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Yamamoto J, Hayama H, Enomoto Y, Yamamoto M, Hara H, Hiroi Y. Impact of left ventricular diastolic function and direct oral anticoagulant use for predicting embolic events in patients with heart failure and atrial fibrillation. J Arrhythm 2024; 40:489-500. [PMID: 38939759 PMCID: PMC11199849 DOI: 10.1002/joa3.13031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 06/29/2024] Open
Abstract
Background Patients with atrial fibrillation (AF) and heart failure (HF) have high stroke risk owing to left atrial dysfunction. However, anticoagulation is a concern in patients with high bleeding risk. We aimed to identify independent predictors of stroke in HF patients with AF. Methods We retrospectively examined 320 patients (mean age 79 ± 12 years, 163 women) hospitalized with acute HF complicated by AF between January 2014 and December 2018. Patients were followed from admission until ischemic stroke or systemic embolism (SSE) onset or death or were censored at the last contact date or September 2023. Results SSE occurred in 40 patients (median follow-up of 528 days). Multivariate Cox regression analysis identified age (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.00-1.07, p = .034), direct oral anticoagulant (DOAC) use (HR 0.26, 95% CI 0.11-0.60, p = .002), and early diastolic peak flow velocity to early diastolic peak annular velocity (E/e'; HR 1.05, 95% CI 1.02-1.08, p < .001) to be independent predictors of SSE, whereas left atrial reservoir strain was not. After determining an appropriate E/e' cutoff by receiver-operating characteristic curve analysis and adjusting the multivariate Cox model, E/e' ≥17.5 (HR 3.30, 95% CI 1.56-6.83, p = .001) independently predicted SSE. The results were consistent with no interaction in the subanalysis except for gender. Conclusion Elderly patients not on DOACs with elevated E/e' may be at higher risk of stroke, suggesting that DOACs should be the first choice for patients with elevated E/e' and aggressive additional prophylaxis and careful follow-up are needed.
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Affiliation(s)
- Jumpei Yamamoto
- Department of CardiologyNational Center for Global Health and MedicineTokyoJapan
| | - Hiromasa Hayama
- Department of CardiologyNational Center for Global Health and MedicineTokyoJapan
| | - Yoshinari Enomoto
- Department of CardiologyNational Center for Global Health and MedicineTokyoJapan
| | - Masaya Yamamoto
- Department of CardiologyNational Center for Global Health and MedicineTokyoJapan
| | - Hisao Hara
- Department of CardiologyNational Center for Global Health and MedicineTokyoJapan
| | - Yukio Hiroi
- Department of CardiologyNational Center for Global Health and MedicineTokyoJapan
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2
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Kim M, Bae S, Park JH, Jung IH. Relative importance of left atrial reservoir strain compared with components of the HFA-PEFF score: a cross-sectional study. Front Cardiovasc Med 2023; 10:1213557. [PMID: 37900564 PMCID: PMC10602785 DOI: 10.3389/fcvm.2023.1213557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Background The relative importance of left atrial reservoir strain (LASr) regarding the Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology (HFA-PEFF) score, a diagnostic tool for patients with heart failure with preserved ejection fraction (HFpEF), remains unclear. We aimed to identify the relative importance of LASr compared with variables associated with HFpEF and HFA-PEFF scores. Methods Between August 2021 and July 2022, we obtained retrospective data from the participants visiting a single cardiovascular center with subjective symptoms of heart failure, such as dyspnea or chest discomfort. In total, 2,712 participants with sinus rhythm and ejection fraction of more than 50% were enrolled. Multivariable logistic regression analysis, random forest analysis, and supervised machine learning algorithms were performed to identify the relative importance of LASr to the HFA-PEFF score. Results The average HFA-PEFF score was 2.4 ± 1.6 points. Two hundred and thirty-eight participants had 5 or 6 points. LASr showed a moderate correlation with the HFA-PEFF score (r = -0.50, p < 0.001). Impaired LASr < 25.2% was an independent variable affecting a high HFA-PEFF score with traditional diastolic function parameters and components of the HFA-PEFF diagnostic algorithm. The odds ratio (OR) [1.74, 95% confidence interval (CI) 1.23-2.47] for LASr was higher compared to that of left ventricular global longitudinal strain (OR 1.59, 95% CI 1.14-2.21), septal E/e' (OR 1.23, 95% CI 0.85-1.77), and relative wall thickness (OR 1.20, 95% CI 0.76-1.89). LASr was also a relatively more important variable in estimating a high HFA-PEFF score than TR-Vmax, septal E/e', septal e', left ventricular mass index, and relative wall thickness, the major echocardiographic components of the HFA-PEFF score. Conclusions LASr is an important factor with components of the HFA-PEFF score and is a useful tool to assess patients with HFpEF. Clinical Trial Registration URL: https://clinicaltrials.org. Unique identifiers: NCT05638230.
