Heart failure (HF) patients with exercise-induced left atrial hypertension (EILAH) appeared to have similar symptom severity but less advanced myocardial and pulmonary vascular disease when compared to patients with resting left atrial hypertension (RELAH), according to a study using data from the REDUCE LAP-HF II trial presented at THT 2023 and simultaneously published in JACC: Heart Failure.

Patients (n=626) with ejection fraction (EF) ≥40% and pulmonary capillary wedge pressure (PCWP) ≥25  mm Hg were randomized to undergo either an atrial shunt or sham procedure. The primary outcome was a hierarchical composite of death, HF hospitalization, intensification of diuretics and change in health status.

When comparing patients with EILAH to those with RELAH (resting PCWP ≥15 mm Hg), researchers found that the win ratio for the primary outcome was 1.56 (p=0.08) vs. 1.51 (p=0.04) respectively.

Sheldon E. Litwin, MD, FACC, et al., noted that patients with EILAH (29% of the study population) showed similar symptom severity along with lower natriuretic peptide levels, higher 6-minute walk distance, less atrial fibrillation, lower left ventricular mass, smaller left atrial volumes, lower E/e’ and better left atrial strain.

Patients with EILAH were more likely to have characteristics associated with atrial shunt responsiveness (peak exercise pulmonary vascular resistance <1.74 WU and no pacemaker [63% vs. 46%, p<0.001]), and neither group saw a significant difference in shunt therapy vs. sham.

"[Patients with exercise-induced left atrial hypertension] may be difficult to diagnose without invasive exercise hemodynamics, but [have] characteristics associated with favorable response to atrial shunt therapy,” the researchers write.

In an accompanying editorial comment, Mathew S. Maurer, MD, FACC, and Hannah R. Rosenblum, MD, write, “Now that Litwin et al., have shown us how common HFpEF with EILAH is and how to identify affected individuals, we need to further understand this phenotype and how to address it.”

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Hospitalization, Natriuretic Peptides, Phenotype, Vascular Diseases, Stroke Volume, Diuretics, Heart Failure, ACC International

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