Left atrial volume as an independent predictor of exercise capacity in patients with isolated diastolic dysfunction presented with exertional dyspnea

Measurement of left atrial size as a predictor of severity of illness in sickle cell disease

BACKGROUND

Sickle cell disease (SCD) is characterized by microvascular occlusion which leads to multiorgan damage, including left ventricular diastolic dysfunction. Left ventricular diastolic dysfunction has been shown to be an independent risk factor for death in SCD patients. Left atrial dilation (LAD) has been used as a surrogate marker for identification of left ventricular diastolic dysfunction.

OBJECTIVE

Investigate the association of LAD, as determined by echocardiography, with increased disease burden in SCD as reflected by increased emergency department (ED) utilization, increased hemolysis markers, and worsening anemia.

METHODS

A retrospective cohort study of patients from a single university hospital were selected from a national registry. Age, sickle cell phenotype, echocardiogram findings, ED utilization, baseline hemoglobin, and lab values needed for calculation of hemolytic index were recorded for each patient. Patients were then stratified into two distinct groups based on the presence or absence of LAD to compare ED utilization, baseline hemoglobin and hemolytic index between the two groups.

RESULTS

129 patients met the criteria for inclusion with 88 having normal left atrial volume and 41 with LAD. There was a higher percentage of high ED utilizers in the LAD group compared to the normal left atrial volume group [34% vs. 17%, p = 0.03]. Average hemoglobin was lower in the LAD group compared with the normal left atrial volume group [mean 8.57 g/dL vs. 9.47 g/dL, p = 0.011]. The mean hemolytic index was higher in the LAD group when compared with the normal left atrial volume group [0.44 vs. -0.21, p < 0.001].

CONCLUSIONS

LAD was associated with higher ED utilization, lower hemoglobin level, and more hemolysis in patients with SCD.

Lifestyle and Cardiac Structure and Function in Healthy Midlife Population

The association between lifestyle and cardiac structure and function measures, such as global longitudinal strain and diastolic function in a healthy midlife general population, is not well known. A subpopulation of the Northern Finland Birth Cohort 1966 took part in follow-up, including echocardiography (n = 1,155) at the age of 46. All antihypertensive medication users (n = 164), patients with diabetes (n = 70), subjects with any cardiac diseases (n = 24), and subjects with echocardiography abnormalities (n = 21) were excluded. Moderate to vigorous physical activity (MVPA) was recorded with a wrist-worn accelerometer over 14 days and categorized into high, moderate, and low MVPA groups. Similarly, alcohol consumption was categorized as low, moderate, and high-dose users of alcohol and smoking as nonsmokers, former, and current smokers. The total number of healthy subjects included in the study was 715 (44% males). Left ventricular mass index and left atrial end-systolic volume index were significantly higher in the high MVPA group compared with the low MVPA group (adjusted main effect p = 0.002 and p <0.001, respectively). Cardiac function did not differ among the physical activity groups. High alcohol consumption was associated with impaired global longitudinal strain and diastolic function (adjusted main effect p = 0.002 and p = 0.004, respectively) but not with any cardiac structure variables. Smoking was not associated with cardiac structure or function. In healthy middle-aged adults, MVPA was independently associated with structural changes in the heart but not with cardiac function. High alcohol consumption was associated with impaired modern cardiac function measures but not with cardiac structure.

Atrial Strain Assessment for the Early Detection of Cancer Therapy-Related Cardiac Dysfunction in Breast Cancer Women (The STRANO STUDY: Atrial Strain in Cardio-Oncology)

Left ventricular global longitudinal strain (GLS) has an important role in the diagnosis of cancer therapy-related cardiac dysfunction (CTRCD). Little is known about the role of atrial function in diagnosing CTRCD. The aim of our study was to assess the impact of anti-cancer drugs on atrial function measured by speckle-tracking echocardiography in breast cancer women. A prospective multicenter study was conducted enrolling 169 breast cancer women treated with anthracyclines. A cardiological evaluation including an electrocardiogram and echocardiogram with an analysis of GLS, left atrial (LA) strain, and LA stiffness (LASi) was performed at baseline (T0), 3 (T1), and 6 months (T2) after starting chemotherapy. The patients were divided into two groups: patients with asymptomatic mild cardiotoxicity at T1 (with a relative reduction in GLS > 15%; Group 1) and those without (Group 2). We did not find a significant change in left ventricular ejection fraction (LVEF) at T1 and T2; we found a significant change in GLS (p-value < 0.0001) in the peak atrial longitudinal strain (PALS) and in LASi (p-value < 0.0001). Impairment of atrial function was greater in Group 1 compared to Group 2. A PALS variation > 20.8% identified patients who were most likely to develop asymptomatic mild cardiotoxicity [AUC 0.62; CI (0.51-0.73) p = 0.06, sensitivity 45%, specificity 69.5%]. Conclusions: PALS and LASi significantly change during chemotherapy in association with GLS. Atrial strain is an additional parameter that could be measured together with GLS to detect cardiotoxicity early.