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Affiliation(s)
| | | | | | - In Hyun Jung
- Division of Cardiology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Republic of Korea
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López-Galvez R, Rivera-Caravaca JM, Roldán V, Orenes-Piñero E, Esteve-Pastor MA, López-García C, Saura D, González J, Lip GYH, Marín F. Imaging in atrial fibrillation: A way to assess atrial fibrosis and remodeling to assist decision-making. Am Heart J 2023; 258:1-16. [PMID: 36526006 DOI: 10.1016/j.ahj.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/22/2022] [Accepted: 12/10/2022] [Indexed: 05/11/2023]
Abstract
The 2020 ESC atrial fibrillation (AF) guidelines suggest the novel 4S-AF scheme for the characterization of AF. Imaging techniques could be helpful for this objective in everyday clinical practice, and information derived from these techniques reflects basic aspects of the pathophysiology of AF, which may facilitate treatment decision-making, and optimal management of AF patients. The aim of this review is to provide an overview of the mechanisms associated with atrial fibrosis and to describe imaging techniques that may help the management of AF patients in clinical practice. Transthoracic echocardiography is the most common procedure given its versatility, safety, and simplicity. Transesophageal echocardiography provides higher resolution exploration, and speckle tracking echocardiography can provide incremental functional and prognostic information over conventional echocardiographic parameters. In addition, LA deformation imaging, including LA strain and strain rate, are related to the extent of fibrosis. On the other hand, multidetector-row computed tomography and cardiac magnetic resonance provide higher resolution data and more accurate assessment of the dimensions, structure, and spatial relationships of the LA. Imaging is central when deciding on catheter ablation or cardioversion, and helps in selecting those patients who will really benefit from these procedures. Moreover, imaging enhances the understanding of the underlying mechanisms of atrial remodeling and might assists in refining the risk of stroke, which help to select the best medical therapies/interventions. In summary, evaluation of LA enlargement, LA remodeling and fibrosis with imaging techniques adds clinical and prognostic information and should be assessed as a part of routine comprehensive AF evaluation.
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Affiliation(s)
- Raquel López-Galvez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain; School of Nursing, University of Murcia, Murcia, Spain; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Esteban Orenes-Piñero
- Department of Biochemistry and Molecular Biology, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Cecilia López-García
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Daniel Saura
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Josefa González
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
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Maheshwari A, Norby FL, Inciardi RM, Wang W, Zhang MJ, Soliman EZ, Alonso A, Johansen MC, Gottesman RF, Solomon SD, Shah AM, Chen LY. Left Atrial Mechanical Dysfunction and the Risk for Ischemic Stroke in People Without Prevalent Atrial Fibrillation or Stroke : A Prospective Cohort Study. Ann Intern Med 2023; 176:39-48. [PMID: 36534978 DOI: 10.7326/m22-1638] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Atrial myopathy-characterized by changes in left atrial function and size-may precede and promote atrial fibrillation (AF) and cardiac thromboembolism. In people without prior AF or stroke, whether analysis of left atrial function and size can improve ischemic stroke prediction is unknown. OBJECTIVE To evaluate the association of echocardiographic left atrial function (reservoir, conduit, and contractile strain) and left atrial size (left atrial volume index) with ischemic stroke and determine whether these measures can improve the stroke prediction achieved by CHA2DS2-VASc score variables. DESIGN Prospective cohort study. SETTING ARIC (Atherosclerosis Risk in Communities) study. PARTICIPANTS 4917 ARIC participants without prevalent stroke or AF. MEASUREMENTS Ischemic stroke events (2011 to 2019) were adjudicated by physicians. Left atrial strain was measured using speckle-tracking echocardiography. RESULTS Over 5 years, the cumulative incidences of ischemic stroke in the lowest quintiles of left atrial reservoir, conduit, and contractile strain were 2.99% (95% CI, 1.89% to 4.09%), 3.18% (CI, 2.14% to 4.22%), and 2.15% (CI, 1.09% to 3.21%), respectively, and that of severe left atrial enlargement was 1.99% (CI, 0.23% to 3.75%). On the basis of the Akaike information criterion, left atrial reservoir strain plus CHA2DS2-VASc variables was the best predictive model. With the addition of left atrial reservoir strain to CHA2DS2-VASc variables, 11.6% of the 112 participants with stroke after 5 years were reclassified to higher risk categories and 1.8% to lower risk categories. Among the 4805 participants who did not develop stroke, 12.2% were reclassified to lower and 12.7% to higher risk categories. Decision curve analysis showed a predicted net benefit of 1.34 per 1000 people at a 5-year risk threshold of 5%. LIMITATION Underascertainment of subclinical AF. CONCLUSION In people without prior AF or stroke, when added to CHA2DS2-VASc variables, left atrial reservoir strain improves stroke prediction and yields a predicted net benefit, as shown by decision curve analysis. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute of the National Institutes of Health.
