Original Article

Comparing Left Atrial Strain and the HFA-PEFF Score in Diagnosing Heart Failure with Preserved Ejection Fraction: A Cross-Sectional Study

Abstract

Background: Heart failure with preserved ejection fraction (HFpEF) has a high hospitalization rate. While recent guidelines recommend parameters like E/e’ and e’ velocity for diagnosis, their accuracy remains limited. Left atrial (LA) strain is a potential diagnostic parameter, yet its role in the Vietnamese population is unclear. This study aims to evaluate LA strain’s diagnostic value in HFpEF among Vietnamese patients, exploring its relationship with established parameters of left ventricle diastolic function.
Methods: A cross-sectional study (15/04/2022 - 01/12/2023) included 49 patients with HFpEF and 69 individuals without cardiac dysfunction. The study subjects were evaluated for LA strain and HFA-PEFF score. Diagnostic criteria for HFpEF were based on the 2021 European Society of Cardiology guidelines for diagnosing and treating acute and chronic heart failure.
Results: LA strain including LA reservoir (LASr), conduit (LAScd), and contractile (LASct) functions, in the HFpEF group were 20.80% [13.30-26.50], 10.89±5.16%, and 9.08±6.18%, respectively. The control group had corresponding LASr, LAScd, and LASct values of 34.45% [31.14-38.07], 17.38±4.41%, and 17.33±5.72% (p<0.001). The area under the curve (AUC) for LASr, LAScd, LAScr, and HFA-PEFF score to diagnose HFpEF was 0.852, 0.770, 0.778, and 0.890, respectively. Comparing the AUCs for diagnosing HFpEF between LASr and HFA-PEFF score, no difference was found with p=0.419.
Conclusion: LASr has a diagnostic value equivalent to the HFA-PEFF score in diagnosing HFpEF and could be incorporated into the existing HFpEF diagnostic guidelines.

Redfield MM, Borlaug BA. Heart failure with preserved ejection fraction: a review. JAMA. 2023;329(10):827-38.

Obokata M, Reddy YNV, Borlaug BA. Diastolic dysfunction and heart failure with preserved ejection fraction. JACC Cardiovasc Imaging. 2020;13(1 Pt 1):245-57.

Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29(4):277-314.

Ma C, Liao Y, Fan J, Zhao X, Su B, Zhou B. The novel left atrial strain parameters in diagnosing of heart failure with preserved ejection fraction. Echocardiography. 2022;39(3):416-25.

Boe E, Smiseth OA. Left atrial strain imaging: ready for clinical implementation in heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging. 2022;23(9):1169-70.

Rosca M, Lancellotti P, Popescu BA, Pierard LA. Left atrial function: pathophysiology, echocardiographic assessment, and clinical applications. Heart. 2011;97(23):1982-9.

Dang HNN, Luong TV, Tran TT. Evaluating left atrial function changes by speckle tracking echocardiography in type 2 diabetes patients in Central Vietnam: a cross-sectional comparative study. Egypt Heart J. 2024;76(1):38.

Gard EK, Beale AL, Telles F, Kosmala W, Marwick TH, Wright L, et al. Left atrial enlargement is associated with pulmonary vascular disease in heart failure with preserved ejection fraction. Eur J Heart Fail. 2023;25(6):806-14.

Dye C, Dela Cruz M, Larsen T, Rashid M, Sharma K, Lo KB, et al. A review of the impact, pathophysiology, and management of atrial fibrillation in patients with heart failure with preserved ejection fraction. Am Heart J Plus. 2023;33:100309.

Anderson T, Hummel SL, Konerman MC. Epidemiology, diagnosis, pathophysiology, and initial approach to heart failure with preserved ejection fraction. Cardiol Clin. 2022;40(4):397-413.

Gan GCH, Ferkh A, Boyd A, Thomas L. Left atrial function: evaluation by strain analysis. Cardiovasc Diagn Ther. 2018;8(1):29-46.

Jarasunas J, Aidietis A, Aidietiene S. Left atrial strain - an early marker of left ventricular diastolic dysfunction in patients with hypertension and paroxysmal atrial fibrillation. Cardiovasc Ultrasound. 2018;16(1):29.

Reddy YNV, Obokata M, Egbe A, Yang JH, Pislaru S, Lin G, et al. Left atrial strain and compliance in the diagnostic evaluation of heart failure with preserved ejection fraction. Eur J Heart Fail. 2019;21(7):891-900.

Brand A, Romero Dorta E, Wolf A, Kuehne T, Stangl V, Baldenhofer G, et al. Phasic left atrial strain to predict worsening of diastolic function: results from the prospective Berlin Female Risk Evaluation follow-up trial. Front Cardiovasc Med. 2023;10:1070450.

Kim D, Seo JH, Choi KH, Lee MM, Choi JO, Lee HY, et al. Prognostic implications of left atrial stiffness index in heart failure patients with preserved ejection fraction. JACC Cardiovasc Imaging. 2023;16(4):435-45.

