Left Atrial Strain for Predicting Atrial Fibrillation Onset in Hypertensive Patients

Left Atrial Strain to Predict Postoperative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting

BACKGROUND

Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery being associated with poorer outcomes. Revealing before the operation of left atrial subtle structural/functional abnormalities may help to identify patients at increased risk of POAF. We investigated the role of left atrial strain parameters by preoperative speckle tracking echocardiography as independent predictors of POAF in patients undergoing coronary artery bypass graft.

METHODS

Consecutive patients undergoing isolated coronary artery bypass graft were prospectively enrolled at three Italian centers. All patients underwent transthoracic echocardiography before the operation. The occurrence of POAF up to discharge was monitored.

RESULTS

Overall, a total of 310 patients were included. POAF was demonstrated in 103 patients (33%). At receiver operating characteristic curve analysis, lower global peak atrial longitudinal strain (PALS) values significantly predicted the risk of POAF (area under the curve, 0.74; P<0.001). The optimal cutoff value for the arrhythmia prediction was a global PALS value <28%, with a specificity of 86% and a sensitivity of 36%. The incidence of POAF was 51% in patients with global PALS <28% versus 14% in those with PALS ≥28% (P<0.001), with a POAF-free survival at Kaplan-Meier analysis of 45.4% and 85.7%, respectively (P<0.001). At multivariate analysis, a global PALS <28% carried a 3.6-fold higher risk of POAF (hazard ratio, 3.6 [95% CI, 2.2-5.9]; P<0.001). The risk increase was even higher when PALS <28% was associated with age ≥70 years (adjusted hazard ratio, 11.2 [4.7-26.6], P<0.001).

CONCLUSIONS

A presurgery global PALS <28% is a specific parameter to stratify patients at increased risk of POAF after coronary artery bypass graft. This assessment can be useful to identify patients at higher arrhythmic risk in whom perioperative preventive strategies and stricter monitoring aimed at early diagnosing and treating POAF may be applied.

Use of speckle tracking echocardiography in evaluating cardiac dysfunction in patients with acromegaly: an update

In recent years, cardiovascular disease has garnered increasing attention as the second leading cause of death in individuals with acromegaly, following malignancy. Identifying cardiac dysfunction early in acromegaly patients for timely intervention has become a focal point of clinical research. Speckle tracking echocardiography, a well-established ultrasound technique, surpasses conventional Doppler ultrasound in its sensitivity to assess both local and global cardiac mechanics. It can accurately detect subclinical and clinical myocardial dysfunction, including myocardial ischemia, ventricular hypertrophy, and valvular changes. Over the past five years, the use of speckle tracking echocardiography in acromegaly patients has emerged as a novel approach. Throughout the cardiac cycle, speckle tracking echocardiography offers a sensitive evaluation of the global and regional myocardial condition by quantifying the motion of myocardial fibres in distinct segments. It achieves this independently of variations in ultrasound angle and distance, effectively simulating the deformation of individual ventricles across different spatial planes. This approach provides a more accurate description of changes in cardiac strain parameters. Importantly, even in the subclinical stage when ejection fraction remains normal, the strain parameters assessed by speckle tracking echocardiography hold a good predictive value for the risk of cardiovascular death and hospitalization in acromegaly patients with concomitant cardiovascular disease. This information aids in determining the optimal timing for interventional therapy, offering important insights for cardiac risk stratification and prognosis. In the present study, we comprehensively reviewed the research progress of speckle tracking echocardiography in evaluating of cardiac dysfunction in acromegaly patients, to pave the way for early diagnosis of acromegaly cardiomyopathy.

Downregulation of fibromodulin attenuates inflammatory signaling and atrial fibrosis in spontaneously hypertensive rats with atrial fibrillation via inhibiting TLR4/NLRP3 signaling pathway

BACKGROUND

Myocardial fibrosis is an important factor in the induction and maintenance of atrial fibrillation (AF). Fibromodulin (FMOD) promotes fibrotic gene expression. However, its specific role in spontaneously hypertensive rats (SHR)-AF remains unclear.

METHODS

We analyzed FMOD mRNA and protein expression in rat atrial tissues using RT-qPCR, Western blot analysis, and immunohistochemistry. Histopathological examination of atrial tissues was performed using hematoxylin and eosin (H&E), Masson's trichrome, and Picrosirius red staining. The levels of inflammatory and fibrosis-related proteins were measured using Western blot analysis.