Cardiac function and exercise capacity in patients with metabolic syndrome: A cross-sectional study

Background

Metabolic syndrome is a pre-diabetes condition that is associated with increased cardiovascular morbidity and mortality. We aimed to explore how exercise capacity, cardiac structure, and function were affected in patients with metabolic syndrome.

Methods

Outpatients with echocardiography and exercise stress test combined with impedance cardiography (ETT + ICGG) results available from Nov 2018 to Oct 2020 were retrospectively enrolled. Echocardiographic, ETT + ICG profiles, and exercise performance were compared between patients with metabolic syndrome and the ones without. Sensitivity analyses were performed excluding patients without established coronary heart disease and further 1:1 paired for age and gender, respectively. Multiple linear regression was used to find out related predictors for maximal metabolic equivalents (METs).

Results

Three hundred and twenty-third patients were included, among whom 97 were diagnosed as metabolic syndrome. Compared to patients without metabolic syndrome, echocardiography showed that patients with metabolic syndrome had a significantly lower E/A ratio (p &lt; 0.001). Besides, they have larger left atrium, larger right ventricle, and thicker interventricular septum (all p &lt; 0.001), but similar left ventricular ejection fraction (P = 0.443). ICG showed that patients with metabolic syndrome had significantly higher stroke volume at rest and maximum (p &lt; 0.001), higher left cardiac work index at rest and maximum (p = 0.005), higher systemic vascular resistance (SVR) at rest (p &lt; 0.001), but similar SVI (p = 0.888). During exercise, patients with metabolic syndrome had lower maximal METs (p &lt; 0.001), and a higher proportion suffering from ST-segment depression during exercise (p = 0.009). Sensitivity analyses yielded similar results. As for the linear regression model, 6 independent variables (systolic blood pressure, BMI, E/A ratio, the height of O wave, the peak value of LCWi, and the baseline of SVR) had statistically significant effects on the maximal METs tested in exercise (R = 0.525, R2 = 0.246, P &lt; 0.001).

Conclusion

Patients with metabolic syndrome had significant structural alteration, apparent overburden of left ventricular work index, pre-and afterload, which may be the main cause of impaired exercise tolerance.

Effect of Cardiac Rehabilitation on Left Ventricular Diastolic Function in Patients with Acute Myocardial Infarction

Cardiac rehabilitation (CR) improves symptoms and survival in patients with acute myocardial infarction (AMI). We studied the change of diastolic function and its prognostic impact after CR. After reviewing all consecutive AMI patients from January 2012 to October 2015, we analyzed 405 patients (mean, 63.7 ± 11.7 years; 300 males) with baseline and follow-up echocardiographic examinations. We divided them into three groups according to their CR sessions: No-CR group (n = 225), insufficient-CR group (CR < 6 sessions, n = 117) and CR group (CR ≥ 6 sessions, n = 63). We compared echocardiographic parameters of diastolic dysfunction including E/e' ratio > 14, septal e' velocity < 7 cm/s, left atrial volume index (LAVI) > 34 mL/m2, and maximal TR velocity > 2.8 m/s. At baseline, there were no significant differences in all echocardiographic parameters among the three groups. At follow-up echocardiographic examination, mitral annular e' and a' velocities were higher in the CR group (p = 0.024, and p = 0.009, respectively), and mitral E/e' ratio was significantly lower (p = 0.009) in the CR group. The total number of echocardiographic parameters of diastolic dysfunction at the baseline echocardiography was similar (1.29 vs. 1.41 vs. 1.52, p = 0.358). However, the CR group showed the lowest number of diastolic parameters at the follow-up echocardiography (1.05 vs. 1.32 vs. 1.50, p = 0.017). There was a significant difference between the No-CR group and CR group (p = 0.021). The presence of CR was a significant determinant of major adverse cardiovascular events in the univariate analysis (HR = 0.606, p = 0.049). However, the significance disappeared in the multivariate analysis (HR = 0.738, p = 0.249). In conclusion, the CR was significantly associated with favorable diastolic function, with the highest mitral e' and a' velocity, and the lowest mitral E/e' ratio and total number of echocardiographic parameters of diastolic dysfunction at the follow-up echocardiographic examinations in AMI patients.

