Left atrial volume index is a predictor of silent myocardial ischemia in high-risk patients with end-stage renal disease

The Role of the Left Atrium: From Multimodality Imaging to Clinical Practice: A Review

In recent years, new interest is growing in the left atrium (LA). LA functional analysis and measurement have an essential role in cardiac function evaluation. Left atrial size and function are key elements during the noninvasive analysis of diastolic function in several heart diseases. The LA represents a “neuroendocrine organ” with high sensitivity to the nervous, endocrine, and immune systems. New insights highlight the importance of left atrial structural, contractile, and/or electrophysiological changes, introducing the concept of “atrial cardiomyopathy”, which is closely linked to underlying heart disease, arrhythmias, and conditions such as aging. The diagnostic algorithm for atrial cardiomyopathy should follow a stepwise approach, combining risk factors, clinical characteristics, and imaging. Constant advances in imaging techniques offer superb opportunities for a comprehensive evaluation of LA function, underlying specific mechanisms, and patterns of progression. In this literature review, we aim to suggest a practical, stepwise algorithm with integrative multimodality imaging and a clinical approach for LA geometry and functional analysis. This integrates diastolic flow analysis with LA remodelling by the application of traditional and new diagnostic imaging techniques in several clinical settings such as heart failure (HF), atrial fibrillation (AF), coronary artery disease (CAD), and mitral regurgitation (MR).

[Relationship between left ventricular diastolic dysfunction and coronary disease in type 2 diabetes mellitus]

INTRODUCTION

Type 2 diabetes is associated with an increased risk of coronary disease and is the leading cause of morbidity and mortality in this population. The main objective of our work is to study the correlation of diastolic function of the left ventricle with coronary disease in type 2 diabetics.

MATERIAL AND METHODS

Analytical cross-sectional, monocentric prospective-looking study of 703 type 2 diabetic patients performed at the Military Regional Hospital of Constantine over a period of 04 years (2016-2019). We excluded 338 patients who did not receive coronary angiography; thus 365 patients are ultimately analyzed. Evaluation of diastolic function was performed by two-dimensional transthoracic echocardiography with the search of coronary disease. The data was analyzed using the Epi Info 7.2.1.0 with study of the relationship of the diastolic function to coronary disease by multiple logistic regression.

RESULTS

The average age of our final cohort is 57,7±6,5 years, an average of 7.4±1.8% of glycated hemoglobin, an average of 5,8±4,1 years of diabetes, a sex ratio to 1.27. 49.3% had diastolic dysfunction. The prevalence of coronary disease is 32,9%. In multivariate analysis; diastolic dysfunction is correlated with coronary involvement significantly (OR=2.02, _95% CI [1.50 - 2.90], p=0.02).

CONCLUSION

The prevalence of diastolic dysfunction is high in type 2 diabetics and is significantly correlated with coronary heart disease.

P Wave Peak Time for Predicting an Increased Left Atrial Volume Index in Hemodialysis Patients

OBJECTIVE

An increased left atrial volume index (LAVI) is related to increased mortality in hemodialysis patients. In the present study, we evaluated the association between the LAVI and the P wave peak time (PWPT), a newly introduced electrocardiographic parameter, in hemodialysis patients.

METHODS

The study population was made up of 79 hemodialysis patients with a mean age of 53 ± 18 years (55.7% were males). These patients were divided into a normal LAVI (≤28 mL/m2) group (n = 45) and an increased LAVI (>28 mL/m2) group (n = 34). The demographic, clinical, laboratory, echocardiographic, and electrocardiographic variables of the groups were compared.

RESULTS

The P wave terminal force from lead V1, P wave dispersion and PWPTs obtained from leads V1 and D2 (PWPTD2) were significantly higher in the patients with increased LAVIs. In multivariable analysis, only the PWPTD2was an independent predictor of an increased LAVI (odds ratio = 1.117, 95% CI = 1.052-1.185, p < 0.001). The receiver-operating characteristic curve analysis showed that the best PWPTD2 cutoff value for predicting an increased LAVI was 60 ms, with a sensitivity of 76.5% and a specificity of 66.7% (area under the curve = 0.736, 95% CI = 0.625-0.829, p < 0.001).

CONCLUSION

This study showed that a prolonged PWPTD2 was independently associated with an increased LAVI in hemodialysis patients. Therefore, measuring the PWPTD2 duration on an electrocardiogram may help define high-risk hemodialysis patients with increased LAVIs.

Screening coronary angiography in patients with long-standing diabetes mellitus undergoing kidney transplant evaluation

BACKGROUND

The utility of coronary angiography in patients with diabetes mellitus undergoing kidney transplant evaluation is unclear. Predictors of critical angiography lesions in these patients will aid in appropriate use of angiography.