RESULTS

FMOD relative mRNA and protein expression levels were notably upregulated in atrial tissues of both AF groups (normal-AF and SHR-AF groups) than that in atrial tissues of the no-AF group (normal and SHR group). This effect was particularly pronounced in the SHR-AF group. Pathological changes revealed that the extracellular matrix, collagen, collagen fibers, and left atrial diameter were notably increased in the atrial tissues from the SHR-AF group compared to those in the atrial tissues from the SHR group, whereas the left ventricular fractional shortening and left ventricular ejection fraction were notably lower. Expression of TLR4, MyD88, NLRP3, TGF-β1, collagen I, and collagen II mRNA were clearly higher in atrial tissues from the SHR-AF group than in those from the SHR group. Protein levels of TLR4, MyD88, NLRP3, Cleavage-Caspase-1, Cleavage-IL-1β, TGF-β1, p-Smad2, collagen I, and collagen II were clearly higher in atrial tissues from the SHR-AF group than in those from the SHR group. FMOD knockdown inhibited atrial fibrosis, collagen accumulation, and the TLR4/MyD88/NLRP3 signaling pathway.

CONCLUSION

Downregulation of FMOD attenuated inflammatory signaling and atrial fibrosis in SHR-AF by inhibiting the TLR4/NLRP3 signaling pathway. Therefore, FMOD may be a promising therapeutic target in AF.

Left atrial booster-pump function as a predictive parameter for atrial fibrillation in patients with severely dilated left atrium

BACKGROUND

Left atrial (LA) dimension ≥50 mm had approximately four times the risk of developing atrial fibrillation (AF). The aim of this study was to investigate whether the application of clinical and echocardiographic parameters could differentiate between the patients having severely dilated left atrium with and without AF.

METHODS

This retrospective cross-sectional study enrolled consecutive patients with LA dimension ≥50 mm and divided them into three groups: no AF (no-AF), paroxysmal AF (PAF) and non-paroxysmal AF (non-PAF) groups. For PAF and non-PAF groups, all patients underwent radiofrequency ablation, and the echocardiographic parameters were obtained on the next day after ablation.

RESULTS

Our study population comprised 160 patients, including 80, 53, and 27 patients in the non-AF, PAF and non-PAF groups, respectively. The no-AF group had a significantly higher body mass index (kg/m2) (29.31±6.27, 27.58±4.12 and 26.57±2.81, P=0.01), and a higher prevalence of diabetes mellitus (DM) [31 (38.80%), 13 (25.00%) and 4 (14.80%), P=0.01] and hypertension [67 (83.80%), 34 (65.40%), and 19 (70.40%), P=0.04], but a lower prevalence of rheumatic heart disease (RHD) [3 (3.80%), 6 (11.50%) and 5 (18.50%), P=0.02] and sick sinus syndrome [0 (0.00%), 6 (11.50%) and 4 (14.80%), P=0.045]. Echocardiographic studies showed that the non-AF group had significantly smaller LA minimal volume index (24.89±9.74, 34.06±19.38 and 42.83±17.44 mL/m2, P<0.01), higher LA emptying fraction (51.99%±13.97%, 38.40%±15.96% and 33.89%±10.73%, P<0.01), longitudinal strain (23.87%±7.72%, 17.11%±8.52% and 12.38%±4.28%, P<0.01) and strain rate than the AF groups. The multivariate analysis showed that the late diastolic component of LA strain rate was the only independent factor associated with the presence of AF (odds ratio, 21.69; 95% CI, 9.77-48.13, P<0.01).

CONCLUSIONS

LA function plays an important role in the absence of AF in patients with LA dimension ≥50 mm; the late diastolic component of LA strain rate was the only independent variable on multivariate analysis.

Follow-up study of depressive state on patients with atrial fibrillation 1 year after radio-frequency ablation

OBJECTIVE

To analyze the effect of depression on the recurrence of atrial fibrillation (AF) 1 year after radio-frequency ablation.

METHODS

A total of 91 patients with AF admitted to our hospital from January 2020 to July 2021 were studied. All patients were followed up 1 year after radio-frequency ablation. A total of 91 subjects were divided into recurrence group (n = 30) and no recurrence group (n = 61) according to the recurrence situation 1 year after radio-frequency ablation. Age, disease course, body mass index (BMI), gender, echocardiography (left atrial diameter), blood inflammatory indicators (neutrophil count, lymphocyte count, and monocyte count), and Self-rating Depression Scale (SDS) scores were compared between the two groups. Logistic multivariate regression analysis was used to analyze the effect of SDS score and other indexes on the recurrence of AF 1 year after radio-frequency ablation.