Rimbas RC, Visoiu IS, Magda SL, Mihalcea DJ, Florescu M, Rimbas M, et al. New insights into the potential utility of the left atrial function analysis in heart failure with preserved ejection fraction diagnosis. PLoS One. 2022;17(5):e0267962.

McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-726.

Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2019;32(1):1-64.

Doan C, Tran K, Luong V, Nguyen N, Nu V. Efficacy of artificial intelligence software in the automated analysis of left ventricular function in echocardiography in Central Vietnam. Acta Inform Med. 2024;32(1):32-6.

Dang HNN, Luong TV, Nguyen Khoi Q, Nguyen Minh D, Tran Quang A, Nguyen Thi Yen N, et al. Alterations in aortic elasticity indices among type 2 diabetes patients in a low and middle income country using M-mode echocardiography: a cross-sectional comparative study. PLoS One. 2024;19(10):e0305799.

Dang HNN, Luong TV, Nguyen NTY, Le VTQ, Le MT, Nguyen KQ, et al. Assessment of the right ventricular strain, left ventricular strain and left atrial strain using speckle tracking echocardiography in patients with chronic obstructive pulmonary disease. BMJ Open Respir Res. 2025;12(1):e002706.

Park JJ, Hwang I, Kang S, Park J, Park J, Cho G. Myocardial strain for heart failure with preserved ejection fraction but without diastolic dysfunction. ESC Heart Fail. 2022;9(5):3308-16.

Luong TV, Dang HNN, Nguyen TBN, Le VTQ, Le MT. Quantifying left atrial dysfunction in heart failure: a single-center study in Vietnam comparing heart failure with preserved and reduced ejection fractions via speckle tracking echocardiography. J Diagn Med Sonogr. 2025 Feb 4 [Epub ahead of print].

Cameli M. Echocardiography strain: why is it used more and more? Eur Heart J Suppl. 2022;24(Suppl I):I38-I42.

Pieske B, Tschöpe C, De Boer RA, Fraser AG, Anker SD, Donal E, et al. How to diagnose heart failure with preserved ejection fraction: the HFA–PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur Heart J. 2019;40(40):3297-317.

DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837-45.

Aung SM, Güler A, Güler Y, Huraibat A, Karabay CY, Akdemir I. Left atrial strain in heart failure with preserved ejection fraction. Herz. 2017;42(2):194-9.

Obokata M, Negishi K, Kurosawa K, Tateno R, Tange S, Arai M, et al. Incremental diagnostic value of LA strain with leg lifts in heart failure with preserved ejection fraction. JACC Cardiovasc Imaging. 2013;6(7):749-58.

Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK. Left atrial strain in evaluation of heart failure with preserved ejection fraction. J Am Soc Echocardiogr. 2020;33(12):1490-9.

Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891-975.

Dzhioeva O, Belyavskiy E. Diagnosis and management of patients with heart failure with preserved ejection fraction (HFpEF): current perspectives and recommendations. Ther Clin Risk Manag. 2020;16:769-85.

Braunauer K, Düngen HD, Belyavskiy E, Aravind Kumar R, Kropf M, Genger M, et al. Potential usefulness and clinical relevance of a novel left atrial filling index to estimate left ventricular filling pressures in patients with preserved left ventricular ejection fraction. Eur Heart J Cardiovasc Imaging. 2020;21(3):260-9.

Lin J, Ma H, Gao L, Wang J, Li J, Zhou Q, et al. Left atrial reservoir strain combined with E/E’ as a better single measure to predict elevated LV filling pressures in patients with coronary artery disease. Cardiovasc Ultrasound. 2020;18(1):11.

Choi KH, Yang JH, Seo JH, Choi JO, Lee SC, Park SW, et al. Discriminative role of invasive left heart catheterization in patients suspected of heart failure with preserved ejection fraction. J Am Heart Assoc. 2023;12(6):e027581.

Papolos A, Narula J, Bavishi C, Chaudhry FA, Sengupta PP. U.S. hospital use of echocardiography: insights from the Nationwide Inpatient Sample. J Am Coll Cardiol. 2016;67(5):502-11.

Bunting KV, Steeds RP, Slater K, Rogers JK, Gkoutos GV, Kotecha D. A practical guide to assess the reproducibility of echocardiographic measurements. J Am Soc Echocardiogr. 2019;32(12):1505-15.

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IssueVol 20 No 2 (2025) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/jthc.v20i2.19706
Keywords
Speckle Tracking Echocardiography Left Atrial Strain Heart Failure with Preserved Ejection Fraction HFA-PEFF

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How to Cite
1.
Dang H, Luong T, Ho B, Hoang T, Mai A, Nguyen H. Comparing Left Atrial Strain and the HFA-PEFF Score in Diagnosing Heart Failure with Preserved Ejection Fraction: A Cross-Sectional Study. Res Heart Yield Transl Med. 2025;20(2):105-115.