What is the significance of elevated left atrial pressure, moderate left atrium (LA) dilation, and grade 2 diastolic dysfunction?

From the Guidelines

The findings of elevated left atrial pressure, moderate left atrium dilation, and grade 2 diastolic dysfunction indicate significant heart dysfunction that requires medical attention, and treatment should focus on reducing fluid overload and controlling blood pressure to improve morbidity, mortality, and quality of life. These findings suggest heart failure with preserved ejection fraction (HFpEF), which means the heart is not relaxing properly between beats, leading to increased pressure in the left atrium and its enlargement 1. According to the American Society of Echocardiography and the European Association of Cardiovascular Imaging, the assessment of LV filling pressures is important in patients with HFpEF as it can successfully guide medical treatment 1.

Key Findings and Recommendations

• The patient's E/A ratio and peak E velocity should be evaluated to determine the grade of diastolic dysfunction, and if the E/A ratio is ≤ 0.8 along with a peak E velocity of ≤50 cm/sec, then mean LAP is either normal or low, and the corresponding grade of diastolic dysfunction is grade I 1.
• If the E/A ratio is ≥2, LA mean pressure is elevated and grade III diastolic dysfunction is present, but in patients with recent cardioversion to sinus rhythm, mitral DT should be used for assessment of LV diastolic function 1.
• Treatment typically includes diuretics like furosemide 20-40mg daily or hydrochlorothiazide 12.5-25mg daily to reduce fluid overload, along with blood pressure control using ACE inhibitors (such as lisinopril 5-40mg daily) or ARBs (such as losartan 25-100mg daily) 2.
• Lifestyle modifications are essential, including sodium restriction (<2g/day), regular physical activity, weight management, and limiting alcohol consumption.
• These findings are associated with increased risk of atrial fibrillation, stroke, and worsening heart failure symptoms like shortness of breath, fatigue, and reduced exercise tolerance, and the condition is often caused by long-standing hypertension, coronary artery disease, diabetes, or aging 2.

Monitoring and Follow-up

• Regular follow-up with a cardiologist is necessary to monitor disease progression and adjust treatment as needed.
• The patient's LA volume index, LV mass, and PASP should be monitored to assess the effectiveness of treatment and adjust the treatment plan accordingly 1.

From the Research

Clinical Significance of Elevated Left Atrial Pressure, Moderate Left Atrium Dilation, and Grade 2 Diastolic Dysfunction

• Elevated left atrial pressure, moderate left atrium dilation, and grade 2 diastolic dysfunction are significant indicators of left ventricular diastolic dysfunction (LVDD) 3, 4, 5.
• Left atrial overload, as shown by electrocardiogram (ECG), can be used as an aid for evaluating LVDD, with P-duration and terminal force (PTFV1) being useful indices 3.
• Left atrial strain (LAS) has emerged as a sensitive marker of LA function and elevated filling pressures, and can be used to predict LVDD with high sensitivity and specificity 4.
• Integrating left atrial reservoir strain (LASr) into the first-line assessment of diastolic function can improve classification and risk stratification of patients with normal left ventricular systolic function 6.

Diagnostic and Prognostic Implications

• The presence of elevated left atrial pressure, moderate left atrium dilation, and grade 2 diastolic dysfunction can indicate an increased risk of heart failure with preserved ejection fraction 5, 7.
• LA diastolic dysfunction, in addition to left ventricular diastolic dysfunction, may contribute to the syndrome of heart failure with preserved left ventricular systolic function 7.
• The use of LAS and LASr can provide additive value in diagnosing and grading the severity of LVDD, as well as monitoring the effects of treatment 4, 6, 5.

Echocardiographic Assessment

• Echocardiography remains a crucial tool in assessing LVDD, with parameters such as transmitral flow, tissue velocity, maximum left atrial volume (LAV), and estimated pulmonary artery systolic pressure being used to evaluate diastolic function 5.
• However, the shortcomings of these parameters can lead to the presence and severity of LVDD remaining undetermined in a significant proportion of patients, highlighting the need for additional markers such as LAS and LASr 5.