Abstract
Context:
Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome associated with diastolic function abnormalities. It remains unclear which factors, if any, can predict the transition from asymptomatic diastolic dysfunction to an overt symptomatic phase.
Materials and Methods:
Patients hospitalized with suspected heart failure between January 2012 and November 2014 with a transthoracic echocardiogram demonstrating preserved systolic function were screened (n = 425). Patients meeting the American College of Cardiology Foundation/American Heart Association definition for HFpEF (n = 40) were matched in a 1:1 fashion to individuals admitted for hypertensive urgency with diastolic dysfunction and neither pulmonary edema nor history of heart failure (n = 40). The clinical records and echocardiograms of all eighty patients included in this retrospective study were reviewed.
Results:
Patients with HFpEF had higher body mass index (BMI), creatinine, beta-blocker use, and Grade 2 diastolic dysfunction when compared to the hypertensive control population. Echocardiographic analysis demonstrated higher right ventricular systolic pressures, left ventricular mass index, E/A, and E/e’ in patients with HFpEF. Similarly, differences were observed in most left atrial (LA) parameters including larger LA maximum and minimum volume indices, as well as smaller LA-emptying fractions in the heart failure group. Multivariate logistic regression analysis revealed LA minimum volume index (odds ratio [OR]: 1.23 [1.09–1.38], P = 0.001) to have the strongest association with heart failure hospitalization after adjustment for creatinine (OR: 7.09 [1.43–35.07], P = 0.016) and BMI (OR: 1.11 [0.99–1.25], P = 0.074).
Conclusion:
LA minimum volume index best correlated with HFpEF in this patient cohort with diastolic dysfunction.
Keywords: Diastolic dysfunction, heart failure with preserved ejection fraction, left atrium
Introduction
Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome that continues to gain recognition for its rising prevalence and rates of morbidity and mortality that mirror the syndrome of heart failure with reduced ejection fraction.[1] Unfortunately, there remains a poor understanding of the underlying pathophysiology in patients with HFpEF, and only a few existing therapeutic strategies have proven to improve outcomes.[1]
HFpEF is defined as typical symptoms and signs of heart failure in a patient with normal left ventricular (LV) ejection fraction, in the absence of significant valvular abnormalities by echocardiogram.[2] The onset of this syndrome is typically preceded by asymptomatic phase of LV diastolic dysfunction that over time can evolve into clinically overt failure, disability, and even death. Thus, the emphasis should be placed on the detection of these abnormalities in the preclinical phase.[3,4]
In addition to diastolic grading, there are other echocardiographic findings such as LV hypertrophy (LVH) and increased left atrial (LA) size that have been associated with poor cardiac outcomes in patients with HFpEF.[5,6,7,8] However, it remains unclear which factors, if any, are associated with the early transition from asymptomatic diastolic dysfunction to overt heart failure. The objective of this retrospective, cross-sectional study is to identify echocardiographic markers that may correlate with the development of symptomatic heart failure in the early stages of this disease.
Materials and Methods
Study population
After obtaining approval from our Institutional Review Board, we retrospectively screened all patients hospitalized at our institution between January 2012 and November 2014 for suspected heart failure, who also had a complete transthoracic echocardiogram performed during the index hospitalization demonstrating preserved LV function (n = 425). Of these patients, only 128 patients actually met the American College of Cardiology Foundation/American Heart Association definition for HFpEF, defined as the presence of clinical heart failure, as assessed by physical examination, and a preserved LV ejection fraction (≥50%) on a transthoracic echocardiogram, without the presence of significant valvular abnormalities (moderate or worse by standard echocardiographic guidelines). From this population, all patients with prior valve surgery, history of atrial fibrillation, end-stage renal disease, or significant pericardial disease were excluded from the study.
Eligible patients (n = 40) were then matched in a 1:1 fashion by age and sex to a control population of patients admitted during the same period with a diagnosis of hypertensive urgency, some degree of diastolic dysfunction on a transthoracic echocardiogram performed during the hospitalization, and no evidence of heart failure (n = 40). The medical records of all the eighty patients included in the study were reviewed for prior medical history and clinical data relating to their hospitalization.
