Relationship between left ventricular geometry and left atrial size and function in patients with systemic hypertension

Predictors of Progression of Tricuspid Regurgitation in Patients with Persistent Atrial Fibrillation

Previous studies have shown that tricuspid regurgitation (TR) can be developed in patients with atrial fibrillation (AF) due to annular dilatation. This study aimed to investigate the incidence and predictors of the progression of TR in patients with persistent AF. A total of 397 patients (66.9±11.4 years, 247 men; 62.2%) with persistent AF were enrolled between 2006 and 2016 in a tertiary hospital, and 287 eligible patients with follow-up echocardiography were analyzed. They were divided into two groups according to TR progression (progression group [n=68, 70.1±10.7 years, 48.5% men] vs. non-progression group [n=219, 66.0±11.3 years, 64.8% men]). Among 287 patients in the analysis, 68 had worsening TR severity (23.7%). Patients in the TR progression group were older and more likely to be female. Patients with left ventricular ejection fraction <50% were less frequent in the progression group than those in the non-progression group (7.4% vs. 19.6%, p=0.018). Patients with mitral valve disease were more frequent in the progression group. Multivariate analysis with COX regression demonstrated independent predictors of TR progression, including left atrial (LA) diameter >54 mm (HR 4.85, 95%CI 2.23-10.57, p<0.001), E/e' (HR 1.05, 95%CI 1.01-1.10, p=0.027), and no use of antiarrhythmic agents (HR 2.20, 95%CI 1.03-4.72, p=0.041). In patients with persistent AF, worsening TR was not uncommon. The independent predictors of TR progression turned out to be greater LA diameter, higher E/e', and no use of antiarrhythmic agents.

Prognostic value of left atrial size in hypertensive African Americans undergoing stress echocardiography

BACKGROUND

Left atrial (LA) enlargement is a marker of increased risk in the general population undergoing stress echocardiography. African American (AA) patients with hypertension are known to have less atrial remodeling than whites with hypertension. The prognostic impact of LA enlargement in AA with hypertension undergoing stress echocardiography is uncertain.

AIM

To investigate the prognostic value of LA size in hypertensive AA patients undergoing stress echocardiography.

METHODS

This retrospective outcomes study enrolled 583 consecutive hypertensive AA patients who underwent stress echocardiography over a 2.5-year period. Clinical characteristics including cardiovascular risk factors, stress and echocardiographic data were collected from the electronic health record of a large community hospital. Treadmill exercise and Dobutamine protocols were conducted based on standard practices. Patients were followed for all-cause mortality. The optimal cutoff value of antero-posterior LA diameter for mortality was assessed by receiver operating characteristic analysis. Cox regression was used to determine variables associated with outcome.

RESULTS

The mean age was 57 ± 12 years. LA dilatation was present in 9% (54) of patients (LA anteroposterior ≥ 2.4 cm/m²). There were 85 deaths (15%) during 4.5 ± 1.7 years of follow-up. LA diameter indexed for body surface area had an area under the curve of 0.72 ± 0.03 (optimal cut-point of 2.05 cm/m²). Variables independently associated with mortality included age [P = 0.004, hazard ratio (HR) 1.34 (1.10-1.64)], tobacco use [P = 0.001, HR 2.59 (1.51-4.44)], left ventricular hypertrophy [P = 0.001 , HR 2.14 (1.35-3.39)], Dobutamine stress [P = 0.003, HR 2.12 (1.29-3.47)], heart failure history [P = 0.031, HR 1.76 (1.05-2.94)], LA diameter ≥ 2.05 cm/m² [P = 0.027, HR 1.73 (1.06-2.82)], and an abnormal stress echocardiogram [P = 0.033, HR 1.67 (1.04-2.68)]. LA diameter as a continuous variable was also independently associated with mortality but LA size ≥ 2.40 cm/m² was not.

CONCLUSION

LA enlargement is infrequent in hypertensive AA patients when traditional reference values are used. LA enlargement is independently associated with mortality when a lower than “normal” threshold (≥ 2.05 cm/m²) is used.

Atrial fibrillation is associated with increased central blood pressure and arterial stiffness

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice and beta blockers (BBs) are the drugs of choice for rate or rhythm control in these patients. The purpose of this study was to describe differences in arterial stiffness (AS), central blood pressure (cBP), and the role of BBs on cBP in patients with AF compared to healthy individuals. The authors included 76 patients with paroxysmal/persistent AF. Carotid‐femoral pulse wave velocity (PWV) and cBP were measured and compared with data from 75 healthy individuals. Patients with AF had higher PWV (8.0 m/s vs. 7.2 m/s, p < .001), central systolic blood pressure (cSBP) (118 mm Hg vs. 114 mm Hg, p = .033), central pulse pressure (cPP) (39 mm Hg vs. 37 mm Hg, p = .035) and lower pulse pressure amplification (PPA) (1.24 vs. 1.30, p = .015), without differences in peripheral blood pressure (pBP) and heart rate (HR). AF patients had significantly increased PWV (β= 0.500, p = .010, adjusted R² = 0.37) after adjustment for confounding factors. The use of BBs significantly reduced PPA (β = ‐0.059, p = .017, adjusted R² = 0.30). AF patients have higher PWV, cSBP, cPP, and lower PPA, compared to healthy patients. These findings support the role of AS in the development of AF. Use of BBs is related to a potential adverse effect on cBP.

The impact of left ventricular geometry on left atrium phasic function in obstructive sleep apnea syndrome: a multimodal echocardiography investigation

BACKGROUND

Left ventricular geometry and left atrium (LA) enlargement are risk factors for cardiovascular disease. However, reports on the relationship between left ventricular geometry and LA volume yielded contradictory findings, and LA phasic function remains unclear. Hence, this study aimed to investigate the influence of left ventricular geometry on LA volume and phasic function in patients with obstructive sleep apnea syndrome (OSAS) via a multimodal echocardiographic approach.

METHODS

In this cross-sectional study, 221 patients with OSAS (age 20-68 years, mean age 45.27 ± 12.50 years) underwent clinical evaluation, polysomnography, and multimodal echocardiographic examination with two-dimensional echocardiography (2DE), two-dimensional speckle-tracking echocardiography (2D-STE) and three-dimensional echocardiography (3DE). Based on conventional classification of left ventricular geometry, patients with OSAS were divided into four groups: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH).

RESULTS

Based on 2DE and 3DE, the LA volumes and indices gradually increased from NG to CH. Additionally, 2DE and 3DE LA maximum volume index (LAVImax) were higher in patients with CH and EH than in patients with NG and CR (P < 0.05). The reservoir function, estimated by LA total emptying fraction (LA TotEF) was lower in patients with CH than in patients with NG in 2DE and 3DE (both, P < 0.05). Also, LA conduit function, evaluated by LA passive emptying fraction (LA PassEF) was lower in patients with CH than in patients with NG and CR, and in patients with EH than in those with NG in 2DE and 3DE (all, P < 0.05). The LA booster pump function, evaluated by LA active emptying fraction (LA ActEF) showed no statistically significant difference in 2DE; however, it was greater in patients with CH than in those with NG in 3DE. Similar results were obtained by 2D-STE, and CH was significantly associated with LA strain during systole (LAS-S, β = - 0.546, 95%CI: - 6.371-(- 3.444); P < 0.001), early diastole (LAS-E, β = - 0.636, 95%CI: - 9.532-(- 5.710); P < 0.001), and late diastole (LAS-A, β = - 0.450, 95%CI: 1.518-3.909; P < 0.001) in multiple linear regression.