Cardiovascular and systemic determinants of exercise capacity in people with type 2 diabetes mellitus

The global burden of heart failure (HF) is on the rise owing to an increasing incidence of lifestyle related diseases, predominantly type 2 diabetes mellitus (T2D). Diabetes is an independent risk factor for cardiovascular disease, and up to 75% of those with T2D develop HF in their lifetime. T2D leads to pathological alterations within the cardiovascular system, which can progress insidiously and asymptomatically in the absence of conventional risk factors. Reduced exercise tolerance is consistently reported, even in otherwise asymptomatic individuals with T2D, and is the first sign of a failing heart. Because aggressive modification of cardiovascular risk factors does not eliminate the risk of HF in T2D, it is likely that other factors play a role in the pathogenesis of HF. Early identification of individuals at risk of HF is advantageous, as it allows for modification of the reversible risk factors and early initiation of treatment with the aim of improving clinical outcomes. In this review, cardiac and extra-cardiac contributors to reduced exercise tolerance in people with T2D are explored.

Left Atrial Volume, Cardiorespiratory Fitness, and Diastolic Function in Healthy Individuals: The HUNT Study, Norway

Background Left atrial (LA) size and cardiorespiratory fitness (CRF) are predictors of future cardiovascular events in high-risk populations. LA dilatation is a diagnostic criterion for left ventricular diastolic dysfunction. However, LA is dilated in endurance athletes with high CRF, but little is known about the association between CRF and LA size in healthy, free-living individuals. We hypothesized that in a healthy population, LA size was associated with CRF and leisure-time physical activity, but not with echocardiographic indexes of left ventricular diastolic dysfunction. Methods and Results In this cross-sectional study from HUNT (Nord-Trøndelag Health Study), 107 men and 138 women, aged 20 to 82 years, without hypertension, cardiovascular, pulmonary, or malignant disease participated. LA volume was assessed by echocardiography and indexed to body surface area LAVI (left atrial volume index). CRF was measured as peak oxygen uptake (VO_2peak) using ergospirometry, and percent of age- and-sex-predicted VO_2peak was calculated. Indexes of left ventricular diastolic dysfunction were assessed in accordance with latest recommendations. LAVI was >34 mL/m² in 39% of participants, and LAVI was positively associated with VO_2peak and percentage of age- and-sex-predicted VO_2peak (β [95% CI], 0.11 [0.06-0.16] and 0.18 [0.09-0.28], respectively) and weighted minutes of physical activity per week (β [95% CI], 0.01 [0.003-0.015]). LAVI was not associated with other indexes of left ventricular diastolic dysfunction. There was an effect modification between age and VO_2peak/percentage of age- and-sex-predicted VO_2peak showing higher LAVI with advanced age and higher VO_2peak/percentage of age- and-sex-predicted VO_2peak as presented in prediction diagrams. Conclusions Interpretation of LAVI as a marker of diastolic dysfunction should be done in relation to age-relative CRF. Studies on the prognostic value of LAVI in fit subpopulations are needed.

Left Atrial Fractional Shortening: A Simple and Practical "Strain" for Everyone

Background:

The function of the left atrium (LA) is reduced in many cardiac diseases even with normal size. The assessment of its compliance could represent an added value in an echocardiographic report in case the gold standard technique (speckle-tracking echocardiography [STE]) is not available. We sought to test a simple and quick method as surrogate of STE: the dynamic measurement of the LA anteroposterior diameter (APD) that we called LA fractional shortening (LAFS).

Materials and Methods:

A total of 153 consecutive patients underwent a transthoracic echocardiography in our echo laboratory between January and June 2017. The only inclusion criteria were the presence of an acoustic window and the informed consent. We chose to not apply exclusion criteria to assess LAFS feasibility. The LAFS was calculated as (maxAPD−minAPD)/(maxAPD) × 100 in parasternal long-axis view. We evaluated the correlation of its value with the peak atrial longitudinal strain (PALS) and the LA emptying fraction (EF).

Results:

Mean execution time was 32.1 ± 5 s for LAFS, 2.3 ± 0.7 min for LAEF, and 2 ± 1 min for PALS. LAFS, with a feasibility of about 97%, was moderately correlated with PALS and LAEF (R between 0.20 and 0.30, P < 0.05). LAFS fractional shortening also emerged as surrogate for PALS via the relationship PALS = 21.07 + 0.364x (LAFS).

Conclusions:

LAFS demonstrated a correlation with PALS, a short execution time, a high feasibility, and the possibility to be used as a surrogate of PALS, applying a specific formula.

Global longitudinal strain, ejection fraction, effort tolerance and normal echocardiography measurements in healthy Indians

Introduction

Normative comprehensive echocardiographic measurements data for healthy Indians are not available while data for American and European population is available from American Society of echocardiography and European Society of Cardiology/European Association of Cardio-Vascular Imaging and their publications. Available studies of Indian subjects are small and report only limited measurements with focus on left ventricular (LV) volumes.

Objective

We aim to provide comprehensive normative echocardiographic data for healthy Indians from a large sample size.