Echocardiographic methods
All transthoracic echocardiograms were performed with the patients in the supine position in accordance with the standard guidelines, using commercially available ultrasound systems (General Electric Vivid 7 system, Horten, Norway), and all measurements were performed offline using Echopac PC (GE-Vingmed, Horten, Norway). The complete transthoracic echocardiograms and Doppler echocardiograms for each of the eighty patients included in the study were analyzed in a blinded fashion. Each echocardiographic study used for analysis was obtained during the first 24 h of the patient's heart failure hospitalization. Two echocardiographers extracted all the data for the analysis. A third, level 3 reader reviewed each individual echocardiogram for comparison.
The atrial volumes were obtained using the area-length biplane technique.[9] The contours were methodically traced in the four- and two-chamber views, with care taken to exclude the pulmonary veins and the LA appendage. The maximum and minimum LA areas were measured in ventricular systole just prior to the opening of the mitral valve and in diastole just after closing of the mitral valve. The two shorter LA lengths obtained in the four- and two-chamber views were used in the volume calculation as recommended in the Chamber Quantification Guidelines. The maximal volume and minimal volume indices were computed by dividing the calculated volume by each patient's body surface area. The LA emptying fraction was calculated using the following formula: ([(maximal volume − minimal volume)/maximal volume] ×100).
Pulse-wave Doppler of the peak mitral inflow velocities in early diastole (E) and late diastole (A) was obtained in the apical four-chamber view. Pulse-wave tissue Doppler imaging was also used to obtain the early diastolic (e’) and late diastolic (a’) velocities, at both the septal and lateral sides of mitral annulus. Both measurements were obtained in the apical four-chamber window as recommended by the American Society of Echocardiography.[10] An average e’ was used in the calculation of the E/e’. LA strain analysis by speckle tracking echocardiography was also completed in the two- and four-chamber apical views.
Statistical methods
Data were presented as mean and standard deviation for continuous variables and as frequency and percentage for categorical variables. We utilized Student's independent sample t-test and Pearson's Chi-square analysis to compare means between continuous and categorical variables, respectively. Receiver operating characteristic curves were generated for each echocardiographic variable and utilized to compare their strength of association with heart failure. The c-statistic was calculated, indicating the strength of the discriminatory ability for each echocardiographic variable. Univariate (unadjusted) and multivariate (adjusted) logistic regression analyses were utilized to identify independent associations with heart failure in patients with diastolic dysfunction. Each echocardiographic variable was analyzed with the two best clinical variables (body mass index [BMI] and creatinine) in the adjusted analysis. P < 0.05 was considered statistically significant. In addition, as a supplementary analysis, a generalized propensity score-adjusted analysis was conducted whereby the propensity of levels of the echocardiographic variables was modeled as a function of the baseline characteristics such as BMI, creatinine, age, sex, diabetes, systolic blood pressure, ejection fraction, and beta-blocker use through linear regression, and the resulting probabilities were used as an adjustment factor along with each echocardiographic variable in the final logistic regression model. Goodness of fit of all models was assessed through the Hosmer–Lemeshow test. A Hosmer-Lemeshow P < 0.05 indicates lack of fit. All analyses were performed using SAS Software, version 9.4. Copyright, SAS Institute Inc. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA. The inter- and intra-reader variability among the three echocardiographers who participated in this study was evaluated through intraclass correlations and was found to be adequate. P < 0.05 was considered statistically significant with no adjustment for multiple comparisons.
Results
When compared to the hypertensive controls, patients with HFpEF had higher BMI (32.5 ± 11.3 vs. 27.7 ± 5.2, P = 0.019), creatinine (1.79 ± 1.01 vs. 1.02 ± 0.47, P < 0.001), and beta-blocker use (37.5% vs. 23.8%, P = 0.022) [Table 1]. They also had lower systolic (161.4 ± 33.4 vs. 194.1 ± 29.4, P < 0.001) and diastolic (82.8 ± 18.8 vs. 98.6 ± 19.9, P < 0.001) blood pressures [Table 1].
Table 1.