CONCLUSIONS

The LA phasic function changed with left ventricular geometry via multimodal echocardiography. CH had the most notable negative effect on the maximum volume and phasic function of the LA.

Left atrial stiffness index as a marker of early target organ damage in hypertension

This study aimed to evaluate left atrial (LA) mechanics using two-dimensional speckle-tracking echocardiography (2DSTE) and investigate their correlations with measures of target organ damage (TOD) in hypertension. We enrolled 42 healthy controls (Group I) and 286 hypertension patients: Group II (n = 79) had an LA volume index (LAVI) <28 ml/m²; Group III (n = 92) had an LAVI ≥28 ml/m²; and Group IV (n = 115) had hypertension with left ventricular hypertrophy (LVH). We measured the following parameters: LA reservoir strain and strain rate (LA_S-S, LA_SR-S), LA conduit strain and strain rate (LA_S-E and LA_SR-E), and LA booster strain and strain rate (LA_S-A and LA_SR-A). The LA stiffness index (LASI) was defined as the ratio of early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') to LA_S-S. We performed correlation and regression analyses of individual TOD with LA phasic functions, the LASI, and cardiovascular risk factors. Our findings showed that there was a trend toward a gradual increase in the LASI from controls to normal LA and enlarged LA patients and finally to hypertrophic LV patients. The LASI was significantly higher in Group III [0.28 (0.20, 0.38)] than in Group I [0.20 (0.16, 0.23)] and Group II [0.22 (0.18, 0.27)] and was the highest in Group IV [0.33 (0.26, 0.43)]. The LA reservoir and conduit function gradually decreased from Group I to Group IV. Multivariate regression analysis revealed that the LASI was independently correlated with individual TOD. In conclusion, abnormal LA mechanics precede LA enlargement and LVH, and an increased LASI can be used as a marker of early TOD in hypertension.

Reduced nNOS activity is responsible for impaired fatty acid-dependent mitochondrial oxygen consumption in atrial myocardium from hypertensive rat

Fatty acid (FA)-dependent mitochondrial activities of atrial myocardium in hypertension (HTN) and its regulation by nitric oxide (NO) remain unidentified. Here, we have studied palmitic acid (PA) regulation of cardiac mitochondrial oxygen consumption rate (OCR) in left atrial (LA) myocardium of sham and angiotensin II-induced HTN rats and their regulations by endothelial NO synthase (eNOS) and neuronal NO synthase (nNOS). The effects were compared with those of left ventricular (LV) myocytes. Our results showed that OCR was greater in HTN-LA compared with that in sham-LA. PA increased OCR in sham-LA, sham-LV, and HTN-LV but reduced it in HTN-LA. Inhibition of nNOS (S-methyl-L-thiocitrulline, SMTC) or eNOS/nNOS (Nω-nitro-L-arginine methyl ester hydrochloride, L-NAME) reduced PA increment of OCR in sham-LA but exerted no effect on OCR in HTN-LA. SMTC reduced OCR in HTN-LV and L-NAME reduced OCR in sham-LV. nNOS was the predominant source of NO in LA and LV. nNOS-derived NO was increased in HTN-LA and HTN-LV. PA reduced eNOS^Ser1177, nNOS^Ser1417, and NO level in HTN-LA but exerted no effect in sham-LA. In contrast, PA increased NO in HTN-LV and enhanced nNOS^Ser1417 but reduced NO level in sham-LV without affecting eNOS^Ser1177, eNOS^Thr495, or nNOS^Ser1417. 2-Bromopalmitate (2BP), which blocks the S-palmitoylation of target proteins, prevented PA-dependent decrease of nNOS^Ser1417 and OCR in HTN-LA. In HTN-LV, 2BP prevented PA-induced OCR without affecting nNOS^Ser1417. Our results reveal that FA-induced mitochondrial activity in atrial myocardium is impaired in HTN which is mediated by reduced nNOS activity and NO bioavailability. Metabolic dysregulation may underlie diastolic dysfunction of atrial myocardium in HTN.

Global diastolic strain rate for the assessment of left ventricular diastolic dysfunction in young peritoneal dialysis patients: a case control study

Background

Left ventricular (LV) myocardial longitudinal diastolic strain rate measured by two-dimensional speckle tracking imaging (2D-STI) was proved to have a better correlation with the LV diastolic function. We aimed to use this sensitive tool to predict LV myocardial diastolic dysfunction in young peritoneal dialysis (PD) patients with preserved LV ejection fraction (LVEF).

Methods

We enrolled 30 PD patients aged ≤60 with LVEF ≥54% and classified as normal LV diastolic function by conventional echocardiography, and 30 age- and sex-matched healthy people as the control group. The left atrial maximum volume index (LAVI), LV mass index (LVMI), LVEF, LV posterior wall thickness (LVPWT), interventricular septal thickness (IVST), peak velocity of tricuspid regurgitation (TR), peak early diastolic velocity/late diastolic velocity (by Pulsed Doppler) (E/A) and E/peak velocity of the early diastolic wave (by Pulsed-wave tissue Doppler) (E/e’) were recorded by conventional echocardiographic. Next, the average LV global longitudinal systolic strain (GLS avg) and the average LV global longitudinal diastolic strain rate (DSr avg) during early diastole (DSrE avg), late diastole (DSrA avg) and isovolumic relaxation period (DSrIVR avg) were obtained from 2D-STI. Combined them with E, the new noninvasive indexes (E/DSrE avg., E/DSrA avg. and E/DSrIVR avg) were derived.

Results

The PD group ‘s LVEF, E/e′, TR and LAVI were in the normal range compared with the controls, and only e′ (p < 0.001) was decreased. The LVMI (p < 0.001), LVPWT (p < 0.001), IVST (p < 0.001) increased while E/A (p < 0.001) decreased. The GLS avg. (p = 0.008) was significantly decreased in PD patients compared with the controls. DSrA avg. (p = 0.006) and E/DSrE avg. (p = 0.006) were increased, while DSrE avg. (p < 0.001), DSrIVR avg. (p = 0.017) and E/DSrA avg. (p < 0.001) decreased. After the multivariable regression analysis, the correlation between DSrE and the conventional parameters including LVPWT (p < 0.001), E/A (p < 0.001) still remained significant.

Conclusions

Young PD patients with preserved LVEF already exhibited myocardial diastolic dysfunction. Global diastolic strain rate indexes were valuable parameters to evaluate diastolic dysfunction. Additionally, LVPWT was highly correlated with DSrE, such parameter should be taken into account for predicting the early LV diastolic dysfunction in clinical practice.

Early predictors of left ventricular dysfunction in hypertensive patients: comparative cross-section study

Identifying hypertensive patients who are at higher risk and thus to assess early echocardiographic markers of LV dysfunction in this population. Our comparative cross-section study included 100 patients divided into two groups; Group1: Hypertensive with preserved ejection fraction (EF) (n = 50) & Group 2: Normotensive (Control) (n = 50). Who underwent 2D Echo imaging with analysis of multible parameters of LV systolic and diastolic function including: left atrial volume index (LAVI), LV mass index, relative wall thickness, LV systolic function (EF%), diastolic function (trans-mitral pulsed and tissue Doppler study of E, A, e'-wave velocities& E/A, E/e' ratios), Global myocardial longitudinal strain (GLS) by speckle tracking echocardiography (STE) and the early diastolic driving force (DF) which calculated as (DF = mass × acceleration; DF = 0.004E²/DT). We reported significant differences between the two groups in LV mass, LA volume and DF, which were all elevated in the hypertensive group, as well as reduced GLS magnitude. We also reported that a GLS cutoff of > - 18.1% was able to accurately "predict subclinical LV systolic dysfunction". Finally, DF showed a moderate correlation (r = 0.33, which was established with statistical confidence) with E/e' ratio, and a DF cutoff of ≥ 0.25 N was able to accurately "predict subclinical diastolic dysfunction". GLS cutoff > - 18.1% could be used for early prediction of LV systolic dysfunction in hypertensive. The early diastolic DF cutoff ≥ 0.25 N could be a useful tool for early prediction of LV diastolic dysfunction in hypertensive. These sensitive parameters could be used for early diagnosis and proper management for better outcomes.

