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 Table of Contents  
ORIGINAL RESEARCH
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 237-242

Left Atrial ReModeling in Disease: Association with Clinical Markers


1 Department of Cardiology, Goa Medical College and Hospital, Bambolim, Goa, India
2 Department of Cardiology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
3 Department of Pharmacology, St. John's Medical College, Bengaluru, Karnataka, India
4 Department of Biostatistics, St. John's Research Institute, Bengaluru, Karnataka, India
5 Department of Cardiology, University of Florence, Florence, Italy

Date of Submission03-May-2020
Date of Decision26-Jun-2020
Date of Acceptance26-Jul-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Dr. Srilakshmi M Adhyapak
Department of Cardiology, St. John's Medical College Hospital, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_19_20

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  Abstract 

Background: The role of left atrial (LA) enlargement has a significant and independent association with moderate and severe diastolic dysfunction, atrial fibrillation, and left ventricular (LV) end-diastolic volume. Clinical features of heart failure have shown a correlation with LV dilatation and LV ejection fraction (LV). Aims: Correlation of clinical features with substrates of cardiac remodeling, especially left atrial (LA) remodeling, has not been well-documented. We sought to determine the major clinical factors that are associated with LA enlargement in subjects with heart failure. Materials and Methods: We studied 200 patients who presented with breathlessness due to underlying cardiac disease. The association of clinical features of cardiac disease with LA remodeling was studied using three-dimensional echocardiography. Results: This was a cross-sectional study conducted between January 2016 and January 2017. We found that clinical features of heart failure such as breathlessness, elevated jugular venous pressure, dilated LV, diastolic dysfunction, severe mitral regurgitation, pulmonary hypertension, and abnormal tricuspid annular plane systolic excursion were significantly associated with LA enlargement. LA volume was significantly and independently associated with moderate and severe diastolic dysfunction, atrial fibrillation, lower hemoglobin levels, and LV diastolic size on echocardiography. The sensitivity and specificity of breathlessness with LA enlargement were not significant. Conclusions: Clinical features of heart failure, namely breathlessness, were significantly associated with LA enlargement. LA enlargement was not a sensitive or specific marker of breathlessness in heart failure.

Keywords: Heart failure, left atrial volume, left atrium


How to cite this article:
Piedade JQ, Adhyapak SM, Muralidharan P, Raj JM, Fantini F, Varghese K. Left Atrial ReModeling in Disease: Association with Clinical Markers. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:237-42

How to cite this URL:
Piedade JQ, Adhyapak SM, Muralidharan P, Raj JM, Fantini F, Varghese K. Left Atrial ReModeling in Disease: Association with Clinical Markers. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2021 Jan 27];4:237-42. Available from: https://www.jiaecho.org/text.asp?2020/4/3/237/303931


  Introduction Top


It is well known that several diseases and risk factors influence cardiac remodeling. LA enlargement has a significant and independent association with moderate and severe diastolic dysfunction, atrial fibrillation, and left ventricular (LV) end-diastolic volume. Clinical features of heart failure have shown a correlation with LV dilatation and LV.[1],[2],[3] Correlation of clinical features with substrates of cardiac remodeling, especially left atrial (LA) remodeling, has not been well-documented. We wanted to investigate the association of clinical features of heart failure with LA remodeling.

Aim

The pathophysiology of LA enlargement is multifactorial, but the association of clinical factors with LA enlargement has not been well defined. We sought to determine the major clinical factors that are associated with LA enlargement in subjects with heart failure. We used indexed LA volume, as it is a more precise marker of LA size than LA diameter.[2],[3],[4]

As three-dimensional (3D) echocardiography-derived LA volume measurements have been found more accurate than 2D echocardiography-based analysis with similar reproducibility when compared with reference standards such as magnetic resonance imaging, biplane contrast ventriculography, and cine computed tomography (CT), we used 3D echocardiography to estimate LA volume.[4],[5],[6],[7],[8]


  Materials and Methods Top


This was a cross-sectional study conducted at the Department of Cardiology of St. John's Medical College Hospital from January 2016 to January 2017. Institutional Ethics Committee (IEC) approved the conduct of the study No. 3/13-16(1) 2016 and all patients gave informed consent. We studied 200 patients who presented with breathlessness due to underlying cardiac disease using 3D echocardiography.

Inclusion criteria

All patients aged >18 years admitted with heart disease with a LA diameter on M-mode more than or equal to 4 cm were studied. These patients underwent further imaging using 3D echocardiography for LA volume estimation.