Methods

A retrospective cross-sectional single-center study of 707 healthy Indian adults age and sex segregated which presented detailed and comprehensive echocardiographic measurements including two-dimensional, M-mode, tissue Doppler imaging, speckle tracking echocardiography, chamber volumes, LV ejection fraction (LVEF), global longitudinal strain (GLS), segmental longitudinal strain and effort tolerance.

Results

Our findings show healthy Indians, as compared to US and European population, to have higher relative wall thickness. LV volumes, LV mass, LVEF and effort tolerance that were within American Society of Echocardiography described ranges for chamber quantification. Higher GLS values were observed in Indian population compared to European and American population. Women had higher LVEF and GLS values as compared to men and both showed a gradual decline with aging.

Conclusion

We present normal reference values for echocardiographic measurements in healthy Indian population, which could be used for future reference and comparison work.

Left atrium: the last bulwark before overt heart failure

Heart failure (HF) with preserved ejection fraction (HFpEF) has emerged as an important public health issue in recent years. It represents the most common type of HF in ambulatory setting, and it has been recognized as a different entity from the reduced ejection fraction (EF) form. In HFpEF, continuous growing attention has been focused on the role of the left atrium (LA) in preserving good ventricular function and asymptomatic condition of the patient since the very first stages of diastolic dysfunction (DD). Non-invasive and complete echocardiographic evaluation of diastolic phase cannot exempt from accurately analyzed LA size, mostly LA volume, and its function, in particular LA myocardial deformation by speckle tracking echocardiography (STE). This review examines the expanding role of the LA in DD and HFpEF and the importance of its complete assessment in various settings, from diagnosis to correlation with major cardiovascular events.

Value of nitric oxide level in assessment of cardiac function in patients with cirrhosis

AIM: To assess the correlations between heart function, serum nitric oxide (NO) level and Child-Pugh grade of liver cirrhosis in patients with cirrhosis.

METHODS: Cardiac systolic and diastolic function was measured by echocardiography, and serum concentrations of NO were measured by nitrate reductase method. The correlations between NO level, heart function and Child-Pugh grade were then analyzed.

RESULTS: Left ventricular ejection fraction (LVEF) was significantly higher in patients with Child-Pugh grade A or B cirrhosis than in those with Child-Pugh grade C, and there were also significant differences in LVEF between Child-Pugh grades A and B, and Child-Pugh grades B and C (P < 0.01). The E/A ratio decreased with the increase in the grade of Child-Pugh classification, and there were significant differences in the E/A ratio between the three groups (P < 0.01). Spearman correlation analysis showed that there was a significant negative correlation between E/A ratio and Child-Pugh grade (r = -0.935, P < 0.01). The left atrial diameter (LA) was significantly higher in patients with Child-Pugh grade C than in those with Child-Pugh grade A or B (P < 0.01). Plasma NO levels were elevated with the increase in the grade of Child-Pugh classification, and there were significant differences in plasma NO levels between the three groups (P < 0.01). Spearman correlation analysis showed that there was a significant positive correlation between plasma NO levels and Child-Pugh grade (r = 0.942, P < 0.01).

CONCLUSION: Plasma NO levels in patients with liver cirrhosis are higher than in normal people, and increase with the increase in the grade of Child-Pugh classification. There is a correlation between cardiac function and the degree of hepatic dysfunction in liver cirrhosis patients. Plasma NO levels in patients with liver cirrhosis are related to the damage of liver function.

Ergospirometry and echocardiography in early stage of heart failure with preserved ejection fraction and in healthy individuals

Background

Heart failure with preserved ejection fraction is a syndrome characterized by changes in diastolic function; it is more prevalent among the elderly, women, and individuals with systemic hypertension (SH) and diabetes mellitus. However, in its early stages, there are no signs of congestion and it is identified in tests by adverse remodeling, decreased exercise capacity and diastolic dysfunction.

Objective

To compare doppler, echocardiographic (Echo), and cardiopulmonary exercise test (CPET) variables - ergospirometry variables - between two population samples: one of individuals in the early stage of this syndrome, and the other of healthy individuals.

Methods

Twenty eight outpatients diagnosed with heart failure according to Framingham’s criteria, ejection fraction > 50% and diastolic dysfunction according to the european society of cardiology (ESC), and 24 healthy individuals underwent Echo and CPET.

Results

The group of patients showed indexed atrial volume and left ventricular mass as well as E/E’ and ILAV/A´ ratios significantly higher, in addition to a significant reduction in peak oxygen consumption and increased VE/VCO₂ slope, even having similar left ventricular sizes in comparison to those of the sample of healthy individuals.

Conclusion

There are significant differences between the structural and functional variables analyzed by Echo and CPET when comparing two population samples: one of patients in the early stage of heart failure with ejection fraction greater than or equal to 50% and another of healthy individuals.