Association between CHA2DS2-VASc Score and Left Atrial Function by Speckle Tracking Echocardiography in Patients with Sinus Rhythm

Association between CHA2DS2-VASc Score and Left Atrial Function by Speckle Tracking Echocardiography in Patients with Sinus Rhythm | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association between CHA 2 DS 2 -VASc Score and Left Atrial Function by Speckle Tracking Echocardiography in Patients with Sinus Rhythm Kareem Mahmoud, Khaled Mostafa, Sameh Bakhoum, Heba ElDeeb This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9231263/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Background The CHA 2 DS 2 -VASc score is an established tool for thromboembolic risk assessment in atrial fibrillation (AF). Individual components of the score may affect left atrial function. Speckle-tracking echocardiography (STE) enables detection of early, subtle changes in the left atrium. Aim This study aimed to test whether left atrial function, as assessed by speckle-tracking echocardiography, differs among patients with sinus rhythm according to their CHA 2 DS 2 -VASc score. Methods This study included 150 patients with sinus rhythm. They were grouped by CHA 2 DS 2 -VASc score: low (1 for females, 0 for males), moderate (2 for females, 1 for males), and high (≥ 3 for females, ≥ 2 for males), with 50 patients per group. All participants gave written consent, provided medical histories, underwent a 12-lead ECG, and received standard and STE echocardiography. Results The high-risk group had significantly lower left atrial strain during both the reservoir (33.2 ± 7.1) and conduit phases (20.3 ± 5.7) compared to the moderate-risk group (36.9 ± 6.1, 23.5 ± 4.8) and low-risk group (40.6 ± 5.6, 26.9 ± 3.9), with all p-values < 0.01. Moderate-risk patients also showed lower strain values than low-risk patients. In contrast, left atrial maximal volume index did not differ among the groups (p = 0.536). Conclusion Increased CHA 2 DS 2 -VASc scores correlated with reduced left atrial strain in reservoir and conduit phases, suggesting early atrial dysfunction prior to enlargement. Further research should assess the clinical relevance of these echocardiographic findings for risk stratification in patients with high CHA 2 DS 2 -VASc score. Sinus Rhythm Speckle Tracking Echocardiography Left Atrium CHA2DS2-VASc score Figures Figure 1 Figure 2 Introduction Atrial fibrillation (AF) substantially increases the risk of cardioembolic stroke, contributing to considerable illness and death among affected individuals ( 1 ). Multiple clinical scoring systems have been created to help predict the likelihood of stroke in patients with non-valvular atrial fibrillation (NVAF) ( 2 , 3 ). The CHA 2 DS 2 -VASc score is the most widely used ( 4 , 5 ). This scoring system assigns points for a variety of clinical factors: - Congestive heart failure, including clinical symptoms or evidence of significant left ventricular dysfunction, or hypertrophic cardiomyopathy (1 point) - Hypertension or the use of antihypertensive medication (1 point) - Age: 1 point for ages 65 to 74 years, and 2 points for those 75 years or older - Diabetes mellitus, defined as use of oral hypoglycemic agents, insulin, fasting blood glucose ≥ 126 mg/dL (7 mmol/L), or HbA1c ≥ 6.5% (1 point) - Prior stroke, transient ischemic attack (TIA), or systemic thromboembolism (2 points) - Vascular disease, such as significant coronary artery disease (CAD) by angiography, previous myocardial infarction, aortic plaque, or similar conditions (1 point) - Female sex, which acts as a stroke risk modifier rather than a direct risk factor (1 point) ( 6 ). Although designed for AF patients, this score also predicts thromboembolic events in those without AF, such as heart failure ( 7 ), chronic obstructive pulmonary disease ( 9 ), and post-coronary artery bypass grafting (CABG) ( 9 , 10 ). It can also predict AF development in diabetes ( 11 ), systemic lupus erythematosus ( 12 ), myocardial infarction ( 14 ), and after cardiac surgery ( 15 – 16 ). The CHA 2 DS 2 -VASc score is associated with other adverse events, such as failed reperfusion after thrombolytic therapy ( 17 ), the no-reflow phenomenon ( 18 ), and contrast-induced nephropathy ( 19 ). Although the CHA2DS2-VASc score is commonly applied, its direct association with subtle abnormalities in left atrial function among individuals in sinus rhythm remains uncertain. This highlights a need for further research. The left atrium (LA) is essential for effective filling of the left ventricle (LV), serving as a reservoir, a passive conduit, and an active contractile chamber ( 20 , 21 ). Speckle-tracking echocardiography (STE) allows early detection of LA functional changes, even before LA enlargement ( 22 ). There is limited research examining the relationship between left atrial function and CHA2DS2-VASc score in individuals who are in sinus rhythm. The present study evaluated whether this risk score predicts early, subclinical atrial dysfunction prior to enlargement, using speckle-tracking echocardiography, to inform assessment and early intervention in patients without overt atrial fibrillation. Materials and Methods This cross-sectional observational study enrolled both male and female participants with different CHA2DS2-VASc scores, all were in sinus rhythm. The study ran from May 1 to October 30, 2022. We recruited 150 patients and grouped them by CHA 2 DS 2 -VASc score: low (1 for females, 0 for males), moderate (2 for females, 1 for males), and high (≥ 3 for females, ≥ 2 for males). Exclusion criteria included atrial fibrillation or atrial flutter, infective endocarditis, significant valvular heart disease, presence of prosthetic valves, pacemakers, poor echocardiographic windows, or LVEF below 50%. The Medical Ethics Committee approved the study. We adhered to the Declaration of Helsinki ( 23 ) and the STROBE checklist ( 24 ). All patients received an explanation of the study and gave written consent. All patients underwent the following assessment: A comprehensive medical history was obtained for each participant, with particular attention to CHA2DS2-VASc risk elements including heart failure, age, diabetes, previous stroke, vascular disease, and sex ( 6 ). A standard 12-lead surface electrocardiogram (ECG) to assess cardiac rhythm and heart rate. Two experienced cardiologists performed conventional transthoracic echocardiography using a Philips Affinity 50C machine with an S5-1 transducer. Images were captured while participants held their breath, adhering to the guidelines set by the American Society of Echocardiography (ASE) ( 25 ). Left atrial (LA) volumes were determined using the biplane area-length technique from both apical four- and two-chamber views, and subsequently indexed to body surface area. Volume measurements were taken at ( 26 – 27 ): LAV max measured at end-systole, immediately before the mitral valve opens LAV min recorded at end-diastole, right before the mitral valve closes LAV preA assessed at the beginning of the P-wave on the ECG Several parameters were derived from these measurements: Total emptying volume (LATEV) determined by subtracting LAV min from LAV max Passive emptying volume (LAPEV) calculated as LAV max minus LAV preA Active emptying volume (LAAEV) calculated as LAV preA minus LAV min Corresponding emptying fractions were computed as (volume/LAVmax) ×100 for total and passive fractions, and (LAAEV/LAVpreA) ×100 for active emptying fraction. To assess left ventricular (LV) diastolic function, mitral inflow was evaluated using pulsed Doppler with the sample volume positioned between the tips of the mitral leaflets during diastole. Measurements included peak velocities during early diastole (E wave) and late diastole (A wave), the E/A ratio, and deceleration time (DT). Tissue Doppler imaging (TDI) was employed to obtain septal and lateral e' velocities, which allowed calculation of the E/e' ratio as an indicator of LV filling pressure. Isovolumic relaxation time (IVRT) was measured in the apical five-chamber view by placing the pulsed wave Doppler sample volume in the LV outflow tract to simultaneously visualize the end of aortic ejection and the onset of mitral inflow. Speckle-tracking echocardiography (STE) was also performed for left atrial imaging. Left atrial (LA) strain analysis was performed offline utilizing QLAB version 10 (Philips Medical Systems). Two-dimensional grayscale images with a high frame rate (60–80 frames per second) were acquired from apical four-chamber and two-chamber views while participants held their breath. The LA endocardial border was manually traced at ventricular end-systole, excluding pulmonary veins and LA appendage. The region of interest width was adjusted to ensure optimal tracking of atrial myocardium. Automatic frame-by-frame speckle tracking was performed by the software. Manual correction was applied as needed if inadequate tracking occurred (adjusting > 2 segments). Global longitudinal strain (GLS) of the left atrium was measured from apical four- and two-chamber views by STE. Left atrial longitudinal strain was assessed in three phases ( 28 ): reservoir phase (LASr, measured as the difference between strain at mitral valve opening and ventricular end-diastole) conduit phase (LAScd, difference between strain at the onset of atrial contraction and mitral valve opening) contraction phase (LASct, difference between strain at ventricular end-diastole and the onset of atrial contraction). Figure 1 . shows an example of speckle tracking echocardiography of the left atrium. Statistical analysis was performed as follows. Sample size was determined using G*Power 3.1.9.7. We required 150 patients to detect an effect size of 0.2 for mean STE parameters ( 29 ). The significance level was set at 0.05 with 80% power. Data management and analysis were conducted with IBM SPSS Statistics version 24.