Usefulness of Atrial Size Inequality as an Indicator of Abnormal Left Ventricular Filling Cecilia Wallentin Guron, MD, Marianne Hartford, MD, PhD, Annika Rosengren, MD, PhD, Dag Thelle, MD, PhD, Ingemar Wallentin, MD, PhD, and Kenneth Caidahl, MD, PhD Although pulsed Doppler echocardiography estimates current left ventricular (LV) ﬁlling, left atrial (LA) size reﬂects LV ﬁlling and pressure over time. However, the wide normal LA size range may blunt this diagnostic tool. Our objective was to compare the intraindividual atrial area difference (LA  right atrial [RA] area) and absolute LA area in their detection of a LA enlargement with respect to the degree of current LV ﬁlling impair- ment. We examined patients with acute coronary syn- dromes in sinus rhythm and without valvular disease (n  154), and age- and gender-matched healthy controls (n  50) with echocardiography, applying pulsed Dopp- ler international recommendations to group the patients according to the LV ﬁlling pattern: 0, normal; 1, delayed relaxation; 2, an isolated abnormal mitral pulmonary venous A-wave duration difference; 3, pseudonormal; and 4, restrictive. The LA and RA areas were measured in the 4-chamber view. Control values deﬁned the nor- mal range of: absolute LA area, LA area adjusted for body height, and LA-RA area. These areas indicated a LA enlargement in: (1) controls, 2%, 2%, and 4%, re- spectively; (2) patients with LV ﬁlling graded as normal/ mildly impaired (groups 0 and 1), 15%, 17%, and 46%, respectively; moderately impaired (group 2), 26%, 29%, and 52%, respectively; and severely impaired (group 3 and 4), 42%, 38%, and 54%, respectively. Unequally sized atria appear to detect LA enlargement sensitively, especially when Doppler evidence of LV ﬁlling pathology is sparse. Clinically, with no obvious current cause for LA enlargement, a diagnosed “atrial size inequality” may still indicate a history of such causes. 2005 by Ex- cerpta Medica Inc. (Am J Cardiol 2005;95:1448 –1452) L eft atrial (LA) size is a well-known marker of left ventricular (LV) ﬁlling, 1 its pressure over time, 2 and prognosis. 3,4 The purpose of a reliable estimate of LA size is to reveal LA enlargement. However, this intention can be hampered by the normal wide range of LA size, 5 often permitting considerate LA enlargement within ref- erence limits. The left and right atria may differ in shape and morphology, yet they usually appear equally sized in young healthy subjects when viewed in a correctly per- formed 6 4-chamber view. This view allows each heart to serve as its own reference. We aimed to compare the intraindividual atrial area difference, the absolute LA area, and body height-adjusted LA area in their ability to detect LA enlargement as an indirect indicator of LV ﬁlling abnormalities, speciﬁed by applied international Doppler recommendations. 7–9 METHODS Study population: We studied 160 patients with diagnosed acute coronary syndromes, admitted to the coronary care unit at Sahlgrenska University Hospital, Göteborg, Sweden, who were examined echocardio- graphically. All were in sinus rhythm and without any hemodynamically signiﬁcant valvular disease. 10 Echo- cardiograms were recorded in the early stable phase (approximately 3 days from admission) using an Acu- son XP ultrasonic scanner (Acuson/Siemens, Moun- tain View, California) with a 2.5- to 4-MHz trans- ducer. Acute coronary syndromes were deﬁned as an ST elevation (42%, n = 64) or a non–ST-elevation acute myocardial infarction (45%, n = 70) or unstable an- gina pectoris (13%, n = 20), the latter with typical chest pain and either electrocardiographic signs of myocardial ischemia (ST depression of 0.1 mV or T-wave inversion in 2 adjacent leads), a minor in- crease in biochemical markers (creatine kinase-MB 5 to 10 g/L or troponin T 0.05 to 0.19 g/L), or previously diagnosed ischemic heart disease. Poor im- age quality or inadequate recordings of the pulsed Doppler echocardiography resulted in exclusion in 4% (n = 6), which left a total of 154 patients. Before admission, 18% of patients had a previous myocardial infarction, 43% had angina pectoris, 47% had sys- temic hypertension, 9% had symptomatic LV heart failure, 19% had diabetes mellitus, and 10% had un- dergone coronary artery bypass surgery or percutane- ous coronary intervention therapy, or both. As controls, we selected 50 healthy subjects, age- and gender-matched to the patients (see Table 1 for descriptive population data), and 10 young (27  2 years) gender-matched (70% men) volunteers from a From the Departments of Clinical Physiology, Cardiology, and Internal Medicine, Göteborg University, Sahlgrenska University Hospital, Göteborg; and Department of Clinical Physiology, Karolinska Institute, Stockholm, Sweden. This study was supported by The Swedish Re- search Council (Grant 14231), the Swedish Heart and Lung Founda- tion, and the Vardal Foundation, Stockholm, Sweden; and Göteborg University, the Västra Gütaland Region and the Göteborg Medical Society, Göteberg, Sweden. Manuscript received October 13, 2004; revised manuscript received and accepted February 7, 2005. Address for reprints: Cecilia Wallentin Guron, MD, Department of Clinical Physiology, Sahlgrenska University Hospital/Östra, Smörslottsga- tan 1, S-416 85 Göteborg, Sweden. E-mail: c.wallentin@home.se. 1448 ©2005 by Excerpta Medica Inc. All rights reserved. 0002-9149/05/$–see front matter The American Journal of Cardiology Vol. 95 June 15, 2005 doi:10.1016/j.amjcard.2005.02.011