Patient characteristics
| Variable | Heart failure | P | |
|---|---|---|---|
| Yes (40) | No (40) | ||
| Age (years) | 72.1±13.0 | 72.1±12.7 | 0.993 |
| Women (%) | 20 (50) | 20 (50) | 1.0 |
| BMI (kg/m2) | 32.5±11.3 | 27.7±5.2 | 0.019 |
| Diabetes mellitus (%) | 24 (60) | 16 (40) | 0.074 |
| Hypertension (%) | 38 (96) | 39 (98) | 0.556 |
| Coronary artery disease (%) | 15 (37.5) | 13 (32.5) | 0.639 |
| Ischemic stroke (%) | 3 (7.5) | 8 (20) | 0.105 |
| Peripheral vascular disease (%) | 5 (12.5) | 3 (7.5) | 0.456 |
| Heart rate | 77.9±18.6 | 76.1±13.8 | 0.619 |
| Systolic blood pressure | 161.4±33.4 | 194.1±29.4 | <0.001 |
| Diastolic blood pressure | 82.8±18.8 | 98.6±19.9 | <0.001 |
| Pro-BNP | 10,436±21,199 | 651±632 | 0.105 |
| Creatinine | 1.79±1.01 | 1.02±0.47 | <0.001 |
| Troponin | 0.15±0.30 | 0.06±0.05 | 0.055 |
| LV ejection fraction (%) | 62.9±3.56 | 64.3±3.31 | 0.078 |
| Diastolic dysfunction* (%) | |||
| None | 2.5 | 0 | <0.001 |
| Grade 1 | 40 | 95 | <0.001 |
| Grade 2 | 45 | 2.5 | <0.001 |
| Beta-blocker use (%) | 30 (75) | 19 (47.5) | 0.012 |
| Statin use (%) | 25 (62.5) | 23 (57.5) | 0.648 |
| Angiotensin-converting enzyme inhibitor use (%) | 23 (57.5) | 30 (75) | 0.098 |
*There were insufficient echocardiographic data to make an accurate assessment for the stage of diastolic dysfunction in five patients in the HFpEF group as well as one patient in the control group. BMI: Body mass index, Pro-BNP: Pro-B-type natriuretic peptide, HFpEF: Heart failure with preserved ejection fraction, LV: Left ventricular
As expected, a higher incidence of advanced (Stage II) diastolic dysfunction (45% vs. 2%, P < 0.001) was noted in the heart failure group [Table 1]. In addition, the group of patients that had heart failure was noted to have higher values for right ventricular systolic pressure (42.0 ± 10.4 vs. 31.6 ± 7.1, P < 0.001), LV mass index (126.2 ± 32.6 vs. 110.8 ± 27.8, P = 0.026), E (0.91 ± 0.25 vs. 0.64 ± 0.16, P < 0.001), E/A (1.17 ± 0.62 vs. 0.75 ± 0.29, P < 0.001), and E/e’ (16.4 ± 6.7 vs. 11.3 ± 3.7, P < 0.001) [Table 2]. Similarly, significant differences were observed in all LA size parameters including larger LA maximum volume (71.4 ± 18.6 vs. 45.9 ± 15.8, P < 0.001), maximum volume index (37.8 ± 8.3 vs. 29.0 ± 9.4, P < 0.001), minimum volume (40.2 ± 14.8 vs. 19.8 ± 9.1, P < 0.001), and minimum volume index (22.3 ± 8.5 vs. 13.2 ± 5.8, P < 0.001) in the heart failure group [Table 2]. In addition, LA-emptying fraction (43.6 ± 15.4 vs. 56.4 ± 13.1, P < 0.001) and atrial strain (maximum: 22.3 ± 9.8 vs. 29.3 ± 12.6, P = 0.011, average: 23.1 ± 9.1 vs. 30.4 ± 11.0, P = 0.011), both of which reflect LA function, were noted to be smaller (worse) in the HFpEF group [Table 2].
Table 2.