Endothelial dysfunction predicted increased left atrial volume index in newly diagnosed nondiabetic hypertensive patients

BACKGROUND

Arterial hypertension is associated with cardiovascular morbidity and mortality. It was previously shown that left atrium volume increase associated with mortality and atherosclerotic heart disease. The aim of the present study was to demonstrate the value of endothelial dysfunction in predicting left atrium volume increase in newly diagnosed hypertension patients.

METHODS

This study included 96 consecutive newly diagnosed hypertensive patients. Left atrium volume and left ventricular ejection fraction were calculated. Pulse wave velocity and brachial artery flow-mediated dilation measurements were obtained from each patient.

RESULTS

Left Ventricle Mass Index (114 ± 29 g/m, 91 ± 17 g/m, P < 001), left ventricular septum (P < 0.001) and posterior wall thickness (P = 0.001), left ventricular end diastolic diameter (P = 0.016) were significantly higher in patients with higher left atrial volume index. FMD% was lower in patients with higher left atrial volume index those without (9.7 ± 3.5 vs. 13.31 ± 6.01, P = 0.004). Lateral wall E wave velocity was significantly lower (8.68 ± 2.8, 10.2 ± 2.8; P = 0.009), while isovolumetric relaxation time (101.9 ± 19.9 ms, 85.7 ± 15.2 ms; P < 0.001), and ejection time was longer (101.9 ± 19.9 ms, 85.7 ± 15.2 ms; P = 0.077) and Mitral E/ lateral wall E ratio (E/E relation) was significantly higher (P = 0.031) in patients with higher left atrial volume index.

CONCLUSION

The rate of isovolumetric relaxation time, FMD% and E/E' ratio independently predicted left atrial volume index increase in newly diagnosed hypertension patients.

Ischemic stroke risk during post-discharge phases of heart failure: association of left ventricular concentric geometry

Despite a higher risk of ischemic stroke in hospitalized patients with acute heart failure (HF), little is known about the risk of ischemic stroke during the post-discharge phases of HF. Here we investigated (1) the ischemic stroke incidence rate during the post-discharge phases among HF patients receiving standard treatments; (2) the association between ischemic stroke incidence and clinical background, including cardiac structure and function. Among 950 patients who required hospitalization for HF (median duration: 19 days) at our institution, where they received standard treatments, we investigated stroke occurrences during the 2-year period following their discharge and retrospectively evaluated their clinical data. Relative wall thickness (RWT) and left ventricular (LV) mass were determined based on echocardiographic measurements and then used to determine LV geometric patterns. During the follow-up period, ischemic stroke occurred in 25 patients (2.6%) after hospital discharge (1.4 per 100 patient-years). The incidence rate of IS tended to be higher in patients with AF than those without AF (1.8 vs. 1.0 per 100 patient-years, respectively). Notably, multivariate analysis revealed a significant association between RWT and ischemic stroke risk (p < 0.05). RWT was associated with ischemic stroke risk in patients with AF or left atrial enlargement, but not in patients without them. These findings suggest that even with standard HF treatments, the risk of ischemic stroke is high in patients with HF. Moreover, LV concentric geometry is a significant risk factor for ischemic stroke in patients with HF, especially in those with left atrial remodeling and/or AF.

Greater nighttime blood pressure variability is associated with left atrial enlargement in atrial fibrillation patients with preserved ejection fraction

Left atrial enlargement is an independent risk factor for ischemic stroke in patients with atrial fibrillation. Little is known regarding the association between nighttime blood pressure variability and left atrial enlargement in patients with atrial fibrillation and preserved ejection fraction. The study population consisted of 140 consecutive patients with atrial fibrillation (mean age 64 ± 10 years) with preserved ejection fraction (≥50%). Nighttime blood pressure was measured at hourly intervals, using a home blood pressure monitoring device. Nighttime blood pressure variability was expressed as the standard deviation of all readings. Left atrial volume index was measured using the modified Simpson's biplane method with transthoracic echocardiography. Multiple regression analysis indicated that nighttime mean systolic/diastolic blood pressure and its variability remained independently associated with left atrial enlargement after adjustment for age, sex, anti-hypertensive medication class, and left ventricular mass index (P < 0.01). When patients were divided into four groups according to nighttime blood pressure and its variability, the group with higher nighttime blood pressure and its variability had significantly larger left atrial volume than the group with lower nighttime blood pressure and its variability (46.6 ml/m² vs. 35.0 ml/m², P < 0.0001). Higher nighttime blood pressure and its variability are associated with left atrial enlargement. The combination of nighttime blood pressure and its variability has additional predictive value for left atrial enlargement. Intensive intervention for these high-risk patients may avoid or delay progression of left atrial enlargement and reduce the risk of stroke.

Association between atrial fibrillation, atrial enlargement, and left ventricular geometric remodeling

This study investigated the relationship between atrial fibrillation (AF) and left ventricular (LV) geometric patterns in a hospital-based population in Japan. We retrospectively analyzed 4444 patients who had undergone simultaneous scheduled transthoracic echocardiography (TTE) and electrocardiography during 2013. A total of 430 patients who had findings of previous myocardial infarctions (n = 419) and without the data on body surface area (n = 11) were excluded from the study. We calculated the LV mass index (LVMI) and relative wall (RWT) and categorized 4014 patients into four groups as follows: normal geometry (n = 3046); concentric remodeling (normal LVMI and high RWT, n = 437); concentric hypertrophy (high LVMI and high RWT, n = 149); and eccentric remodeling (high LVMI and normal RWT, n = 382). The mean left atrial volume indices (LAVI) were 22.5, 23.8, 33.3, and 37.0 mm/m² in patients with normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy, respectively. The mean LV ejection fractions (LVEF) were 62.7, 62.6, 60.8, and 53.8%, respectively, whereas the prevalence of AF was 10.4%, 10.5%, 14.8%, and 16.8% in patients with normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy, respectively. In conclusion, the prevalence of AF was increasing according to LV geometric remodeling patterns in association with LA size and LVEF.

Quantification of the left atrium applying cardiovascular magnetic resonance in clinical routine

OBJECTIVES

In recent years the impact of the left atrium (LA) has become more evident in different cardiovascular pathologies. We aim to provide LA parameters in healthy volunteers for cardiovascular magnetic resonance (CMR) using a fast approach.

DESIGN

We analyzed 203 healthy volunteers (mean age 44.6 years (y), range 19y-76y) at 1.5 and 3.0 Tesla (T) using steady-state free precession (SSFP) cine in routine long axis view. Left atrial enddiastolic volume (LA-EDV), endsystolic volume (LA-ESV), stroke volume (LA-SV) and ejection fraction (LA-EF) were quantified and indexed to body-surface-area (BSA). Dependency on age and sex was analyzed.

