Left atrial stiffness in women with ischemia and no obstructive coronary artery disease: Novel insight from left atrial feature tracking

BACKGROUND: Women with signs and symptoms of ischemia and no obstructive coronary artery disease (INOCA) are at risk of heart failure with preserved ejection fraction (HFpEF); however, the mechanism for HFpEF progression remains unclear. Studies in INOCA have largely focused on left ventricular function. The left atrium serves an important role in maintaining transmitral flow, and is impaired in HFpEF; however, it remains unclear if left atrial function is impaired in INOCA. HYPOTHESIS: Left atrial function is progressively worse in INOCA and HFpEF compared to controls. METHODS: We compared 39 reference control subjects to 64 women with INOCA and 22 subjects with HFpEF. Left atrial strain was assessed by feature tracking using magnetic resonance cine images. RESULTS: Peak left atrial strain was reduced in HFpEF compared to controls (22.9 ± 4.8% vs 25.9 ± 3.2%, P < .01), but similar in INOCA (24.8 ± 4.5%) compared to HFpEF and controls (P = .18). However, left ventricular end‐diastolic pressure (LVEDP) was elevated in 33% of INOCA participants, suggesting that left atrial stiffness (LVEDP/LA strain) is elevated in a large portion of women with INOCA. CONCLUSIONS: Taken together, we interpret these data to support our working hypothesis that INOCA is a pre‐HFpEF state, with left atrial stiffness preceding overt left atrial dysfunction; representing a putative therapeutic target to prevent HFpEF progression in this at‐risk population.