CTA -derived left to right atrial size ratio distinguishes between pulmonary hypertension due to heart failure and idiopathic pulmonary arterial hypertension

Abstract Background/objectives Assessing atrial sizes by routine non-gated CT-angiography (CTA) could be of value in discriminating between pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (HFpEF) and idiopathic pulmonary arterial hypertension (IPAH). We aimed to determine how left (LA) and right atrial (RA) sizes on non-gated CTA can help discriminate between these patients. Methods and results In an initial study, CMR was used in 15 IPAH and 15 PH-HFpEF patients to determine LA- and RA size throughout the cardiac cycle. While significant variations were noted in LA size over the cardiac cycle, the calculated ratio of left over right atrial size (LA/RA ratio) remained stable in both groups and discriminated between PH-HFpEF and IPAH. In a second study, routine non-gated CTA was used to validate the diagnostic use of a LA/RA ratio in 95 consecutive treatment-naive patients with a final diagnosis of either IPAH (n = 64) or PH-HFpEF (n = 31). ROC analyses were conducted to determine the discriminative properties of atrial size parameters. On a transversal view, LA size was 19 cm2 (± 5) in the IPAH group versus 27 cm2 (± 6) in the PH-HFpEF group ( p < 0.001). CTA derived LA/RA ratio was significantly higher in PH-HFpEF patients compared to IPAH patients and had good discriminative abilities (AUC = 0.833). Conclusions Assessing LA/RA size ratio by non-gated CTA allows for accurate discrimination between PH-HFpEF and IPAH patients. Because CTA is often available in the early diagnostic work-up, a LA/RA size ratio may guide clinical and diagnostic decision-making, even before invasive hemodynamic measurements.