Left ventricular diastolic dysfunction as a mediator between the CHA2DS2-VASc score and left atrial strain

Abstract The CHA₂DS₂-VASc score, originally developed for stroke risk stratification in atrial fibrillation, comprises cardiovascular risk factors that promote left ventricular (LV) diastolic dysfunction and left atrial (LA) remodeling. In this issue, Mahmoud et al. examined the association between the CHA₂DS₂-VASc score and LA function assessed by speckle-tracking echocardiography in 150 patients in sinus rhythm. LA reservoir and conduit strain decreased progressively with increasing risk category, whereas LA volume index did not differ significantly, indicating that functional impairment preceded overt LA enlargement. Using mediation analysis, the authors showed that the association with conduit strain was largely mediated by LV diastolic dysfunction, whereas reservoir strain retained a smaller direct association, suggesting an intrinsic atrial component consistent with atrial cardiomyopathy. This commentary discusses these findings within the framework of atrial remodeling and contemporary echocardiographic assessment, considers the study's principal limitations, and highlights the need for longitudinal studies to determine the prognostic significance of subclinical LA dysfunction in patients without atrial fibrillation.