Unmasking the silent threat: essential hypertension as a catalyst for ischemic stroke through atrial myopathy

Background Emerging evidence suggests that atrial myopathy (AM), through structural and functional atrial remodeling, may contribute to ischemic stroke (IS) even before the onset of atrial fibrillation (AF). Essential hypertension (EHT), a highly prevalent and modifiable risk factor, may promote AM by impairing left atrial (LA) structure and function. However, data evaluating the contribution of EHT to AM across AF progression stages using LA functional parameters remain limited. Purpose To assess the impact of EHT compared with other modifiable risk factors on the development of AM, as measured by LA functional indices, across stages of AF progression in patients with and without ischemic stroke. Methods We performed a 5-year cross-sectional study stratifying patients according to AF progression stages based on the 2023 ACC/AHA/ACCP/HRS AF guidelines: Stage 1 (At Risk for AF without IS, n=140), Stage 2 (Pre-AF with IS, n=187), Stage 3 (Paroxysmal AF with IS, n=102), and Stage 4 (Permanent AF with IS, n=72), plus 102 healthy controls. Left atrial reservoir strain (ReSt), global longitudinal strain (GLS), and LA emptying fraction (LAEF) were assessed using velocity vector imaging echocardiography. Associations between modifiable risk factors and AF stages were analyzed using multivariable logistic regression. Results A total of 603 participants were included (mean age 62.5 ± 12.5 years; 61.2% male). Essential hypertension was highly prevalent (70.3%) and remained the dominant risk factor across AF stages (77.3%, 90.9%, 91.2%, and 75.0% in Stages 1–4, respectively). Multivariable analysis identified EHT (OR 6.59, 95% CI 3.63–11.98), LAEF < 35% (OR 3.05, 95% CI 1.17–7.99), reduced LA ReSt (OR 0.89, 95% CI 0.84–0.94), and impaired GLS (OR 0.90, 95% CI 0.81–0.99) as independent predictors of ischemic stroke. LA functional parameters declined progressively across AF stages from At Risk for AF to Permanent AF (all p < 0.0001). Conclusions Essential hypertension is strongly associated with progressive atrial myopathy across AF stages and independently predicts ischemic stroke. Assessment of LA function using echocardiographic strain imaging may improve early risk stratification in hypertensive patients, even before overt atrial fibrillation develops.forest plotnetwork analysis