Echocardiographic data
| Variable | Heart failure | P | |
|---|---|---|---|
| Yes (40) | No (40) | ||
| Right ventricular systolic pressure | 42.0±10.4 | 31.6±7.1 | <0.001 |
| LV mass index | 126.2±32.6 | 110.8±27.8 | 0.026 |
| LA maximum volume (4C) | 71.4±18.6 | 45.9±15.8 | <0.001 |
| LA maximum volume index | 37.8±8.3 | 29.0±9.4 | <0.001 |
| LA maximum area (4C) | 22.5±4.2 | 17.1±3.7 | <0.001 |
| LA maximum length (4C) | 5.8±0.7 | 5.2±0.6 | <0.001 |
| LA minimum volume (4C) | 40.2±14.8 | 19.8±9.1 | <0.001 |
| LA minimum volume index | 22.3±8.5 | 13.2±5.8 | <0.001 |
| LA minimum area (4C) | 16.0±3.9 | 10.2±3.1 | <0.001 |
| LA minimum length (4C) | 5.2±0.8 | 4.1±0.7 | <0.001 |
| LA-emptying fraction (4C) | 43.6±15.4 | 56.4±13.1 | <0.001 |
| Maximum LA strain (4C) | 22.3±9.8 | 29.3±12.6 | 0.011 |
| Average LA strain (4C) | 23.1±9.0 | 30.4±11.0 | 0.005 |
| Diastology | |||
| E | 0.91±0.25 | 0.64±0.16 | <0.001 |
| A | 0.89±0.28 | 0.89±0.21 | 0.987 |
| E/A | 1.17±0.62 | 0.75±0.29 | <0.001 |
| E/e’ | 16.4±6.7 | 11.3±3.7 | <0.001 |
LA: Left atrial, LV: Left ventricular, 4C: Four chamber
Of the 54 patients with Grade 1 diastolic dysfunction included in the study, 16 were in the heart failure group (30%) and 38 were in the control group (70%). In this population with early diastolic disease (Grade 1), the left atrial minimum volume index (LAmVI) was also significantly higher in patients who presented with heart failure as compared with hypertensive controls (20.7 ± 8.9 vs. 13 ± 5.7 P = 0.001).
Almost every echocardiographic variable listed in the univariate (unadjusted) analysis in Table 3 had a good correlation with HFpEF with the exception of a’. The parameter that correlated strongly with HFpEF, after adjustment for BMI and creatinine, was LAmVI (c-statistic 0.914) [Table 4], (odds ratio = 1.23 [1.09–1.38], P = 0.001) [Table 5]. All echocardiographic variables demonstrated adequate goodness of fit as indicated by Hosmer–Lemeshow P < 0.05. The results were similar between the BMI/creatinine-adjusted model and the propensity-adjusted model.
Table 3.
Univariate (unadjusted) analyses
| Effect | n | c-statistic | OR (95% CI) | Effect P |
|---|---|---|---|---|
| Right ventricular systolic pressure | 53 | 0.815 | 1.16 (1.06-1.26) | 0.001 |
| LV mass index | 79 | 0.651 | 1.02 (1.00-1.04) | 0.026 |
| LA maximum volume (4C) | 77 | 0.845 | 1.09 (1.05-1.13) | <0.001 |
| LA maximum volume index | 72 | 0.767 | 1.12 (1.05-1.2) | 0.001 |
| LA maximum area (4C) | 77 | 0.829 | 1.4 (1.2-1.63) | <0.001 |
| LA maximum length (4C) | 77 | 0.788 | 6.71 (2.54-17.68) | <0.001 |
| LA minimum volume (4C) | 77 | 0.893 | 1.17 (1.09-1.26) | <0.001 |
| LA minimum volume index | 72 | 0.838 | 1.26 (1.12-1.42) | <0.001 |
| LA minimum area (4C) | 77 | 0.876 | 1.61 (1.3-1.98) | <0.001 |
| LA minimum length (4C) | 77 | 0.821 | 6.3 (2.61-15.22) | <0.001 |
| LA-emptying fraction (4C) | 77 | 0.745 | 0.94 (0.9-0.97) | 0.001 |
| Maximum LA strain (4C) | 72 | 0.698 | 0.93 (0.88-0.99) | 0.018 |
| Average LA strain (4C) | 67 | 0.728 | 0.92 (0.86-0.98) | 0.009 |
| E | 77 | 0.822 | 559.68 (28.13-11136.62) | <0.001 |
| A | 77 | 0.517 | 1.02 (0.16-6.38) | 0.986 |
| E/A | 77 | 0.772 | 18.56 (2.98-115.61) | 0.002 |
| E/e’ | 75 | 0.778 | 1.29 (1.12-1.49) | <0.001 |
OR: Odds ratio, CI: Confidence interval, LA: Left atrial, LV: Left ventricular, 4C: Four chamber
Table 4.