RESULTS

21 subjects had to be excluded. In the remaining, there was no significant difference between 1.5 T and 3.0 T. Absolut LA-EDV and LA-ESV were larger in men than in women (LA-EDV: male 70 ± 19 ml vs. female 61 ± 16 ml (p = .001); LA-ESV: male 24 ± 9 ml vs. female 21 ± 8 ml (p = .01)). These differences disappeared after indexing to BSA (LA-EDV/BSA: male 34 ± 10 ml/m² vs. female 33 ± 9 ml/m² (p = .65) and LA-ESV/BSA: male 12 ± 4 ml/m² vs. female 11 ± 4 ml/m² (p = .71)). LA-EDV/BSA decreased with older age.

CONCLUSIONS

Reference values for LA size and function based on a fast approach are provided. LA size decreases with older age. Normalization to body size overcomes sex-dependency. Reports should be related to body size.

The Association of Functional Capacity With Right Atrial Deformation in Patients With Pulmonary Arterial Hypertension: A Study With Two-Dimensional Speckle Tracking

BACKGROUND

The purpose of this study was to assess right atrial (RA) myocardial mechanics in pulmonary hypertension (PH) patients using two-dimensional speckle tracking (2D-STE), and define the relationship between RA function and exercise capacity in PH patients.

METHODS

Thirty-eight consecutive PH patients were studied and compared with a control group of 25 healthy volunteers. Peak atrial longitudinal strain (PALS), RA strain rate were measured in all subjects. PALS values were obtained by averaging all segments (global PALS), and by averaging segments measured in the four-chamber view.

RESULTS

Right atrial PALS was significantly lower in PH patients than in controls, and gradually reduced with the development of cardiac insufficiency. A significantly positive correlation between global PALS and 6-minute walk distance (6MWD) was found (p=0.003). Furthermore, global PALS demonstrated the highest diagnostic accuracy (AUC of 0.979) and excellent sensitivity and specificity of 86.8% and 84%, respectively, to predict functional status using a cut-off value less than 38.08%.

CONCLUSIONS

Right atrial deformation is significantly damaged in PH patients. Right atrial reservoir function can be estimated using 2D-STE, which gradually decreases in PH patients with different World Health Organization-functional class (WHO-FC). Right atrial PALS is a valuable factor for predicting the functional status and exercise capacity in PH patients.

Association of left atrial enlargement with ventricular remodeling in hypertensive Chinese elderly

BACKGROUND

It is not well known whether left atrial (LA) enlargement is associated with left ventricular (LV) remodeling in Asian subjects with preserved LV ejection fraction (LVEF ≥50%). Therefore, we studied whether LA enlargement is related to ventricular remodeling in hypertensive Chinese elderly with preserved LVEF.

METHODS

Data of 480 hypertensive Chinese elderly (age from 65 to 94 years) with LVEF ≥50% were consecutively included in the study.

RESULTS

We observed a total of 248 patients (51.7%) with increased LA size. Univariate analysis showed that LA size was positively related to duration of hypertension, prevalence of coronary heart disease and atrial fibrillation, interventricular septal thickness, LV posterior wall thickness, LV end-diastolic and end-systolic diameter, LV mass index, right ventricular (RV) diameter and aortic diameter; meanwhile, LA size was inversely related to LVEF and relative wall thickness of LV. Multivariate regression analysis showed that LA enlargement was positively related to duration of hypertension (P=.012) and RV diameter (P<.001).

CONCLUSIONS

Left atrial enlargement is independently associated with a longer duration of hypertension and RV dilative remodeling in hypertensive elderly with preserved LVEF. LA enlargement is an early sign of RV eccentric remodeling in hypertensive elderly.

ASSESSMENT OF DIASTOLIC DYSFUNCTION, ARTERIAL STIFFNESS, AND CAROTID INTIMA-MEDIA THICKNESS IN PATIENTS WITH ACROMEGALY

OBJECTIVE

Early diagnosis and treatment of cardiovascular diseases, the most frequent cause of morbidity and mortality in acromegaly, may be an efficient approach to extending the lifespan of affected patients. Therefore, it is crucial to determine any cardiovascular diseases in the subclinical period. The study objectives were to determine markers of subclinical atherosclerosis and asses heart structure and function.

METHODS

This was a cross-sectional, single-center study of 53 patients with acromegaly and 22 age- and sex-matched healthy individuals. Carotid intima-media thickness (CIMT), pulse-wave velocity (PWV), and echocardiographic data were compared between these groups.

RESULTS

CIMT and PWV were higher in the acromegaly group than in the healthy group (P = .008 and P = .002, respectively). Echocardiography showed that left ventricular diastolic dysfunction was present in 11.3% of patients. Left ventricular mass index and left atrial volume index were higher in the patients (P = .016 and P<.001, respectively). No differences in the CIMT, PWV, or echocardiographic measurements were identified between the patients with biochemically controlled and uncontrolled acromegaly and the control group.

CONCLUSION

Our results showed that subclinical atherosclerosis (i.e., CIMT and PWV markers) and heart structure and function were worse in patients with acromegaly than in healthy individuals. Because there were no differences in these parameters between patients with controlled and uncontrolled acromegaly, our results suggest that the structural and functional changes do not reverse with biochemical control.

ABBREVIATIONS

AA = active acromegaly BSA = body surface area CA = biochemically controlled acromegaly CH = concentric hypertrophy CIMT = carotid intima-media thickness DBP = diastolic blood pressure DM = diabetes mellitus ECHO = echocardiography EDV = enddiastolic volume EF = ejection fraction ESV = endsystolic volume GH = growth hormone HC = healthy control HL = hyperlipidemia HT = hypertension IGF-1 = insulin-like growth factor 1 LA = left atrial LAV = left atrial volume LAVI = left atrial volume index LV = left ventricular LVDD = left ventricular diastolic dysfunction LVEF = left ventricular ejection fraction LVH = left ventricular hypertrophy LVMI = left ventricular mass index PWV = pulse-wave velocity RWT = relative wall thickness.

Left atrial area index predicts adverse cardiovascular events in patients with unstable angina pectoris

Background

The left atrial size has been considered as a useful marker of adverse cardiovascular outcomes. However, it is not well known whether left atrial area index (LAAI) has predictive value for prognosis in patients with unstable angina pectoris (UAP). This study was aimed to assess the association between LAAI and outcomes in UAP patients.

Methods

We enrolled a total of 391 in-hospital patients diagnosed as UAP. Clinical and echocardiographic data at baseline were collected. The patients were followed for the development of adverse cardiovascular (CV) events, including hospital readmission for angina pectoris, acute myocardial infarction (AMI), congestive heart failure (CHF), stroke and all-cause mortality.

Results

During a mean follow-up time of 26.3 ± 8.6 months, 98 adverse CV events occurred (84 hospital readmission for angina pectoris, four AMI, four CHF, one stroke and five all-cause mortality). In a multivariate Cox model, LAAI [OR: 1.140, 95% CI: 1.016–1.279, P = 0.026], diastolic blood pressure (OR: 0.976, 95% CI: 0.956–0.996, P = 0.020) and pulse pressure (OR: 1.020, 95% CI: 1.007–1.034, P = 0.004) were independent predictors for adverse CV events in UAP patients.

Conclusions

LAAI is a predictor of adverse CV events independent of clinical and other echocardiographic parameters in UAP patients.

