Left atrial diameter as an independent predictor of first clinical cardiovascular events in middle-aged and elderly adults: the Strong Heart Study (SHS)

New onset left atrial dilatation in the general population: A quarter-century follow-up

BACKGROUND

Information on the incidence of left atrial enlargement (LAE) and the factors underlying progressive LA remodelling in long-term longitudinal population-based studies is scanty. We investigated the incidence of new onset LAE and its determinants among middle aged adults over a 25-year time period.

METHODS

A total of 423 participants with measurable echocardiographic parameters at baseline (mean age 41+10 years, 52 % men) and after a 25-year follow-up were included in the analysis. LA diameter (LAD) was measured with 2D-guided M-mode technique. LAE was detected according to sex-specific non-indexed criteria and a sex-independent indexed to body surface area (BSA) criterion recommended by contemporary echocardiographic guidelines.

RESULTS

New LAE occurred in 27.4 % (absolute LA diameter, LAD) and 16.5 % (LAD/BSA), respectively. Initial LAD and body mass index (BMI), as well as the 25-year change in BMI and left ventricular mass index (LVMI) were independently correlated to incident non-indexed LAE. Besides age, the independent modifiable predictors of new-onset LAE/BSA were initial LAD/BSA, the 25-year change in BMI and 24-h pulse pressure (PP).

CONCLUSIONS

The incidence of LAE from mid to late adulthood occurs in a large clinically relevant fraction of participants and is affected by initial LAD, BMI and 25-year change in BMI, LVMI and 24-h PP. The findings provided by the present study support the view that avoid obesity and maintain normal levels of BMI, blood pressure and LVMI during life can contribute to strengthen cardiovascular prevention in the general population through prevention of LA remodelling and its harmful consequences.

Impact of atrial remodeling on efficacy of catheter ablation in reducing cardiovascular risk in atrial fibrillation: Results from CABANA trial

BACKGROUND

The efficacy of catheter ablation in reducing major adverse events in atrial fibrillation (AF) is still inconclusive, warranting identification of clinical markers.

OBJECTIVE

The purpose of this study was to explore whether the benefits of catheter ablation varied across different extents of atrial remodeling in the CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial.

METHODS

The CABANA trial randomized 2204 participants with AF to catheter ablation or drug therapy. Patients who underwent echocardiographic measurement for left atrial diameter (LAD) at baseline constituted the study population of this present analysis. The primary outcome was composite of death, disabling stroke, serious bleeding, or cardiac arrest.

RESULTS

Of the 1130 patients with documented LAD at baseline (median LAD 44 mm), 570 (50.4%) were randomized to ablation and 560 (49.6%) to drug therapy. The estimated benefits of ablation vs drug therapy on the primary outcome (a composite of death, disabling stroke, serious bleeding, or cardiac arrest) and total mortality were greatest in the lowest end of the LAD spectrum and declined substantially as LAD increased. For the primary outcome, the adjusted hazard ratios were 0.30 (95% confidence interval [CI] 0.11-0.78) in patients without enlarged LAD (LAD ≤ 40 mm) and 0.92 (95% CI 0.55-1.54) in those with enlarged LAD (LAD > 40 mm) (interaction P = .035). The corresponding adjusted hazard ratios for total mortality were 0.09 (95% CI 0.01-0.58) and 0.76 (95% CI 0.40-1.41) in patients without and with enlarged LAD (interaction P = .045).

CONCLUSION

In CABANA patients without enlarged LAD, catheter ablation significantly reduced major cardiovascular events while the prognostic benefits of ablation diminished with atrial remodeling aggravation. Ablation at the initial stage of atrial remodeling provided an effective early rhythm control strategy to reduce cardiovascular risk in AF.

The preferable position for quantifying left ventricular diameter by transthoracic echocardiography

BACKGROUND

In quantifying left ventricular (LV) diameter, which position for echocardiographic measurements, mitral valve tip level (MV-tip) or LV mid level (LV-mid), more accurately represents the LV volume is unclear. Furthermore, which factor affects the measurement error also has not been elucidated.

METHODS

We enrolled 150 patients without myocardial infarction and local asynergy who underwent echocardiography and cardiac magnetic resonance imaging (CMRI). Echocardiographic LV diastolic diameter (LVDD) and LV systolic diameter (LVDS) were measured at both MV-tip and LV-mid, and the LV end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were quantified using CMRI. We quantified the degree of aortic wedging as the angle between the anterior wall of the aorta and the ventricular septal surface (ASA).

RESULTS

The average LVDD was smaller and average LVDS larger when measured at the MV-tip than at the LV-mid. In regression analyses, the correlation coefficient between LVDD and LVEDV was larger at LV-mid (R = 0.89) than at MV-tip (R = 0.82), and the correlation coefficient between LVDS and LVESV also larger at LV-mid (R = 0.93) than MV-tip (R = 0.87). ASA, Valsalva diameter, left atrial diameter, patient height, and LV mass significantly affected the echocardiographic measurement error, but no factor affected the measurement error when quantifying LVDD at the LV-mid level.

CONCLUSIONS

The echocardiographic LV diameter measured at LV-mid has a stronger correlation with LV chamber size derived from CMRI than measurements at MV-tip. The LVDD measured at the LV-mid level is not affected by other factors.

Echocardiographic assessment of atrial, ventricular, and valvular function in patients with atrial fibrillation-an expert proposal by the german working group of cardiovascular ultrasound

Echocardiography in patients with atrial fibrillation is challenging due to the varying heart rate. Thus, the topic of this expert proposal focuses on an obvious gap in the current recommendations about diagnosis and treatment of atrial fibrillation (AF)-the peculiarities and difficulties of echocardiographic imaging. The assessment of systolic and diastolic function-especially in combination with valvular heart diseases-by echocardiography can basically be done by averaging the results of echocardiographic measurements of the respective parameters or by the index beat approach, which uses a representative cardiac cycle for measurement. Therefore, a distinction must be made between the functionally relevant status, which is characterized by the averaging method, and the best possible hemodynamic status, which is achieved with the most optimal left ventricular (LV) filling according to the index beat method with longer previous RR intervals. This proposal focuses on left atrial and left ventricular function and deliberately excludes problems of echocardiography when assessing left atrial appendage in terms of its complexity. Echocardiography of the left atrial appendage is therefore reserved for its own expert proposal.

Latent class analysis of cardiac structure and function and association with premature cardiovascular disease: The Coronary Artery Risk Development in Young Adults (CARDIA) study

Objective

To generate data-driven phenogroups of cardiac structure and function based on echocardiographic measures assessed in asymptomatic middle-aged adults free of CVD, and examine associations between these newly defined phenogroups and incident premature cardiovascular disease (CVD).

Methods

Data were analyzed from participants in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study free of CVD who underwent an echocardiogram at the Year 25 (2010-2011) in-person examination. Continuous echocardiographic measures of left heart structure, left ventricular systolic function (including strain) and diastolic function, right ventricular systolic function, and hemodynamic measures were included in latent class analysis to generate novel phenogroups. Associations between data-driven phenogroups and risk of premature CVD (coronary artery disease, stroke, or heart failure) were estimated using Cox proportional hazards regression adjusted for traditional CVD risk factors.

Results

Among 3361 participants, mean (standard deviation) age was 50.1 (3.6) years, 57% were female, and 46% were non-Hispanic Black. Three overall phenogroups were identified and labeled as: (1) optimal cardiac mechanics (36.2%); (2) suboptimal systolic function (38.2%); and (3) suboptimal diastolic function (25.6%). Over a median 8.9 years of follow-up, 121 premature CVD events occurred. Risk of CVD was higher in the suboptimal diastolic function group (unadjusted hazard ratio [HR] 4.08 [95% CI: 2.48, 6.71] and adjusted HR 1.95 [1.12, 3.40]) compared with the optimal group. The suboptimal systolic function group had a higher unadjusted risk of CVD (1.86 [1.10, 3.15]), which was attenuated after adjustment for CVD risk factors (1.36 [0.79, 2.36]).

Conclusions and relevance

Unbiased, data-driven clustering of echocardiographic measures in middle-aged adults identified distinct patterns of cardiac remodeling that were associated with risk of premature CVD. Premature CVD risk was highest with the pattern of suboptimal diastolic function. This suggests potential utility of a composite echocardiography-based index for prioritizing prevention strategies earlier in the life course.

Influencing and prognostic factors of end-stage hypertrophic cardiomyopathy

AIMS

End-stage hypertrophic cardiomyopathy (ES-HCM) is a disease with severe complications and a poor prognosis. This study aimed to explore the influencing and prognostic factors of ES-HCM.

METHODS AND RESULTS

A total of 1282 patients with HCM who were hospitalized for the first time at Fujian Medical University Union Hospital between 1 January 2013 and 30 September 2021 were recorded. The patients with HCM and left ventricular ejection fraction (LVEF) < 50% were defined as having ES-HCM, and a control group (LVEF ≥ 50%) was generated from the collected medical records of HCM. The patients were matched in a ratio of 4:1 based on age and sex. Logistic regression analysis was used to determine the influencing factors of ES-HCM. Kaplan-Meier survival analysis was performed to analyse the clinical outcomes of ES-HCM patients. A total of 250 inpatients with HCM were enrolled in the study; 50 patients had ES-HCM, and 200 had HCM with LVEF ≥ 50%. The mean age of the patients at enrolment was 62.5 ± 10.3 years, and 215 patients (215/250, 86.0%) were male. The median follow-up time of the patients was 2.8 (1.4-5.4) years. The incidence of all-cause death and cardiovascular death in patients with ES-HCM was higher than those in patients with HCM and LVEF ≥ 50% (22/50 [44.0%] vs. 13/200 [6.5%]; 12/50 [24.0%] vs. 4/200 [2.0%], all P < 0.001). Multivariate logistic regression analysis showed that the influencing factors associated with ES-HCM included age at first symptom onset (odds ratio [OR] = 0.95, 95% CI [0.90, 1.00], P = 0.042), New York Heart Association (NYHA) class (OR = 7.73, 95% CI [2.93, 20.41], P < 0.001), heart rate (OR = 1.07, 95% CI [1.02, 1.12], P = 0.003), QRS duration (OR = 1.03, 95% CI [1.00, 1.05], P = 0.020), left ventricular end-diastolic diameter (LVEDD) (OR = 1.15, 95% CI [1.04, 1.28], P = 0.006), left atrial anteroposterior diameter (LAD) (OR = 1.13, 95% CI [1.03, 1.24], P = 0.012), and maximum left ventricular wall thickness (MLVWT) (OR = 0.80, 95% CI [0.68, 0.93], P = 0.005). Among the 50 patients with ES-HCM, NYHA class (P < 0.001) and heart rate (P = 0.017) were each associated with a higher likelihood and earlier occurrence of heart transplantation or all-cause mortality in univariate analyses.