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Affiliation(s)
- Ankit Maheshwari
- Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania (A.M.)
| | - Faye L Norby
- Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California (F.L.N.)
| | - Riccardo M Inciardi
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts (R.M.I., S.D.S., A.M.S.)
| | - Wendy Wang
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota (W.W.)
| | - Michael J Zhang
- Cardiovascular Division, Department of Medicine, and Lillehei Heart Institute, University of Minnesota Medical School, Minneapolis, Minnesota (L.Y.C, M.J.Z.)
| | - Elsayed Z Soliman
- Department of Epidemiology, Wake Forest University, Winston-Salem, North Carolina (E.Z.S.)
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia (A.A.)
| | - Michelle C Johansen
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland (M.C.J.)
| | - Rebecca F Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland (R.F.G.)
| | - Scott D Solomon
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts (R.M.I., S.D.S., A.M.S.)
| | - Amil M Shah
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts (R.M.I., S.D.S., A.M.S.)
| | - Lin Yee Chen
- Cardiovascular Division, Department of Medicine, and Lillehei Heart Institute, University of Minnesota Medical School, Minneapolis, Minnesota (L.Y.C, M.J.Z.)
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Assessment of Left Atrial Structure and Function by Echocardiography in Atrial Fibrillation. Diagnostics (Basel) 2022; 12:diagnostics12081898. [PMID: 36010248 PMCID: PMC9406407 DOI: 10.3390/diagnostics12081898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia with significant morbidity and mortality. Exacerbated by the aging population, the prevalence of AF is gradually increasing. Accurate evaluation of structure and function of left atrium (LA) has important prognostic significance in patients with AF. Echocardiography is the imaging technique of first choice to assess LA structure and function due to its better availability, accessibility and safety over cardiac computed tomography and cardiac magnetic resonance. Therefore, the aim of this review is to summarize the recent research progress of evaluating LA size by three-dimensional echocardiography and LA function by speckle tracking echocardiography (STE) in predicting the occurrence and recurrence of AF and determining the risk of stroke in AF. In addition, we summarized the role of traditional echocardiography in detecting AF patients that are at high risk of heart failure or cardiovascular death.
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Kuo L, Chan YH, Liao JN, Chen SA, Chao TF. Stroke and Bleeding Risk Assessment in Atrial Fibrillation: Where Are We Now? Korean Circ J 2021; 51:668-680. [PMID: 34227269 PMCID: PMC8326217 DOI: 10.4070/kcj.2021.0170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/26/2021] [Indexed: 11/23/2022] Open
Abstract
Stroke prevention with oral anticoagulants (OACs) is the cornerstone for the management of patients with atrial fibrillation (AF). It is crucial to assess the stroke and bleeding risks of individual AF patients to make appropriate decisions for OAC use and achieve optimal patient care. In this review, we provided an overview on the correct use of CHA2DS2-VASc and HAS-BLED scores, and update important revisions about the definitions of some of the CHA2DS2-VASc components. Also, data about the biomarkers and potential roles of AF duration and left atrial functions in the prediction of stroke in AF were also discussed. Most important international guidelines recommend the use of CHA2DS2-VASc and HAS-BLED scores for stroke and bleeding risk assessments in atrial fibrillation (AF) patients, respectively. The 2020 AF guidelines of European Society of Cardiology have revised the definition of “C: congestive heart failure (HF)” component, and now patients with either HF with reduced ejection fraction or preserved ejection fraction should be assigned 1 point. Hypertrophic cardiomyopathy was also included. Besides, the revised “V: vascular diseases” component included both prior myocardial infarction and “angiographically significant coronary artery disease”. It is important to understand that the stroke and bleeding risks of AF patients were not static and should be re-assessed regularly. A high HAS-BLED score itself should not be the only reason to withhold or discontinue oral anticoagulants, but remind physicians for the corrections of modifiable bleeding risk factors and more regular follow up. In the future, the AF duration and left atrial function may play an important role for personalized evaluation of individual stroke risk while more studies are necessary.
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Affiliation(s)
- Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi Hsin Chan
- Division of Cardiology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Microscopy Core Laboratory, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jo Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tze Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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