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics—such as means, standard deviations, medians, ranges, frequencies, and percentages—were reported. The chi-square test was applied to evaluate categorical variables. The normality of continuous variables was checked using either the Kolmogorov–Smirnov or Shapiro–Wilk tests. Differences in means between dichotomous groups were assessed using the Student's t-test. One-way ANOVA compared means across more than two groups, with Tukey’s post-hoc test for pairwise comparisons. Pearson correlation analysis assessed associations between variables. Statistical significance was set at p < 0.05. Results Participants were categorized into three groups according to their CHA2DS2-VASc score: low (1 for females, 0 for males), moderate (2 for females, 1 for males), and high (≥ 3 for females, ≥ 2 for males). The ages of the patients ranged from 28 to 82 years, with an average age of 45.2 ± 12.3 years. There was an equal distribution of males and females (ratio 1:1), and the mean body surface area (BSA) measured 1.9 ± 0.1 m². Among participants, one-third had a history of stroke, approximately 40% had hypertension, about 20% had diabetes mellitus, and 4% had vascular disease. undefined Correlations CHA 2 DS 2 -VASc score and different conventional echocardiographic and STE parameters Table 1 . summarizes the univariate correlations between total CHA 2 DS 2 -VASc score and various left ventricular (LV) and left atrial (LA) parameters. The strongest positive correlations were observed with time-dependent diastolic indices: isovolumic relaxation time (IVRT) (r = 0.714, p < 0.001) and deceleration time (DT) (r = 0.639, p < 0.001). Moderate negative correlations were observed with LAPEV and LATEV (r = -0.53 and − 0.47; p < 0.001). There were mild negative correlations with LVEF, LAPEF, LAAEV, and LATEF (r = -0.14, -0.27, -0.20, -0.17; p = 0.046, 0.001, 0.008, 0.018). In contrast, significant, mild positive correlations were seen with LA diameter, LA maximum volume, minimum volume, pre-A volume, minimum volume index, and pre-A volume index (r = 0.20, 0.16, 0.22, 0.26, 0.21, 0.25; p = 0.006, 0.023, 0.004, 0.003, 0.005, 0.001). There was no significant correlation between the score and LA maximum volume index. Table 1 Correlation between Total CHA2DS2- VASc score and different LV and LA parameters. Total CHA 2 DS 2 - VASc score Parameters r (p-value) Parameters r (p-value) EF% -0.138 ( 0.046) LAPEV (ml) -0.533 (< 0.001) LA Diameter (cm) 0.203 ( 0.006) LAPEF% -0.266 (< 0.001) LAV Max (ml) 0.163 ( 0.023) LAAEV (ml) -0.198 ( 0.008) LAV Min (ml) 0.216 ( 0.004) LAAEF% -0.103 ( 0.105) LAV Pre-A (ml) 0.255 ( 0.003) LATEV (ml) -0.471 (< 0.001) LAV Max Index (ml/m 2 ) 0.129 ( 0.058) LATEF% -0.171 ( 0.018) LAV Min Index (ml/m2) 0.212 ( 0.005) IVRT (ms) 0.714 (< 0.001) LAV Pre-A Index (ml/m 2 ) 0.249 ( 0.001) DT (cm/s) 0.639 (< 0.001) DT : deceleration time; EF : ejection fraction; IVRT : isovolumic relaxation time; LA : left atrium; LAAEF : Left atrial active emptying fraction; LAAEV : Left atrial active emptying volume; LAPEF : Left atrial passive emptying fraction; LAPEV : Left atrial passive emptying volume; LATEF : Left atrial total emptying fraction; LATEV : Left atrial total emptying volume; LAV Max : Maximal left atrial volume; LAV Min : Minimal left atrial volume; LAV Pre−A : Pre-A wave left atrial volume. Table 2 shows the correlations between CHA 2 DS 2 -VASc score and speckle-tracking echocardiography (STE) parameters. There were significant, moderate negative correlations with LASr, LAScd, and LAScd/ct (r = -0.37, -0.43, and − 0.31, respectively; p < 0.001). Table 2 Correlation between Total CHA 2 DS 2 - VASc score and STE parameters Total CHA 2 DS 2 - VASc score Parameters r (p-value) LASr% -0.370 (< 0.001) LAScd% -0.428 (< 0.001) LASct% 0.045 (0.291) LAS cd/ct -0.309 (< 0.001) LASct : Left atrial strain in contractile phase; LAScd : Left atrial strain in conduit phase; LASr : Left atrial strain in reservoir phase; STE : Speckle-tracking echocardiography Comparison of conventional echocardiographic and STE parameters across CHA 2 DS 2 -VASc risk categories Table 3 presents comparisons of mitral inflow and tissue Doppler data by risk score. High-risk patients had lower E-wave velocity (68.1 ± 7.6 cm/s) than those in the low-risk group (77.8 ± 11.2 cm/s, p = 0.001). Low-risk patients had lower A-wave velocity (56.8 ± 8.4 cm/s) compared to moderate (66.5 ± 6.7 cm/s, p = 0.001) and high-risk patients (67.1 ± 5.9 cm/s, p = 0.001). Low-risk patients also had a higher E/A ratio (1.41 ± 0.3) than moderate (1.14 ± 0.2, p < 0.001) and high-risk patients (1.07 ± 0.3, p < 0.001). High-risk patients had longer IVRT (96.3 ± 9.1 ms) than moderate (90.7 ± 10.9 ms, p = 0.004) and low-risk patients (87.7 ± 8.6 ms, p < 0.001). Low-risk patients had shorter DT (152.9 ± 17.2 ms) compared to moderate (172.2 ± 19.9 ms, p < 0.001) and high-risk patients (165.5 ± 20.3 ms, p = 0.007). Table 4 compares LV dimensions and ejection fraction across CHA 2 DS 2 -VASc risk categories. Patients in the high-risk group had a significantly greater LA diameter (3.69 ± 0.40 cm) than those in the moderate (3.50 ± 0.50 cm, p = 0.039) and low-risk groups (3.43 ± 0.1 cm, p = 0.005). High-risk patients also had significantly higher LA minimum volume, minimum volume index, pre-A volume, and pre-A volume index (14.9 ± 5.1 ml, 8.18 ± 1.8 ml/m², 25.1 ± 7.7 ml, and 13.75 ± 5.5 ml/m², respectively) compared to low-risk patients (12.5 ± 2.6 ml, 6.87 ± 1.6 ml/m², 20.3 ± 5.4 ml, and 11.2 ± 3.1 ml/m²; p = 0.006, 0.01, 0.004, and 0.006, respectively). Figure 2 compares phasic LA volumes by risk group. Low-risk patients had significantly higher LAPEV (15.3 ± 4.1 ml) than those in the moderate (8.3 ± 2.7 ml, p < 0.001) and high-risk groups (7.3 ± 2.8 ml, p < 0.001). High-risk patients had significantly lower LAPEF (35.1 ± 9.2%) compared to those in the moderate (39.8 ± 9.1%, p < 0.001) and low-risk groups (42.6 ± 7.8%, p < 0.001). Table 5 presents a comparison of STE data across risk categories. High-risk patients had markedly lower LASr and LAScd values (33.2 ± 7.1 and 20.3 ± 5.7) than those in the moderate (36.9 ± 6.1 and 23.5 ± 4.8, p = 0.005 and 0.003) and low-risk groups (40.6 ± 5.6 and 26.9 ± 3.9, p < 0.001). The moderate-risk group also had significantly lower LASr and LAScd than the low-risk group (p = 0.007 and 0.001, respectively) (Graphical abstract). For LAScd/ct, low-risk patients had higher values (2.1 ± 0.6) compared to those in the moderate (1.9 ± 0.8, p = 0.007) and high-risk groups (1.7 ± 0.7, p = 0.023). Discussion his study found that elevated CHA2DS2-VASc scores were linked to gradual worsening of left ventricular diastolic function, as well as reduced left atrial reservoir and conduit function, while contractile function—measured by speckle-tracking echocardiography—remained largely unchanged. The CHA2DS2-VASc score was originally designed to assess the risk of thromboembolism in individuals with atrial fibrillation (AF). More recently, its usefulness has been explored in populations without AF, such as patients with heart failure ( 7 ), chronic obstructive pulmonary disease ( 8 ), and those who have undergone coronary artery bypass grafting (CABG) ( 9 , 10 ). Despite this, it is still uncertain whether the score can reliably detect left atrial dysfunction in people with sinus rhythm. The current study aimed to investigate the CHA2DS2-VASc score as a potential early marker for left atrial dysfunction in this group. In the current