RESULTS

The age of patients in relapse group was higher than that in no relapse group (P < 0.05) and the course of disease was longer than that of the no recurrence group (P < 0.05). The BMI was higher than that of the no recurrence group (P < 0.05) and the left atrial diameter was greater than that of the no recurrence group (P < 0.05). Neutrophil count and monocyte count were significantly higher than those in no recurrence group (P < 0.05) and the lymphocyte count was significantly lower than that in the no recurrence group (P < 0.05). There were significant differences in SDS score composition between the two groups (P < 0.05) and the composition ratio of patients with moderate and major depression in the relapsing group was significantly higher than that in the non-relapsing group. The composition ratio of patients without depression in the relapsing group was significantly lower than that in the non-relapsing group. Multivariate analysis showed that age, disease course, BMI, left atrial diameter, neutrophil count, lymphocyte count, monocyte count, and SDS score were all independent factors affecting the recurrence of AF patients 1 year after radio frequency ablation (P < 0.05). Compared with patients without depression, patients with mild, moderate and major depression had an increased risk of recurrence by 74.0, 98.2, and 151.2% 1 year after radio-frequency ablation, respectively (OR = 1.740, 1.982, and 2.512).

CONCLUSION

There is a high rate of depression in patients with AF. Depression is an important factor affecting the early recurrence of patients with AF after radio-frequency ablation.

The usefulness of morphology-voltage-P wave duration ECG score for predicting early left atrial dysfunction in hypertensive patients

OBJECTIVE

Left atrial (LA) function is an important predictor of adverse cardiovascular outcomes in patients with hypertension (HT). Therefore, recognition of subtle LA dysfunction in the early stages of HT is essential for controlling modifiable variables. Several electrocardiographic and echocardiographic parameters have been studied to show early LA dysfunction. The goal of this study was to investigate the relationship between newly defined morphology-voltage-P wave duration electrocardiography (MVP ECG) score and early LA dysfunction in hypertensive patients.

MATERIALS AND METHODS

Eighty-nine hypertensive patients were included in this study. Based on speckle tracking echocardiography results, the patients were divided into two groups: 67 patients with normal LA function were included in Group 1, and 22 patients with abnormal LA function in Group 2.

RESULTS

Age, diabetes mellitus history, duration of HT history, left ventricular mass index, E/Em, and MVP ECG score values were statistically significant between the two groups. Based on the results of the multivariate logistic regression test, duration of HT history, E/Em, and MVP ECG score were determined as independent predictive parameters for early LA dysfunction in hypertensive patients.

CONCLUSION

In conclusion, MVP ECG score assessment could be a novel approach to detect early LA dysfunction in hypertensive patients.

The strain and strain rate imaging paradox in echocardiography: overabundant literature in the last two decades but still uncertain clinical utility in an individual case

Almost two decades ago strain and strain rate imaging were proposed as a new, potentially more sensitive modality for quantifying both regional and global myocardial function. Until now, however, strain and strain rate imaging have been slow to be incorporated into everyday clinical practice. More recently, two dimensional strain has been claimed as of greater clinical utility, given that it is angle independent, with improved feasibility and reproducibility as compared to tissue Doppler strain. Nevertheless, speckle tracking strain is reliant on 2D image quality and frame rates. Three dimensional speckle tracking could eliminate the problem of through-plane motion inherent in 2D imaging, but 3D strain is currently limited by low frame rates. Another limitation of strain imaging is that the results are dependent on the ultrasound machine on which analyses are performed, with variability in measurements between different vendors. Despite the diagnostic and prognostic advantages of 2D strain, there is a lack of specific therapeutic interventions based on strain and a paucity of long-term large-scale randomized trial evidence on cardiovascular outcomes. After overabundant literature the same definition of normal cut-off values is controversial and not univocal. Further studies are needed, involving both manufacturers and medical professionals, on the additive contribution, possibly different case by case, of interfering and artifactual factors, aside from myocardial function per se. These artifactual determinants and motion artifacts components could be dominant in individual cases and should always be taken into account in the clinical decision making process in a single case.