CONCLUSIONS

The influencing factors for ES-HCM included the age at first symptom onset, NYHA class, heart rate, QRS duration, LVEDD, LAD, and MLVWT. Both NYHA class and heart rate were related to the prognosis of ES-HCM.

Artificial intelligence applied to coronary artery calcium scans (AI-CAC) significantly improves cardiovascular events prediction

Coronary artery calcium (CAC) scans contain valuable information beyond the Agatston Score which is currently reported for predicting coronary heart disease (CHD) only. We examined whether new artificial intelligence (AI) applied to CAC scans can predict non-CHD events, including heart failure, atrial fibrillation, and stroke. We applied AI-enabled automated cardiac chambers volumetry and calcified plaque characterization to CAC scans (AI-CAC) of 5830 asymptomatic individuals (52.2% women, age 61.7 ± 10.2 years) in the multi-ethnic study of atherosclerosis during 15 years of follow-up, 1773 CVD events accrued. The AUC at 1-, 5-, 10-, and 15-year follow-up for AI-CAC vs. Agatston score was (0.784 vs. 0.701), (0.771 vs. 0.709), (0.789 vs. 0.712) and (0.816 vs. 0.729) (p < 0.0001 for all), respectively. AI-CAC plaque characteristics, including number, location, density, plus number of vessels, significantly improved CHD prediction in the CAC 1-100 cohort vs. Agatston Score. AI-CAC significantly improved the Agatston score for predicting all CVD events.

Computed Tomography Confirms Increased Left Atrial Volume in Patients with Bayés Syndrome Referred for Catheter Ablation of Atrial Fibrillation

Background: Bayés syndrome is a recently identified condition that is defined by the presence of an interatrial block on a surface electrocardiogram, in addition to atrial arrhythmias such as atrial fibrillation, tachycardia, or left atrial flutter. This syndrome is linked to an increased risk of stroke, morbidity, and mortality. An interatrial block is a conduction delay between the right atrium and left atrium and can be recognized by a P wave duration >120 ms. It is known that P wave duration can estimate the size of the left atrium measured via echocardiography, which is a marker for stratifying cardiovascular risk. Our study aims to verify whether the duration of the P wave can estimate the volume of the left atrium measured by computed tomography in patients with an interatrial block. Methods: We included 105 patients with a sinus rhythm and a partial or advanced interatrial block (IAB) who underwent contrast-enhanced cardiac computed tomography (CT). The mean age was 62.2 ± 10.1 years, and 38% of the patients were women. Results: The mean P wave duration was 122.6 ± 11.4 ms in the partial IAB group and 150 ± 8.4 ms in the advanced IAB group (p < 0.01). The mean left atrial volume was 115 ± 39 mL in the partial IAB group and 142 ± 34 mL in the advanced IAB group (p = 0.001). P wave duration was longer in patients with an advanced as opposed to partial interatrial block. Left atrial volume and LAVI were higher in patients with an advanced as opposed to partial interatrial block. Conclusions: All the patients (100%) with an advanced IAB had a dilated left atrium. P wave duration can accurately estimate LA volume in patients with an IAB using the formula: LA volume = 0.6 × P wave + 46 mL.

Potential Role of Left Atrial Strain to Predict Atrial Fibrillation Recurrence after Catheter Ablation Therapy: A Clinical and Systematic Review

Pulmonary vein isolation (PVI) with catheter ablation (CA) represents an effective therapy for atrial fibrillation (AF). Unfortunately, it is still not exempt from severe complications. The balance of risks and benefits should be assessed, and a patient-tailored approach is desirable. So far, several clinical and cardiac imaging parameters have been evaluated to investigate pre- and post-procedural features that could help clinicians in the selection of patients at high risk of a poor outcome after CA. This clinical and systematic review analyses the potential role of new LA parameters, such as LA reservoir strain, to predict AF recurrence after CA therapy. Notably, LA reservoir strain gains substantial clinical importance in patients with paroxysmal AF and when a low CHADS2-VASc score is retrieved. LA reservoir strain provides data concerning the risk of AF recurrence after PVI and, thus, in the management of long-term medical therapy in this patient's group.

Neglected cardiometabolic risk factors and subclinical target organ damage in post-menopausal women with normal glucose tolerance

BACKGROUND

Menopausal transition is a crucial step in the women's cardiovascular health, and the risk stratification in apparently health post-menopausal females has been rarely assessed. Heart ultrasonography, unusually performed in such subjects, would be able to detect initial signs of organ damage. We described the cardiovascular risk profile of non-diabetic post-menopausal women, evaluating how easily computed, biochemistry-derived scores were related to ultrasonographic measures of target organ damage.

METHODS

We analyzed the characteristics of a cohort of two-hundred and seventy-three women consecutively referring to a prevention program of Azienda Ospedaliero-Universitaria Pisana (years 2017-2022) who underwent clinical evaluation, complete routine biochemical analyses with proxies of insulin resistance, heart and carotid ultrasonography. The cohort was further divided into four groups according to presence of isolated hypercholesterolemia (HC, 37%), isolated hypertension (HT, 5%), both HC/HT (38%), or none of them.

RESULTS

In HC and HC/HT, LDL cholesterol was sharply above the recommended values (149 [134-171] mg/dL and 141 [123-159] mg/dL, respectively). E/e' ratio and left atrium size were augmented in HT women and further worsened in HT/HC, with an independent effect of hypertension (E/e' ß=0.055, P=0.013, left atrium volume ß=0.059, P=0.003). Presence of carotid plaques was independently linked to hypertension (ß=0.474, P=0.003). In HC and HC/HT, the Triglycerides-Glucose Index, a surrogate of insulin resistance, was higher than in the other classes (P=0.0013), and it was associated with E/A in HC and HT/HC, with a significative interaction (P=0.0004) with hypertension. Past hormone replacement therapy did not influence clinical, biochemical or echocardiographic parameters.

CONCLUSIONS

Postmenopausal women display a high cardiovascular risk burden; a simple clinical and biochemistry screening would be advisable to identify and treat those more at risk. Cardiac ultrasonographic parameters were worse in hypertensive, hypercholesterolemic and insulin-resistant subjects, who may also deserve a deep and early instrumental characterization, especially when these conditions are associated.

Long-term changes in cardiac remodelling in prevalent kidney graft recipients

BACKGROUND

Approximately 15% of kidney transplant (KT) recipients develop de novo heart failure after KT. There are scarce data reporting the long-term changes in cardiac structure and function among KT recipients. Despite the improvement in renal function, transplant-related complications as well as immunosuppressive therapy could have an impact on cardiac remodelling during follow-up. We aimed to describe the long-term changes in echocardiographic parameters in prevalent KT recipients and identify the clinical and laboratory factors associated with these changes.

METHODS

A centralised blinded review of two echocardiographic examinations after KT (on average after 17 and 39 months post-KT respectively) was performed among 80 patients (age 50.4 ± 16.2, diabetes 13.8% pre-KT), followed by linear regression to identify clinico-biological factors related to echocardiographic changes.

RESULTS

Left atrial volume index (LAVI) increased significantly (34.2 ± 10.8 mL/m2vs. 37.6 ± 15.0 mL/m2, annualised delta 3.1 ± 11.4 mL/m2/year; p = 0.034) while left ventricular ejection fraction (LVEF) decreased (62.1 ± 9.0% vs. 59.7 ± 9.9%, annualised delta -2.7 ± 13.6%/year; p = 0.04). Male sex (β = 8.112 ± 2.747; p < 0.01), pre-KT hypertension (β = 9.725 ± 4.156; p < 0.05), graft from expanded criteria donor (β = 3.791 ± 3.587; p < 0.05), and induction by anti-thymocyte globulin (β = 7.920 ± 2.974; p = 0.01) were associated with an increase in LAVI during follow-up. Higher haemoglobin (>12.9 g/dL) at the time of the first echocardiography (β = 6.029 ± 2.967; p < 0.05) and ACEi/ARB therapy (β = 8.306 ± 3.161; p < 0.05) were associated with an increase in LVEF during follow-up.

CONCLUSION

This study confirms the existence of long-term cardiac remodelling after KT despite dialysis cessation, characterised by an increase in LAVI and a decrease in LVEF. A better management of anaemia and using ACEi/ARB therapy may prevent such remodelling.

Characterizing the influence of cardiorespiratory fitness on left atrial size and function in the general population

Increased left atrial (LA) size and reduced LA function have been associated with heart failure and atrial fibrillation (AF) in at-risk populations. However, atrial remodeling has also been associated with exercise training and the relationship between fitness, LA size, and function has not been defined across the fitness spectrum. In a cross-sectional study of 559 ostensibly healthy participants, comprising 304 males (mean age, 46 ± 20 yr) and 255 females (mean age, 47 ± 15 yr), we sought to define the relationship between cardiorespiratory fitness (CRF), LA size, and function. We also aimed to interrogate sex differences in atrial factors influencing CRF. Echocardiographic measures included biplane measures of LA volumes indexed to body surface area (LAVi) and atrial deformation using two-dimensional speckle tracking. CRF was measured as peak oxygen consumption (V̇o2peak) during cardiopulmonary exercise testing (CPET). Using multivariable regression, age, sex, weight, and LAVi (P < 0.001 for all) predicted V̇o2peak (P < 0.001, R2 = 0.66 for combined model). After accounting for these variables, heart rate reserve added strength to the model (P < 0.001, R2 = 0.74) but LA strain parameters did not predict V̇o2peak. These findings add important nuance to the perception that LA size is a marker of cardiac pathology. LA size should be considered in the context of fitness, and it is likely that the adverse prognostic associations of increased LA size may be confined to those with LA enlargement and low fitness.NEW & NOTEWORTHY Left atrial (LA) structure better predicts cardiorespiratory fitness (CRF) than LA function. LA function adds little statistical value to predictive models of peak oxygen uptake (V̇o2peak) in healthy individuals, suggesting limited discriminatory for CRF once LA size is factored. In the wider population of ostensibly healthy individuals, the association between increased LA volume and higher CRF provides an important counter to the association between atrial enlargement and heart failure symptoms in those with cardiac pathology.