Left Atrial Structure and Function Across the Spectrum of Cardiovascular Risk in the Elderly: The Atherosclerosis Risk in Communities Study

BACKGROUND

Although left atrial (LA) enlargement is a recognized risk factor for adverse cardiovascular outcomes, emerging evidence supports the importance of LA function. We examined LA emptying fraction (LAEF) across the spectrum of cardiovascular disease burden in a large cohort of elderly adults living in the community.

METHODS AND RESULTS

We studied 1142 participants in the Atherosclerosis Risk in Communities (ARIC) study who were in sinus rhythm, free of valvular disease, and had acceptable quality 3-dimensional echocardiograms (mean age, 76±5 years; 59% women). We determined the cross-sectional correlates of LAEF and compared LAEF among elderly adults without cardiovascular disease or cardiovascular risk factors (n=201), those with hypertension (n=734), and those with overt heart failure (HF; n=207). In multivariable analysis, lower LAEF was associated with higher LA volumes and worse left ventricular systolic and diastolic functions. Elderly participants free of cardiovascular disease or risk factors had smaller LA volumes than those with hypertension (LA volume max/ body surface area 30.2±6.6 versus 33.0±9.0 mL/m(2); P=0.001), but similar LAEF (55.2±10.3% versus 53.8±11.5%, respectively; P=0.357). Participants with HF had higher LA volume (39.8±13.3 mL/m(2)) and worse LAEF (47.6±14.6%) than participants with hypertension or participants free of cardiovascular disease or risk factors (all P<0.001).

CONCLUSIONS

In a community-based cohort, LA function was impaired in participants with prevalent HF, but there were no significant differences in LA function between participants with hypertension and those with free of cardiovascular disease or risk factors, despite greater LA size in the former.

Racial Differences in Left Atrial Size: Results from the Coronary Artery Risk Development in Young Adults (CARDIA) Study

Whites have an increased risk of atrial fibrillation (AF) compared to Blacks. The mechanism underlying this association is unknown. Left atrial (LA) size is an important AF risk factor, and studies in older adults suggest Whites have larger LA diameters. However, because AF itself causes LA dilation, LA size differences may be due to greater subclinical AF among older Whites. We therefore assessed for racial differences in LA size among young adults at low AF risk. The Coronary Artery Risk Development in Young Adults (CARDIA) study enrolled White and Black participants between 18 and 30 years of age. LA diameter was measured in a subset of participants using echocardiography at Year 5 (n = 4,201) and Year 25 (n = 3,373) of follow up. LA volume was also assessed at Year 5 (n = 2,489). Multivariate linear regression models were used to determine the adjusted association between race and LA size. In unadjusted analyses, mean LA diameter was significantly larger among Blacks compared to Whites both at Year 5 (35.5 ± 4.8 mm versus 35.1 ± 4.5 mm, p = 0.01) and Year 25 (37.4 ± 5.1 mm versus 36.8 ± 4.9 mm, p = 0.002). After adjusting for demographics, comorbidities, and echocardiographic parameters, Whites demonstrated an increased LA diameter (0.7 mm larger at Year 5, 95% CI 0.3-1.1, p<0.001; 0.6 mm larger at Year 25, 95% CI 0.3-1.0, p<0.001). There was no significant association between race and adjusted Year 5 LA volume. In conclusion, in a young, well-characterized cohort, the larger adjusted LA diameter among White participants suggests inherent differences in atrial structure may partially explain the higher risk of AF in Whites. The incongruent associations between race, LA diameter, and LA volume suggest that LA geometry, rather than size alone, may have implications for AF risk.

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

BACKGROUND

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

OBJECTIVES

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

METHODS AND RESULTS

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

CONCLUSION

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

Principles of transthoracic echocardiographic evaluation

Transthoracic echocardiography is the most widely used imaging test in cardiology. Although completely noninvasive, transthoracic echocardiography has a well-established role in the diagnosis of numerous cardiovascular diseases, and also provides critical qualitative and quantitative information on their prognosis and pathophysiological processes. The aim of this Review is to outline the broad principles of transthoracic echocardiography, including the traditional techniques of two-dimensional, colour, and spectral Doppler echocardiography, and newly developed advances including tissue Doppler, myocardial deformation imaging, torsion, stress echocardiography, contrast and three-dimensional echocardiography. The advantages and disadvantages, clinical application, prognostic value, and salient research findings of each modality are described. Advances in complex imaging techniques are expected to continue unabated, and this Review highlights technical improvements that will influence the diagnosis and improve our understanding of cardiovascular function and disease.

Arterial-atrial coupling in untreated hypertension

Recently, there has been growing interest in an interplay of vascular mechanics and heart function (arterial-ventricular-atrial coupling). The contribution of arterial stiffness (AS) to left atrial (LA) enlargement is unclear. The aim of this study was to verify whether the association between carotid AS and LA volume in untreated arterial hypertension is independent of such confounders as age, sex, body mass index (BMI), blood pressure, left ventricular hypertrophy (LVH), left ventricular (LV) diastolic and systolic function. The study included 133 patients, among them 107 individuals with hypertension (51 men and 56 women, mean age 56.8 ± 10.3 years) and 26 matched controls. Each patient was subjected to echocardiography, ultrasonographic measurement of mean carotid intima-media thickness (IMT) and echo-tracking assessment of AS and wave reflection. LA volume was calculated by ellipsoid method. The indexed LA volume showed significant linear correlations with age (r = 0.32; p < 0.05), BMI (r = 0.21; p < 0.05), pulse pressure (r = 0.26; p < 0.05), B-type natriuretic peptide (r = 0.64; p < 0.05), LV end-diastolic volume (r = 0.42; p < 0.05), LV mass index (LVMI; r = 0.58; p < 0.05), septum thickness (r = 0.40; p < 0.05), posterior wall thickness (r = 0.34; p < 0.05), early filling wave of mitral inflow (E; r = 0.30; p < 0.05), early diastolic myocardial velocity of mitral annulus (e'; r = - 0.22; p < 0.05), E/e' ratio (r = 0.45; p < 0.05), IMT (r = 0.26; p < 0.05) and augmentation index (AI; r = 0.27; p < 0.05). Progressive multivariate analysis identified LVMI, age, AI and BMI as independent determinants of indexed LA volume in patients with arterial hypertension. The study showed the significant relationship between wave reflection expressed by AI and LA structural remodeling, which supports the hypothesis of arterial-atrial coupling in hypertension.

The three integrated phases of left atrial macrophysiology and their interactions

Our understanding of the left atrium is growing, although there are many aspects that are still poorly understood. The left atrium size as an imaging biomarker has been consistently shown to be a powerful predictor of outcomes and of different cardiovascular disorders, such as, but not limited to, atrial fibrillation, congestive heart failure, mitral regurgitation and stroke. Left atrial function has been conventionally divided into three integrated phases: reservoir, conduit and booster-pump. The highly dynamic left atrium and its response to the stretch and secretion of atrial neuropeptides leaves the left atrium far from being a simple transport chamber. The aim of this review is to provide an understanding of the left atrial physiology and its relation to disorders within the heart.

Analysis of left atrial performance in patients with type 2 diabetes mellitus without overt cardiac disease and inducible ischemia: high prevalence of increased systolic force related to enhanced left ventricular systolic longitudinal function

OBJECTIVES

In patients with chronic pressure overload, higher left atrial systolic force (LASF) is associated with high-risk cardiovascular (CV) phenotype, with increased left ventricular (LV) mass, concentric hypertrophy, and diastolic dysfunction. In hypertension and aortic stenosis, LASF predicts increased rate of CV events independent of traditional risk factors. Moreover, LASF is an independent predictor of heart failure in diabetic and nondiabetic patients. Limited data are available about LASF and its relationship with LV systolic function in type 2 diabetes mellitus (T2DM).