study, a mild yet statistically significant inverse relationship was found between the CHA2DS2-VASc score and left ventricular ejection fraction (LVEF), although no significant differences in LVEF appeared across the three groups. It is important to note that patients with LVEF below 50% were excluded from the study. Earlier research has shown that higher CHA2DS2-VASc scores are linked to declining LVEF in individuals with coronary artery disease ( 30 , 31 ). This study also demonstrated that mitral s' wave velocity was significantly reduced in both the high- and moderate-risk groups when compared to the low-risk group. These findings align with those of Hadadi et al. ( 30 ), who observed a marked reduction in mean mitral s' wave velocity in the high-risk group. Mitral s' wave velocity has been identified in prior studies as an indicator of subtle left ventricular systolic dysfunction ( 32 ). This study revealed that left ventricular diastolic function was impaired in the high- and moderate-risk groups relative to the low-risk group. Conventional pulsed-wave Doppler analysis showed a strong positive correlation between deceleration time (DT) and isovolumic relaxation time (IVRT) (with r-values of 0.639 and 0.714, respectively) and the overall CHA2DS2-VASc score, alongside a moderate, significant negative correlation with the E/A ratio. These findings are consistent with Hadadi et al. ( 30 ), who also noted a significant decrease in the E/A ratio as CHA2DS2-VASc scores increased, although they did not observe significant DT prolongation. The decline in the E/A ratio was mainly due to a significant rise in A wave velocity across groups. Azarbal et al. ( 31 ) reported a similar trend in patients with stable coronary artery disease and preserved ejection fraction. In the current study, E wave velocity (reflecting conduit function) was lower in the high-risk group compared to the low-risk group, whereas A wave velocity (reflecting contractile function) was higher, likely indicating an early compensatory rise in contractile function. Regarding tissue Doppler indices, a mild, significant positive correlation was observed between the average E/e' and the total CHA 2 DS 2 -VASc score, while a moderate, significant negative correlation was found with the average e'. These findings are consistent with those of Hadadi et al. ( 26 ), who reported a decrease in e' and an elevation of E/e' with increasing CHA 2 DS 2 -VASc score. Jang et al. ( 33 ) also demonstrated that increasing CHA 2 DS 2 -VASc score was associated with higher left atrial volume index and E/e' in patients with nonvalvular atrial fibrillation. Speckle-tracking analysis of the left atrium showed a moderate, significant inverse relationship between LASr, LAScd, LAScd/ct, and the CHA2DS2-VASc score. These measures were notably lower in the high-risk group compared to both the moderate- and low-risk groups. This observation is consistent with the findings of Hadadi et al. ( 30 ), who documented decreased left atrial strain and strain rate during the reservoir phase in individuals with higher risk scores. The various components of the CHA2DS2-VASc score may impact left atrial function through different mechanisms, including myocardial fibrosis, insulin resistance, oxidative stress related to diabetes, age-associated fibrosis, hypertension, estrogen deficiency following menopause, neurohormonal activation in heart failure, and other processes seen in patients with myocardial infarction and stroke ( 34 – 37 ). Volumetric assessment supported the left atrial strain findings. Mild, significant positive correlations were observed between left atrial diameter, maximum volume, minimum volume, minimum volume index, pre-A volume, and the CHA 2 DS 2 -VASc score. There was no significant correlation between CHA 2 DS 2 -VASc score and LA maximum volume index. Hadadi et al. ( 30 ) similarly reported increases in maximum volume index, pre-A volume, and minimum volume index across score groups. The high-risk group demonstrated worsening of reservoir function (lower LATEV and LATEF) and conduit function (lower LAPEV and LAPEF) compared to the low-risk group, with no significant difference in contractile function (LAAEV and LAAEF). Hadadi et al. ( 30 ) also found reduced LATEF, while reductions in LAPEF and LAAEF were not significant. Study limitation Several limitations should be acknowledged. The cross-sectional design restricts generalizability. The absence of follow-up precluded observation of atrial fibrillation or thromboembolic events in high-risk patients with reduced left atrial strain. The study's findings could be enhanced by incorporating three-dimensional echocardiography, cardiac MRI, invasive left ventricular filling pressure measurements, or Holter monitoring. Additionally, left atrial speckle tracking was performed using software intended for left ventricular analysis due to the unavailability of dedicated left atrial software. Conclusion In summary, patients with higher CHA 2 DS 2 -VASc risk scores generally demonstrate lower left atrial strain as measured by speckle-tracking echocardiography. These patients also exhibit impaired left ventricular diastolic function and increased left atrial phasic volumes, with reduced phasic emptying except for a compensatory increase in contractile function. These findings suggest that the CHA 2 DS 2 -VASc score may be useful not only for predicting thromboembolic risk but also for identifying early, subclinical changes in left atrial function among patients in sinus rhythm. Declarations Disclosure Statement : The authors have no conflicts of interest to declare. Funding: No funding has been received for this work. Declarations Ethics approval and consent to participate: The Institutional Review Board (IRB) of our University gave ethical approval for patient data. Written informed consent was obtained from all patients before the procedure for their participation in the study. Author Contribution KaM was responsible for conceptualization, methodology, and investigation (performed echo studies). KhM collected the data, wrote the draft, and gathered relevant literature. KaM and KhM created the figures and tables. SB approved the idea and revised the collected data. HE performed echo studies and edited the final manuscript. All authors approved the current version of the manuscript. Data Availability The data that support the findings of this study are available from the authors upon request. References Go A., Hylek E., Phillips K., Chang Y., Henault L., Selby J., et al., Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study, JAMA 285. 2001; 2370–2375. 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Association of CHADS2, CHA2DS2-VASc, and R2CHADS2 Scores With Left Atrial Dysfunction in Patients With Coronary Heart Disease (from the Heart and Soul Study). The American Journal of Cardiology . 2014;113:1166–1172. Park YS, Park J-H, Ahn KT, et al. Usefulness of Mitral Annular Systolic Velocity in the Detection of Left Ventricular Systolic Dysfunction: Comparison with Three Dimensional Echocardiographic Data. Journal of Cardiovascular Ultrasound . 2010;18:1. Jang AY, Yu J, Park YM, Shin MS, Chung W-J, Moon J. Cardiac Structural or Functional Changes Associated with CHA2DS2-VASc Scores in Nonvalvular Atrial Fibrillation: A Cross-Sectional Study Using Echocardiography. Journal of Cardiovascular Imaging . 2018;26:135. Tadic M, Cuspidi C. influence of type 2 diabetes on atrial remodeling. Clin Cardiol. 2015; 38:48–55. Yoshida Y, Nakanishi K, Daimon M, et al. Alteration of cardiac performance serum B-type natriuretic peptide level in healthy aging. J Am Coll Cardiol. 2019; 74:1789–800. Cameli M, Ciccone MM, Maiello M, et al. Speckle tracking analysis: new tool for atrial function analysis in systemic hypertension: an overview. J Cardiovasc Med (Hagerstown). 2016; 17:339–43. Keskin Kurt R, Nacar AB, Guler A, et al. Menopausal cardiomyopathy: does it really exist? case-control deformation imaging study. J Obstet Gynaecol Res. 2014;40:1748–53. Tables Tables 3 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files GA.png Graphical Abstract: Speckle-tracking echocardiography across different CHA2DS2- VASc Risk Score categories shows lower left atrial strain during reservoir and conduit phases with increasing risk score. LAScd:Left atrial strain in conduit phase; LASr: Left atrial strain in reservoir phase. Table3to5.