CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 1, January – April 2024 50 AFRICA With recent advances in technology, Nemes et al.39 and Qu et al.40 using 3D STE and CMR, respectively, demonstrated obvious gender differences in RA strain. In contrast to our findings, they noted RA strain to be higher in females and showed an age-related decline in both genders.39,40 The differences in analysis software and technique used in these studies may explain the discordances in results. Further studies are warranted to confirm our findings in a larger African population and also to further assess RALS. We have confirmed the utility of RALS as a marker of subclinical disease in this population, as we did not see changes in RAVI with age but noted a trend towards lower RALS with increasing age. Therefore, RALS may anticipate RA impairment in disease prior to changes in traditional parameters such as RA size and volume. This may assist in earlier diagnosis of disease and prompt treatment strategies at a subclinical stage of the disease. Study limitations A minority of subjects were older than 60 years, due to the lower life expectancy in the South African population (the average life expectancy of an adult in 2014 was estimated at 59.1 years for males and 63.1 years for females, according to Statistics South Africa).41 RA strain measurement values vary with different vendors and software packages and this needs to be taken into consideration when defining normal values. Exercise capacity of the study subjects was not assessed to unmask subclinical diastolic dysfunction and symptoms. Since this was a secondary data analysis, sample size was restricted to what was collected in the parent study. A larger sample size might have been able to detect finer differences. The majority of the patients were obese or overweight and this is a reflection of the current ‘normal’ South African population. As this was a retrospective sub-study analysis, we did not have access to blood tests to screen for diseases, as these were not performed as part of the main study. Conclusion We have presented the first normative values for RALS in a sub-Saharan African population. The normative data on RA strain and volumes according to age will help in differentiating normal from abnormal RA function and thus help in cardiovascular disease risk stratification in this population. Furthermore, this study provides a platform for future larger studies on RALS. References 1. Austin C, Alassas K, Burger C, Safford R, Pagan R, Duello K, et al. Echocardiographic assessment of estimated right atrial pressure and size predicts mortality in pulmonary arterial hypertension. Chest 2015; 147(1): 198–208. 2. Bouchardy J, Marelli AJ, Martucci G, Bottega N, Therrien J. Mirror image atrial dilatation in adult patients with atrial fibrillation and congenital heart disease. Int J Cardiol 2013; 167(3): 816–820. 3. 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