METHODS

We used baseline clinic and echocardiographic data from 333 patients recruited in the SHORTWAVE study evaluating LV and left atrial performance in T2DM patients without cardiac disease. LASF was calculated by Manning's method and defined high when exceeded 16 Kdynes (90th percentile of LASF found in 120 healthy subjects used as controls).

RESULTS

Mean LASF was 15.8 Â ± 9.4 Kdynes/cm(2) and showed a close positive correlation with peak mitral annular systolic velocity (function of LV longitudinal fibers), independent of E/E', age, systolic blood pressure, heart rate, and concentric geometry (multiple R = 0.57, P < 0.0001). Such independent correlation (tested in patients with and without concomitant hypertension) was confirmed at multiple logistic regression analysis where patients were dichotomized for having high (119 = 36%) or normal LASF.

CONCLUSIONS

High LASF is present in one third of T2DM patients without overt cardiac disease and is positively and independently related to an increased LV longitudinal shortening function, suggesting a close interaction between LV systolic and diastolic function.

Noninvasive assessment of left atrial phasic function in patients with hypertension and diabetes using two-dimensional speckle tracking and volumetric parameters

OBJECTIVE

To evaluate the left atrial phasic function of hypertensive patients with or without coexisting diabetes using two-dimensional speckle tracking echocardiography (2DSTE)-based strain and strain rate imaging and volumetric parameters.

METHODS

The study included an isolated hypertension group (HT group) comprising 99 patients, a hypertension and diabetes group (HT + DM group) comprising 65 patients, and 26 age-matched healthy controls. The 2DSTE-based strain and strain rate images were studied, and the following parameters were measured: peak left atrial longitudinal strain (LAS-S ), early diastolic (LAS-E ) and late diastolic (LAS-A ) atrial longitudinal strains, and systolic (LASR-S ), early diastolic (LASR-E ) and late diastolic (LASR-A ) strain rates.

RESULTS

The LAS-S and LASR-S were lower in the HT group and the HT + DM group compared with the control group (P < 0.001). The LAS-E and LASR-E were lower in the HT group (14.9 ± 5.5% and -1.1 ± 0.4/sec, respectively) than in the control group (22.1 ± 8.3% and -1.7 ± 0.6/sec, respectively) (P < 0.001), and they were further depressed in the HT + DM group (12.3 ± 6.3% and -1.0 ± 0.4/sec, respectively) (P < 0.05). There were no significant differences in LAS-A or LASR-A among the 3 groups (P > 0.05). Multivariate regression analysis revealed that HT and DM were independently related to LAS-E and LASR-E .

CONCLUSIONS

Hypertension can lead to abnormal left atrial reservoir and conduit functions, and coexisting diabetes can further impair conduit function. 2DSTE-derived strain and strain rate imaging are sensitive methods for evaluating left atrial phasic function.

The normal impact of age and gender on right heart structure and function

BACKGROUND

As the proportion of elderly population increases rapidly, it might be difficult to differentiate physiological changes in cardiac function due to age from the pathophysiological ones. In addition, cardiac function variations with gender are well established. The right ventricular (RV) plays an important role in the overall cardiac function, but reference values varying with age and gender are lacking.

MATERIAL AND METHODS

We studied 255 healthy individuals from a general population register, mean age of 58 ± 19 (range 22-89) years, 125 were females. We used 2D and M-mode echocardiography to measure RV inflow tract (RVIT) and RV outflow tract (RVOT) dimensions and fractional shortening (fs). Spectral Doppler echocardiography was also used.

RESULTS

We found a modest decrease in RVIT dimensions (P < 0.05), but increase in RVOT dimensions with advancing age (P < 0.05). A small decrease in RVOT fs with age was also found (P < 0.05). Estimated pulmonary pressures and pulmonary vascular resistance increased (P < 0.001) as did RVOT wall thickness (P < 0.001), but RV diastolic function was not altered (P < 0.001) with age. Despite correction for the BSA, males showed larger RVIT dimensions (P < 0.001 for both), but RVOT end-diastolic dimension was larger in females (P < 0.05). RVIT and RVOT fractional shortening were increased in females (P < 0.01 for both).

CONCLUSION

In a cohort of normal individuals, age has significant impact on RV structure and function, inlet area falls and outflow tract dimensions increase and fractional shortening also increase in females. In addition, RVOT wall thickness significantly increases and Doppler markers of pulmonary vascular resistance show a consistent rise. The age-related changes should carefully be considered when commenting on normality and when using absolute values.

Left atrial enlargement and right ventricular hypertrophy in essential hypertension

AIM

Diastolic dysfunction related to hypertensive left ventricular hypertrophy (LVH) has been shown to affect right-sided cardiac morphology and haemodynamics. As left atrial enlargement (LAE) is a marker of chronically elevated left ventricular (LV) filling pressure and diastolic dysfunction, we investigated the relationship between LAE and right ventricular hypertrophy (RVH) in systemic hypertension.

METHODS

A total of 330 essential hypertensives, categorized according to tertiles of left atrial (LA) diameter indexed to body surface area were considered for the analysis. All subjects underwent a quantitative echocardiographic examination as well as extensive clinical and laboratory investigations. RVH was defined as anterior right ventricular (RV) wall thickness ≥ 6.0/5.5 mm in men and women, respectively, and LVH as LV mass index ≥ 51/47 g/m(2.7) in men and women, respectively.

RESULTS

The prevalence of LVH increased across LA diameter tertiles from 21.0% to 50% and that of RVH from 26.3% to 41.8% (p < 0.01for both). This was also the case for biventricular hypertrophy (from 10.0% to 26.0%, p < 0.01). Differences in both LV and RV structure across LA diameter tertiles remained significant after adjusting for age, office systolic/diastolic blood pressure and duration of hypertension. Similar results were obtained when study population was divided according to absolute LA diameter tertiles.

CONCLUSIONS

Our findings provide further evidence of an interaction between left and right chambers in systemic hypertension by showing that LAE is associated with RVH. The clinical and prognostic implications of such observation remain be evaluated in future prospective studies.

Prevalence of echocardiographic left-atrial enlargement in hypertension: a systematic review of recent clinical studies

BACKGROUND

Left atrial enlargement (LAE) is a marker of hypertensive heart disease associated with increased cardiovascular risk. We reviewed recent literature about the prevalence of LAE, as assessed by echocardiography, to update our information about the clinical relevance of this cardiac phenotype in human hypertension.

METHODS

We performed a search of MEDLINE using the key words "left atrial enlargement," "left atrial dilatation," "left atrial size," "hypertension," "echocardiography," and "atrial fibrillation" to identify relevant papers. We considered full articles published in English from January 1, 2000 to July 1, 2012 reporting studies involving adult individuals.

RESULTS

We analyzed a total of 15 studies, including 10,141 untreated and treated subjects. LAE was defined according to 11 different criteria (4 studies applied two or three criteria), and its prevalence consistently varied among studies, from 16.0-83.0%, with a prevalence in the pooled population of 32%. A gender-based analysis of 9 studies (8,588 patients) showed the prevalence of LAE as being similar in women and men (OR, 1.23; 95% CI, 0.83-1.83; P = 0.30). Data provided by 10 studies (n = 9,354 patients) showed the prevalence of left-ventricular hypertrophy as being significantly higher in patients with LAE (68.2%) than in their counterparts without LAE (41.8%) (OR, 2.97; 95% CI, 2.68-3.29; P < 0.01).

