Left Atrial Strain in Patients with Chronic Heart Failure with Preserved Ejection Fraction: A Narrative Review

Heart failure with preserved ejection fraction (HFpEF) represents a significant portion of heart failure cases, but diagnosis is challenging due to its diverse presentation and the limitations of traditional echocardiographic parameters. Left atrial (LA) strain provides valuable insights into LA function and is increasingly used to evaluate cardiac function, including left ventricular (LV) diastolic function. LA strain, particularly reservoir strain, is considered a reliable indicator of LV diastolic function and can be used to grade diastolic function and estimate LV filling pressure. Unlike traditional LA measurements, LA strain offers detailed insights into LA function, conduit, and booster-pump phases, making it crucial for evaluating both structural and functional cardiac performance, especially in HFpEF. HFpEF diagnosis currently relies on a combination of echocardiographic parameters, clinical symptoms, and natriuretic peptide levels, encompassing various pathophysiological entities and complicating standardized management. Precise characterization of cardiac pathologies in HFpEF patients is essential. This review assesses global longitudinal strain (GLS) and left atrial strain (LAS) as echocardiographic biomarkers for diagnosing and characterizing HFpEF. Strain imaging, particularly speckle tracking echocardiography, offers a refined assessment of myocardial deformation, providing detailed insights into left heart function beyond traditional measures. Normal ranges for GLS and LAS are discussed, acknowledging demographic and technical influences. Clinical studies confirm the prognostic value of GLS and LAS in HFpEF, especially for predicting cardiovascular outcomes and distinguishing HFpEF from other dyspnea causes. However, variability in strain measurements and false-negative risks necessitate cautious clinical interpretation. The HFA-PEFF scoring system includes these biomarkers but does not fully cover the HFpEF pathology spectrum. Combining GLS and LAS shows promise in defining HFpEF phenogroups, potentially guiding individualized treatments. Global longitudinal strain (GLS) and left atrial strain (LAS) are central to non-invasive HFpEF diagnosis and stratification, with potential for more tailored therapies. Integration of these biomarkers into standard diagnostic practice requires an organized approach, and future guidelines should recommend their combined use for comprehensive HFpEF assessment.