Association of left atrial enlargement with left ventricular hypertrophy and diastolic dysfunction: a tissue Doppler study in echocardiographic practice

Exploring vectorcardiography: An extensive vectocardiogram analysis across age, sex, BMI, and cardiac conditions

BACKGROUND

The vectocardiogram (VCG) offers a three-dimensional view of the heart's electrical activity, yet many VCG parameters remain unexplored in diverse clinical contexts.

OBJECTIVES

This study aims to explore the relationships between various VCG parameters and specific patient characteristics.

METHODS

ECG signals from adults were transformed into VCGs utilizing the Kors matrix, yielding 315 parameters per patient from the P, QRS and T loops. Univariable analysis, circular statistics, and stepwise logistic regression were employed to examine the relationships between VCG parameters and factors such as age, sex, BMI, hypertension, echocardiographic ischemic heart disease (Echo-IHD), and left ventricular hypertrophy (Echo-LVH).

RESULTS

We included 664 adults and considered an alpha value of 0.05 and a power of 90%. The study revealed significant associations, such as age with P loop roundness index (RI) (OR = 3.825, 95% confidence interval [95%CI] = 2.079-7.04), male sex with QRS loop RI (OR = 6.08, 95%CI = 1.835-20.153), abnormal BMI with the T loop's RI (OR = 0.544, 95%CI = 0.325-0.909), hypertension with the T loop planarity index (PI) (OR = 8.01, 95%CI = 2.134-30.117), Echo-IHD with QRS loop curvature at the 4/10th segment (OR = 7.58, 95%CI = 1.954-29.458), and Echo-LVH with the T loop lag-1/10 dihedral angle (OR = 10.3, 95%CI = 1.822-58.101). In the study, several additional VCG parameters demonstrated statistically significant, albeit smaller, associations with patient demographics and cardiovascular conditions.

CONCLUSIONS

The findings enhance our understanding of the intricate relationships between VCG parameters and patient characteristics, emphasizing the potential role of VCG analysis in assessing cardiovascular diseases. These insights may guide future research and clinical applications in cardiology.

Clinical and Structural Factors Affecting Ablation Outcomes in Atrial Fibrillation Patients - A Review

Catheter ablation is an effective and durable treatment option for patients with atrial fibrillation (AF). Ablation outcomes vary widely, with optimal results in patients with paroxysmal AF and diminishing results in patients with persistent or long-standing persistent AF. A number of clinical factors including obesity, hypertension, diabetes, obstructive sleep apnea, and alcohol use contribute to AF recurrence following ablation, likely through modulation of the atrial electroanatomic substrate. In this article, we review the clinical risk factors and the electro-anatomic features that contribute to AF recurrence in patients undergoing ablation for AF.

A retrospective study of baseline peritoneal transport character and left ventricular hypertrophy in incident peritoneal dialysis patients: interrelationship and prognostic impacts

BACKGROUND

Left ventricular hypertrophy is associated with adverse outcomes among peritoneal dialysis patients. The aim of this study was to evaluate the prognostic impact of baseline left ventricular hypertrophy and its relationship with baseline peritoneal transfer characteristics in peritoneal dialysis patients.

METHODS

We enrolled 151 incident peritoneal dialysis patients to perform a multicentric retrospective cohort study since January 1, 2017 to January 31, 2021. Patients were grouped based on baseline dialysate-to-plasma creatinine ratio at 4 h as follows: low (<0.50), low average (0.5-0.64), high average (0.65-0.80) and high (≥0.81). Echocardiography and clinic data were recorded yearly. The Cox proportional hazards models and competing risk model were used to evaluate patients' survival. Generalized linear mixed models were performed to explore risk factors associated with left ventricular hypertrophy.

RESULTS

During a median follow-up period of 33 months (range, 16-48 months), 21 (13.9%) patients died, including 16 (10.60%) cardiovascular deaths. Controlling the competing risks of switching to hemodialysis, kidney transplantation and loss to follow-up, baseline left ventricular hypertrophy was an independent risk factor for all-cause mortality (subdistribution hazard ratio, 2.645; 95% confidence interval, 1.156-6.056; p = 0.021). Baseline high and high average transport status were positively related to left ventricular mass index and left atrium diameter 2 years after PD initiation.

CONCLUSION

Baseline fast peritoneal solute transport rate may be an effect factor for aggravating left ventricular hypertrophy which predicted poor outcomes for peritoneal dialysis patients. The findings offered important ideas for further prospective intervention study.

Age, creatinine clearance, and ejection fraction (mACEF) score predicts long-term cardiac mortality in patients with hypertrophic obstructive cardiomyopathy treated non-invasively

OBJECTIVE

Presently, an effective model to predict long-term cardiac mortality in patients with hypertrophic obstructive cardiomyopathy (HOCM) is lacking. Therefore, the objective of this study was to evaluate the predictive value of the modified Age, Creatinine clearance, and Ejection Fraction (mACEF) score for long-term cardiac mortality in patients with HOCM.

METHODS

Two hundred and ninety two patients with HOCM treated non-invasively were enrolled in this study, all of whom had intact medical information.