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 02 May, 2026 Reviews received at journal 27 Apr, 2026 Reviews received at journal 24 Apr, 2026 Reviewers agreed at journal 07 Apr, 2026 Reviewers agreed at journal 03 Apr, 2026 Reviewers invited by journal 01 Apr, 2026 Editor assigned by journal 01 Apr, 2026 Submission checks completed at journal 01 Apr, 2026 First submitted to journal 26 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9231263","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617030169,"identity":"f3b030d4-6d48-4851-a948-968af0573202","order_by":0,"name":"Kareem Mahmoud","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYDCCAwzMEAZ7Y/uHDwwMCSRo4TncxjiDNC0S6W3MPMRo4bt9gNng5x4bOd2GxLbHtm12efzsDYwfPubg1iJ5LoE5sedZmrHZgYPtxrltycWSPQeYJWduw63F4AwD8wGeA4cTtx1sbJDObWNO3HAjgY2Zl4CWg38O/K/fdpixQdqyrZ44Lck8Bw4kmB1jbJNmbDtMWIvkGcZmY5kDyYbbgAzDnnPHE2f2HGzG6xe+M8yHJd8csJM3u//84YMfZdWJ/ezNBz98xKOFgYGxAYnNhi5CGPwhRfEoGAWjYBSMFAAAVPdZn75CJHkAAAAASUVORK5CYII=","orcid":"","institution":"Cairo University","correspondingAuthor":true,"prefix":"","firstName":"Kareem","middleName":"","lastName":"Mahmoud","suffix":""},{"id":617030171,"identity":"29c73721-5b7b-4aa5-8f81-a0deec2a34d1","order_by":1,"name":"Khaled Mostafa","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Khaled","middleName":"","lastName":"Mostafa","suffix":""},{"id":617030182,"identity":"5c691b6d-ff9e-4db2-ad34-72e15a7131e9","order_by":2,"name":"Sameh Bakhoum","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Sameh","middleName":"","lastName":"Bakhoum","suffix":""},{"id":617030189,"identity":"54cea4cb-eb3e-4a1a-9938-869e0049c704","order_by":3,"name":"Heba ElDeeb","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Heba","middleName":"","lastName":"ElDeeb","suffix":""}],"badges":[],"createdAt":"2026-03-26 08:23:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9231263/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9231263/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106347506,"identity":"e4b761ce-2e42-4355-b29e-84f0779ae66b","added_by":"auto","created_at":"2026-04-07 16:40:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":515775,"visible":true,"origin":"","legend":"\u003cp\u003eSpeckle tracking echocardiography of the left atrium\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9231263/v1/a018889f56e41cf4bc61596a.png"},{"id":106347474,"identity":"1e23c2d7-f441-4010-b38f-efd6dfb9dc1e","added_by":"auto","created_at":"2026-04-07 16:40:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":60960,"visible":true,"origin":"","legend":"\u003cp\u003eMean LA phasic volumes and functions Data Comparison in CHA2DS2- VASc Risk Score categories. \u003cstrong\u003eLAAEF:\u003c/strong\u003e Left atrial active emptying fraction, \u003cstrong\u003eLAPEF\u003c/strong\u003e: Left atrial passive emptying fraction, \u003cstrong\u003eLAPEV:\u003c/strong\u003eLeft atrial passive emptying volume, \u003cstrong\u003eLATEF:\u003c/strong\u003e Left atrial total emptying fraction, \u003cstrong\u003eLATEV:\u003c/strong\u003e Left atrial total emptying volume\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9231263/v1/1dbcab6ea9efbe94e233033d.png"},{"id":106404207,"identity":"b1cf5f18-9abf-4721-ae71-00be799bdc7e","added_by":"auto","created_at":"2026-04-08 09:15:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1407953,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9231263/v1/052d4041-22bd-42e5-8538-3a4db0ac01b4.pdf"},{"id":106347422,"identity":"246b0f4b-3ee9-4419-82e9-76222b21ddac","added_by":"auto","created_at":"2026-04-07 16:39:58","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":415076,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraphical Abstract: \u003c/strong\u003eSpeckle-tracking echocardiography across different CHA2DS2- VASc Risk Score categories shows lower left atrial strain during reservoir and conduit phases with increasing risk score. \u003cstrong\u003eLAScd:\u003c/strong\u003eLeft atrial strain in conduit phase; \u003cstrong\u003eLASr:\u003c/strong\u003e Left atrial strain in reservoir phase.\u003c/p\u003e","description":"","filename":"GA.png","url":"https://assets-eu.researchsquare.com/files/rs-9231263/v1/b5343f676e0e9ed88e8bb445.png"},{"id":106347557,"identity":"ddcb0353-f181-4c44-8cb9-53f13d4f233d","added_by":"auto","created_at":"2026-04-07 16:40:26","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":31947,"visible":true,"origin":"","legend":"","description":"","filename":"Table3to5.docx","url":"https://assets-eu.researchsquare.com/files/rs-9231263/v1/f1b55f2147ae7355c6215c64.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAssociation between CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc Score and Left Atrial Function by Speckle Tracking Echocardiography in Patients with Sinus Rhythm\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAtrial fibrillation (AF) substantially increases the risk of cardioembolic stroke, contributing to considerable illness and death among affected individuals (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Multiple clinical scoring systems have been created to help predict the likelihood of stroke in patients with non-valvular atrial fibrillation (NVAF) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score is the most widely used (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This scoring system assigns points for a variety of clinical factors:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e- Congestive heart failure, including clinical symptoms or evidence of significant left ventricular dysfunction, or hypertrophic cardiomyopathy (1 point)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Hypertension or the use of antihypertensive medication (1 point)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Age: 1 point for ages 65 to 74 years, and 2 points for those 75 years or older\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Diabetes mellitus, defined as use of oral hypoglycemic agents, insulin, fasting blood glucose\u0026thinsp;\u0026ge;\u0026thinsp;126 mg/dL (7 mmol/L), or HbA1c\u0026thinsp;\u0026ge;\u0026thinsp;6.5% (1 point)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Prior stroke, transient ischemic attack (TIA), or systemic thromboembolism (2 points)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Vascular disease, such as significant coronary artery disease (CAD) by angiography, previous myocardial infarction, aortic plaque, or similar conditions (1 point)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Female sex, which acts as a stroke risk modifier rather than a direct risk factor (1 point) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAlthough designed for AF patients, this score also predicts thromboembolic events in those without AF, such as heart failure (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), chronic obstructive pulmonary disease (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and post-coronary artery bypass grafting (CABG) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). It can also predict AF development in diabetes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), systemic lupus erythematosus (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), myocardial infarction (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and after cardiac surgery (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score is associated with other adverse events, such as failed reperfusion after thrombolytic therapy (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), the no-reflow phenomenon (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), and contrast-induced nephropathy (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Although the CHA2DS2-VASc score is commonly applied, its direct association with subtle abnormalities in left atrial function among individuals in sinus rhythm remains uncertain. This highlights a need for further research.\u003c/p\u003e \u003cp\u003eThe left atrium (LA) is essential for effective filling of the left ventricle (LV), serving as a reservoir, a passive conduit, and an active contractile chamber (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Speckle-tracking echocardiography (STE) allows early detection of LA functional changes, even before LA enlargement (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is limited research examining the relationship between left atrial function and CHA2DS2-VASc score in individuals who are in sinus rhythm. The present study evaluated whether this risk score predicts early, subclinical atrial dysfunction prior to enlargement, using speckle-tracking echocardiography, to inform assessment and early intervention in patients without overt atrial fibrillation.