Factors associated with changes in echocardiographic parameters following kidney transplantation

BACKGROUND

Chronic kidney disease leads to cardiac remodelling of multifactorial origin known as "uraemic cardiomyopathy", the reversibility of which after kidney transplantation (KT) remains controversial. Our objectives were to assess, in the modern era, changes in echocardiographic parameters following KT and identify predictive clinical and biological factors associated with echocardiographic changes.

METHODS

One hundred six patients (mean age 48 ± 16, 73% male) who underwent KT at the University Hospital of Nancy between 2007 and 2018 were retrospectively investigated. Pre- and post-KT echocardiography findings (8.6 months before and 22 months after KT on average, respectively) were centralised, blind-reviewed and compared.

RESULTS

A majority of patients (60%) had either a left ventricular (LV) ejection fraction < 50%, at least moderately abnormal LV mass index or left atrial (LA) dilatation at pretransplanted echocardiography. After KT, LV remodelling and diastolic doppler indices did not significantly change whereas LA volume index (LAVI) increased (35.9 mL/m2 post-KT vs. 30.9 mL/m2 pre-KT, p = 0.006). Advancing age, cardiac valvular disease, delayed graft function, lower post-KT haemoglobin, and more severe post-KT hypertension were associated with higher LAVI after KT. Higher post-KT serum creatinine, more severe post-KT hypertension and lower pre-KT blood calcium levels were associated with a deterioration in LAVI after KT.

DISCUSSION/CONCLUSION

Adverse remodelling of the left atrial volume occurred after KT, predominantly in patients with lower pre-KT blood calcium, poorer graft function and post-KT hypertension. These results suggest that a better management of modifiable factors such as pre-KT hyperparathyroidism or post-KT hypertension could limit post-KT cardiac remodelling.

Noncontrast cardiac computed tomography-derived mitral annular calcification scores in mitral valve disease

BACKGROUND AND AIMS

Mitral annular calcification (MAC) by computed tomography (CT) is reported as an independent predictor of poor outcomes. However, it currently remains unclear if quantitative MAC parameters provide more value for mitral valve disease (MVD) management, therefore, we examined the prognostic value of MAC scores using noncontrast cardiac-CT in MVD patients.

METHODS

Between January 2020 and December 2021, we prospectively enrolled 300 consecutive patients with MVD (MAC-present = 80 and MAC-absent = 220) undergoing preoperative cardiac-CT and mitral valve (MV) surgery. Noncontrast cardiac-CT images were used to qualitatively detect MAC (present or absent) and evaluate MAC scores. For analyses, we also collected baseline clinical data, intraoperative conversion (from MV repair to MV replacement), and follow-up arrhythmia data.

RESULTS

Compared with the MAC-absent group, MAC-present patients were older (62 ± 7 vs. 58 ± 9 years, p < .001), mostly women (55% vs. 39.5%, p = .017), and also had aortic valve calcification (57.5% vs. 23.2%, p < .001), mitral stenosis (82.5% vs. 61.8%, p < .001), atrial fibrillation (30% vs. 11.8%, p < .001), and larger left atrial end-diastolic dimension (LADD, 49 [44-56] versus 46 [41-50], p = .001]. Furthermore, MAC-present patients underwent more MV replacements (61.8% vs. 82.5%, p = .001) and experienced a higher intraoperative conversion prevalence (11.8% vs. 61.3%, p < .001). Multiple logistic regression analyses showed that the female gender (odds ratio [OR]/95% confidence interval [CI]/p = 2.001/1.042-3.841/0.037) and MAC scores (OR/95% CI/p = 10.153/4.434-23.253/p < .001) were independent predictors of intraoperative conversion. During a follow-up of 263 ± 134 days, MAC-present patients had more arrhythmias (42.5% vs. 9.5%, p < .001). Also, MAC-scores (hazard ratio [HR]/95% CI/p = 6.841/3.322-14.089/p < .001) and LADD (HR/95% CI/p = 1.039/1.018-1.060/p < .001) were independently associated with arrhythmias by Cox regression analyses.

CONCLUSIONS

Noncontrast cardiac CT-derived MAC-scores showed a high risk for intraoperative conversion and follow-up arrhythmias in MVD-patients.

Echocardiographic Phenotypes of Subclinical Organ Damage: Clinical and Prognostic Value in the General Population. Findings from the Pamela Study

Subclinical alterations in cardiac structure and function include a variety of abnormal phenotypes of established adverse prognostic significance such as left ventricular hypertrophy (LVH), alterations of LV geometry, left atrial (LA) enlargement, and aortic root (AR) dilatation. The excess cardiovascular (CV) risk associated with these phenotypes has been consistently demonstrated in different clinical settings such in patients with systemic hypertension, coronary heart disease, diabetes mellitus, chronic kidney disease, heart failure and in geneal population samples. The Pressioni Monitorate e Loro Associazioni (PAMELA), a longitudinal population-based study originally designed to assess the normality values, prognostic significance of office, home and 24-hour blood pressure, including among the many clinical and laboratory variables the collection of echocardiographic data, allowed to gather important information on the clinical prognostic significance of subclinical cardiac damage during a long follow-up period. This article summarizes the original findings provided by the PAMELA study on the clinical correlates and prognostic significance of echocardiographic markers of subclinical organa damage namely LVH, left atrial enlargement (LA) and AR dilatation at the community level.

Predictive Values of the CHA2DS2-VASc Score and Left Atrial Diameter for Cerebral Small Vessel Disease in Geriatric Patients With Atrial Fibrillation

Objective The objective of this study was to determine whether the CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex) score and left atrial diameter (LAD) could predict the presence of cerebral small vessel disease (cSVD) in patients older than 65 years with atrial fibrillation as the cause of ischemic stroke. Materials and methods In this study, we included patients over 65 years of age who had suffered an ischemic stroke caused by atrial fibrillation within 30 days after the onset of symptoms. The data recorded included demographics, electrocardiograms, Holter monitors, and echocardiography reports. The anteroposterior LAD, determined by transthoracic echocardiography, was analyzed. Each patient's CHA2DS2-VASc score was calculated. Brain magnetic resonance imaging (MRI) assessed white matter hyperintensities (WMH) on fluid-attenuated inversion recovery (FLAIR) images and cerebral microbleeds (CMBs) on susceptibility-weighted sequences. The Fazekas score, based on WMH on MRI, was used to grade the severity of gliosis. Participants were categorized into three groups according to their quantitative CMB burden. Findings The study included 60 participants, with a mean age of 80 years (range 65-99), and 43.3% (n = 26) were male. The CHA2DS2-VASc score had a mean value of 4.21 (range 2-8), and the mean LAD was 4.17 (range 2.6-5.3) cm. The CHA2DS2-VASc score did not predict CMBs (OR, 1.389; 95% CI, 0.961-2.008, p = 0.08) in geriatric stroke patients with atrial fibrillation. However, in the subgroup of patients with diabetes mellitus, the CHA2DS2-VASc score was higher in those with CMB 1-4 and CMB ≥ 5 than in those without CMB. Additionally, the risk of CMBs 1-4 increased with higher LAD compared to patients without LAD. Conclusion The LAD and CHA2DS2-VASc scores were not significantly associated with CMB prediction in elderly stroke patients with atrial fibrillation. In a diabetes mellitus subgroup, the CHA2DS2-VASc score was indicative of CMB. An increased LAD elevates the risk of CMBs in patients with coronary artery disease.

Atrial Speckle Tracking Echocardiography for Detecting Atrial Fibrillation in Cryptogenic Stroke: A Meta-Analysis

Cryptogenic stroke (CS) accounts for approximately 25% of ischemic stroke cases, with atrial fibrillation (AF) accounting for 30% of CS cases. We investigated the utility of left atrial (LA) speckle-tracking echocardiography in identifying patients at high risk of AF after CS and potentially guiding patients who will benefit from long-term rhythm monitoring devices. Cochrane Library, MEDLINE, and EMBASE were searched for relevant studies. We included studies that examined patients with new CS without a history of AF and further examined LA strain parameters (peak and/or reservoir strain). Continuous data were pooled as a mean difference (MD) comparing patients who developed AF vs no AF.  We used the inverse variance method with the DerSimonian-Laird estimator for tau2 and Hartung-Knapp adjustment for random effect analysis. I2 was used to assess heterogeneity. Thirteen observational studies met our criteria and included 3031 patients with new CS. Of those, 420 patients developed AF on follow-up, and 2611 patients did not develop AF. The AF group vs. no AF had significantly reduced LA reservoir strain (LARS) [MD: -8.61; 95% CI: -10.76, -6.47, I2 = 85%, p < 0.01] at presentation. LARS is significantly lower in patients who developed AF after CS. More studies are needed to validate this data.

Left atrial volume by cardiac CTA prior to catheter ablation: comparison to echocardiography and association with recurrent atrial fibrillation

OBJECTIVE

Left atrial volume index (LAVI) by echocardiography can be challenging and its accuracy is highly dependent on image quality. Cardiac computed tomography angiography (CTA) can overcome echocardiographic LAVI measurement challenges; however, data are limited. Therefore, we evaluated the reproducibility of LAVI by CTA, its correlation to echocardiography, and its association with recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI) in this retrospective cohort study of patients who underwent CTA prior to PVI. LAVI was measured by CTA and echocardiography using the area length method.

RESULTS

74 patients had echocardiography and CTA within 6 months and were included in this study. The interobserver variability of LAVI measured by CTA was low (1.2%). CTA correlated with echocardiography but found larger LAVI values by a factor of 1.6. Also, LAVI cut off of ≥ 55 ml/m² measured by CTA correlated with recurrent AF after PVI (adjusted Odds Ratio 3.47, p = 0.033).