Multivariate (adjusted) analysis
| Effect | Covariate adjusted | ||||
|---|---|---|---|---|---|
| n | c-statistic | OR (95% CI) | Effect P | Hosmer-Lemeshow P | |
| Right ventricular systolic pressure | 52 | 0.881 | 1.16 (1.05-1.29) | 0.004 | 0.184 |
| LV mass index | 78 | 0.847 | 1.01 (0.99-1.03) | 0.281 | 0.018 |
| LA maximum volume (4C) | 76 | 0.881 | 1.08 (1.03-1.12) | 0.001 | 0.426 |
| LA maximum volume index | 71 | 0.883 | 1.13 (1.04-1.22) | 0.002 | 0.003 |
| LA maximum area (4C) | 76 | 0.885 | 1.37 (1.14-1.65) | 0.001 | 0.334 |
| LA maximum length (4C) | 76 | 0.860 | 4.43 (1.56-12.55) | 0.005 | 0.662 |
| LA minimum volume (4C) | 76 | 0.907 | 1.13 (1.06-1.21) | <0.001 | 0.404 |
| LA minimum volume index | 71 | 0.914 | 1.23 (1.09-1.38) | 0.001 | 0.276 |
| LA minimum area (4C) | 76 | 0.903 | 1.46 (1.19-1.8) | <0.001 | 0.782 |
| LA minimum length (4C) | 76 | 0.876 | 4.64 (1.8-11.94) | 0.001 | 0.999 |
| LA-emptying fraction (4C) | 76 | 0.877 | 0.94 (0.91-0.98) | 0.005 | 0.827 |
| Maximum LA strain (4C) | 71 | 0.887 | 0.91 (0.84-0.98) | 0.011 | 0.019 |
| Average LA strain (4C) | 66 | 0.894 | 0.89 (0.82-0.97) | 0.007 | 0.332 |
| E | 76 | 0.884 | 182.56 (6.93-4809) | 0.002 | 0.185 |
| A | 76 | 0.831 | 1.21 (0.13-11.37) | 0.868 | <0.001 |
| E/A | 76 | 0.885 | 10.01 (1.51-66.25) | 0.017 | 0.319 |
| E/e’ | 74 | 0.882 | 1.27 (1.09-1.49) | 0.003 | 0.631 |
OR: Odds ratio, CI: Confidence interval, LA: Left atrial, LV: Left ventricular, 4C: Four chamber
Table 5.
Final multivariate model
| Variable | OR | P |
|---|---|---|
| BMI | 1.11 (0.99-1.25) | 0.074 |
| Creatinine | 7.09 (1.43-35.07) | 0.016 |
| LA minimum volume index | 1.23 (1.09-1.38) | 0.001 |
BMI: Body mass index, OR: Odds ratio, LA: Left atrial
Discussion
The findings of our study are 2-fold. First, in a population of hospitalized patients with varying degrees of diastolic dysfunction and preserved LV systolic function, all the echocardiographic parameters that correlate with increased LV-filling pressures were associated with heart failure hospitalizations. Second, LAmVI had the best association of these echocardiographic parameters.
HFpEF is a complex clinical entity with a magnitude of proposed mechanisms that likely involve interplay between primary structural changes within the heart and related comorbid conditions.[1] Many of these known clinical comorbidities, including renal failure, obesity, and LVH, demonstrated consistent associations with HFpEF in this cross-sectional investigation. However, the most recognized structural mechanism for HFpEF is diastolic dysfunction.