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This cross-sectional observational study enrolled both male and female participants with different CHA2DS2-VASc scores, all were in sinus rhythm. The study ran from May 1 to October 30, 2022. We recruited 150 patients and grouped them by CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score: low (1 for females, 0 for males), moderate (2 for females, 1 for males), and high (\u0026ge;\u0026thinsp;3 for females, \u0026ge;\u0026thinsp;2 for males). Exclusion criteria included atrial fibrillation or atrial flutter, infective endocarditis, significant valvular heart disease, presence of prosthetic valves, pacemakers, poor echocardiographic windows, or LVEF below 50%. The Medical Ethics Committee approved the study. We adhered to the Declaration of Helsinki (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and the STROBE checklist (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). All patients received an explanation of the study and gave written consent.\u003c/p\u003e \u003cp\u003eAll patients underwent the following assessment:\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eA comprehensive medical history was obtained for each participant, with particular attention to CHA2DS2-VASc risk elements including heart failure, age, diabetes, previous stroke, vascular disease, and sex (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eA standard 12-lead surface electrocardiogram (ECG) to assess cardiac rhythm and heart rate.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTwo experienced cardiologists performed conventional transthoracic echocardiography using a Philips Affinity 50C machine with an S5-1 transducer. Images were captured while participants held their breath, adhering to the guidelines set by the American Society of Echocardiography (ASE) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Left atrial (LA) volumes were determined using the biplane area-length technique from both apical four- and two-chamber views, and subsequently indexed to body surface area. Volume measurements were taken at (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e):\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLAV max\u003c/strong\u003e \u003cp\u003emeasured at end-systole, immediately before the mitral valve opens\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLAV min\u003c/strong\u003e \u003cp\u003erecorded at end-diastole, right before the mitral valve closes\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLAV preA\u003c/strong\u003e \u003cp\u003eassessed at the beginning of the P-wave on the ECG\u003c/p\u003e \u003c/p\u003e \u003cp\u003eSeveral parameters were derived from these measurements:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTotal emptying volume (LATEV)\u003c/strong\u003e \u003cp\u003edetermined by subtracting LAV min from LAV max\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePassive emptying volume (LAPEV)\u003c/strong\u003e \u003cp\u003ecalculated as LAV max minus LAV preA\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eActive emptying volume (LAAEV)\u003c/strong\u003e \u003cp\u003ecalculated as LAV preA minus LAV min\u003c/p\u003e \u003c/p\u003e \u003cp\u003eCorresponding emptying fractions were computed as (volume/LAVmax) \u0026times;100 for total and passive fractions, and (LAAEV/LAVpreA) \u0026times;100 for active emptying fraction.\u003c/p\u003e \u003cp\u003eTo assess left ventricular (LV) diastolic function, mitral inflow was evaluated using pulsed Doppler with the sample volume positioned between the tips of the mitral leaflets during diastole. Measurements included peak velocities during early diastole (E wave) and late diastole (A wave), the E/A ratio, and deceleration time (DT). Tissue Doppler imaging (TDI) was employed to obtain septal and lateral e' velocities, which allowed calculation of the E/e' ratio as an indicator of LV filling pressure. Isovolumic relaxation time (IVRT) was measured in the apical five-chamber view by placing the pulsed wave Doppler sample volume in the LV outflow tract to simultaneously visualize the end of aortic ejection and the onset of mitral inflow.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSpeckle-tracking echocardiography (STE) was also performed for left atrial imaging. Left atrial (LA) strain analysis was performed offline utilizing QLAB version 10 (Philips Medical Systems). Two-dimensional grayscale images with a high frame rate (60\u0026ndash;80 frames per second) were acquired from apical four-chamber and two-chamber views while participants held their breath. The LA endocardial border was manually traced at ventricular end-systole, excluding pulmonary veins and LA appendage. The region of interest width was adjusted to ensure optimal tracking of atrial myocardium. Automatic frame-by-frame speckle tracking was performed by the software. Manual correction was applied as needed if inadequate tracking occurred (adjusting\u0026thinsp;\u0026gt;\u0026thinsp;2 segments). Global longitudinal strain (GLS) of the left atrium was measured from apical four- and two-chamber views by STE. Left atrial longitudinal strain was assessed in three phases (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ereservoir phase (LASr, measured as the difference between strain at mitral valve opening and ventricular end-diastole)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003econduit phase (LAScd, difference between strain at the onset of atrial contraction and mitral valve opening)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003econtraction phase (LASct, difference between strain at ventricular end-diastole and the onset of atrial contraction).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. shows an example of speckle tracking echocardiography of the left atrium.\u003c/p\u003e \u003cp\u003eStatistical analysis was performed as follows. Sample size was determined using G*Power 3.1.9.7. We required 150 patients to detect an effect size of 0.2 for mean STE parameters (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The significance level was set at 0.05 with 80% power. Data management and analysis were conducted with IBM SPSS Statistics version 24.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics\u0026mdash;such as means, standard deviations, medians, ranges, frequencies, and percentages\u0026mdash;were reported. The chi-square test was applied to evaluate categorical variables. The normality of continuous variables was checked using either the Kolmogorov\u0026ndash;Smirnov or Shapiro\u0026ndash;Wilk tests. Differences in means between dichotomous groups were assessed using the Student's t-test. One-way ANOVA compared means across more than two groups, with Tukey\u0026rsquo;s post-hoc test for pairwise comparisons. Pearson correlation analysis assessed associations between variables. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants were categorized into three groups according to their CHA2DS2-VASc score: low (1 for females, 0 for males), moderate (2 for females, 1 for males), and high (\u0026ge;\u0026thinsp;3 for females, \u0026ge;\u0026thinsp;2 for males). The ages of the patients ranged from 28 to 82 years, with an average age of 45.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3 years. There was an equal distribution of males and females (ratio 1:1), and the mean body surface area (BSA) measured 1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1 m\u0026sup2;. Among participants, one-third had a history of stroke, approximately 40% had hypertension, about 20% had diabetes mellitus, and 4% had vascular disease.\u003c/p\u003e\n\u003ch3\u003eundefined\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cb\u003eCorrelations CHA\u003c/b\u003e\u003csub\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sub\u003e\u003cb\u003eDS\u003c/b\u003e\u003csub\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sub\u003e\u003cb\u003e-VASc score and different conventional echocardiographic and STE parameters\u003c/b\u003e\u003c/div\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. summarizes the univariate correlations between total CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score and various left ventricular (LV) and left atrial (LA) parameters. The strongest positive correlations were observed with time-dependent diastolic indices: isovolumic relaxation time (IVRT) (r\u0026thinsp;=\u0026thinsp;0.714, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and deceleration time (DT) (r\u0026thinsp;=\u0026thinsp;0.639, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Moderate negative correlations were observed with LAPEV and LATEV (r = -0.53 and \u0026minus;\u0026thinsp;0.47; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There were mild negative correlations with LVEF, LAPEF, LAAEV, and LATEF (r = -0.14, -0.27, -0.20, -0.17; p\u0026thinsp;=\u0026thinsp;0.046, 0.001, 0.008, 0.018). In contrast, significant, mild positive correlations were seen with LA diameter, LA maximum volume, minimum volume, pre-A volume, minimum volume index, and pre-A volume index (r\u0026thinsp;=\u0026thinsp;0.20, 0.16, 0.22, 0.26, 0.21, 0.25; p\u0026thinsp;=\u0026thinsp;0.006, 0.023, 0.004, 0.003, 0.005, 0.001). There was no significant correlation between the score and LA maximum volume index.