Atrial cardiomyopathy: Current and future imaging methods for assessment of atrial structure and function

Changes in atrial size and function have historically been considered a surrogate marker of ventricular dysfunction. However, it is now recognized that atrial cardiomyopathy (ACM) may also occur as a primary myocardial disorder. Emerging evidence that ACM is a major risk factor for atrial fibrillation, heart failure, and thromboembolic stroke, has highlighted the significance of this disorder and the need for better assessment of atrial metrics in clinical practice. Key barriers in this regard include a lack of standardized criteria or hierarchy for the diagnosis of ACM and lack of consensus for the most accurate phenotyping methods. In this article we review existing literature on ACM, with a focus on current and future non-invasive imaging methods for detecting abnormalities of atrial structure and function. We discuss the relative advantages and disadvantages of transthoracic echocardiography and cardiac magnetic resonance imaging for assessing a range of parameters, including atrial size and contractile function, strain, tissue characteristics, and epicardial adipose tissue. We will also present the potential application of novel imaging methods such as sphericity index and four- or five-dimensional flow.

Association between arterial stiffness and left ventricular diastolic function: A large population-based cross-sectional study

Background

The association between arterial stiffness and left ventricular (LV) diastolic function has been demonstrated in several studies, but the samples size in those studies was small. This study aims to verify this issue in a large number of study subjects.

Methods

A total of 7,013 consecutive participants (mean age 60.6 years and 43.3% female) who underwent both baPWV and transthoracic echocardiography were retrospectively analyzed. Subjects with significant cardiac structural abnormalities were excluded.

Results

There were significant correlations of baPWV with septal e′ velocity (r = – 0.408; P < 0.001), septal E/e′ (r = 0.349; P < 0.001), left atrial volume index (LAVI) (r = 0.122; P < 0.001) and maximal velocity of tricuspid valve regurgitation (TR Vmax) (r = 0.322; P < 0.001). The baPWV values increased proportionally with an increase in the number of LV diastolic indices meeting LV diastolic dysfunction criteria (P-for-trend < 0.001). In multivariable analyses with adjustment for confounding effects of various clinical covariates, higher baPWV was independently associated with septal e′ < 7 (odds ratio [OR], 1.30; 95% confidence interval [CI] 1.20–1.60; P < 0.001), septal E/e′ ≥ 15 (OR, 1.46; 95% CI, 1.21–1.78; P < 0.001), and TR Vmax > 2.8 m/s (OR, 1.60; 95% CI, 1.23–2.09; P < 0.001) but not with LAVI ≥ 34 mL/m² (OR, 0.89; 95% CI, 0.76–1.03; P = 0.123).

Conclusions

Increased arterial stiffness, as measured by baPWV, was associated with abnormal diastolic function parameters in a large number of study participants, providing strong evidence to the existing data about ventricular-vascular coupling.

Impact of right atrial enlargement on clinical outcome in patients with atrial fibrillation

Background

Left atrial (LA) remodeling is associated with adverse cardiovascular events, including heart failure (HF) and stroke in patients with atrial fibrillation (AF). However, there are limited data on the value of right atrial (RA) remodeling in this population. We investigated the prognostic role of RA enlargement in patients with non-valvular AF.

Methods and results

We analyzed 254 consecutive patients (age = 69 ± 12years, male:female = 165:89, mean left ventricular ejection fraction = 58.0 ± 7.2%) with non-valvular AF who underwent two-dimensional echocardiography from a single center. RA and LA volumes were measured from apical views and indexed to the body surface areas (right atrial volume index [RAVI] and left atrial volume index [LAVI]) and RAVI &gt; 30mL/m2 and LAVI &gt; 34mL/m2 were considered as enlarged. The relationship between RA enlargement and composite clinical outcome of hospitalization for HF (HHF), stroke, systemic embolism, or death from any cause was assessed. Right atrial (RA) enlargement was associated with older age and more frequent prevalence of persistent or permanent AF. During a median follow-up of 47.1 months, 77 patients (30%) had experienced primary composite outcome. In a multivariable model, RA enlargement, but not LA enlargement, was independently associated with adverse clinical outcomes even after adjusting for clinical and echocardiographic factors {adjusted hazard ratio [HR], 1.90 [95% confidence interval (CI), 1.14–3.18], p = 0.014 for primary composite outcome; adjusted HR, 2.70 [95% CI, 1.27–5.67], p = 0.001 for HHF or all cause death}.

Conclusion

RA enlargement was independently associated with an increased risk of HF, stroke, systemic embolization or death in patients with non-valvular AF, suggesting that RA volume can be helpful in assessing future cardiovascular risk in this population.

Quantification of Left Atrial Size and Function in Cardiac MR in Correlation to Non-Gated MR and Cardiovascular Risk Factors in Subjects without Cardiovascular Disease: A Population-Based Cohort Study

Background: In magnetic resonance imaging (MRI), the comparability of gated and non-gated measurements of the left atrial (LA) area and function and their association with cardiovascular risk factors have not been firmly established. Methods: 3-Tesla MRIs were performed on 400 subjects enrolled in the KORA (Cooperative Health Research in the Augsburg Region) MRI study. The LA maximum and minimum sizes were segmented in gated CINE four-chamber sequences (LAmax and LAmin) and non-gated T1 VIBE-Dixon (NGLA). The area-based LA function was defined as LAaf = (LAmax − LAmin)/LAmax. Inter-and intra-reader reliability tests were performed (n = 31). Linear regression analyses were conducted to link LA size and function with cardiovascular risk factors. Results: Data from 378 subjects were included in the analysis (mean age: 56.3 years, 57.7 % male). The measurements were highly reproducible (all intraclass correlation coefficients ≥ 0.98). The average LAmax was 19.6 ± 4.5 cm2, LAmin 11.9 ± 3.5 cm2, NGLA 16.8 ± 4 cm2 and LAaf 40 ± 9%. In regression analysis, hypertension was significantly associated with larger gated LAmax (β = 1.30), LAmin (β = 1.07), and non-gated NGLA (β = 0.94, all p ≤ 0.037). Increasing age was inversely associated with LAaf (β = −1.93, p < 0.001). Conclusion: LA enlargement, as measured in gated and non-gated CMR is associated with hypertension, while the area-based LA function decreases with age.

Harmful Impact of Tobacco Smoking and Alcohol Consumption on the Atrial Myocardium

Tobacco smoking and alcohol consumption are widespread exposures that are legal and socially accepted in many societies. Both have been widely recognized as important risk factors for diseases in all vital organ systems including cardiovascular diseases, and with clinical manifestations that are associated with atrial dysfunction, so-called atrial cardiomyopathy, especially atrial fibrillation and stroke. The pathogenesis of atrial cardiomyopathy, atrial fibrillation, and stroke in context with smoking and alcohol consumption is complex and multifactorial, involving pathophysiological mechanisms, environmental, and societal aspects. This narrative review summarizes the current literature regarding alterations in the atrial myocardium that is associated with smoking and alcohol.

Premorbid echocardiography and risk of hospitalization in COVID-19

BACKGROUND

COVID-19 has caused a global pandemic unprecedented in a century. Though primarily a respiratory illness, cardiovascular risk factors predict adverse outcomes. We aimed to investigate the role of baseline echocardiographic abnormalities in further refining risk in addition to clinical risk factors.

METHODS

Adults with COVID-19 positive RT-PCR test across St Luke's University Health Network between March 1st 2020-October 31st 2020 were identified. Those with trans-thoracic echocardiography (TTE) within 15-180 days preceding COVID-19 positivity were selected, excluding severe valvular disease, acute cardiac event between TTE and COVID-19, or asymptomatic patients positive on screening. Demographic, clinical, and echocardiographic variables were manually extracted from patients' EHR and compared between groups stratified by disease severity. Logistic regression was used to identify independent predictors of hospitalization.

RESULTS

192 patients met inclusion criteria. 87 (45.3%) required hospitalization, 34 (17.7%) suffered severe disease (need for ICU care/mechanical ventilation/in-hospital death). Age, co-morbidities, and several echocardiographic abnormalities were more prevalent in those with moderate-severe disease than in mild disease, with notable exceptions of systolic/diastolic dysfunction. On multivariate analysis, age (OR 1.039, 95% CI 1.011-1.067), coronary artery disease (OR 4.184, 95% CI 1.451-12.063), COPD (OR 6.886, 95% CI 1.396-33.959) and left atrial diameter ≥ 4.0 cm (OR 2.379, 95% CI 1.031-5.493) predicted need for hospitalization. Model showed excellent discrimination (ROC AUC 0.809, 95% CI 0.746-0.873).

CONCLUSIONS

Baseline left atrial enlargement is an independent risk factor for risk of hospitalization among patients with COVID-19. When available, baseline LA enlargement may identify patients for (1) closer outpatient follow up, and (2) counseling vaccine-hesitancy.

Cardiovascular magnetic resonance assessment of left atrial size and function in endurance athletes

Background: Left atrial (LA) dilatation is linked to cardiovascular disease and atrial fibrillation but its associations in athletes are unknown. The authors investigated whether aerobic fitness and clinical parameters are associated with LA dilatation and emptying fraction (EF) in endurance athletes. Materials & methods: 65 endurance athletes underwent cardiovascular magnetic resonance to assess LA size and function along with fitness assessment. 25 sedentary controls underwent an identical cardiovascular magnetic resonance protocol. Results: In athletes, LA volume index was elevated, while total and passive LAEFs were decreased versus sedentary controls. Increasing age and maximal oxygen uptake were associated with LA volume index. Only older age was associated with decreased total LAEF. Conclusion: LA dilatation in athletes is associated with increasing age and aerobic fitness rather than conventional cardiovascular risk factors.

Age impacts left atrial functional remodeling in athletes

Aim

Age-associated changes in cardiac filling and function are well known in the general population. Yet, the effect of aging on left atrial (LA) function, and its interaction with left ventricular (LV) adaptation, remain less described when combined with high-intensity chronic training. We aimed to analyze the effects of aging on LA and LV functions in trained athletes.

Methods and results

Ninety-five healthy highly-trained athletes referred for resting echocardiography were included. Two groups of athletes were retrospectively defined based on age: young athletes aged <35 years (n = 54), and master athletes aged ≥35 years (n = 41). All subjects were questioned about their sports practice. Echocardiographic analysis of LV systolic and diastolic functions (2D-echo, 3D-echo, and Doppler), as well as LA 2D dimensions and phasic deformations assessed by speckle tracking, were analyzed. Master athletes (mean age = 46.3 ± 8.3 years, mean duration of sustained training = 13.7 ± 8.9 years) exhibited significantly stiffer LV and LA with reduced LV early diastolic functional parameters (ratio E/A, peak e’, and ratio e’/a’), LA reservoir and conduit strain, whereas LA volume, LA contractile strain and LV peak a’ were higher, compared to young athletes. Multivariate regression analysis confirmed that age was predictive of peak e’, LA reservoir strain and LA conduit strain, independently of training variables. LA phasic strains were strongly associated with LV diastolic function.