METHODS

Single-center study of 80 patients with ≥15 years of diabetes mellitus who underwent a screening coronary angiography despite a negative cardiac stress test. Risk factors for needing coronary intervention (CI) (percutaneous or bypass grafting) were analyzed.

RESULTS

Eighteen patients (23%) had a ≥70% occlusion in one or more major coronary vessel(s), with right coronary artery being the most commonly involved (71%). Fifteen patients (19%) underwent coronary intervention: ten percutaneously and five with bypass surgery. Risk factors for needing CI were not being on statin (OR 3.54, P = 0.047) and history of stroke or peripheral vascular disease (PVD; OR 3.5, P = 0.034). A model that included statin use, stroke/PVD history, and glycosylated hemoglobin had a receiver operating characteristic curve area under the curve of 0.8 to predict CI.

CONCLUSION

Despite a negative stress test, the prevalence of critical coronary lesions was high among kidney transplant candidates with long-standing diabetes. Risk factors for needing coronary intervention were absence of statin use and a history of stroke or peripheral vascular disease.

Relationship between cardiac calcification and left ventricular hypertrophy in patients with chronic kidney disease at hemodialysis initiation

Coronary artery calcification (CAC), cardiac valve calcification (CVC) and left ventricular hypertrophy (LVH) are frequently observed in chronic kidney disease (CKD) patients. These abnormalities significantly affect morbidity and mortality. The aim of this study was to investigate the relationship between CAC, CVC and LVH in CKD patients. This study included 96 patients who were hospitalized and initiated hemodialysis between December 2011 and July 2014 at our five institutions. Multi-detector computed tomography for the quantification of CAC using the Agatston score and transthoracic echocardiography for assessing CVC and LVH were performed for all patients included in the study. We semi-quantitatively evaluated the severity of CVC as a valvular calcification score. We also assessed the presence of LVH in patients with CAC and/or CVC. Among the 96 patients, the prevalence of CAC was 81.3% and CVC was 65.0%. The severity of CAC was closely and significantly associated with that of CVC. The percentage of patients with LVH was the greatest in those with both severe CAC and CVC. CAC was significantly more severe in patients with concentric hypertrophy compared to those with normal geometry. At the initiation of hemodialysis, most CKD patients had CAC, CVC and LVH. In addition, cardiac calcification was significantly associated with LVH in these patients.

Correlation between aortic stiffness and left atrial volume index in hypertensive patients

BACKGROUND

Both arterial stiffness and left atrial volume index are crucial predictors of cardiovascular outcomes in hypertensive patients. The correlation between these two factors has not been previously well established in hypertensive population.

OBJECTIVES

To determine the correlation between arterial stiffness and left atrial volume index in hypertensive patients.

METHODS AND RESULTS

The study was performed in 111 consecutive hypertensive patients (49.5% male, mean age 70.8 ± 10.3 years) undergoing cardiac magnetic resonance imaging (CMR). Arterial stiffness was determined by pulse wave velocity in the thoracic aorta by velocity-encoded imaging. Left atrial volume was assessed by biplane area-length method. Pulse wave velocity was significantly correlated with left atrial volume index in univariate analysis (r = 0.20, p = 0.032). In multivariate analysis, pulse wave velocity, coronary artery disease and left ventricular mass remain independent predictors (β = 1.01, p = 0.02).

CONCLUSION

Increased arterial stiffness correlates with left atrial enlargement in hypertensive patients. The prevention of left atrial enlargement and subsequent complications by specific antihypertensive drugs with positive effect on aortic stiffness warrants further studies.

Left atrial volumes: two-dimensional, three-dimensional, cardiac magnetic resonance and computed tomography measurements

PURPOSE OF REVIEW

Evaluation of left atrial volume is important, as it is a biomarker of cardiovascular disease and outcomes and correlates with diastolic dysfunction severity. Left atrial volume measurements by different imaging modalities, including 2D and 3D echocardiography (2DE and 3DE), cardiac magnetic resonance (CMR) and computed tomography (CT), are reviewed in regard to recent advances, methodology, prognostic value and limitations.

RECENT FINDINGS

Left atrial volume assessments correlate well between the different imaging modalities; however, 2DE significantly underestimates left atrial measurements. Assessment of the left atrial minimum volume and left atrial phasic function derived volumetrically have reported superior predictive value for major adverse cardiovascular events and elevated left ventricular diastolic pressure compared with the left atrial maximum volume.

SUMMARY

The different imaging modalities used to assess left atrial volumes are not interchangeable, particularly for serial measurements. Although 2DE underestimates left atrial volumes, most normative as well as predictive data have been obtained using this modality. Standardization, with established normative data and classification criteria, needs to be established for other imaging modalities, additionally incorporating assessment of left atrial minimum and phasic volumes. Despite the limitations of the more simplistic 2DE, its measurements are well defined with significant prognostic value. The incremental prognostic value of the more complex imaging techniques needs to be further validated.