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between Total CHA2DS2- VASc score and different LV and LA parameters.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eTotal CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e- VASc score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003er (p-value)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eParameters\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003er (p-value)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEF%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e-0.138 ( 0.046)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLAPEV (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.533 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLA Diameter (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.203 ( 0.006)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLAPEF%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.266 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAV \u003csub\u003eMax\u003c/sub\u003e (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.163 ( 0.023)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLAAEV (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.198 ( 0.008)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAV \u003csub\u003eMin\u003c/sub\u003e (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.216 ( 0.004)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLAAEF%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.103 ( 0.105)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAV \u003csub\u003ePre-A\u003c/sub\u003e (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.255 ( 0.003)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLATEV (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.471 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAV \u003csub\u003eMax\u003c/sub\u003e Index (ml/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.129 ( 0.058)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLATEF%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.171 ( 0.018)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAV \u003csub\u003eMin\u003c/sub\u003e Index (ml/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.212 ( 0.005)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eIVRT (ms)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.714 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAV \u003csub\u003ePre-A\u003c/sub\u003e Index (ml/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.249 ( 0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDT (cm/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.639 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eDT\u003c/b\u003e: deceleration time; \u003cb\u003eEF\u003c/b\u003e: ejection fraction; \u003cb\u003eIVRT\u003c/b\u003e: isovolumic relaxation time; \u003cb\u003eLA\u003c/b\u003e: left atrium; \u003cb\u003eLAAEF\u003c/b\u003e: Left atrial active emptying fraction; \u003cb\u003eLAAEV\u003c/b\u003e: Left atrial active emptying volume; \u003cb\u003eLAPEF\u003c/b\u003e: Left atrial passive emptying fraction; \u003cb\u003eLAPEV\u003c/b\u003e: Left atrial passive emptying volume; \u003cb\u003eLATEF\u003c/b\u003e: Left atrial total emptying fraction; \u003cb\u003eLATEV\u003c/b\u003e: Left atrial total emptying volume; \u003cb\u003eLAV\u003c/b\u003e\u003csub\u003e\u003cb\u003eMax\u003c/b\u003e\u003c/sub\u003e: Maximal left atrial volume; \u003cb\u003eLAV\u003c/b\u003e\u003csub\u003e\u003cb\u003eMin\u003c/b\u003e\u003c/sub\u003e: Minimal left atrial volume; \u003cb\u003eLAV\u003c/b\u003e\u003csub\u003e\u003cb\u003ePre\u0026minus;A\u003c/b\u003e\u003c/sub\u003e: Pre-A wave left atrial volume.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the correlations between CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score and speckle-tracking echocardiography (STE) parameters. There were significant, moderate negative correlations with LASr, LAScd, and LAScd/ct (r = -0.37, -0.43, and \u0026minus;\u0026thinsp;0.31, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation between Total CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e- VASc score and STE parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTotal CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e- VASc score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er (p-value)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLASr%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.370 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAScd%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.428 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLASct%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.045 (0.291)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAS cd/ct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.309 (\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003eLASct\u003c/b\u003e: Left atrial strain in contractile phase; \u003cb\u003eLAScd\u003c/b\u003e: Left atrial strain in conduit phase; \u003cb\u003eLASr\u003c/b\u003e: Left atrial strain in reservoir phase; \u003cb\u003eSTE\u003c/b\u003e: Speckle-tracking echocardiography\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cb\u003eComparison of conventional echocardiographic and STE parameters across CHA\u003c/b\u003e\u003csub\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sub\u003e\u003cb\u003eDS\u003c/b\u003e\u003csub\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sub\u003e\u003cb\u003e-VASc risk categories\u003c/b\u003e\u003c/div\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents comparisons of mitral inflow and tissue Doppler data by risk score. High-risk patients had lower E-wave velocity (68.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 cm/s) than those in the low-risk group (77.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2 cm/s, p\u0026thinsp;=\u0026thinsp;0.001). Low-risk patients had lower A-wave velocity (56.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 cm/s) compared to moderate (66.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7 cm/s, p\u0026thinsp;=\u0026thinsp;0.001) and high-risk patients (67.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 cm/s, p\u0026thinsp;=\u0026thinsp;0.001). Low-risk patients also had a higher E/A ratio (1.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3) than moderate (1.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and high-risk patients (1.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). High-risk patients had longer IVRT (96.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1 ms) than moderate (90.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9 ms, p\u0026thinsp;=\u0026thinsp;0.004) and low-risk patients (87.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 ms, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Low-risk patients had shorter DT (152.9\u0026thinsp;\u0026plusmn;\u0026thinsp;17.2 ms) compared to moderate (172.2\u0026thinsp;\u0026plusmn;\u0026thinsp;19.9 ms, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and high-risk patients (165.5\u0026thinsp;\u0026plusmn;\u0026thinsp;20.3 ms, p\u0026thinsp;=\u0026thinsp;0.007).\u003c/p\u003e\n\u003cp\u003eTable \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e compares LV dimensions and ejection fraction across CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc risk categories. Patients in the high-risk group had a significantly greater LA diameter (3.69\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40 cm) than those in the moderate (3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50 cm, p\u0026thinsp;=\u0026thinsp;0.039) and low-risk groups (3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1 cm, p\u0026thinsp;=\u0026thinsp;0.005). High-risk patients also had significantly higher LA minimum volume, minimum volume index, pre-A volume, and pre-A volume index (14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 ml, 8.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 ml/m\u0026sup2;, 25.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7 ml, and 13.75\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5 ml/m\u0026sup2;, respectively) compared to low-risk patients (12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 ml, 6.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 ml/m\u0026sup2;, 20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4 ml, and 11.