Exclusion criteria

Patients with rheumatic valvular heart disease, pacemaker implantation, congenital heart disease, prosthetic valve, and inadequate ultrasonic images due to poor echo windows were excluded from the study. All relevant medical history and comorbidities were noted for each patient.

All patients underwent a comprehensive transthoracic echocardiographic examination using Vivid E9 (GE) echocardiography machine. LA diameter was determined by M-mode echocardiography at the aortic valve level of parasternal short-axis view.[9] LV ejection fraction (LV) was assessed in accordance with published guidelines (Simpson's method).[9] The LV diastolic function was evaluated by Doppler echocardiography of transmitral flow and TDI of the mitral annulus. Right ventricular systolic function was evaluated by assessing the tricuspid annular plane systolic excursion (TAPSE).

LA volume was estimated using 3D technique and it was later indexed to body surface area. Harmonic real time 3 dimensional echocardiography (RT3DE) imaging was obtained with an X3-1 matrix array transducer with a temporal resolution of 35–50 frames/s. The participants were all in the left lateral decubitus position. A wide-angled “full-volume acquisition mode” was obtained over four to five consecutive cardiac cycles, during held respiration. The RT3DE data sets were analyzed with commercial software in the Vivid machine. In principle, the focus was laid on the most optimal imaging of the left atrium in the four-chamber view. Since the first frame in the loop corresponded to ventricular end-diastole, initial measurements were performed in the frame with the largest atrial dimension, corresponding to ventricular end-systole, just before opening of the atrioventricular valves. Five anatomic landmarks were manually initialized for the left atrium. Following this manual identification, the program automatically identified the endocardial surface. Then, manual adjustments of the endocardial surface were performed in all examinations presented to exclude atrial appendages and large veins from the cavity volumes. Then, the frame with the smallest atrial dimension was selected with similar surface detection and manual editing. Atrial maximum (max) and minimum (min) volumes were obtained; usually, the time consumed to obtain these measurements was 4–5 min. LA enlargement was defined as an LA diameter exceeding 4.0 cm on M-mode echocardiography.[9] LA volume indexed (LAVI) to body surface area was defined as 34 ml/m2 as the upper limit of normal according to the American Society of Echocardiography. LVH on echocardiography was defined based on the M-mode criteria (interventricular thickness + posterior wall thickness of more than 2.4 cm). The ejection fraction was calculated based on the biplane Simpson's method (>55% was defined as normal).[9] Diastolic function was classified as normal or abnormal (DD), and then, DD (when it was present) was assigned one of three grades (i) E/A ratio <0.7 (Grade I, impaired relaxation); (ii) E/A ratio >0.7 and <1.5 and e' velocity <7 cm/s (Grade II, pseudonormalized pattern); or (iii) E/A ratio >1.5 and e' velocity <7 cm/s (Grade III, restrictive pattern). LV hypertrophy (LVH) was defined on electrocardiogram (ECG) according to the Sokolow–Lyon voltage criteria (SV1 + RV5 >3.5 mV). According to JNC-7 report,[10],[11],[12],[13],[14],[15] hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg and/or use of antihypertensive medications. Body mass index was categorized into four groups as underweight, normal, overweight, and obese according to the World Health Organization (WHO) criteria. Anemia was defined according to the WHO as hemoglobin <12 g/dl in women and <13.0 g/dl in men, it was further subdivided as mild 11–12.9 g/dl in men and 11–11.9 g/dl in women, moderate as 8–11 g/dl and severe as <8 g/dl. Diabetes mellitus was diagnosed according to the WHO criteria: FPG ≥7 mmol/L (126 mg/dL) and/or being on treatment for diabetes and/or Hba1c >6.5%.[16] Patients were classified as smokers when reporting current smoking habit or ex-smokers when reporting quitting smoking for at least 1 year. Alcoholics were defined according to the International Classification of Diseases and Health Problems-10.

Statistical analysis

All values were expressed as mean ± standard deviation (SD). All continuous variables were analyzed using independent t-test in case of two groups and one-way ANOVA in the presence of more than two groups. Pearson's correlation was used to determine the relationship between the clinical and echocardiographic variables and the LA volume (continuous variables). Variables with P < 0.2 were taken up for multivariate regression and the stepwise regression was done to determine the most significant factors. Receiver operating characteristic curves were analyzed for sensitivity and specificity of breathlessness and LAVI, LV, LV internal diameter in diastole (LVIDd), and LV diastolic dysfunction. SPSS version 14 (Chicago, Ill) was used for the analysis and P < 0.05 was considered significant.


