Left atrial function as a predictor of stroke or systemic embolism: Beyond the CHA2DS2‐VASc score

In a recent edition of the Annals of Noninvasive Electrocardiology, Choi et al. published an article on predictors of stroke or systemic embolism in patients with nonvalvular atrial fibrillation (AF) with CHA2DS2-VASc score of 0 (Choi et al., 2023). It was a retrospective study evaluating the predictors of stroke and systemic embolism in AF patients with a very low risk of stroke. Also, it emphasized that the rate of stroke and systemic embolism as primary outcome was 0.78%/year in these low-risk patients and that age of ≥50 years, LVEDD of ≥46 mm, and nonparoxysmal AF were independent predictors. Moreover, the authors showed that the prognostic effect of the combined use of independent risk factors was stronger in predicting stroke or systemic embolism in patients with AF stratified into very-low-risk groups in the CHA2DS2-VASc scoring system. Left atrial (LA) remodeling is an important underlying substrate for AF and stroke (Delgado et al., 2017). However, the authors in this study included only the left atrium A-P diameter for left atrial echocardiographic evaluation. Previously, it has been demonstrated that LA size is a valuable marker for AF, stroke, or even “stroke regardless of AF status” (Tiwari et al., 2016). Additionally, it was reported that AF may occur in patients with normal LA dimensions. The occurrence of AF in patients with normal LA size is explained by LA functional remodeling. Left atrial remodeling refers to the spectrum of pathophysiological changes in atrial structure and physiological function. Recently, more and more attention has been given to the holistic assessment of LA function. Moreover, left atrial structural and functional parameters are evaluated in many cardiac settings other than AF and stroke (Murat et al., 2023). Left atrial reservoir strain, when added to the CHA2DS2-VASc variables, has been shown to improve stroke prediction in people without prior AF or stroke (Maheshwari et al., 2023). Pagola et al. investigated the effect of LA dysfunction markers in predicting paroxysmal AF episodes with a high risk of embolization in patients with cryptogenic stroke. In this study, they reported the presence of silent AF in 86% of cryptogenic stroke patients with normal LA size and decreased LA strain (Pagola et al., 2021). Although the present study did not primarily aim to examine echocardiographic parameters associated with AF and stroke, its results are important because it represents a specific population with a CHA2DS2-VASc score of 0. However, in low-risk cases with normal LA dimensions, adding structural and functional holistic evaluation of LA, other than LA dimension, to the CHA2DS2-VASc score may reveal important results in predicting stroke and systemic embolism. None. None. Research data are not shared.