Conclusions

Regardless of chronic sports practice, master athletes exhibited age-related changes in LA function closely coupled to LV diastolic properties, which led to LV filling shifts to late diastole.

Determinants of Left Atrial Compliance in the Metabolic Syndrome: Insights from the "Linosa Study"

The association between left atrial (LA) impairment and cardiovascular diseases (CVD) and between dyslipidaemia and CVD are well known. The present study aims to investigate the relationships between metabolic factors and LA dimensions and compliance, as well as test the hypothesis that metabolic factors influence LA function independent from hemodynamic mechanisms. Arterial blood pressure (BP), waist and hip circumference, metabolic indices, and a complete echocardiographic assessment were obtained from 148 selected inhabitants (M/F 89/59; age 20−86 years) of Linosa Island, who had no history of CVD. At enrollment, 27.7% of the subjects met the criteria for metabolic syndrome (MetS) and 15.5% for arterial hypertension (HTN). LA compliance was reduced in subjects with MetS compared to those without (53 ± 27% vs. 71 ± 29%, p = 0.04) and was even lower (32 ± 17%, p = 0.01) in those with MetS and HTN. At multiple regression analysis, the presence of MetS independently determined LA maximal area (r = 0.56, p < 0.001), whereas systolic BP and the total cholesterol/HDL cholesterol ratio determined LA compliance (r = 0.41, p < 0.001). In an apparently healthy population with a high prevalence of MetS, dyslipidaemia seems to independently influence LA compliance. At a 5-year follow-up, LA compliance was reduced in both all-cause and CVD mortality groups, and markedly impaired in those who died of CVD. These findings may contribute to understanding the prognostic role of LA function in CVD and strengthen the need for early and accurate lipid control strategies.

Cardiovascular outcomes in patients with left atrial enlargement undergoing transcatheter aortic valve implantation

Background

Increased left ventricular afterload resulting from severe aortic stenosis (AS) leads to progressive cardiac remodeling. Left atrial enlargement (LAE) is an early manifestation in a series of maladaptive changes and may affect clinical outcomes after valvular replacement therapy. The aim of this study is to determine the impact of LAE on clinical outcomes in symptomatic patients with severe AS undergoing transcatheter aortic valve implantation (TAVI).

Methods

In a prospective single‐center TAVI registry, we analyzed LA dimensions measured by echocardiography before intervention. Patients with atrial fibrillation or concomitant mitral valve disease were excluded. LAE was defined as indexed LA volume >34 ml/m². The primary endpoint was cardiovascular death (CVD) at 1 year.

Results

Among 1663 patients undergoing TAVI between August 2007 and December 2016, 768 (46.2%) were eligible for the present analysis and 486 patients had LAE. The prevalence of LAE was higher in males (68.3%) as compared to females (58.8%). Patients with LAE were older (82.3 ± 6.7 years vs. 80.0 ± 6.4 years) and had a higher STS‐PROM score (6.1 ± 4.7% vs. 4.7 ± 2.9%). After adjustment, patients with LAE had an increased risk of CVD at 1‐year compared to patients with normal LA dimensions (49 [10.4%] vs. 8 [2.9%]; HR_adj, 3.52; 95% CI, 1.66–7.44)]. In multivariable analysis, LAE was independently associated with an increased risk of CVD at 1‐year (HR_adj, 3.52; 95% CI, 1.66–7.44).

Conclusions

LAE secondary to AS was documented in a significant proportion of patients undergoing TAVI and was associated with a more than threefold increased risk of CVD at 1‐year.

Association of Left Atrial Size Measured by Non-Contrast Computed Tomography with Cardiovascular Risk Factors—The Danish Cardiovascular Screening Trial (DANCAVAS)

Left atrium (LA) size is associated with adverse cardiovascular events. The purpose of this study was to investigate the association of LA enlargement measured by non-contrast CT (NCCT) with traditional cardiovascular risk factors. Individuals aged 60–75 years from the population-based multicentre Danish Cardiovascular Screening (DANCAVAS) trial were included in this cross-sectional study. The LA was manually traced on the NCCT scans, and the largest cross-section area was indexed to body surface area. All traditional risk factors were recorded, and a subgroup received an echocardiographic examination. We enrolled 14,987 individuals. Participants with known cardiovascular disease or lacking measurements of LA size or body surface area were excluded, resulting in 10,902 men for the main analysis and 616 women for a sensitivity analysis. Adjusted multivariable analysis showed a significantly increased indexed LA size by increasing age and pulse pressure, while smoking, HbA1c, and total cholesterol were associated with decreased indexed LA size. The findings were confirmed in a supplementary analysis including left ventricle ejection fraction and mass. In this population-based cohort of elderly men, an association was found between age and pulse pressure and increasing LA size. Surprisingly, smoking, HbA1c, and total cholesterol were associated with a decrease in LA size. This indicates that the pathophysiology behind atrial cardiomyopathy is not only reflected by enlargement, but also shrinking.

Left atrial volume index predicts adverse events in asymptomatic moderate or severe aortic stenosis

OBJECTIVE

In aortic stenosis (AS), chronic pressure overload on left ventricle (LV) leads to LV hypertrophy, impaired relaxation, increased chamber stiffness, fibrosis and left atrial (LA) dilatation. An enlarged LA may be a marker of longstanding diastolic dysfunction (DD) and more advanced disease in AS. We aimed to assess the impact of LA volume index (LAVI) on events in patients with moderate or severe AS.

METHODS

A total of 324 patients (mean age 69 ± 13 years, 61% men) were included. LA volume was measured by biplane Simpson's method using apical four- and two-chamber views and indexed to body surface area. An increased LAVI was defined as > 34 ml/m² .

RESULTS

The mean EF was 64 ± 8%, LAVI 35 ± 14 ml/m² and flow rate 244 ± 70 ml/s. The number of total events was 275 (85%): 243 (75%) aortic valve replacement and 32 (10%) deaths. Mean follow-up 23.7 ± 23.8 months (median 15.2 months). An increased LAVI (45% [n = 145]) was associated with adverse events (HR 1.86; 95% CI 1.24-2.82, p = 0.003) independent of age, smoking, diabetes, atrial fibrillation, LV ejection fraction, LV mass, aortic valve area, and low flow rate (<200 ml/s). In the same multivariate model, when increased LAVI was replaced by E/e' ratio ≥14 cm, no association was found between E/e' ratio ≥14 cm and adverse events (HR 1.18; 95% CI .78-1.78, p = 0.430).

CONCLUSION

LAVI was an independent predictor of adverse events in patients with moderate or severe AS and preserved ejection fraction. Including LAVI in the risk assessment of AS patients may further improve risk stratification.

Enlarged left atrium and decreased left atrial strain are associated with atrial fibrillation in patients with hyperthyroidism irrespective of conventional risk factors

The purpose of this study was to investigate factors associated with AF in patients with hyperthyroidism beyond heart failure (HF), coronary heart disease (CHD), or valvular diseases. A total of 136 patients (mean age, 52 ± 15 years; 86 [63%] female) who were diagnosed with hyperthyroidism for the first time were enrolled. Patients who had HF, CHD, or significant valvular diseases were excluded. Patients were classified into two groups according to the presence (group 1, n = 40) and absence of AF (group 2, n = 96). AF occurred in 40 (29%) patients and 23 (58%) of these patients showed paroxysmal AF. Among the symptoms of hyperthyroidism, the most common chief complaint was palpitation (30%). Advanced age, presence of prior cerebrovascular events, and presence of palpitations were associated with AF. Larger left atrial volume index (LAVI), increased left ventricular mass index, and decreased left ventricular ejection fraction (LVEF) and S' velocity were associated with AF. Among them, presence of palpitations and increased LAVI were independently associated with the occurrence of AF. In addition, strain analysis, decreased LA expansion index (EI), ejection fraction (EF), peak atrial longitudinal strain, contraction strain, and late diastolic strain rate (A sr) and systolic strain rate (S sr) were associated with the occurrence of AF and LAVI. Presence of palpitations and enlarged left atrium were associated with the occurrence of AF in patients with hyperthyroidism irrespective of conventional risk factors. Additional LA analysis revealed that decreased LA function was associated with AF and enlarged left atrium.

Aortic Root Dilatation Is Attenuated with Diabetes but Is Not Associated with Renal Progression in Chronic Kidney Disease

Patients with chronic kidney disease (CKD) often have cardiac functional and structural abnormalities which can lead to adverse cardiovascular outcomes. In this study, we investigated associations between diabetes mellitus (DM) and cardiac functional and structural parameters in patients with CKD focusing on aortic root diameter (ARD). We also investigated associations of renal outcomes with DM and cardiac functional and structural characteristics. We enrolled 419 patients with CKD stage 3–5 were enrolled. ARD was normalized to body surface area (BSA) (ARD/BSA), and the rate of decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope (mL/min/1.73 m²/year). ARD/BSA ≥2.1 cm/m² in men or ≥2.2 cm/m² in women was defined as indicating aortic root dilatation. The patients with DM had lower ARD/BSA, higher left atrial dimension (LAD), lower left ventricular ejection fraction, lower ratio of peak early transmitral filling wave velocity to peak late transmitral filling wave velocity, and higher left ventricular relative wall thickness, than those without DM. After multivariable analysis, DM (vs. non-DM; coefficient β, −0.060; p = 0.018) was significantly associated with low ARD/BSA. Significantly fewer patients with DM had aortic root dilatation compared to those without DM (14.3% vs. 23.1%, p = 0.022). In the patients with DM, there were significant associations between a high left ventricular mass index (LVMI) (per 1 g/m², β, −0.016; p = 0.040) and high LAD (per 1 cm; β, −1.965; p < 0.001) with a low eGFR slope. However, other parameters, including ARD/BSA, were not associated with eGFR slope. Furthermore, there were no associations between eGFR slope and any of the echocardiographic parameters in the patients without DM. Aortic root dilatation was attenuated in the patients with DM, but it was not associated with a decline in renal function. However, high LAD and LVMI were associated with rapid renal function decline in the CKD patients with DM.

