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Independent association of left atrial function with exercise capacity in patients with preserved ejection fraction
  1. Kenya Kusunose,
  2. Hirohiko Motoki,
  3. Zoran B Popovic,
  4. James D Thomas,
  5. Allan L Klein,
  6. Thomas H Marwick
  1. Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
  1. Correspondence to Dr Thomas H Marwick, Heart and Vascular Institute, Cleveland Clinic J1-5, 9500 Euclid Avenue, Cleveland, OH 44195, USA; marwict{at}


Objective Left atrial (LA) function is an important contributor to cardiac function in a variety of disease states and especially with exercise. The purpose of this study was to assess the role of LA function in the left ventricular (LV) filling pressure (E/e') response to exercise and exercise tolerance in patients with preserved LV ejection fraction (LVEF).

Methods LA contractile function (LA strain peak negative), conduit function (LA strain peak positive), and reservoir function (LA strain total) were measured from speckle tracking in 486 patients with preserved LVEF and negative exercise echocardiography for ischaemia. Maximal exercise tolerance was expressed as the estimated metabolic equivalents (METs). Per cent predicted METs was calculated in accordance with described nomograms. Features associated with exercise capacity were sought in a multiple linear regression, and compared using standardised β.

Results Patients with increased stress E/e' had significantly lower LA strain profiles and larger LA volume than the remainder. LA strain total was strongly associated with exercise capacity in multivariate analysis (ß=0.21, p<0.001). E/e' rest was also associated with exercise capacity (ß=−0.11, p=0.001). Other independent correlates of exercise capacity were age (ß=−0.36, p<0.001), male gender (ß=0.34, p<0.001) and body mass index (ß=−0.23, p<0.001). The best predictor of per cent predicted METs was total LA strain in multivariate analysis.

Conclusions The association of reduced LA function with impaired exercise capacity was similar to that of elevated LVE/e', emphasising the role of ventriculo-atrial coupling to cardiac dysfunction with preserved LVEF.

  • Echocardiography
  • exercise capacity
  • atrial function
  • cardiac function
  • myocardium
  • myocardial function
  • diastolic function
  • ventricular function
  • EBM
  • doppler
  • echocardiography (three-dimensional)
  • doppler ultrasound
  • contrast echocardiography
  • tissue doppler
  • stress echocardiography

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  • See Editorial, p 1261

  • Funding Dr Kusunose was supported by the Uehara Memorial Foundation postdoctoral fellowship and the Naito Foundation for research abroad.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval The study protocol was approved by the Cleveland Clinic Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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