CONCLUSIONS

Our analysis shows that LAE is present in a relevant fraction of the hypertensive population. Because LAE is an independent predictor of cardiovascular events, the accurate detection of this phenotype may improve the evaluation of risk in hypertensive patients.

Hypertension accelerates the 'normal' aging process with a premature increase in left atrial volume

Hypertension (HT) is associated with left ventricular (LV) diastolic dysfunction and consequent left atrial (LA) dilatation. We investigated changes in LA size and phasic function by decade in patients with HT. Patients with mild or moderate HT (n = 122) were compared with a case controlled normal cohort (blood pressure <140/90 mm Hg). Biplane LA maximum, minimum, and pre 'a' wave volumes were measured; LA filling, passive emptying, and active emptying volumes and fractions were calculated. Transmitral inflow and pulsed wave mitral annular tissue Doppler velocity were measured as expressions of LV diastolic function. The HT group had larger LA maximum volumes compared with normal controls for all decades until the 8th decade. Subjects with HT in decade 4 had LA maximum volume similar to that of normal controls from decade 8 (27.8 ± 4.3 mL/m(2) vs 25.6 ± 6.1 mL/m(2) respectively, P = .22). Active emptying volume and fraction were higher in the HT group across all decades, while there was no difference between the HT and normal groups for passive emptying volume. LV mass and E/E' ratio were significantly higher across all decades in the HT group. HT alters atrial dynamics significantly, with resultant increased LA volume and active emptying volume consequent to altered LV diastolic function. HT 'accelerates' the normal aging process with patients as early as decade 4 having similar LA size to that of normal controls in decade 8. This premature increase in LA volume may result in the future development of atrial fibrillation in HT patients.

Right atrial volume and phasic function in pulmonary hypertension

BACKGROUND

Few studies have focused on right atrial (RA) structure and function in pulmonary hypertension (PH). We sought to evaluate RA volume and phasic function using cardiac magnetic resonance (CMR), and to examine their clinical relevance in PH.

METHODS

We prospectively studied 50 PH patients and 21 control subjects. RA volume and indices of phasic function (reservoir volume, ejection fraction [EF], and conduit volume) were evaluated by CMR.

RESULTS

Maximum RA volume index was significantly higher in PH patients (56 [44-70] ml/m(2)) than in controls (40 [30-48] ml/m(2)) (p<0.001). Reservoir volume index was significantly lower in PH than in controls (p<0.001), but conduit volume index was higher in PH than in controls (p=0.008). RA EF was similar when comparing the two groups (p=0.925). Interestingly, RA EF was increased in PH patients with WHO functional class III patients as compared with controls (p<0.001) but was reduced in advanced PH patients with WHO functional class IV (p<0.01). Maximum RA volume and RA EF significantly correlated with pulmonary hemodynamic indices, atrial and brain natriuretic hormone levels, and CMR-derived right ventricular indices. By contrast, RA reservoir volume correlated with cardiac index and 6-minute walk distance.

CONCLUSIONS

PH is associated with increased size, decreased reservoir function, and increased conduit function of the right atrium. RA systolic function indicated by RA EF increases in patients with mild to moderate PH but decreases in patients with advanced PH. Varying associations between RA indices and conventional PH indices suggest their unique role in the management of PH.

Left atrial structure and function and clinical outcomes in the general population

AIMS

Left atrial (LA) structural and functional abnormalities may be subclinical phenotypes, which identify individuals at increased risk of adverse outcomes.

METHODS AND RESULTS

Maximum LA volume (LAmax) and LA emptying fraction (LAEF) were measured via cardiac magnetic resonance imaging in 1802 participants in the Dallas Heart Study. The associations of LAEF and LAmax indexed to body surface area (LAmax/BSA) with traditional risk factors, natriuretic peptide levels, and left ventricular (LV) structure [end-diastolic volume (EDV) and concentricity(0.67) (mass/EDV(0.67))] and function (ejection fraction) were assessed using linear regression analysis. The incremental prognostic value of LAmax/BSA and LAEF beyond traditional risk factors, LV ejection fraction, and LV mass was assessed using the Cox proportional-hazards model. Both increasing LAmax/BSA and decreasing LAEF were associated with hypertension and natriuretic peptide levels (P < 0.05 for all). In multivariable analysis, LAmax/BSA was most strongly associated with LV end-diastolic volume/BSA, while LAEF was strongly associated with LV ejection fraction and concentricity(0.67). During a median follow-up period of 8.1 years, there were 81 total deaths. Decreasing LAEF [hazard ratio (HR) per 1 standard deviation (SD) (8.0%): 1.56 (1.32-1.87)] but not increasing LAmax/BSA [HR per 1 SD (8.6 mL/m(2)): 1.14 (0.97-1.34)] was independently associated with mortality. Furthermore, the addition of LAEF to a model adjusting Framingham risk score, diabetes, race, LV mass, and ejection fraction improved the c-statistic (c-statistics: 0.78 vs. 0.77; P < 0.05, respectively), whereas the addition of LAmax/BSA did not (c-statistics: 0.76, P = 0.20).

CONCLUSION

In the general population, both LAmax/BSA and LAEF are important subclinical phenotypes but LAEF is superior and incremental to LAmax/BSA.

Left atrial systolic force and outcome in asymptomatic mild to moderate aortic stenosis

BACKGROUND AND AIMS

In patients with chronic pressure overload due to hypertension or aortic valve stenosis (AS), higher left atrial systolic force (LASF) is associated with a high-risk cardiovascular (CV) phenotype. We tested LASF as prognostic marker in patients with AS.

METHODS

We used baseline and outcome data from 1,566 patients recruited in the Simvastatin and Ezetimibe in AS (SEAS) study evaluating the effect of placebo-controlled simvastatin and ezetimibe treatment on CV events. The primary outcome was a composite of major CV events, including CV death, aortic valve replacement, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure caused by progression of AS, coronary artery bypass grafting, percutaneous coronary intervention, and nonhemorrhagic stroke. LASF was calculated by Manning's method. High LASF was defined as >95th percentile (50 Kdynes/cm(2)) of the distribution within the study population.

RESULTS

During 4.3 years of follow-up, a major CV event occurred in 38 of 78 patients with high LASF (49%) and in 513 of 1,488 (34%) with normal LASF (P = 0.01). In multivariate Cox regression analysis, high LASF predicted higher rate of major CV events (Hazard ratio 1.43 [95% confidence interval 1.01-2.03] independent of aortic valve area and LV mass index. A simple risk score including absence or presence of these three variables allowed risk stratification into low, intermediate, high and very high risk for major CV events during follow-up (22%, 28%, 38%, and 53%, respectively).

CONCLUSIONS

Higher LASF provides additional prognostic information in patients with asymptomatic mild-to-moderate AS.

