Impact of Menopause on Left Atrial Mechanics and Left Atrioventricular Coupling: The Role of Sex Hormones and Cardiovascular Remodeling

Abstract

Background: Menopause is associated with an increased cardiovascular risk that cannot be explained by aging and conventional risk factors alone. The abrupt decline in estradiol, relative androgen predominance, and accompanying vascular and myocardial changes may adversely affect left atrial (LA) function and left atrioventricular coupling. This review summarizes current evidence on LA mechanics, available imaging methods, and menopause-related cardiac remodeling. LA strain, assessed mainly by two-dimensional speckle-tracking echocardiography, quantifies reservoir, conduit, and booster-pump function and may detect subclinical dysfunction before LA enlargement or a reduction in left ventricular ejection fraction becomes apparent. Cardiac magnetic resonance-derived left atrioventricular coupling index provides complementary information on the relationship between LA and left ventricular volumes. Evidence indicates that postmenopausal women demonstrate greater concentric left ventricular remodeling, larger LA size, impaired diastolic function, reduced longitudinal LA deformation, and increased atrial stiffness. These abnormalities become more pronounced with longer time since menopause and lower estradiol levels. Higher testosterone-to-estradiol ratios have also been associated with impaired atrioventricular coupling. Importantly, abnormal LA mechanics and coupling predict atrial fibrillation, heart failure, coronary events, and cardiovascular mortality. Assessment of LA strain and atrioventricular coupling may therefore improve early risk identification and guide preventive strategies in peri- and postmenopausal women.