The association between diabetes mellitus and left atrial strain in individuals with hypertension: Authors’ Reply to the Letter to the Editor

The association between diabetes mellitus and left atrial strain in individuals with hypertension: Authors’ Reply to the Letter to the Editor | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Echocardiography This is a preprint and has not been peer reviewed. Data may be preliminary. 24 September 2025 V1 Latest version Share on The association between diabetes mellitus and left atrial strain in individuals with hypertension: Authors’ Reply to the Letter to the Editor Authors : Camila Mota Guida 0000-0002-9679-388X [email protected] , Jonathan Batista Souza , and Fernando Yue Cesena Authors Info & Affiliations https://doi.org/10.22541/au.175874434.40753820/v1 Published Echocardiography Version of record Peer review timeline 384 views 132 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Diabetes mellitus has been increasingly recognized as a contributor to subclinical atrial dysfunction, particularly in hypertensive patients with preserved left ventricular ejection fraction. In our study, we demonstrated an association between diabetes and impaired left atrial mechanics assessed by two-dimensional speckle-tracking echocardiography. While the cross-sectional design does not allow causal inference, our findings support the hypothesis that diabetes may adversely affect atrial strain independent of overt cardiovascular disease. We adjusted for relevant clinical and echocardiographic variables, though residual confounding cannot be excluded. Patients with known atrial fibrillation were excluded, and although prolonged rhythm monitoring was not performed, this limitation reflects the real-world challenges of detecting silent paroxysmal arrhythmias. Echocardiography was chosen for its accessibility and widespread applicability, and reproducibility analyses confirmed good intra- and inter-observer agreement. Validation against other modalities such as cardiac magnetic resonance imaging was beyond the scope of the present study. The association between diabetes mellitus and left atrial strain in individuals with hypertension: Authors’ Reply to the Letter to the Editor Camila Mota Guida, MD, MSc¹; Jonathan Batista Souza MD, PhD¹; Fernando Yue Cesena, MD, PhD¹. ¹ Dante Pazzanese Institute of Cardiology, Division of Cardiology, São Paulo, Brazil. Running title: DM and LA strain in hypertension: Authors’ Reply Word count: 2,472 Abstract word count: 145 Corresponding Author: Camila Mota Guida, 500, Avenida Dante Pazzanese, São Paulo, 04012-909. E-mail: [email protected] Key-words: Left atrial strain; hypertension; diabetes mellitus; Speckle-tracking echocardiography, heart failure with preserved ejection fraction. ABSTRACT Diabetes mellitus has been increasingly recognized as a contributor to subclinical atrial dysfunction, particularly in hypertensive patients with preserved left ventricular ejection fraction. In our study, we demonstrated an association between diabetes and impaired left atrial mechanics assessed by two-dimensional speckle-tracking echocardiography. While the cross-sectional design does not allow causal inference, our findings support the hypothesis that diabetes may adversely affect atrial strain independent of overt cardiovascular disease. We adjusted for relevant clinical and echocardiographic variables, though residual confounding cannot be excluded. Patients with known atrial fibrillation were excluded, and although prolonged rhythm monitoring was not performed, this limitation reflects the real-world challenges of detecting silent paroxysmal arrhythmias. Echocardiography was chosen for its accessibility and widespread applicability, and reproducibility analyses confirmed good intra- and inter-observer agreement. Validation against other modalities such as cardiac magnetic resonance imaging was beyond the scope of the present study. Dear Editor, We would like to sincerely thank Dr. Kalcik for his thoughtful comments and valuable insights regarding our study on the association between diabetes mellitus and left atrial (LA) strain in individuals with hypertension. 