Effects of Age and Gender on Left Atrial Ejection Force and Volume from Real-Time Three-Dimensional Echocardiography

Introduction: This study was carried out to (i) provide the methodology for determining left atrial (LA) volume, emptying fraction and ejection force (LAEF), from real-time 3-dimensional echocardiography (RT3DE), and (ii) evaluate the effects of age and gender on LA volume and LAEF in a wide age range of healthy participants. Materials and Methods: RT3DE was performed in 102 healthy participants (age range, 20 to 80 years). From full-volume data sets, LA endocardial borders were automatically traced and LA volumes were determined. LAEF was calculated as 1/3×mitral annular area × (blood density) × (peak velocity of A wave)2 according to Newton’s law of motion and hydrodynamics; wherein the mitral annular area (MVA) is traced using RT3DE and A is the peak Doppler-derived blood velocity at atrial systole with the sample volume placed at the mitral annulus level. Results: ANOVA analysis revealed that LA volume indices were significantly correlated with age (r = 0.366, P <0.0001 for maximal volume index and r = 0.288, P <0.005 for minimal volume index). LAEF was also significantly positively correlated with age (r = 0.49, P <0.0001). The LA emptying fraction was maintained across ages. LA volume indices and LAEF did not differ significantly with gender. Conclusion: Our data can be used as normal reference values for LA volumes and LAEF. We have demonstrated that age is positively related to LA volume indices and LAEF, which suggests that age-dependent cut-off values should be considered in those with heart disease. Key words: Age, LA Ejection Force, RT3DE, Volume

Arterial stiffness is associated with tissue Doppler atrial conduction times and P wave dispersion in hypertensive patients

BACKGROUND

Arterial stiffness is strongly predictive for cardiovascular events in hypertensive individuals and it may increase the risk of stroke. This study was designed to evaluate the possible relationship between arterial stiffness and atrial electromechanical delay and P wave dispersion (PWD), as determinants of AF risk.

MATERIALS AND METHODS

The study included 75 hypertensive patients and 45 healthy control subjects. Atrial electromechanical coupling (time interval from the onset of P wave on ECG to the beginning of A wave with tissue Doppler echocardiography [PA]), intraatrial and interatrial electromechanical delay (EMD) and PWD were measured. Stiffness index β & PWV was measured to assess the arterial stiffness.

RESULTS

The interatrial EMD and PWD were prolonged in hypertensive patients compared to controls (p<0.01 for both), There was increased arterial stiffness (PWV and stiffness index β) in hypertensive patients compared to controls (6.43 ± 1.73 vs. 4.8 ± 1.6 m/sec & 4.9 ± 2.8 vs. 2.63 ± 1.2, p<0.01 for both). By multivariate analysis; PWV and Stiffness index β were independently correlated with interatrial EMD (B ± SE=0.42 ± 1.87, B ± SE=0.39 ± 0.21 p<0.01 for both) and PWD (B ± SE=0.37 ± 1.93, p<0.01, B ± SE=0.25 ± 0.18, p<0.05 respectively).

CONCLUSION

In hypertensive patients arterial stiffness indexes increased and showed a significant correlation with interatrial EMD and PWD independent of other variables. Further research is needed to determine whether interventions that reduce arterial stiffness will limit the growing incidence of AF.

Left atrial volume index predictive of mortality independent of left ventricular geometry in a large clinical cohort with preserved ejection fraction

OBJECTIVE

To determine the effect on mortality of the left atrial volume index (LAVI) and left ventricular (LV) geometry (normal, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy).

PATIENTS AND METHODS

From January 1, 2004, through December 31, 2006, we evaluated 36,561 patients with preserved ejection fraction with an average follow-up of 1.7±1.0 years. The LAVI was categorized as normal (≤28 mL/m(2)) or increased (mild, 29-33 mL/m(2); moderate, 34-39 mL/m(2); severe, ≥40 mL/m(2)).

RESULTS

Progressive increases in LAVI and mortality were noted with abnormal LV geometry. Similarly, abnormal LV geometry and mortality were significantly higher in patients with increased LAVI. In patients who died vs surviving patients, the LAVI ± SD was significantly higher (33.0±14.8 vs 28.1±10.8 mL/m(2); P<.001) and abnormal LV geometry was significantly more prevalent (62% vs 44%; P<.001). Compared with those with a normal LAVI, patients with a severe LAVI had a 42% increased risk of mortality. In patients with normal LV geometry or concentric remodeling, a severe LAVI was a significant independent predictor of mortality, with an increased risk of 28% and 46%, respectively. Similarly, in patients with eccentric hypertrophy and concentric hypertrophy, the mortality risk in patients with a severe LAVI was twice that of patients with a normal LAVI. Comparison of area under the curve (0.565 [without LAVI] vs 0.596 [with LAVI]; P<.001] and predictive models with and without LAVI for mortality prediction were significant, indicating increased mortality prediction by the addition of LAVI to other independent predictors.

CONCLUSION

The LAVI significantly predicts mortality risk, independent of LV geometry, and adds to the overall mortality prediction in a large cohort of patients with preserved systolic function.

Impact of 6-year body weight change on cardiac geometry and function in ageing adults: the SUpplémentation en Vitamines et Minéraux AntioXydants -2 (SU.VI.MAX-2) cardiovascular ultrasound substudy

BACKGROUND AND OBJECTIVE

Although the relationships between BMI and cardiac geometry and function have been established, information remains limited on the impact of BMI, waist circumference and body composition variations over time on echocardiographic changes in ageing adults.

METHODS AND RESULTS

Multiple linear regressions were used to correlate cardiac echographic parameters and baseline anthropometric data and their changes over 6 years in 280 participants of the SU.VI.MAX 2 cohort study. During the follow-up, BMI increased by 0.6 (95% confidence interval: 0.3-0.8) kg/m, waist circumference by 2.3 (1.6-3.0) cm and percentage body fat mass (%BFM) by 4.0 (3.4-4.6) %. A 6-year change (2001-2007) by 1 kg/m in BMI or 1 cm in waist circumference was associated with an increase in indexed left ventricular mass by 2.3 g/m (1.3-3.3, P < 0.001) and 0.4 g/m (0.06-0.6, P < 0.017), respectively, and an increase in left atrial area by 0.3 cm (0.1-0.5, P < 0.001) and 0.05 cm (0.003-0.10, P < 0.037), respectively. Follow-up left ventricular mass and left atrial area were not impacted by changes in percentage body fat mass. A significant correlation was observed between E-wave transmitral flow deceleration time and baseline BMI and waist circumference, but not with their changes over time.

CONCLUSION

Changes in anthropometric markers over time are associated with increased left ventricular mass and left atrial size. These findings reinforce the potential benefit of a healthy diet and lifestyle to maintain body weight and, in turn, cardiac geometry and function in ageing adults.

Assessment of left atrial function in diabetes mellitus by left atrial volume tracking method

The value of the left atrial volume tracking (LAVT) method in the evaluation of left atrial (LA) function in patients with diabetes mellitus (DM) was examined in this study. Fifty-eight DM patients as DM group and 40 healthy people as normal control group were enrolled in this study. EUB-6500 echocardiographic imaging system with LAVT was applied to display and analyze the LA volume curve imaging on LV apical two and four chamber views. The maximal LA volume at end-systole (LAV(max)), LA volume at the onset of ECG-P wave (LAV(p)), the minimal LA volume at end-diastole (LAV(min)) from the LA volume curve were acquired and recorded. All values above were standardized by body surface area (BSA). Then the passive, active and total LA volume (LAVIpass, LAVIact, LAVItotal) and empting rate (%LAVIpass, %LAVIact, %LAVItotal), effective passive and active empting rate (%eLAVIpass, %eLAVIact), and the proportionality of passive empting volume and active empting volume were calculated. The LAVIp, LAVIact, LAVItotal, %LAVIact, %LAVItotal and %eLAVIact were significantly higher in the DM group than those in the control group, whereas the LAVIpass, %LAVIpass, %eLAVIpass and LAVIpass/act were lower (all P<0.05). For the LA volume change in DM, the active empting volume was enhanced at end-diastole. It was concluded that LAVT is a potentially useful tool to evaluate the function of LA.