  Results Top


Patient characteristics

There were 138 males (69.3%). The mean age (±SD) was 57.72 ± 13.1. Symptoms at presentation were predominantly breathlessness which was seen in 150 (75%) of patients, followed by chest pain which was seen in 18 (9%) of patients. Jugular venous pressure (JVP) was elevated in 84 (42%) patients.

Underlying disease conditions

Eighty-one (40.5%) patients presented with acute congestive cardiac failure. Chronic kidney disease (CKD) was seen in 60 (30.2%) patients, ischemic heart disease was noted in 53 (26.5%) patients, and patients with chronic obstructive pulmonary disease (COPD) were 5 (2.5%). Atrial fibrillation was seen in 19 (9.5%) patients, while the remaining were in sinus rhythm. On analyzing associated comorbidities, the most common was hypertension (131, 65.8%), followed by diabetes in 98 (55.1%) patients. There were 13 (6.5%) patients with dyslipidemia. Hypothyroidism was noted in 18 (9.1%) of patients, whereas hyperthyroidism was seen in 2 (1%) patients.

Lifestyle parameters were analyzed which revealed 57 (28.5%) smokers with mean pack-years of 16.6. Thirty (15%) patients were alcoholic.

Ophthalmic evaluation done in diabetic patients showed mild and moderate Non proliferative diabetic retinopathy was noted in 34 (28.33%) patients. Severe non proliferative diabetic retinopathy was seen in 5 (4.7%) patients. Among hypertensive patients, Grade 1 hypertensive changes were seen in 60 (30%) patients. Thirty-four (17.2%) CKD patients were on dialysis in our study.

On ECG evaluation, 119 (59.5%) patients had evidence of LA enlargement, LVH was noted in 17 (8.5%) patients, and 19 (9.5%) patients had atrial fibrillation.

LA size by M-Mode was 4.44 ± 0.42 cm. The mean LA volume was 75.4 ± 22.94 ml which when indexed to body surface area (Dubois method) was 46.77 ± 14 ml/m2. The mean LV size in diastole was 5.79 ± 0.88 cm and in systole 3.86 ± 1.09 cm. The mean TAPSE values were noted to be 1.85 ± 0.44 cm. LVH was noted in 81 (40.5%) patients. The mean ejection fraction was 49.66% ± 17.34%. The mean E/e was 11.64 ± 4.51 and mean pulmonary artery systolic pressure were 44.74 ± 12.44 mmHg. Grade 1 diastolic dysfunction was seen in 87 (43.5%) patients, Grade 2 diastolic dysfunction in 65 (32.5%) patients, and Grade 3 in 35 (17.5%) patients, while normal diastolic function was seen in 13 (6.5%) patients.

Effect of clinical features and echocardiographic variables on left atrial volume

Patients with breathlessness had higher mean LA volume (48.5 ± 14.34 vs. 41.43 ± 11.47 ml/m2) (P = 0.001), as with patients with elevated JVP (50.51 ± 44.07 vs. 44.07 ± 12.08 ml/m2) (P = 0.002). Patients with past history of ischemic heart disease had higher LA volume (51.02 ± 15.15 vs. 45.25 ± 13.29 ml/m2) (P = 0.016) and those admitted with CHF had increased LA volume (50.28 ± 15.38 vs. 44.39 ± 12.49 ml/m2) (P = 0.005). Patients who had atrial fibrillation had significantly higher LA volume than those in sinus rhythm (62.44 ± 17.22 vs. 45.13 ± 12.59 ml/m2) (P < 0.001).

Patients with CKD demonstrated a significantly larger LA volume across all stages of CKD (the most significant difference was noted between stages 3 and 2 in the post hoc analysis using the Tukey test P = 0.006). Among patients with anemia, patients with hemoglobin <8 g/dl had higher LA volume as compared to patients with hemoglobin more than 11 g/dl (P = 0.03). When the echocardiographic variables were analyzed, patients with mitral regurgitation had higher LA volumes with patients with severe mitral regurgitation having the highest LA volumes (P = 0.0007, P = 0.04). Patients with LV global hypokinesia had greater LA volume than patients with no regional wall motion abnormality (P = 0.012). There was a graded increase in the LA volume with increasing grades of diastolic dysfunction [Table 1].
Table 1: Echo parameters of patients

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Abnormal TAPSE showed higher mean LA volume (52.03 ± 15.33 vs. 44.93 ± 13.06 ml/m2) (P = 0.004).

LV diastolic size (r = 0.29), PASP (r = 0.23), and E/e (r = 0.15) showed a positive correlation with LA volume. Hemoglobin (r = −0.19) and LVEF (r = −0.24) showed a negative correlation with LA volume.