A comprehensive diastology assessment by echocardiography involves multiple parameters, many of which are dependent on loading conditions and sometimes provide conflicting information.[10,11] An integral part of this evaluation is the estimation of LV-filling pressures. With worsening diastolic dysfunction, these pressures typically change in a predictable manner, with elevation of LV end-diastolic pressure being the first detectable change, followed by elevations in LA pressure and pulmonary capillary wedge pressure (PCWP).[10,12] In patients with normal systolic function, mean LA pressure (and thus PCWP) is estimated by the E/e’ ratio.[12] However, this is a load-dependent variable more reflective of instantaneous filling pressures at the time of the study. In contrast, LA structural changes express chronicity of exposure to elevated filling pressures. This may explain why in prior studies of patients with preserved systolic function, LA dimensions better predicted heart failure hospitalization and other cardiac outcomes.[13]
In this cohort of patients, LA maximum volume index was significantly higher in the group of patients hospitalized for heart failure. This was observed in prior studies in which LA maximum volume >32 ml/m2 was shown to predict both sentinel heart failure hospitalization as well as future hospitalizations.[5,6,14] Similarly, LA maximum volume index >34 ml/m2 has been shown to correlate with other outcomes such as death, atrial fibrillation, and ischemic stroke.[13] For this reason, the new guidelines for the assessment of diastolic dysfunction have added more weight to this variable when grading the disease.[10]
However, LAmVI had the best association with heart failure hospitalization in our patient population [Figure 1]. This novel parameter has been previously described to correlate with PCWP, E/e’, and proBNP better than LA maximum volume index.[7,15,16,17] In addition, there is a growing body of evidence suggesting that it may be a better predictor of heart failure and other cardiac end points.[7,18] In this study, a LAmVI >18 demonstrated the best correlation (94.6% specificity and 61.8% sensitivity) with heart failure hospitalization.
Figure 1.
Association between left atrial minimum volume index and heart failure hospitalization in the overall population.
One explanation for this finding is that minimum volume is measured in end-diastole and is thus influenced by LV end-diastolic pressure, known to be one of the earliest changes in diastolic dysfunction.[7] Therefore, changes in LAmVI can be seen in the early stages of diastolic dysfunction, in contrast to LA maximum volumes which do not correlate as well with Grade 1 dysfunction.[15,19] The findings from this study support this concept since LAmVI also had the best correlation with heart failure hospitalization in the subgroup of patients with Grade 1 diastolic dysfunction.
In this investigation, LA function (as assessed by LA emptying fraction and atrial strain) showed a modest association with heart failure hospitalization. There is evidence that LA function has some utility in predicting cardiac outcomes.[20] However, the most robust data apply to populations with atrial fibrillation, a subgroup that was excluded from this study.
Limitations
Our study has several limitations inherent to the single-center, retrospective, cross-sectional methodology utilized. Despite finding significant associations between echocardiographic variables and heart failure hospitalization, it is important to note that baseline echocardiograms prior to index hospitalization (development of heart failure) were not available. Thus, we are unable to demonstrate a change over time in the various echocardiographic parameters, and for this reason, we could not make any strong conclusion regarding the variables as predictors of HFpEF. In addition, pulmonary vein flow, an important variable in the diastolic assessment, was not included in our analysis. Finally, a large number of the screened patients were excluded, leaving a fairly small sample size. However, a significant association was demonstrated that should not be overlooked.
Conclusions
HFpEF has become a huge economic burden, and with no proven therapies currently available, the focus should be on monitoring diastolic disease progression in the preclinical phase and prevention of heart failure hospitalization. The LA minimum volume index is a novel echocardiographic parameter that may add value to the diastolic assessment as well as offer prognostic data with regard to predicting heart failure hospitalizations, particularly in the subset of patients without valvular disease or atrial fibrillation. This may potentially identify patients who may benefit from closer surveillance and tighter control of their risk factors. For this reason, these findings should be considered as hypothesis generating, and further studies should be conducted to determine the association between LAmVI and HFpEF.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
The authors would like to acknowledge Helen Parise, PhD for her assistance with the statistical methodology and data analysis.