Role of monocyte to high-density lipoprotein cholesterol ratio in predicting left atrial enlargement in hypertensive patients

OBJECTIVE

Left atrium enlargement is common in hypertension due to left atrium inflammation. Monocyte to high-density lipoprotein cholesterol ratio, an inflammation marker that has become very popular in recent years, is associated with many cardiovascular diseases. The aim of this study is to investigate the monocyte to high-density lipoprotein cholesterol ratio level to predict the Left atrium enlargement in hypertensive patients.

METHODS

A total of 216 participants (i.e., 115 hypertensive and 101 control group) were enrolled. Left atrial volumes and left atrial volume indexes were calculated using transthoracic echocardiography. The monocyte to high-density lipoprotein cholesterol ratio was calculated as the ratio of monocyte to high-density lipoprotein cholesterol levels.

RESULTS

The left atrial volumes, left atrial volume indexes, and monocyte to high-density lipoprotein cholesterol levels were significantly higher in the hypertensive group than in the control group (43.3±12.4 versus 31.4±7.9, p<0.001; 22.9±5.8 versus 17.1±3.7, p<0.001; 11.4 [4.2-25.0] versus 8.4 [3.5-18.0], p<0.001, respectively). On the multivariate logistic regression analysis, monocyte to high-density lipoprotein cholesterol ratio (OR 1.38; 95%CI 1.20-1.57; p<0.001), (OR 1.28; 95%CI 1.16-1.42; p<0.001), age, and sex (female) were the independent predictors for hypertension.

CONCLUSIONS

The increased monocyte to high-density lipoprotein cholesterol ratio level was associated with hypertension and increased left atrial volume indexes. The results of this study supported the presence of inflammation, measured with a readily available and inexpensive marker, in hypertensive patients and revealed the association with left atrial enlargement.

Obstructive sleep apnea and cardiovascular comorbidity: common pathophysiological mechanisms to cardiovascular disease

Obstructive sleep apnea (OSA) is associated with many cardiovascular and metabolic diseases. Sleep apnea causes intermittent hypoxemia, chest pressure fluctuations and a reaction from the cerebral cortex in the form of a short awakening during sleep (EEG-activation). The consequences of pathological pathways are studied in experimental models involving cell cultures, animals, and healthy volunteers. At present, the negative impact of intermittent hypoxemia on a variety of pathophysiological disorders of the heart and blood vessels (vascular tone fluctuations, thickening of the intimamedia complex in the vascular wall, direct damaging effect on the myocardium) has a great evidence base. Two other pathological components of OSA (pressure fluctuations and EEG-activation) can also affect cardiovascular system, mainly affecting the increase in blood pressure and changing cardiac hemodynamics. Although these reactions are considered separately in the review, with the development of sleep apnea they occur sequentially and are closely interrelated. As a result, these pathological pathways trigger further pathophysiological mechanisms acting on the heart and blood vessels. It is known that these include excessive sympathetic activation, inflammation, oxidative stress and metabolic dysregulation. In many respects being links of one process, these mechanisms can trigger damage to the vascular wall, contributing to the formation of atherosclerotic lesions. The accumulated data with varying degrees of reliability confirm the participation of OSA through these processes in the formation of cardiovascular disorders. There are factors limiting direct evidence of this interaction (sleep deprivation, causing similar changes, as well as the inability to share the contribution of other risk factors for cardiovascular diseases, in particular arterial hypertension, obesity, which are often associated with OSA). It is necessary to continue the study of processes that implement the pathological effect of OSA on the cardiovascular system.

Small whole heart volume predicts cardiovascular events in patients with stable chest pain: insights from the PROMISE trial

OBJECTIVES

The size of the heart may predict major cardiovascular events (MACE) in patients with stable chest pain. We aimed to evaluate the prognostic value of 3D whole heart volume (WHV) derived from non-contrast cardiac computed tomography (CT).

METHODS

Among participants randomized to the CT arm of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE), we used deep learning to extract WHV, defined as the volume of the pericardial sac. We compared the WHV across categories of cardiovascular risk factors and coronary artery disease (CAD) characteristics and determined the association of WHV with MACE (all-cause death, myocardial infarction, unstable angina; median follow-up: 26 months).

RESULTS

In the 3798 included patients (60.5 ± 8.2 years; 51.5% women), the WHV was 351.9 ± 57.6 cm3/m2. We found smaller WHV in no- or non-obstructive CAD, women, people with diabetes, sedentary lifestyle, and metabolic syndrome. Larger WHV was found in obstructive CAD, men, and increased atherosclerosis cardiovascular disease (ASCVD) risk score (p < 0.05). In a time-to-event analysis, small WHV was associated with over 4.4-fold risk of MACE (HR (per one standard deviation) = 0.221; 95% CI: 0.068-0.721; p = 0.012) independent of ASCVD risk score and CT-derived CAD characteristics. In patients with non-obstructive CAD, but not in those with no- or obstructive CAD, WHV increased the discriminatory capacity of ASCVD and CT-derived CAD characteristics significantly.

CONCLUSIONS

Small WHV may represent a novel imaging marker of MACE in stable chest pain. In particular, WHV may improve risk stratification in patients with non-obstructive CAD, a cohort with an unmet need for better risk stratification.

KEY POINTS

• Heart volume is easily assessable from non-contrast cardiac computed tomography. • Small heart volume may be an imaging marker of major adverse cardiac events independent and incremental to traditional cardiovascular risk factors and established CT measures of CAD. • Heart volume may improve cardiovascular risk stratification in patients with non-obstructive CAD.

Formula to estimate left atrial volume using antero-posterior diameter in patients with catheter ablation of atrial fibrillation

In patients undergoing atrial fibrillation (AF) ablation, an enlarged left atrium (LA) is a predictor of procedural failure as well as AF recurrence on long term. The most used method to assess LA size is echocardiography-measured diameter, but the most accurate remains computed tomography (CT).The aim of our study was to determine whether there is an association between left atrial diameters measured in echocardiography and the left atrial volume determined by CT in patients who underwent AF ablation.The study included 93 patients, of whom 60 (64.5%) were men and 64 (68.8%) had paroxysmal AF, who underwent AF catheter ablation between January 2018 and June 2019. Left atrial diameters in echocardiography were measured from the long axis parasternal view and the LA volume in CT was measured on reconstructed three-dimensional images.The LA in echocardiography had an antero-posterior (AP) diameter of 45.0 ± 6 mm (median 45; Inter Quartile Range [IQR] 41-49, range 25-73 mm), longitudinal diameter of 67.5 ± 9.4 (median 66; IQR 56-88, range 52-100 mm), and transversal diameter of 42 ± 8.9 mm (IQR 30-59, range 23-64.5 mm). The volume in CT was 123 ± 29.4 mL (median 118; IQR 103-160; range 86-194 mL). We found a significant correlation (r = 0.702; P < .05) between the AP diameter and the LA volume. The formula according to which the AP diameter of the LA can predict the volume was: LA volume = AP diam3 + 45 mL.There is a clear association between the left atrial AP diameter measured on echocardiography and the volume measured on CT. The AP diameter might be sufficient to determine the increase in the volume of the atrium and predict cardiovascular outcomes.

Conductance artery stiffness impairs atrio-ventriculo-arterial coupling before manifestation of arterial hypertension or left ventricular hypertrophic remodelling

As part of normal ageing, conductance arteries lose their cushion function, left ventricle (LV) filling and also left atrial emptying are impaired. The relation between conductance artery stiffness and LV diastolic function is normally explained by arterial hypertension and LV hypertrophy as needed intermediaries. We examined whether age-related aortic stiffening may influence LV diastolic function in normal healthy subjects. Aortic distensibility and pulse wave velocity (PWV) were related to LV emptying and filling parameters and left atrial emptying parameters as determined by magnetic resonance imaging in 36 healthy young (< 35 years) and 16 healthy middle-aged and elderly (> 35 years) with normal arterial blood pressure and myocardial mass. In the overall cohort, total aorta PWV correlated to a decrease in LV peak-emptying volume (r = 0.43), LV peak-filling (r = 0.47), passive atrial emptying volume (r = 0.66), and an increase in active atrial emptying volume (r = 0.47) (all p < 0.001). PWV was correlated to passive atrial emptying volume even if only the > 35-year-old were considered (r = 0.53; p < 0.001). Total peripheral resistance demonstrated similar correlations as PWV, but in a regression analysis only the total aorta PWV was related to left atrial (LA) passive emptying volume. Via impaired ventriculo-arterial coupling, the increased aortic PWV seen with normal ageing hence affects atrio-ventricular coupling, before increased aortic PWV is associated with significantly increased arterial blood pressure or LV hypertrophic remodelling. Our findings reinforce the existence of atrio-ventriculo-arterial coupling and suggest aortic distensibility should be considered an early therapeutic target to avoid diastolic dysfunction of the LV.

Left atrial expansion index is associated with recurrent stroke

OBJECTIVE

Although left atrial (LA) expansion index is associated with cardiovascular prognosis, whether it affects recurrent strokes is still unknown.

METHODS

This study enrolled 176 patients hospitalized with first ischemic stroke. Their stroke subtypes were classified as cardioembolic stroke (CE), noncardioembolic stroke (NCE), embolic stroke of undetermined source (ESUS), or transient ischemic attack. The LA expansion index was calculated as (Volmax-Volmin) × 100%/Volmin, where Volmax was defined as maximal LA volume and Volmin as minimal LA volume. The study endpoint was recurrent ischemic stroke.

RESULTS

Over a five-year (mean 4.9 years) follow-up period, 21 (11.9%) participants reached the study endpoint, including 10 with CE, five with NCE, and six with ESUS. The LA expansion index was lower in the event groups compared with the non-event group. For predicting recurrent stroke, LA expansion index <62.5% (76% sensitivity and 68% specificity) was superior to LA volume and E/e'. Kaplan-Meier curves revealed that the five-year cumulative recurrent stroke rate in patients with LA expansion index <62.5% was 23.9%, which was significantly higher than the five-year cumulative recurrent stroke rate of 4.6% in patients with LA expansion index >62.5% (log rank p<0.001). The LA expansion index was a significant independent predictor of recurrent stroke (hazard ratio=0.873; 95% confidence interval: 0.790-0.973 per 10% increase in LA expansion index; p=0.009).

