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Abstract   Aims  Exercise intolerance is the leading manifestation of heart failure with preserved or mid‐range ejection fraction (HFpEF or HFmrEF), and left atrial (LA) function might contribute to modulating left ventricular filling and pulmonary venous pressures. We aim to assess the association between LA function and maximal exercise capacity in patients with HFpEF or HFmrEF.    Methods and results  Sixty‐five patients, prospectively enrolled in the German HFpEF Registry, were analysed. Inclusion criteria were New York Heart Association functional class ≥ II, left ventricular ejection fraction &gt; 40%, structural heart disease or diastolic dysfunction, and elevated levels of N terminal pro brain natriuretic peptide (NT‐proBNP). LA function was evaluated through speckle‐tracking echocardiography by central reading in the Charité Academic Echocardiography core lab. All patients underwent maximal cardiopulmonary exercise test and were classified according to a peak VO 2  cut‐off of prognostic value (14 mL/kg/min). NT‐pro‐BNP was measured. Twenty‐nine patients (45%) reached a peak VO 2  &lt; 14 mL/kg/min (mean value 12.4 ± 1.5) and 36 patients (55%) peak VO 2  ≥ 14 mL/kg/min (mean value 19.4 ± 3.9). There was no significant difference in left ventricular ejection fraction (60 ± 9 vs. 59 ± 8%), left ventricular mass (109 ± 23 vs. 112 ± 32 g/m 2 ), LA volume index (45 ± 17 vs. 47 ± 22 mL/m 2 ), or E/e´ (13.1 ± 4.7 vs. 13.0 ± 6.0) between these groups. In contrast, all LA strain measures were impaired in patients with lower peak VO 2  (reservoir strain 14 ± 5 vs. 21 ± 9%,  P  = 0.002; conduit strain 9 ± 2 vs. 13 ± 4%,  P  = 0.001; contractile strain 7 ± 4 vs. 11 ± 6%,  P  = 0.02; reported lower limits of normality for LA reservoir, conduit and contractile strains: 26.1%, 12.0%, and 7.7%). In linear regression analysis, lower values of LA reservoir strain were associated with impaired peak VO 2  after adjustment for age, sex, body mass index, heart rhythm (sinus/AFib), and log‐NTproBNP [ β  0.29, 95% confidence interval (CI) 0.02–0.30,  P  = 0.02], with an odds ratio 1.22 (95% CI 1.05–1.42,  P  = 0.01) for peak VO 2  &lt; 14 mL/kg/min for LA reservoir strain decrease after adjustment for these five covariates. Adding left ventricular ejection fraction, it did not influence the results. On the other hand, the addition of LA strain to the adjustment parameters alone described above provided a significant increase of the predictive value for lower peak VO 2  values ( R  2  0.50 vs. 0.45,  P  = 0.02). With receiver operating characteristic curve analysis, we identified LA reservoir strain &lt; 22% to have 93% sensitivity and 49% specificity in predicting peak VO 2  &lt; 14 mL/kg/min. Using this cut‐off, LA reservoir strain &lt; 22% was associated with peak VO 2  &lt; 14 mL/kg/min in logistic regression analysis after comprehensive adjustment for age, sex, body mass index, heart rhythm, and log‐NTproBNP [odds ratio 95% CI 10.4 (1.4–74),  P  = 0.02].    Conclusions  In this HFpEF and HFmrEF cohort, a reduction in LA reservoir strain was a sensible marker of decreased peak exercise capacity. Therefore, LA reservoir strain might be of clinical value in predicting exercise capacity in patients with HFpEF or HFmrEF.

Left atrial function and maximal exercise capacity in heart failure with preserved and mid‐range ejection fraction