To identify diagnostic utility of LAD for AF in HFpEF, HFmrEF, and HFrEF, 71 subjects with AF and 71 EF-matched subjects with SR were included in the study. In this study, we found the prediction of LAD, but not Nt-proBNP, for AF in HFpEF, HFmrEF, and HFrEF. The results indicated that LAD was associated with LVEF, Nt-proBNP, and LVEDd expect for NYHA class. Furthermore, LAD was also correlated with coronary heart disease and hypertension. After all the subjects were divided according to LVEF, data showed that LAD in HFrEF was greater than HFpEF and HFmrEF, but HFpEF is close to HFmrEF. HFrEF has higher Nt-proBNP than HFpEF and HFmrEF while HFmrEF is similar to HFpEF and HFrEF. Finally, LAD predicted HFrEF among the 3 categories.
Atrial dilatation is the major marker of left atrium remodeling. LA enlargement could predict the development of 1st AF. Furthermore, it has been showed that patients with incident chronic HF during follow-up had greater LAD. Due to atrial structural remodeling, mainly because of fibrosis, AF patients always had greater LAD. Indeed, the finding of the present study indicated LAD in AF was still higher than SR in the setting of HF. Although it has been reported that HF patients were associated with larger LA dilatation than HF-free controls and LA remodeling and function differed in HFpEF (LVEF ≥ 50%) and HFrEF (LVEF < 50%). To eliminate the effects of LVEF, AF patients and SR patients enrolled in this study were EF matched. Our ROC analysis also showed LAD could predict AF in HF.
The association of LA enlargement with HF has been well established. LA was accompanied remodeling, apoptosis, myosin isoform expression, collagen matrix turnover, and reduced intrinsic contractility when response to increased loading. In SOLVD Registry and Trials, LAD was associated with increased risk of death and cardiovascular hospitalization. LA area is also a powerful predictor of death or hospitalization among HF patients with predominantly impaired systolic function. Furthermore, LA volume index predicted chronic HF hospitalization and mortality as well as LVEF in patients with coronary disease. 3D LAV >100 mL predicted cardiac deaths and hospitalizations as a result of heart failure among patients with severe LV dysfunction. In the present study, we also found LAD was associated with LVEF. There was a significant correlation with LAD index and left ventricular filling pressure; therefore, LAD directly reflected the left ventricular filling pressure. As was shown in this study, although LAD was not associated with NYHA class because of the subjective assessment factors, LAD was associated with Nt-proBNP and LVEDd.
Several risk factors, such as hypertension, diabetes mellitus, and coronary artery disease contributed to development of HF. LA appendage stores about 30% of ANP, which regulates natriuresis and diuresis. Although ANP levels did not have impact on systemic blood pressure, a recent study showed that after LA appendage exclusion, systemic blood pressure was reduced in patients with AF and history of hypertension. Furthermore, the indexed LAD correlated positively with diabetes mellitus, hypertension, and coronary artery disease. In fact, high blood pressure induced anatomic and hemodynamic changes, which was associated with atrial wall stress, and decreasing left ventricular diastolic pressure, subsequently affecting clinical outcomes in HF. Our data showed LAD was also associated with hypertension. Patients with AMIs followed for a mean of 15 months, higher LA volume index was a powerful predictor of all-cause mortality. AMIs and larger LA volume index was correlated with a higher incidence of chronic HF, increased LV dimensions, and reduced LVEF. The result showed LAD was correlated with coronary heart disease and prior myocardial infarction. In this study, LAD was not associated with diabetes, although diabetes mellitus was independent correlates of LA fibrosis and poor outcomes.[25,26]
In several studies, LA remodeling has been compared in HFpEF and HFrEF. LA maximal volume and active emptying fraction were greater in systolic HF (LVEF < 0.5) than diastolic HF (LVEF ≥ 0.5). Moreover, HFrEF (LVEF < 0.5) patients had larger LA volumes than HFpEF (LVEF ≥ 0.5). There was no difference in LV mass and LA volume between diastolic HF and systolic HF, but the sample size of this study was very small. In the present study, LAD increased accompanying with decreased LVEF. And LAD predicted HFrEF across the 3 categories.
Although LAD may less precisely represent the true LA size than LA volume, LAD is still a reliable surrogate. Furthermore, measurement of LAD is more easily conducted than LA volume and has already been included in the routine echocardiographic examination. Despite not wide application, several study also reported that LAD could be used to predict clinical outcomes.[18,29]
In conclusion, in the setting of HF, LAD was higher in AF than in and SR and predicted AF. Furthermore, LAD was associated with severity of HF, and also predicted HFrEF across the three categories. However, it is hard to permit any definite conclusions due to the small sample. Prospective studies with long-term follow-up are required to evaluate the role of LAD in HFpEF, HFmrEF, and HFrEF.
The present study has some limitations. The sample size was small. Furthermore, our study was observational study and longitudinal data are necessary to evaluate the role of LAD in HF. Finally, follow-up study should be conducted to elucidate the predictive role of LAD for outcome of HF. All the patients with paroxysmal could not be confirmed by 24-hour dynamic electrocardiogram.
The authors thank all the study personnel for their contribution.
Ning Zhu orcid: 0000-0002-7521-6266.
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