Predictors of left atrial volume using multivariate regression

On multivariate analysis, the only independent predictors of increased LA volume were hemoglobin levels (P = 0.05), atrial fibrillation (P = 0.0003), and the grades of diastolic dysfunction. Using a best-fit model, the independent correlates of LA volume were waist circumference (P = 0.008), hemoglobin (P = 0.0007), LV diastolic size (P = 0.003), atrial fibrillation (P < 0.001), and the three grades of diastolic dysfunction [Table 2].
Table 2: Effect of clinical features, laboratory parameters, and echocardiographic variables on left atrial volume

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From these findings, it is clear that clinical features of heart failure such as breathlessness, elevated JVP, dilated LV, diastolic dysfunction, severe mitral regurgitation, pulmonary hypertension, and abnormal TAPSE were significantly associated with LA enlargement. Most of these clinical features such as breathlessness and raised JVP also correlated significantly with other features such as dilated LV, reduced LV systolic function, right ventricular dysfunction, and LV diastolic dysfunction. Comorbid conditions such as systemic hypertension, COPD, all stages of CKD, atrial fibrillation, and severe anemia had a significant correlation with LA enlargement.

When the sensitivity and specificity of breathlessness with echocardiographic parameters denoting cardiac remodeling like LAVI, LVEF, and LV diastolic dysfunction (E/A) were analyzed, LAVI and E/A showed an area under the curve (AUC) of 67% as compared to other parameters whose AUC was much lesser (LVEF: AUC: 25%, LVIDd: AUC: 63%, LA diameter: AUC: 62%; PASP: AUC: 53%, E/e': AUC: 60%). However, none were statistically significant.


  Discussion Top


This cross-sectional study of 200 patients was done to try and find a correlation between clinical findings and LA enlargement. All these patients had heart disease and were screened by 2D echocardiography for LA enlargement and only those with LA diameter ≥4 cm were included for LA volume estimation by 3D echocardiography. Patients with rheumatic heart disease and congenital heart disease and those with pacemaker insertions were excluded from the study. It has been studied in large prospective multi-centric studies across a large range of LA sizes with comparison to CMR reference, that 3D Echocardiography-derived LA volume measurements were found to be more accurate than 2D echocardiography-based analysis with similar reproducibility.[4],[5],[6],[7],[8] There is a paucity of studies correlating LA volume with clinical features of heart failure or cardiac disease. We conducted this study to try and define clinical markers for LA enlargement in the presence of cardiac disease.[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27]

We found that eighty-one (40.5%) patients presented with acute congestive cardiac failure, CKD in 60 (30.2%) patients, ischemic heart disease in 53 (26.5%) patients, and COPD in 5 (2.5%). Atrial fibrillation was seen in 19 (9.5%) patients, while the remaining were in sinus rhythm. On analyzing associated comorbidities, the most common was hypertension (131, 65.8%), followed by diabetes in 98 (55.1%) patients. There were 13 (6.5%) patients with dyslipidemia. Hypothyroidism was noted in 18 (9.1%) patients, whereas hyperthyroidism was seen in 2 (1%) patients.

Although there were 5% of patients with COPD who had enlarged LA, this could have been the effect of associated hypertension in them.

All patients were analyzed after they were adequately decongested and were not in acute severe heart failure. The CKD patients were analyzed after dialysis. The volume shifts thus caused may have influenced LA volume measurements.

The effect of treatment on the volume status might thus reflect chronic LA remodeling in the volumetric analysis. Patients with breathlessness and elevated JVP had larger LA volumes. The patients with dilated cardiomyopathy had larger LA than those with ischemic cardiomyopathy and LA was enlarged across all stages of CKD in a graded manner. There was a trend toward a better predictability of breathlessness with increased LA volume and diastolic dysfunction.

Limitations

This is a single-center cross-sectional study and patients were not followed up. Although associations were demonstrated between LAVI and a few clinical symptoms, we could not determine the sensitivity and specificity of LA enlargement and breathlessness due to the small sample size. Another limitation was the assessment of diastolic dysfunction done by the mitral E/A and E/e prime ratio, although half the patients had an LVEF >50%.


  Conclusions Top


Clinical features of heart failure such as breathlessness, elevated JVP, dilated LV, diastolic dysfunction, severe mitral regurgitation, pulmonary hypertension, and abnormal TAPSE were significantly associated with LA enlargement. LA volume was significantly and independently associated with moderate-to-severe diastolic dysfunction, atrial fibrillation, lower hemoglobin levels, and LV diastolic size on echocardiography. LA enlargement was not a sensitive or specific marker of breathlessness in heart failure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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