Atrial Strain Outperforms Ventricular Strain for Detecting Hypertensive HFpEF Using CMR Feature Tracking

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) accounts for ≈50% of heart failure, and hypertension often coexists. Although strain imaging detects subclinical dysfunction, the relative diagnostic value of left atrial (LA) versus left ventricular (LV) strain for identifying hypertensive HFpEF remains uncertain. We compared LA and LV strain using cardiac MR feature tracking to determine optimal markers for HFpEF detection. METHODS: A single-center, retrospective study included 191 participants: 71 with HFpEF and hypertension (HFpEF-HTN), 60 with essential hypertension, and 60 controls who underwent CMR. Cardiac MR feature tracking quantified LV global strains and strain rates, and LA reservoir (εs), conduit (εe), and booster pump (εa) strain with corresponding strain rates. One-way ANOVA compared groups, logistic regression identified HFpEF-HTN predictors, and receiver operating characteristic analysis with area under the curve assessed diagnostic accuracy. RESULTS: All LA strain parameters showed stepwise impairment from controls to hypertension to HFpEF-HTN (all P <0.05). LV global strains decreased in HFpEF-HTN versus controls, while hypertension exhibited only reduced global longitudinal strain (all P <0.05). LA parameters demonstrated superior discriminatory performance over LV parameters. εs best distinguished HFpEF-HTN from hypertension (area under the curve, 0.802 95% CI, 0.724–0.867), while εe best discriminated hypertension from controls (area under the curve, 0.892 95% CI, 0.823–0.942). CONCLUSIONS: LA strain parameters, particularly εs, provided superior diagnostic performance over LV strain in distinguishing HFpEF-HTN from hypertension. These findings support the potential role of LA strain as a sensitive imaging biomarker for detecting HFpEF-HTN. Prospective validation is needed before clinical implementation.