The prognostic role of speckle tracking echocardiography in clinical practice: evidence and reference values from the literature

Speckle tracking echocardiography (STE) is a second-level echocardiographic technique which has gradually gained relevance in the last years. It allows semi-automatic quantification of myocardial deformation and function, overcoming most of the limitations characterizing basic echocardiography and providing an early detection of cardiac impairment. Today, its feasibility and usefulness are highly supported by literature. In particular, several studies demonstrated that STE could provide additional prognostic information beyond conventional echocardiographic and traditional clinical parameters. Moreover, a recent standardization of speckle tracking analysis regarding all cardiac chambers paved the way for the integration of STE in diagnostic and prognostic protocols for particular clinical settings. The aim of this review is to describe the prognostic role of STE in different clinical scenarios basing on currently available evidence.

Clinical Relevance of Orthostatic Hypotension in Patients with Atrial Fibrillation and Suspected Transient Ischemic Attack

INTRODUCTION

Orthostatic hypotension (OH) and atrial fibrillation (AF) are both regarded as independent risk factors for transient ischemic attack (TIA). However, the clinical implication of OH in the presence of AF is unclear. This study investigates, for the first time, the association between blood pressure (BP), OH and mortality in a cohort of patients with AF and TIA symptoms.

AIM

To investigate the incidence of the association between OH, AF and TIA.

METHODS

This retrospective observational study utilised the Leicester one-stop transient TIA clinic patient database to consider the initial systolic and diastolic BP of 688 patients with a diagnosis of AF. The primary outcome was time until death. Covariant measures included status of AF diagnosis (known or new AF), cardiovascular risk factors, and primary clinic diagnosis [cerebrovascular (CV) versus non-cerebrovascular (non-CV)]. Statistical models adjusted for sex, age, previous AF diagnosis.

RESULTS

Mortality rate was higher in the over 85 age group [191.5 deaths per 1000 person years (py) (95% CI 154.0-238.1)] and lower in the aged 75 and younger age group [40.0 deaths per 1000 py (95% CI 27.0-59.2)] compared to intermediate groups. A 10 mmHg increase in supine diastolic BP was associated with a significant reduction in the hazard of mortality for patients suspected of TIA with AF [adjusted HR 0.79 (95% CI 0.68-0.92), p < 0.001]. The mortality rate for patients with OH was 119.0 deaths per 1000 py compared with a rate of 98.0 for patients without OH (rate ratio 1.2, p = 0.275).

CONCLUSION

Higher diastolic BP may be a marker for reduced mortality risk in patients with a previous AF diagnosis and non-CV diagnosis. Lower diastolic BP and the presence of AF pertain to a higher mortality risk. This study raises the importance of opportunistic screening for both OH and AF in patients presenting to TIA clinic.

Left Heart Dysfunction in Acromegaly Revealed by Novel Echocardiographic Methods

Background: Acromegaly is a rare disease that requires modern treatment to decrease the risk of mortality, mainly from vascular diseases. Identifying acromegalic patients with increased cardiovascular risk is challenging. Speckle-tracking echocardiography (STE) is a modern, well-validated, and reproducible method of assessing left ventricular longitudinal deformation and providing a sensitive assessment of myocardial contractility. We hypothesized that STE may be useful in evaluating subclinical dysfunction of the left heart in acromegalic patients, especially when a left ventricle (LV) assessment is completed with STE of the left atrium (LA). Purpose: To assess the diagnostic value of speckle-tracking echocardiography in identifying the occurrence of LV and LA functional impairment in patients with acromegaly, in comparison to patients without this rare pituitary disease. Methods: Echocardiographic assessments of LV and LA function using the new STE method were performed in 60 subjects: 30 acromegalic (ACRO group) patients and a CONTROL group with 30 patients matched in terms of age, gender, systolic/diastolic pressure, and history of hypertension for at least 12 months. Results: The ACRO group, compared to the CONTROL group, presented: (1) higher left ventricular mass (left ventricular mass index: 132 vs. 108 g/m², p < 0.001) and, in consequence, more frequent LV hypertrophy (80.0 vs. 53.3%; p = 0.028); (2) impaired LV systolic function measured by both left ventricular ejection fraction (LVEF) (63.4 vs. 66.9%, p < 0.001) and global longitudinal strain (GLS) (-18.1 vs. -19.4%, p = 0.023); (3) greater LA anteroposterior diameter (40.3 vs. 36.9 mm, p = 0.003) and indexed left atrial volume (37.9 vs. 27.6 ml/m², p < 0.001); and (4) impaired echocardiographic strain parameters corresponding with LA function. Conclusions: Acromegaly, even in young patients with good blood pressure control, may be associated with left ventricular hypertrophy and subclinical impairment of the left ventricular and left atrial mechanical function, which may be identified by speckle-tracking echocardiography. Further research in this area is necessary to clarify the prognostic value of these phenomena.