The Prognostic Role of the Left Atrium in Hypertensive Patients with HFpEF: Does Function Matter More than Structure?

Background: In arterial hypertension (AH), adverse hemodynamic consequences in the left atrium (LA) are often observed. The prognostic significance of functional vs. structural LA abnormalities among high-risk AH patients (with heart failure with preserved ejection fraction [HFpEF]) are not clearly defined. Objective: to compare the prognostic significance of structural vs. functional LA indices in hypertensive patients with HFpEF. Methods: We retrospectively selected 274 hypertensive patients with AH, HFpEF, and sinus rhythm. The primary outcome was a composite of all-cause mortality and HF hospitalization; the median follow-up was 4.3 (2.5–6.5) years. Results: The composite endpoint occurred in 133 patients (49%). Kaplan–Meier analysis revealed significantly lower event-free survival rates in patients with lower functional LA reservoir strain [LASr] (≤median) compared to patients with higher LASr (p < 0.001). Patients with higher structural LA volume index (LAVI) as well as with higher LV filling pressure (E/e′ ratio) or more severe left ventricular (LV) hypertrophy (higher LV mass index) had a similar prognosis to patients with lower values. In multivariable analysis, decreased LASr and paroxysmal atrial fibrillation (AF) were independently associated with adverse outcomes after accounting for potential confounders (for both p < 0.05). Conclusions: Among patients with AH and HFpEF, the functional LA parameter LASr seems to be more effective than the structural LA parameter LAVI, or traditional indexes of LV hypertrophy and filling pressure, in predicting prognosis.