Diagnostic accuracy of cardiovascular magnetic resonance strain analysis and atrial size to identify heart failure with preserved ejection fraction

Ming-Yen Ng, Chi Ting Kwan, Pui Min Yap, Sau Yung Fung, Hok Shing Tang, Wan Wai Vivian Tse, Cheuk Nam Felix Kwan, Yin Hay Phoebe Chow, Nga Ching Yiu, Yung Pok Lee, Ambrose Ho Tung Fong, Subin Hwang, Zachary Fai Wang Fong, Qing-Wen Ren, Mei-Zhen Wu, Eric Yuk Fai Wan, Ka Chun Kevin Lee, Chun Yu Leung, Andrew Li, David Montero, Varut Vardhanabhuti, JoJo Hai, Chung-Wah Siu, Hung-Fat Tse, Dudley John Pennell, Raad Mohiaddin, Roxy Senior, Kai-Hang Yiu, Ming-Yen Ng, Chi Ting Kwan, Pui Min Yap, Sau Yung Fung, Hok Shing Tang, Wan Wai Vivian Tse, Cheuk Nam Felix Kwan, Yin Hay Phoebe Chow, Nga Ching Yiu, Yung Pok Lee, Ambrose Ho Tung Fong, Subin Hwang, Zachary Fai Wang Fong, Qing-Wen Ren, Mei-Zhen Wu, Eric Yuk Fai Wan, Ka Chun Kevin Lee, Chun Yu Leung, Andrew Li, David Montero, Varut Vardhanabhuti, JoJo Hai, Chung-Wah Siu, Hung-Fat Tse, Dudley John Pennell, Raad Mohiaddin, Roxy Senior, Kai-Hang Yiu

Abstract

Aims: Heart failure with preserved ejection fraction (HFpEF) continues to be a diagnostic challenge. Cardiac magnetic resonance atrial measurement, feature tracking (CMR-FT), tagging has long been suggested to diagnose HFpEF and potentially complement echocardiography especially when echocardiography is indeterminate. Data supporting the use of CMR atrial measurements, CMR-FT or tagging, are absent. Our aim is to conduct a prospective case-control study assessing the diagnostic accuracy of CMR atrial volume/area, CMR-FT, and tagging to diagnose HFpEF amongst patients suspected of having HFpEF.

Methods and results: One hundred and twenty-one suspected HFpEF patients were prospectively recruited from four centres. Patients underwent echocardiography, CMR, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements within 24 h to diagnose HFpEF. Patients without HFpEF diagnosis underwent catheter pressure measurements or stress echocardiography to confirm HFpEF or non-HFpEF. Area under the curve (AUC) was determined by comparing HFpEF with non-HFpEF patients. Fifty-three HFpEF (median age 78 years, interquartile range 74-82 years) and thirty-eight non-HFpEF (median age 70 years, interquartile range 64-76 years) were recruited. Cardiac magnetic resonance left atrial (LA) reservoir strain (ResS), LA area index (LAAi), and LA volume index (LAVi) had the highest diagnostic accuracy (AUCs 0.803, 0.815, and 0.776, respectively). Left atrial ResS, LAAi, and LAVi had significantly better diagnostic accuracy than CMR-FT left ventricle (LV)/right ventricle (RV) parameters and tagging (P < 0.01). Tagging circumferential and radial strain had poor diagnostic accuracy (AUC 0.644 and 0.541, respectively).

Conclusion: Cardiac magnetic resonance LA ResS, LAAi, and LAVi have the highest diagnostic accuracy to identify HFpEF patients from non-HFpEF patients amongst clinically suspected HFpEF patients. Cardiac magnetic resonance feature tracking LV/RV parameters and tagging had low diagnostic accuracy to diagnose HFpEF.

Keywords: Cardiac magnetic resonance; Feature tracking; Heart failure with preserved ejection fraction; Left atrium; Strain; Tagging.

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Heart failure with preserved ejection fraction and non-heart failure with preserved ejection fraction patient. Images (A) and (B) show contouring of the left atrium in the two- and four-chamber cines for left atrial strain. Images (C) and (D) show the radial and longitudinal strain assessment in the short-axis and four-chamber cines using cardiovascular magnetic resonance feature tracking. Images (E) and (F) show contouring of the left and right atria in the two- and four-chamber cines in end-systole. Note that the heart failure with preserved ejection fraction patient has lower left atrial strain (reservoir, conduit, and booster) and larger left atrial volume/area compared to the non-heart failure with preserved ejection fraction patient.
Figure 2
Figure 2
CONSORT diagram. ESC, European Society of Cardiology; HCM, hypertrophic cardiomyopathy; HCM, hypertrophic cardiomyopathy; HFpEF, heart failure with preserved ejection fraction, HF, heart failure; * = one patient undertook both stress echocardiography and invasive catheter pressure measurement. † = six patients identified on invasive catheterization and one patient identified on stress echocardiography.
Figure 3
Figure 3
Receiver operating characteristic comparing left atrial reservoir (AUC 0.804), left atrial area index (AUC 0.815), and left atrial volume index (AUC 0.776) against the cardiac magnetic resonance feature tracking left ventricle parameters. CS, circumferential strain; CDSR, circumferential early diastolic strain rate; LS, longitudinal strain; LDSR, longitudinal early diastolic strain rate; LV, left ventricle; RS, radial strain; RDSR, radial early diastolic strain rate.

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