CONCLUSION

The LA expansion index is useful for predicting recurrent stroke.

Prognostic power of conventional echocardiography in individuals without history of cardiovascular diseases: A systematic review and meta-analysis

Echocardiographic abnormalities are associated with a higher incidence of adverse cardiovascular outcomes. This systematic review and meta-analysis aimed to evaluate whether echocardiographic abnormalities are predictors of cardiovascular events in individuals without previous cardiovascular diseases. The PubMed, Scopus, and SciELO databases were searched for longitudinal studies investigating the association between echocardiographic abnormalities and cardiovascular events among individuals without known cardiovascular diseases. Two independent reviewers analyzed data on the number of participants, age and sex, echocardiographic alterations, follow-up time, and cardiovascular outcomes. The meta-analysis estimated the risk ratio (RR) and 95% confidence interval (CI). Heterogeneity was assessed using I2 test. Twenty-two longitudinal studies met the eligibility criteria, comprising a total of 55,603 patients. Left ventricular hypertrophy (LVH) was associated with non-fatal cardiovascular events (RR 2.16; 95% CI 1.22-3.84), death from cardiovascular disease (RR 2.58; 95% CI 1.83- 3.64), and all-cause mortality (RR 2.02; 95% CI 1.34-3.04). Left ventricular diastolic dysfunction (LVDD) and left atrial dilation (LA) were associated with fatal and non-fatal cardiovascular events (RR 2.01; 95% CI 1.32-3.07) and (RR 1.78; 95% CI 1.16-2.73), respectively. Aortic root dilation was associated with non-fatal cardiovascular events (RR 1.25; 95% CI 1.09-1.43). In conclusion, LVH, LVDD, dilations of the LA, and of the aortic root were associated with an increased risk of adverse events in individuals without previous cardiovascular diseases. This study suggests that simple data obtained on conventional echocardiography can be an important predictor of cardiovascular outcomes in a low-risk population.

Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling in the Community

PURPOSE OF REVIEW

Echocardiography is a noninvasive tool of choice for evaluating cardiac structure and function in numerous cardiac conditions ranging from congenital heart disease, myocardial diseases, coronary artery disease (CAD), valvulopathies, arrhythmias, and pericardial disorders. We review the prognostic significance of echocardiographic indices of cardiac remodeling in the general population.

RECENT FINDINGS

Recent meta-analyses have confirmed the prognostic significance of echocardiographic measurements (left ventricular mass/hypertrophy, systolic and diastolic dysfunction, left atrial dimensions and function, and strain rate measures) in asymptomatic people in the community for adverse clinical outcomes including CAD, stroke, heart failure, atrial fibrillation, sudden death, and all-cause mortality. The clinical utility of screening echocardiography has been examined comprehensively in hypertensive patients, where it is challenged by measurement variability. Echocardiographic measures predict cardiovascular disease outcomes consistently in multiple community-based epidemiological studies. However, the clinical utility of screening asymptomatic individuals with echocardiography in population-based settings is limited.

Correlation between left atrial expansion index and stroke subtype: A 10-Year Follow-Up Study

PURPOSE

Although left atrial (LA) expansion index predicts cardiovascular events, its efficacy for predicting cerebral events is unknown.

METHODS

This study enrolled 2205 patients who had sinus rhythm after echocardiography in their first visit. LA expansion index was calculated as (Vol_max -Vol_min ) x100%/Vol_min , where Vol_max was defined as maximal LA volume and Vol_min as minimal LA volume. The study endpoint was ischemic stroke. Stroke subtype was classified as cardioembolic stroke (CE), noncardioembolic stroke with determined mechanism (NCE), or embolic stroke of undetermined source (ESUS).

RESULTS

Over a 10-year (mean 9.7 years) follow-up period, 128 (5.8%) participants reached endpoint, including 46 with CE, 33 with NCE, and 49 with ESUS. Regardless of stroke subtype, LA expansion index was lower in the event groups compared to the nonevent group. The lowest quartile of LA expansion index was associated with high CHA₂ DS₂ -VASc score at enrollment and more events, including CE, ESUS, atrial fibrillation (AF), heart failure, and all-cause mortality, relative to other quartiles. The LA expansion index was an independent predictor of CE (HR 0.82; 95% CI 0.723-0.912, per 10% increase in LA expansion index; P < .0001) and ESUS (HR 0.92; 95% CI 0.881-0.976, per 10% increase in LA expansion index; p 0.003). An LA expansion index <68% predicts the presence of AF after ESUS with 84% sensitivity and 70% specificity.

CONCLUSION

LA expansion index is useful for predicting CE and ESUS. It is also associated with AF, heart failure hospitalization, and all-cause mortality.

Association of Global Cardiac Calcification with Atrial Fibrillation and Recurrent Stroke in Patients with Embolic Stroke of Undetermined Source

BACKGROUND

Calcium deposits in the heart have been associated with cardiovascular events, mortality, stroke, and atrial fibrillation (AF). However, there is no accepted standard method for scoring cardiac calcifications. Existing methods have also not been validated for the assessment of patients with embolic stroke of undetermined source (ESUS). The aim of this study was to evaluate the association of various cardiac calcification scores with new-onset AF and stroke recurrence in a cohort of patients with ESUS.

METHODS

In this study, 181 consecutive patients with stroke diagnosed with ESUS were identified and evaluated. They were followed for new-onset AF and ischemic stroke recurrence for a median duration of 2.1 years. Various echocardiographic cardiac calcification scores were assessed on transthoracic echocardiography performed during the evaluation of ESUS and subsequently assessed for their relation to AF detection and recurrent stroke. The echocardiographic calcium scores assessed were the (1) global cardiac calcium score (GCCS), (2) echocardiographic calcium score (eCS), (3) echocardiographic calcification score, (4) echocardiographic composite cardiac calcium score, and (5) total heart calcification score. Only two of these scoring schemes, GCCS and eCS, quantified the cardiac calcium burden.

RESULTS

Higher calcium scores as measured by GCCS and eCS were found to be significantly associated with subsequent AF detection as well as recurrent ischemic stroke in patients with ESUS. The association with recurrent stroke remained significant even after adjustment for comorbidities and AF.

CONCLUSIONS

Higher cardiac calcification measured using the GCCS and eCS is independently associated with AF detection and recurrent ischemic stroke in patients with ESUS, and these scores can be useful markers for further risk stratification in patients with ESUS.

A fast and reproducible method to estimate left atrial volume using cardiac computed tomography

PURPOSE

The purpose of this study was to do better than the simple maximal axial area (MArea_ax) and to validate simple, fast and robust orthogonal methods for determining the left atrium volume (LAV) with cardiac CT (CCT).

MATERIAL AND METHODS

A total of 60 patients who underwent CTT were retrospectively included. There were 30 men and 30 women with a mean age of 59±12 (SD) years (range: 27-80 years), using four methods to assess LAV beyond the MArea_ax: two orthogonal methods requiring the measurements of axial, coronal and sagittal planes of 3 diameters LAV_3diam or 3 area LAV_3Areas; Area-length biplane method LAV_biplane; and volumetric method LAV_volumetric using a semi-automated tool that served as the reference standard. The orthogonal methods were applied on contrast-enhanced (IV+) and unenhanced (IV-) CCT images. Comparisons were performed using Pearson correlation test (r) and Bland-Altman analysis. Inter- and intra-observer variability were assessed using intraclass correlation coefficient (ICC) with a two-way mixed-effects model.

RESULTS

On IV+ CCT, LAV_biplane, LAV3diam_-IV+, LAV_3Areas-IV+ underestimated LAV (-15±1.99mL; -21±1.37mL; -15±1.98mL; all P<0.001). LAV_3diam-IV+, LAV3_Areas-IV+ better correlated with reference standard (r=0.97 and 0.98) than LAV_biplane (r=0.79) as well as MArea_ax (r=0.90). Estimating LAV on IV- further showed high correlation against the reference (r=0.93 and 0.95 for LAV3diam_-IV- and LAV_3Areass-IV-, respectively). Intra- and inter-observer ICC increased from LAV_volumetric (2.43% and 3.09%); LAV_3Areas-IV+ (3.04 and 3.30%); LAV_3Areas-IV-(3.34 and 4.23%), LAV3diam_-IV+ (3.36 and 5.11%); LAV3diam_-IV- (5.16 and 6.90%); to LAV_biplane (9.65 and 10.28%).

CONCLUSIONS

Better than MArea_ax, orthogonal methods using either diameter or surface are fast and reproducible methods to assess LAV on CCT when performed with or without intravenous administration of contrast material.

Effect of Isolated Obesity on Left Ventricular Function and Structure: A Single-Center Experience

Background and objectives

Obesity can increase cardiac mass and affect cardiac performance independently from other risk factors. Several studies have identified an association in patients who already have comorbidities, however, few studies focused on obesity as an isolated risk factor. This study aimed to assess the associations between isolated obesity and heart morphological and functional characteristics.

Methods

This was a cross-sectional study that recruited 114 patients referred for echocardiographic study in King Faisal Cardiac Center. Adult patients who had a body mass index (BMI) above 25 kg/m² were included, while patients with comorbidities such as hypertension, diabetes mellitus, dyslipidemia, or those who use medications for chronic diseases were excluded from this study. Variables of interest that we collected were age, gender, weight, BMI, and those related to morphological and functional changes in the heart including left ventricular mass index (LVMI), LV end-diastolic volume, and left ventricular ejection fraction (LVEF).

Results

Most of the study participants (63.8%) were class II or class III obesity and about 80% were males. The mean ± SD of LVEF was 55.7% ± 2.8%, while the mean of the left ventricular mass index was 28.5±5.84. The mean of LV end-diastolic volume index (LVEDVI) was slightly higher among males than females (48.8±11.6 versus 46.4±11.7 ml/m²), however, this difference was not statistically significant (p-value= 0.395). There was no correlation between BMI and LVMI in females (R - 0.226, R² 0.05, P-value 0.37), while the LVMI was found to have a negative correlation between BMI and male gender that was significant (R - 0.292, R² 0.09, P-value 0.0052). It was found that there is no correlation between LVEF and BMI for males and females (male= R 0.093, R² 0.032, P-value 0.093; female= R 0.172, R² 0.029, P-value 0.434). With regards to the LVEDVI, there was a negative correlation between higher BMI and male gender that was significant (male= R - 0.396, R² 0.157, P-value 0.0001) while it was not significant in females (R -0.0298, R² 0.0009, P-value 0.893).

