Incorporating right atrial and right ventricular strain parameters into post-AMI risk models may improve risk discrimination and refine the identification of patients at high risk for adverse outcomes.
Acute myocardial infarction (AMI) remains a leading cause of death worldwide and a major contributor to long-term morbidity and health care costs 1. Risk stratification after AMI has traditionally centered on left ventricular (LV) dysfunction and infarct characteristics, which continue to serve as the primary basis for prognostic assessment and therapeutic decision-making in daily practice 2. Although growing evidence indicates that right ventricular (RV) dysfunction provides powerful and independent prognostic information in ischemic heart disease, its integration into routine risk stratification remains limited and often overlooked 3, 4. When performed, RV function is still most commonly described by conventional parameters such as tricuspid annular plane systolic excursion, RV fractional area change, or RV ejection fraction. In contrast, myocardial deformation of the right heart—particularly right atrial (RA) strain—has received far less attention, with the RA often described as a “neglected chamber” in the post-AMI assessment 5. Assessment of myocardial deformation by cardiac magnetic resonance (MR) has evolved substantially over the past two decades, progressing from techniques such as myocardial tagging, displacement encoding with stimulated echoes, and strain encoded imaging to the more recently adopted feature tracking (FT) approach 6. FT, a tissue tracking technique based on conventional cine sequences without the need for additional scan time, is now widely used in clinical and research settings. Prior studies 7, 8 have shown that FT-derived strain metrics are sensitive to myocardial dysfunction and provide a robust means of quantifying both ventricular and atrial myocardial deformation. Serving as the gateway to the heart, the RA plays a critical role in modulating ventricular filling and maintaining cardiac hemodynamic balance. RA conduit function reflects passive atrial emptying into the RV during early diastole and is tightly related to RV relaxation, diastolic stiffness, and the instantaneous atrioventricular pressure gradient 5. As such, RA conduit strain provides an integrative measure of right-sided diastolic function and atrioventricular coupling. Following AMI, modest increases in LV filling pressure and pulmonary artery pressure may propagate backward through the pulmonary circulation, leading to increased RV diastolic stiffness and RA afterload despite apparently preserved RV systolic indices 9. These hemodynamic changes blunt passive atrial emptying, resulting in reduced RA conduit strain. In this context, impaired RA conduit strain may serve as an early integrative marker of right-sided and biventricular diastolic dysfunction, capturing hemodynamic disturbances that may precede overt RV systolic impairment or RA enlargement and are not fully reflected by isolated LV indices. Similarly, RV longitudinal strain provides a sensitive measure of systolic function that complements traditional volumetric assessments. A combined assessment of RA and RV deformation may provide a more physiologically integrated evaluation of right heart function than isolated chamber-specific metrics. Emerging evidence suggests that incorporation of right heart strain parameters into risk models may improve risk discrimination and refine identification of patients at increased risk for adverse cardiovascular outcomes 8. Several key challenges must be addressed before right heart strain can be fully integrated into clinical practice. Standardization of acquisition and analysis protocols remains essential to ensure reproducibility across centers and vendors. In addition, prospective validation in diverse populations is required to establish generalizability and clinical utility. Beyond observational studies, interventional investigations are needed to determine whether right heart strain–guided strategies can improve outcomes. Finally, integration of right-sided strain parameters with myocardial tissue characterization, LV mechanics, and circulating biomarkers may further enhance individualized risk assessment. Taken together, these advances may ultimately shift post-AMI risk assessment from a predominantly LV paradigm toward a more integrated biventricular and atrioventricular framework. This work was supported in part by the Joint Funds of the Zhejiang Provincial Natural Science Foundation Committee under Grant No. LBZ24H100001. The authors declare no conflicts of interest.
Dai et al. (2026) conducted an editorial in Acute Myocardial Infarction. Right heart strain assessment was evaluated. Incorporating right atrial and right ventricular strain parameters into post-AMI risk models may improve risk discrimination and refine the identification of patients at high risk for adverse outcomes.