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Background: Left atrial volume (LAV) is often adjusted for body surface area (BSA). In overweight individuals this may result in underestimation of left atrial (LA) dilation. The authors investigated whether alternative indexing techniques better predict mortality and cardiovascular (CV) events., Objectives: The purpose of this study was to evaluate the efficacy of different methods of indexing LAV in predicting mortality and CV events across a range of body sizes., Methods: LAV was adjusted for BSA, idealized BSA (iBSA), height, and height-squared (H 2 ) in patients aged over 50 years who underwent outpatient echocardiography and longitudinal follow-up at our institution. LA dilation was categorized using published criteria. Mortality and CV events were assessed via medical records., Results: LAVs were calculated in 17,454 individuals. In this study, 71.2% were overweight or obese. Indexing using iBSA, height, and H 2 resulted in reclassification of LA size in up to 28.4% (P < 0.001) compared with indexing using BSA. In severely obese individuals (body mass index [BMI] ≥40 kg/m 2 ), LA dilation indexed for BSA no longer predicted mortality (P = 0.70). Other indexing methods remained predictive of mortality. Height, H 2 , and iBSA all had greater performance, compared with BSA, for prediction of mortality and CV events in all overweight patients with H 2 showing the best overall performance (P < 0.001). Net reclassification index for mortality was significant for all alternative indexing techniques (P < 0.001) and patients whose LA was reclassified from normal to dilated had increased risk of mortality (P < 0.001) and CV events (P < 0.001) across all BMI categories., Conclusions: LA dilation based on standard indexing using BSA is nondiscriminatory for prediction of mortality in the severely obese. Indexing using height, H 2 , or iBSA to diagnose LA dilation better predicts mortality in this population and has better overall predictive performance across all overweight and obese populations. Using BSA indexing may lead to underappreciation of LA dilation and underestimation of patients at increased risk., Competing Interests: Funding Support and Author Disclosures Dr Hung is supported in part by National Institutes of Health–National Heart, Blood, and Lung Institute RO1HL103723-05. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Prior studies have shown that both heart failure (HF) and atrial fibrillation (AF) are factors that impact left atrial function and structure. However, right atrial (RA) function measured as RA emptying fraction (RAEF) on echocardiography has not been analyzed systematically in a chronic HF population. The aim of this study was to assess RA volume index (RAVI) and RAEF in patients with chronic HF and patients with hypertension (HTN) and to relate these findings to other cardiopulmonary ultrasound parameters and 12-month outcomes., Methods and Results: In this prospective observational study, we identified 119 patients with chronic HF (64 patients without a history of AF [HF without AF], 55 with AF [HF with AF]), and 127 patients with HTN but without important cardiac disease who underwent routine outpatient transthoracic echocardiography. We found that RAEF was impaired in patients with HF without AF compared to patients with HTN (35% ±2 vs 50% ±1, P < .001), whereas RAVI did not differ between these two groups. Lower RAEF was associated with larger RAVI and higher estimated RA pressures but not with a higher degree of pulmonary congestion by lung ultrasound. Both lower RAEF and higher RAVI were associated with an increased risk of 12-month HF hospitalizations or all-cause death (age, sex, and AF adjusted HR: 4.07, 95% CI: 1.69-9.79; P = .002, vs 2.74, 95% CI: 1.15-6.54, P = .023)., Conclusions: In an outpatient HF cohort, both lower RAEF and increased RAVI were associated with other markers of impaired cardiac function and 12-month adverse events., (© 2018 Wiley Periodicals, Inc.)