1,2 We appreciate the opportunity to further clarify the methodological aspects of our work. We fully agree that the cross-sectional design does not allow causal inference. Our primary objective, however, was to demonstrate an association between diabetes and subclinical atrial dysfunction, generating hypotheses that can be tested in future longitudinal and multicenter cohorts. As highlighted, LA strain may be influenced by comorbidities such as hypertension, diastolic dysfunction, and obesity. In our analysis, we adjusted for key clinical and echocardiographic variables, including age and body mass index, with additional models incorporating systolic blood pressure, left ventricular mass index, and diastolic function parameters such as the E/A and E/e′ ratios. The overall pattern of association remained consistent across these adjustments. 2 Nevertheless, we acknowledge that residual confounding may persist, a limitation inherent to many observational studies, which we emphasized in our previous discussion. We excluded patients with known atrial fibrillation (AF). Although paroxysmal AF was not systematically assessed with prolonged rhythm monitoring, we believe this reflects a real-world scenario, where detecting asymptomatic paroxysmal AF in clinical practice is inherently challenging and often impractical outside research protocols. Therefore, while we recognize this as a limitation, it also mirrors everyday clinical decision-making, where silent AF episodes may go undetected. Two-dimensional speckle-tracking echocardiography was selected because it is currently the most widely available and routinely used technique for LA strain assessment worldwide. 3–5 Again, this choice reflects a real-world approach: echocardiography remains the most accessible and pragmatic imaging modality in both clinical and research settings. We did perform reproducibility analyses with good intra- and inter-observer agreement, and our protocol adhered to the current recommendations for atrial strain imaging. Validation against other modalities such as cardiac magnetic resonance imaging would certainly add value, it was beyond the scope and feasibility of our study. We thank the authors for underscoring the importance of our findings. Despite the limitations discussed, our results suggest that diabetes is associated with early impairment of atrial mechanics even in hypertensive patients without overt cardiovascular disease. We conclude that prospective, multicenter studies with standardized imaging protocols and more comprehensive arrhythmia screening are warranted to confirm and expand upon these observations. REFERENCES 1. Kalçik M. Methodological Considerations in Assessing Left Atrial Dysfunction in Hypertensive Patients With Diabetes Mellitus. Echocardiogr Mt Kisco N . 2025;42(9):e70276. doi:10.1111/echo.702762. Guida CM, Souza JB, Cesena FY, et al. Association Between Diabetes Mellitus and Left Atrial Strain in Individuals With Hypertension. Echocardiogr Mt Kisco N . 2025;42(6):e70226. doi:10.1111/echo.702263. Cameli M, Incampo E, Mondillo S. Left atrial deformation: Useful index for early detection of cardiac damage in chronic mitral regurgitation. Int J Cardiol Heart Vasc . 2017;17:17-22. doi:10.1016/j.ijcha.2017.08.0034. Inoue K, Khan FH, Remme EW, et al. Determinants of left atrial reservoir and pump strain and use of atrial strain for evaluation of left ventricular filling pressure. Eur Heart J Cardiovasc Imaging . 2021;23(1):61-70. doi:10.1093/ehjci/jeaa4155. Yu ZX, Yang W, Yin WS, et al. Clinical utility of left atrial strain in predicting atrial fibrillation recurrence after catheter ablation: An up-to-date review. World J Clin Cases . 2022;10(23):8063-8075. doi:10.12998/wjcc.v10.i23.8063 Information & Authors Information Version history V1 Version 1 24 September 2025 Peer review timeline Published Echocardiography Version of Record 9 Oct 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Echocardiography Keywords diabetes mellitus diastolic dysfunction heart failure with preserved ejection fraction hypertension left atrial strain Authors Affiliations Camila Mota Guida 0000-0002-9679-388X [email protected] Instituto Dante Pazzanese de Cardiologia View all articles by this author Jonathan Batista Souza Instituto Dante Pazzanese de Cardiologia View all articles by this author Fernando Yue Cesena Instituto Dante Pazzanese de Cardiologia View all articles by this author Metrics & Citations Metrics Article Usage 384 views 132 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Camila Mota Guida, Jonathan Batista Souza, Fernando Yue Cesena. The association between diabetes mellitus and left atrial strain in individuals with hypertension: Authors’ Reply to the Letter to the Editor. Authorea . 24 September 2025. 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