Conclusions

We have found that cardiac function is not affected by isolated obesity. However, indexed cardiac parameters like LVM and LV end diastolic volume were negatively correlated with higher BMI and positively correlated with relative wall thickness (RWT) only in males. This negative correlation might be one of the triggers to the development of obesity-induced cardiomyopathy.

Predictive value of echocardiographic left atrial size for incident stoke and stroke cause mortality: a population-based study

OBJECTIVES

To investigate the associations between echocardiographic left atrial (LA) size and incident stoke and stroke cause mortality among a rural population in China.

DESIGN

A prospective study.

SETTING AND PARTICIPANTS

Based on the Northeast China Rural Cardiovascular Health Study, we selected a total of 10 041 participants aged ≥35 years who agreed to have transthoracic echocardiography at baseline and were successfully followed up for incident stoke and stroke cause mortality.

PRIMARY OUTCOME MEASURE

The outcomes were stroke and stroke cause death according to medical records and death certificates during the follow-up period.

RESULTS

LA enlargement (LAE) group had a higher prevalence of cardiovascular disease than normal LA diameter (LAD) group. After excluding individuals who had a prior stroke, subjects with LAE showed higher incident rates of stroke and its mortality in the overall and specific stratified analyses (all p<0.05). Kaplan-Meier analysis revealed that LAE could predict stroke incidence and stroke-free survival, but the association was no longer observed after the adjustment for potential confounding factors. Cox regression analysis reported that per 1 SD increment in LAD and LAD/body surface area (BSA) was associated with an increased incidence of stroke (LAD: HR=1.20, 95% CI 1.08 to 1.33, p<0.001; LAD/BSA: HR=1.22, 95% CI 1.11 to 1.35, p<0.001) and stroke cause mortality (LAD: HR=1.27, 95% CI 1.08 to 1.50, p<0.01; LAD/BSA: HR=1.41, 95% CI 1.20 to 1.65, p<0.001) in the total population, and similar trends were found in both genders (all p<0.05). LAD or LAD/BSA was related to ischaemic and haemorrhagic stroke incidence, and the risk of ischaemic and haemorrhagic stroke mortality (all p<0.05). The dose-response curves further suggested linear associations between LAD, LAD/BSA and the incidence of stroke and subsequent mortality in the general population (all p<0.05).

CONCLUSIONS

Our population-based study implied that LA size, especially LAD and LAD/BSA, might be useful echocardiographic biomarkers that had the potential to predict incident stroke and stroke cause mortality.

The association of echocardiographic parameters on renal outcomes in chronic kidney disease

BACKGROUND

Patients with chronic kidney disease (CKD) often have structural abnormalities of the heart due to pressure and volume overload. The aim of this study was to evaluate associations between echocardiographic parameters and renal outcomes (estimated glomerular filtration rate [eGFR] slope and progression to dialysis) in patients with stage 3-5 CKD.

METHODS

This longitudinal study enrolled 419 patients. Changes in renal function were assessed using the eGFR slope. Rapid renal progression was defined as an eGFR slope < -3 mL/min/1.73 m²/year, and the renal endpoint was defined as commencing dialysis.

RESULTS

Increased left atrial diameter (LAD), ratio of left ventricular mass to body surface area (LVM/BSA), ratio of LVM to height^2.7 (LVM/ht^2.7), and ratio of observed to predicted LVM (o/p LVM) were associated with eGFR slope in an adjusted model, but left ventricular ejection fraction (LVEF) was not. Furthermore, LAD ≥ 4.7 cm, LVM/BSA > 115 g/m² in males and > 95 g/m² in females, and LVM/ht^2.7 > 48 g/ht^2.7 in males and > 44 g/ht^2.7 in females were correlated with progression to dialysis, but o/p LVM and LVEF were not. The maximum change in χ² change to predict renal outcomes was observed for LAD, followed by LVM/BSA and LVM/ht^2.7.

CONCLUSIONS

A large LAD and increased LVM, regardless of how it was measured (LVM/BSA, LVM/ht^2.7 and o/p LVM), were correlated with adverse renal outcomes in patients with CKD stage 3-5. LAD had superior prognostic value to LVM and LVEF.

Validation of evaluating left ventricular diastolic function with estimated left atrial volume from anteroposterior diameter

Background

Left atrial (LA) volume (LAV) is one of the recommended key variables for evaluating left ventricular (LV) diastolic function. However, only LA anteroposterior diameter (LAAP) is available in numerous large-scale existing databases. Therefore, this study aimed to validate whether LV diastolic function could be evaluated with estimated LAV from LAAP.

Methods

A total of 552 inpatients with sinus rhythm were consecutively enrolled. LAV was measured by biplane Simpson’s disk summation method. LV diastolic function was evaluated according to the 2016 proposed recommendations. Best-fitting regression models of LAAP index (LAAPI)–LAV index (LAVI) were developed and equations with the highest F-value were chosen in the first 276 subjects (derivation set), and concordance for evaluating LV diastolic function between using estimated and observed LAVI was verified in the remaining 276 subjects (validation set).

Results

In the derivation set, the linear model has the highest F-value in all subjects and in the subjects with normal or depressed LV ejection fraction. In the validation set, using the linear equation (LAVI = 2.05 × LAAPI − 13.86), the higher area under curve and narrower range of difference were shown between estimated LAVI and observed LAVI, respectively. Further, concordance for diagnosis (overall proportion of agreement, 88.4%; κ = 0.79) and grading (overall proportion of agreement, 84.8%; κ = 0.74) of LV diastolic dysfunction was substantial between using estimated and observed LAVI.

Conclusions

LV diastolic function can be evaluated with estimated LAVI from LAAPI, which might provide a surrogate method when the direct measurement of LAV is not available.

Impaired Left Atrial Performance Resulting From Age-Related Arial Fibrillation Is Associated With Increased Fibrosis Burden: Insights From a Clinical Study Combining With an in vivo Experiment

Background: Atrial fibrillation (AF) is increasingly considered an age-related degenerative disease, whose process is associated with the development of impaired left atrial (LA) performance. However, the subtle dynamic changes of LA performance in AF during aging have yet to be fully elucidated. Atrial fibrosis is a key substrate for the development of AF, but the progression of fibrosis during aging and its relationship with LA dysfunction need to be further explored. Methods: A total of 132 control individuals and 117 persistent AF patients were prospectively studied. Subjects were further stratified into three age groups (age group 1: younger than 65 years, age group 2: between 65 and 79 years old, and age group 3: older than 80 years). The two-dimensional speckle tracking imaging was carried out for analyzing the alterations in LA function underlying LA remodeling, whereas electroanatomic mapping was performed to investigate LA fibrosis burden. In animal study, aged mice and young mice served as research subjects. Echocardiography and histological staining were used to assess LA performance and fibrosis burden, respectively. Results: Echocardiography showed progressive increases in LA dimension and LA stiffness index, and progressive decreases in LA global longitudinal strain and LA strain rates with advancing age in both AF and control cohorts, which was more prominent in AF cohort. Electroanatomic mapping showed progressive decrease in mean LA voltage and progressive increases in LA surface area, low-voltage area %, and LA volume with advancing age, whereas more significant alterations were observed in AF patients. Moreover, left atrial global longitudinal strain was positively correlated with mean LA voltage, whereas LA stiffness index was negatively related to mean LA voltage. In animal experiment, increased LA size and pulmonary artery dimension as well as longer P-wave duration and more prominent LA fibrosis were found in aged mice. Conclusions: This study provides new evidence of subtle changes in structure and performance of left atrium and their association with atrial fibrosis in both AF and non-AF subjects during physiological aging. In addition, our study also provides normal values for LA structure and performance in both AF and non-AF conditions during aging. These measurements may provide an early marker for onset of AF and LA adverse remodeling.

Detection of Left Atrial Enlargement Using a Convolutional Neural Network-Enabled Electrocardiogram

Background: Left atrial enlargement (LAE) can independently predict the development of a variety of cardiovascular diseases.

Objectives: This study sought to develop an artificial intelligence approach for the detection of LAE based on 12-lead electrocardiography (ECG).

Methods: The study population came from an epidemiological survey of heart disease in Guangzhou. Elderly people (3,391) over 65 years old who had both 10-s 12 lead ECG and echocardiography were enrolled in this study. The left atrial (LA) anteroposterior diameter >40 mm on echocardiography was diagnosed as LAE, and the LA anteroposterior diameter was indexed by body surface area (BSA) to classify LAE into different degrees. A convolutional neural network (CNN) was trained and validated to detect LAE from normal ECGs. The performance of the model was evaluated by calculating the area under the curve (AUC), accuracy, sensitivity, specificity, and F1 score.

Results: In this study, gender, obesity, hypertension, and valvular heart disease seemed to be related to left atrial enlargement. The AI-enabled ECG identified LAE with an AUC of 0.949 (95% CI: 0.911–0.987). The sensitivity, specificity, accuracy, precision, and F1 score were 84.0%, 92.0%, 88.0%, 91.3%, and 0.875, respectively. Physicians identified LAE with sensitivity, specificity, accuracy, precision, and F1 scores of 38.0%, 84.0%, 61.0%, 70.4%, and 0.494, respectively. In classifying LAE in different degrees, the AUCs of identifying normal, mild LAE, and moderate-severe LAE ECGs were 0.942 (95% CI: 0.903–0.981), 0.951 (95% CI: 0.917–0.987), and 0.998 (95% CI: 0.996–1.00), respectively. The sensitivity, specificity, accuracy, positive predictive value, and F1 scores of diagnosing mild LAE were 82.0%, 92.0%, 88.7%, 89.1%, and 0.854, while the sensitivity, specificity, accuracy, positive predictive value, and F1 scores of diagnosing moderate-severe LAE were 98.0%, 84.0%, 88.7%, 96.1%, and 0.969, respectively.

Conclusions: An AI-enabled ECG acquired during sinus rhythm permits identification of individuals with a high likelihood of LAE. This model requires further refinement and external validation, but it may hold promise for LAE screening.