Diagnostic tools of heart failure with preserved ejection fraction: Comparison of left atrial strain to the HFA-PEFF score

Abstract

Introduction

Heart failure with preserved ejection fraction (HFpEF) is an increasingly common health issue with a significant morbidity and mortality burden. Diagnosis remains challenging despite the great number of tests and parameters proposed.

Objective

The aim of this study was to assess the performance of left atrial strain (LAS) function in the diagnosis of HFpEF by comparison to the HFA-PEFF score.

Method

A total of 110 outpatients, symptomatic with exertion dyspnea, were prospectively recruited over the span of 18 months. The HFA-PEFF score was calculated for all patients, who then were sorted in 2 groups: with and without HFpEF. Performance of LAS functions (reservoir, pump, conduit) and the 2016 ASE/EACVI algorithm for the evaluation of Left ventricular filling pressure (LVFP), was assessed for the diagnosis of HFpEF.

Results

Prevalence of HFpEF in our sample was 40%. All LAS functions were significantly correlated to the presence of HFpEF and to the elevation of LVFP at rest and on exertion. Performance of the 2016 algorithm was mediocre in the diagnosis of HFpEF (AUC = 0.70, Specificity (Sp) = 71.2%, Sensitivity (Sn) = 72.7%, Accuracy (Acc) = 71.8%), with significant improvement after exclusion of indeterminate LVFP cases (AUC = 0.89, Sp = 94%, Sn = 84.2%, Acc = 89.7%), and only reaching maximal overall performance (AUC = 0.94, Sp = 94%, Sn = 94.7%, Acc = 94.3%) after exercise testing.

Performance of LAS functions yielded acceptable results, with the reservoir function having the most optimal outcomes, compared to booster and conduit functions, with a cutoff value of 24% (AUC = 0.91, Sp = 86%, Sn = 89.5%, Acc = 88.1%).

Considering the low sensitivity of the 2016 algorithm, we integrated the study of LAS reservoir function when LVFP were evaluated to be normal or indeterminate. The proposed new algorithm demonstrated improved performance (Sp = 90.7%, Sn = 90%, Acc = 90.1%) compared to the 2016 algorithm with inclusion of indeterminate LVFP cases.

Conclusion

LAS reservoir function is an efficient, easy to assess parameter that significantly improves the diagnostic yield of HFpEF in common practice, and diminishes the necessity of exercise echocardiography and invasive testing.