Incremental Value of Left Atrial Strain in HFA-PEFF for Heart Failure With Preserved Ejection Fraction

Because exercise testing is not feasible for a substantial subset of patients with suspected heart failure with preserved ejection fraction (HFpEF), the Heart Failure Association-Pre-test assessment, Echocardiography and natriuretic peptide score, Functional testing in cases of uncertainty, Final etiology (HFA-PEFF) score often leaves many patients in an indeterminate diagnostic category.

The authors aimed to assess whether resting left atrial strain provides incremental diagnostic value beyond the HFA-PEFF score in patients undergoing exercise right heart catheterization.

This prospective study enrolled 77 patients with confirmed HFpEF and 37 patients with noncardiac dyspnea (NCD). HFpEF was diagnosed by exercise right heart catheterization demonstrating elevated pulmonary capillary wedge pressure at rest or during exercise. Patients who did not meet HFpEF criteria were classified as NCD. The median HFA-PEFF score was 4 in patients with HFpEF and 2 in those with NCD (P = 0.007).

Left atrial reservoir strain (LARS) was significantly lower in patients with HFpEF compared with those with NCD (26.4% vs 34.7%; P < 0.001). LARS was significantly correlated with exercise mean pulmonary capillary wedge pressure and peak oxygen consumption and declined progressively as more HFpEF criteria were met. The optimal cutoff of LARS for discriminating HFpEF from NCD was 32% (OR: 5.26; 95% CI: 2.30-12.58; P < 0.001). Adding LARS to the HFA-PEFF score improved the area under the curve from 0.65 (0.56-0.74) to 0.75 (0.65-0.85) (P = 0.019) when LARS was analyzed as a continuous variable and to 0.73 (0.63-0.83) (P = 0.026) when using the 32% cutoff.

LARS provides additive diagnostic value beyond the HFA-PEFF score and may reduce the need for noninvasive and invasive stress testing in patients with suspected HFpEF.