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1 ml/m\u0026sup2;; p\u0026thinsp;=\u0026thinsp;0.006, 0.01, 0.004, and 0.006, respectively).\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e compares phasic LA volumes by risk group. Low-risk patients had significantly higher LAPEV (15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1 ml) than those in the moderate (8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 ml, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and high-risk groups (7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 ml, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). High-risk patients had significantly lower LAPEF (35.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2%) compared to those in the moderate (39.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and low-risk groups (42.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cp\u003eTable \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents a comparison of STE data across risk categories. High-risk patients had markedly lower LASr and LAScd values (33.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 and 20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7) than those in the moderate (36.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1 and 23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8, p\u0026thinsp;=\u0026thinsp;0.005 and 0.003) and low-risk groups (40.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 and 26.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The moderate-risk group also had significantly lower LASr and LAScd than the low-risk group (p\u0026thinsp;=\u0026thinsp;0.007 and 0.001, respectively) (Graphical abstract). For LAScd/ct, low-risk patients had higher values (2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6) compared to those in the moderate (1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8, p\u0026thinsp;=\u0026thinsp;0.007) and high-risk groups (1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7, p\u0026thinsp;=\u0026thinsp;0.023).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ehis study found that elevated CHA2DS2-VASc scores were linked to gradual worsening of left ventricular diastolic function, as well as reduced left atrial reservoir and conduit function, while contractile function\u0026mdash;measured by speckle-tracking echocardiography\u0026mdash;remained largely unchanged.\u003c/p\u003e \u003cp\u003eThe CHA2DS2-VASc score was originally designed to assess the risk of thromboembolism in individuals with atrial fibrillation (AF). More recently, its usefulness has been explored in populations without AF, such as patients with heart failure (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), chronic obstructive pulmonary disease (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), and those who have undergone coronary artery bypass grafting (CABG) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Despite this, it is still uncertain whether the score can reliably detect left atrial dysfunction in people with sinus rhythm. The current study aimed to investigate the CHA2DS2-VASc score as a potential early marker for left atrial dysfunction in this group.\u003c/p\u003e \u003cp\u003eIn the current study, a mild yet statistically significant inverse relationship was found between the CHA2DS2-VASc score and left ventricular ejection fraction (LVEF), although no significant differences in LVEF appeared across the three groups. It is important to note that patients with LVEF below 50% were excluded from the study. Earlier research has shown that higher CHA2DS2-VASc scores are linked to declining LVEF in individuals with coronary artery disease (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This study also demonstrated that mitral s' wave velocity was significantly reduced in both the high- and moderate-risk groups when compared to the low-risk group. These findings align with those of Hadadi et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), who observed a marked reduction in mean mitral s' wave velocity in the high-risk group. Mitral s' wave velocity has been identified in prior studies as an indicator of subtle left ventricular systolic dysfunction (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study revealed that left ventricular diastolic function was impaired in the high- and moderate-risk groups relative to the low-risk group. Conventional pulsed-wave Doppler analysis showed a strong positive correlation between deceleration time (DT) and isovolumic relaxation time (IVRT) (with r-values of 0.639 and 0.714, respectively) and the overall CHA2DS2-VASc score, alongside a moderate, significant negative correlation with the E/A ratio. These findings are consistent with Hadadi et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), who also noted a significant decrease in the E/A ratio as CHA2DS2-VASc scores increased, although they did not observe significant DT prolongation. The decline in the E/A ratio was mainly due to a significant rise in A wave velocity across groups. Azarbal et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) reported a similar trend in patients with stable coronary artery disease and preserved ejection fraction. In the current study, E wave velocity (reflecting conduit function) was lower in the high-risk group compared to the low-risk group, whereas A wave velocity (reflecting contractile function) was higher, likely indicating an early compensatory rise in contractile function.\u003c/p\u003e \u003cp\u003eRegarding tissue Doppler indices, a mild, significant positive correlation was observed between the average E/e' and the total CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score, while a moderate, significant negative correlation was found with the average e'. These findings are consistent with those of Hadadi et al. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), who reported a decrease in e' and an elevation of E/e' with increasing CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score. Jang et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) also demonstrated that increasing CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score was associated with higher left atrial volume index and E/e' in patients with nonvalvular atrial fibrillation.\u003c/p\u003e \u003cp\u003eSpeckle-tracking analysis of the left atrium showed a moderate, significant inverse relationship between LASr, LAScd, LAScd/ct, and the CHA2DS2-VASc score. These measures were notably lower in the high-risk group compared to both the moderate- and low-risk groups. This observation is consistent with the findings of Hadadi et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), who documented decreased left atrial strain and strain rate during the reservoir phase in individuals with higher risk scores. The various components of the CHA2DS2-VASc score may impact left atrial function through different mechanisms, including myocardial fibrosis, insulin resistance, oxidative stress related to diabetes, age-associated fibrosis, hypertension, estrogen deficiency following menopause, neurohormonal activation in heart failure, and other processes seen in patients with myocardial infarction and stroke (\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVolumetric assessment supported the left atrial strain findings. Mild, significant positive correlations were observed between left atrial diameter, maximum volume, minimum volume, minimum volume index, pre-A volume, and the CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score. There was no significant correlation between CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score and LA maximum volume index. Hadadi et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) similarly reported increases in maximum volume index, pre-A volume, and minimum volume index across score groups. The high-risk group demonstrated worsening of reservoir function (lower LATEV and LATEF) and conduit function (lower LAPEV and LAPEF) compared to the low-risk group, with no significant difference in contractile function (LAAEV and LAAEF). Hadadi et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) also found reduced LATEF, while reductions in LAPEF and LAAEF were not significant.\u003c/p\u003e\n\u003ch3\u003eStudy limitation\u003c/h3\u003e\n\u003cp\u003eSeveral limitations should be acknowledged. The cross-sectional design restricts generalizability. The absence of follow-up precluded observation of atrial fibrillation or thromboembolic events in high-risk patients with reduced left atrial strain. The study's findings could be enhanced by incorporating three-dimensional echocardiography, cardiac MRI, invasive left ventricular filling pressure measurements, or Holter monitoring. Additionally, left atrial speckle tracking was performed using software intended for left ventricular analysis due to the unavailability of dedicated left atrial software.