References
- 1.Sharma K, Kass DA. Heart failure with preserved ejection fraction: Mechanisms, clinical features, and therapies. Circ Res. 2014;115:79–96. doi: 10.1161/CIRCRESAHA.115.302922. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147–239. doi: 10.1016/j.jacc.2013.05.019. [DOI] [PubMed] [Google Scholar]
- 3.Wan SH, Vogel MW, Chen HH. Pre-clinical diastolic dysfunction. J Am Coll Cardiol. 2014;63:407–16. doi: 10.1016/j.jacc.2013.10.063. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Herbots L, Jin Y, Stolarz-Skrzypek K, Staessen JA. Systolic and diastolic left ventricular dysfunction: From risk factors to overt heart failure. Expert Rev Cardiovasc Ther. 2010;8:251–8. doi: 10.1586/erc.10.3. [DOI] [PubMed] [Google Scholar]
- 5.Zile MR, Gottdiener JS, Hetzel SJ, McMurray JJ, Komajda M, McKelvie R, et al. Prevalence and significance of alterations in cardiac structure and function in patients with heart failure and a preserved ejection fraction. Circulation. 2011;124:2491–501. doi: 10.1161/CIRCULATIONAHA.110.011031. [DOI] [PubMed] [Google Scholar]
- 6.Takemoto Y, Barnes ME, Seward JB, Lester SJ, Appleton CA, Gersh BJ, et al. Usefulness of left atrial volume in predicting first congestive heart failure in patients > or = 65 years of age with well-preserved left ventricular systolic function. Am J Cardiol. 2005;96:832–6. doi: 10.1016/j.amjcard.2005.05.031. [DOI] [PubMed] [Google Scholar]
- 7.Hoit BD. Left atrial size and function: Role in prognosis. J Am Coll Cardiol. 2014;63:493–505. doi: 10.1016/j.jacc.2013.10.055. [DOI] [PubMed] [Google Scholar]
- 8.Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. Am J Cardiol. 2002;90:1284–9. doi: 10.1016/s0002-9149(02)02864-3. [DOI] [PubMed] [Google Scholar]
- 9.Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16:233–70. doi: 10.1093/ehjci/jev014. [DOI] [PubMed] [Google Scholar]
- 10.Nagueh SF, Smiseth OA, Appleton CP, Byrd BF, 3rd, Dokainish H, Edvardsen T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277–314. doi: 10.1016/j.echo.2016.01.011. [DOI] [PubMed] [Google Scholar]
- 11.Mottram PM, Marwick TH. Assessment of diastolic function: What the general cardiologist needs to know. Heart. 2005;91:681–95. doi: 10.1136/hrt.2003.029413. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. Eur J Echocardiogr. 2009;10:165–93. doi: 10.1093/ejechocard/jep007. [DOI] [PubMed] [Google Scholar]
- 13.Abhayaratna WP, Seward JB, Appleton CP, Douglas PS, Oh JK, Tajik AJ, et al. Left atrial size: Physiologic determinants and clinical applications. J Am Coll Cardiol. 2006;47:2357–63. doi: 10.1016/j.jacc.2006.02.048. [DOI] [PubMed] [Google Scholar]
- 14.Paul B. Left atrial volume – A new index in echocardiography. JAPI. 2009;57:463–5. [Google Scholar]
- 15.Russo C, Hahn RT, Jin Z, Homma S, Sacco RL, Di Tullio MR. Comparison of echocardiographic single-plane versus biplane method in the assessment of left atrial volume and validation by real time three-dimensional echocardiography. J Am Soc Echocardiogr. 2010;23:954–60. doi: 10.1016/j.echo.2010.06.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Hedberg P, Selmeryd J, Leppert J, Henriksen E. Left atrial minimum volume is more strongly associated with N-terminal pro-B-type natriuretic peptide than the left atrial maximum volume in a community-based sample. Int J Cardiovasc Imaging. 2016;32:417–25. doi: 10.1007/s10554-015-0800-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Posina K, McLaughlin J, Rhee P, Li L, Cheng J, Schapiro W, et al. Relationship of phasic left atrial volume and emptying function to left ventricular filling pressure: A cardiovascular magnetic resonance study. J Cardiovasc Magn Reson. 2013;15:99. doi: 10.1186/1532-429X-15-99. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Habibi M, Chahal H, Opdahl A, Gjesdal O, Helle-Valle TM, Heckbert SR, et al. Association of CMR-measured LA function with heart failure development: Results from the MESA study. JACC Cardiovasc Imaging. 2014;7:570–9. doi: 10.1016/j.jcmg.2014.01.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Pritchett AM, Mahoney DW, Jacobsen SJ, Rodeheffer RJ, Karon BL, Redfield MM. Diastolic dysfunction and left atrial volume: A population-based study. J Am Coll Cardiol. 2005;45:87–92. doi: 10.1016/j.jacc.2004.09.054. [DOI] [PubMed] [Google Scholar]
- 20.Koshizuka R, Ishizu T, Kameda Y, Kawamura R, Seo Y, Aonuma K. Longitudinal strain impairment as a marker of the progression of heart failure with preserved ejection fraction in a rat model. J Am Soc Echocardiogr. 2013;26:316–23. doi: 10.1016/j.echo.2012.11.015. [DOI] [PubMed] [Google Scholar]