Left atrial strain, diastolic dysfunction and left ventricular hypertrophy in hypertensive patients with preserved ejection fraction: a cross sectional echocardiographic study

Background Diastolic dysfunction (DD) and left ventricular hypertrophy (LVH) are hallmark manifestations of hypertensive heart disease and powerful predictors of heart failure with preserved ejection fraction. Left atrial (LA) strain has emerged as a promising echocardiographic marker for detecting diastolic dysfunction and estimating filling pressures; however, recent evidence suggests that its diagnostic utility and incremental value over conventional measures may be limited, particularly in patients with preserved left ventricular ejection fraction (LVEF). Objective This study evaluated whether LA strain measurements provide incremental predictive value for identifying diastolic dysfunction and LVH beyond conventional clinical and echocardiographic parameters in hypertensive patients with preserved LVEF. Methods A single-center, cross-sectional study enrolled 99 consecutive hypertensive patients (mean age 60.2 ± 10.8 years, 57.6% male) with LVEF ≥ 55% at Modarres Hospital, Tehran, Iran, between January 2024 and June 2025. All participants underwent comprehensive transthoracic echocardiography using a Philips EPIQ CVx system with semiautomated LA strain analysis. Diastolic dysfunction was graded per 2016 ASE/EACVI criteria, and LVH was defined by increased interventricular septal or posterior wall thickness. Binary logistic regression models incorporating 16 clinical and echocardiographic variables were constructed to identify independent predictors of DD and LVH. Model discrimination was evaluated by receiver operating characteristic (ROC) curve analysis. Results Diastolic dysfunction was present in 80 patients (80.8%), and LVH in 16 patients (16.2%). Multivariable analysis identified age (odds ratio [OR] 3.00, 95% CI 1.87–4.81, p < 0.001), systolic blood pressure (OR 2.53, 95% CI 1.55–4.13, p < 0.001), interventricular septal thickness (OR 2.29, 95% CI 1.51–3.48, p < 0.001), number of antihypertensive medications (OR 1.87, 95% CI 1.24–2.82, p = 0.003), and posterior wall thickness (OR 1.88, 95% CI 1.21–2.93, p = 0.005) as independent predictors of diastolic dysfunction. The combined model achieved excellent discrimination (AUC 0.946, 95% CI 0.89–0.99) with good calibration. Critically, none of the three LA strain components—reservoir, conduit, or contractile strain—retained statistical significance in the multivariable model (all p > 0.5), indicating a lack of incremental predictive value once age, blood pressure, wall thickness, and medication burden were accounted for. Conclusions In hypertensive patients with preserved ejection fraction, conventional clinical parameters and standard echocardiographic measures of structural remodeling dominate the prediction of diastolic dysfunction, while LA strain provides no meaningful incremental diagnostic information. These findings align with recent expert consensus indicating that LA strain has limited diagnostic utility in preserved ejection fraction populations and suggest that routine incorporation of LA strain into diastolic risk models may be unnecessary in this setting. Future research should include external validation in independent cohorts and longitudinal studies in earlier stages of hypertensive remodeling to determine whether LA strain retains value in subclinical disease or more advanced phenotypes.