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, patients with higher CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc risk scores generally demonstrate lower left atrial strain as measured by speckle-tracking echocardiography. These patients also exhibit impaired left ventricular diastolic function and increased left atrial phasic volumes, with reduced phasic emptying except for a compensatory increase in contractile function. These findings suggest that the CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score may be useful not only for predicting thromboembolic risk but also for identifying early, subclinical changes in left atrial function among patients in sinus rhythm.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding has been received for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations Ethics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Institutional Review Board (IRB) of our University gave ethical approval for patient data. Written informed consent was obtained from all patients before the procedure for their participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKaM was responsible for conceptualization, methodology, and investigation (performed echo studies). KhM collected the data, wrote the draft, and gathered relevant literature. KaM and KhM created the figures and tables. SB approved the idea and revised the collected data. HE performed echo studies and edited the final manuscript. All authors approved the current version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the authors upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGo A., Hylek E., Phillips K., Chang Y., Henault L., Selby J., et al., Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study, JAMA 285. 2001; 2370\u0026ndash;2375.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGage B., Waterman A., Shannon W., Boechler M., Rich M., Radford M., Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation, JAMA 285. 2001; 2864\u0026ndash;2870.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChao T., Liu C., Wang K., Lin Y., Chang S., Lo L. et al., Using the CHA2DS2-VASc score for refining stroke risk stratification in \u0026lsquo;low-risk\u0026rsquo; Asian patients with atrial fibrillation, J. 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Usefulness of Mitral Annular Systolic Velocity in the Detection of Left Ventricular Systolic Dysfunction: Comparison with Three Dimensional Echocardiographic Data. \u003cem\u003eJournal of Cardiovascular Ultrasound\u003c/em\u003e. 2010;18:1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJang AY, Yu J, Park YM, Shin MS, Chung W-J, Moon J. Cardiac Structural or Functional Changes Associated with CHA2DS2-VASc Scores in Nonvalvular Atrial Fibrillation: A Cross-Sectional Study Using Echocardiography. \u003cem\u003eJournal of Cardiovascular Imaging\u003c/em\u003e. 2018;26:135.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTadic M, Cuspidi C. influence of type 2 diabetes on atrial remodeling. Clin Cardiol. 2015; 38:48\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoshida Y, Nakanishi K, Daimon M, et al. Alteration of cardiac performance serum B-type natriuretic peptide level in healthy aging. J Am Coll Cardiol. 2019; 74:1789\u0026ndash;800.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCameli M, Ciccone MM, Maiello M, et al. Speckle tracking analysis: new tool for atrial function analysis in systemic hypertension: an overview. J Cardiovasc Med (Hagerstown). 2016; 17:339\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeskin Kurt R, Nacar AB, Guler A, et al. Menopausal cardiomyopathy: does it really exist? case-control deformation imaging study. J Obstet Gynaecol Res. 2014;40:1748\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 3 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiovascular-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Cardiovascular Imaging](https://jcvi.biomedcentral.com/)","snPcode":"44348","submissionUrl":"https://submission.springernature.com/new-submission/44348/3","title":"Journal of Cardiovascular Imaging","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sinus Rhythm, Speckle Tracking Echocardiography, Left Atrium, CHA2DS2-VASc score","lastPublishedDoi":"10.21203/rs.3.rs-9231263/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9231263/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score is an established tool for thromboembolic risk assessment in atrial fibrillation (AF). Individual components of the score may affect left atrial function. Speckle-tracking echocardiography (STE) enables detection of early, subtle changes in the left atrium.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study aimed to test whether left atrial function, as assessed by speckle-tracking echocardiography, differs among patients with sinus rhythm according to their CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study included 150 patients with sinus rhythm. They were grouped by CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score: low (1 for females, 0 for males), moderate (2 for females, 1 for males), and high (\u0026ge;\u0026thinsp;3 for females, \u0026ge;\u0026thinsp;2 for males), with 50 patients per group. All participants gave written consent, provided medical histories, underwent a 12-lead ECG, and received standard and STE echocardiography.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe high-risk group had significantly lower left atrial strain during both the reservoir (33.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1) and conduit phases (20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7) compared to the moderate-risk group (36.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1, 23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8) and low-risk group (40.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6, 26.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9), with all p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.01. Moderate-risk patients also showed lower strain values than low-risk patients. In contrast, left atrial maximal volume index did not differ among the groups (p\u0026thinsp;=\u0026thinsp;0.536).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIncreased CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc scores correlated with reduced left atrial strain in reservoir and conduit phases, suggesting early atrial dysfunction prior to enlargement. Further research should assess the clinical relevance of these echocardiographic findings for risk stratification in patients with high CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score.\u003c/p\u003e","manuscriptTitle":"Association between CHA2DS2-VASc Score and Left Atrial Function by Speckle Tracking Echocardiography in Patients with Sinus Rhythm","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-07 16:38:23","doi":"10.21203/rs.3.rs-9231263/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-02T09:41:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T02:41:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T07:14:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259010661579340776211771662246021476776","date":"2026-04-08T02:47:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147392740401268078104862862339179939681","date":"2026-04-03T08:23:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-01T22:28:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-01T07:14:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-01T07:13:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiovascular Imaging","date":"2026-03-26T08:09:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiovascular-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Cardiovascular Imaging](https://jcvi.biomedcentral.com/)","snPcode":"44348","submissionUrl":"https://submission.springernature.com/new-submission/44348/3","title":"Journal of Cardiovascular Imaging","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79c70ebb-0b17-48c1-94a0-740970a3d3db","owner":[],"postedDate":"April 7th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-02T09:41:19+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-02T09:54:47+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-07 16:38:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9231263","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9231263","identity":"rs-9231263","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}