities was independently associated with MI size (p < 0.001). During 4.4 ± 3.8 years of follow-up in the derivation cohort, 8% developed AF. Both 2-chamber echo- and CMR-derived PALS stratified arrhythmic risk (p = 0.004 and p = 0.02, respectively), including a 4-fold difference among patients in the lowest versus remainder of quartiles of echo-derived PALS (24% vs. 6%). Similarly, echo and CMR PALS were lower (both p < 0.05) among patients with subsequent heart failure hospitalizations.

Conclusions

Echo-derived PALS parallels results of CMR, yields incremental diagnostic utility versus LA geometry for stratifying presence and severity of DD, and improves prediction of AF and congestive heart failure after MI.

Key Words

diastolic dysfunction
left atrium
peak atrial longitudinal strain

Abbreviations and Acronyms

2C
2-chamber
4C
4-chamber
AF
atrial fibrillation
AUC
area under the curve
CMR
cardiac magnetic resonance
DD
diastolic dysfunction
Echo
echocardiography
ICC
intraclass correlation coefficient
LA
left atrium
LOA
limits of agreement
LV
left ventricle
LVEDP
left ventricular end-diastolic pressure
MI
myocardial infarction
PALS
peak atrial longitudinal strain
TR
tricuspid regurgitation

Cited by (0)

This study was supported by National Institutes of Health (NIH) grant 1K23 HL140092-01 to Dr. Kim; NIH grant 1R01HL128278-01 to Dr. Weinsaft; and Memorial Sloan Kettering Cancer Center core grant P30 CA008748 to Dr. Moskowitz. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Imaging author instructions page.