RESULTS

Over a median follow-up period of 41.9 months, 28 cardiac deaths occurred. In univariate Cox regression analysis, the mACEF score was associated with long-term cardiac death [hazard ratio (HR)=1.795, 95% confidence interval (CI) 1.518-2.124, p<0.001]. Multiple Cox regression analysis identified the mACEF score as an independent risk factor for long-term cardiac death (adjusted HR=1.372, 95% CI 1.076-1.749, p=0.011). Analysis of the receiver operating characteristic (ROC) for long-term cardiac death showed that the mACEF score had a considerable predictive value (area under ROC 0.844, sensitivity 89.29%, specificity 75.00%) with an optimum cut-off value of 0.96. The study population was divided into high-risk (mACEF score ≥0.96, n=91) and low-risk (mACEF score <0.96, n=201) groups according to the optimum cut-off value. Kaplan-Meier survival analysis was performed and showed a dramatic higher rate of long-term cardiac mortality in the high-risk group than in the low-risk group (27.4% vs. 1.7%, p<0.001 by log-rank test).

CONCLUSION

The mACEF score has a considerable predictive value for long-term cardiac mortality in patients with HOCM treated non-invasively. A mACEF score ≥0.96 could be considered as a sign of poor prognosis in patients with HOCM.

NR3C2 genotype is associated with response to spironolactone in diastolic heart failure patients from the Aldo-DHF trial

STUDY OBJECTIVE

This study aimed to determine if variants in NR3C2, which codes the target protein of spironolactone, or CYP11B2, which is involved in aldosterone synthesis, were associated with spironolactone response, focused on the primary end point of diastolic function (E/e'), in Aldosterone Receptor Blockade in Diastolic Heart Failure (Aldo-DHF) participants.

DESIGN

Post-hoc genetic analysis.

DATA SOURCE

Data and samples were derived from the multi-center, randomized, double-blind, placebo-controlled Aldo-DHF trial.

PATIENTS

Aldo-DHF participants treated with spironolactone (n = 184) or placebo (n = 178) were included.

INTERVENTION

Participants were genotyped for NR3C2 rs5522, NR3C2 rs2070951 and CYP11B2 rs1799998 via pyrosequencing.

MEASUREMENTS

In the placebo and spironolactone arms, separate multivariable linear regression analyses were performed for change in E/e' with each single nucleotide polymorphism (SNP), adjusted for age, sex, and baseline E/e'. To discern potential mechanisms of a genotype effect, associated SNPs were further examined for their association with change in blood pressure, circulating procollagen type III N-terminal peptide (PIIINP), and left atrial area.

MAIN RESULTS

Carriers of the rs5522 G allele in the placebo arm had a greater increase in E/e' over the 12-month course of the trial compared to noncarriers (β = 1.10; 95% confidence interval [CI]: 0.05-2.16; p = 0.04). No corresponding E/e' worsening by rs5522 genotype was observed in the spironolactone arm. None of the other genotypes were associated with change in E/e'. Compared to noncarriers, rs5522 G carriers also had a greater increase in left atrial area with placebo (β = 0.83; 95% CI: 0.17-1.48; p = 0.01) and a greater reduction in diastolic blood pressure with spironolactone (β = -3.56; 95% CI: -6.73 to -0.39; p = 0.03). Serum PIIINP levels were similar across rs5522 genotypes.

CONCLUSIONS

Our results suggest that spironolactone attenuates progression of diastolic dysfunction associated with the NR3C2 rs5522 G allele. Validation of our findings is needed.

Rare Case of a Giant Left Atrium With Cerebrovascular Accident

Left atrium enlargement is very common in patients with valvular heart disease and atrial fibrillation but an extremely dilated left atrium is a very rare condition and rarely reported in the literature. It is a risk factor for ischemic cerebrovascular accidents due to blood stasis as the cavity diameter increases. We are reporting a case of rarely seen severely dilated left atrium with a normal functioning prosthetic mechanical mitral valve with a cerebrovascular accident on anti-vitamin K and aspirin. The patient had a left atrium diameter of 12.7 cm, an area of 200 cm square, and a volume of 2000 cc. We elected to keep the international normalized ratio (INR) slightly above the therapeutic range in order to decrease the risk of ischemic events. It might be necessary to do the same for patients with a similar condition to decrease the stroke rates.

Deletion of P21-activated kinase-1 induces age-dependent increased visceral adiposity and cardiac dysfunction in female mice

It is known that there is an age-related progression in diastolic dysfunction, especially prevalent in postmenopausal women, who develop heart failure with preserved ejection fraction (HFpEF, EF > 50%). Mechanisms and therapies are poorly understood, but there are strong correlations between obesity and HFpEF. We have tested the hypothesis that P21-activated kinase-1 (PAK1) preserves cardiac function and adipose tissue homeostasis during aging in female mice. Previous demonstrations in male mice by our lab that PAK1 activity confers cardio-protection against different stresses formed the rationale for this hypothesis. Our studies compared young (3-6 months) and middle-aged (12-15 months) female and male PAK1 knock-out mice (PAK1-/-) and wild-type (WT) equivalent. Female WT mice exhibited increased cardiac PAK1 abundance during aging. By echocardiography, compared to young WT female mice, middle-aged WT female mice showed enlargement of the left atrium as well as thickening of posterior wall and increased left ventricular mass; however, all contraction and relaxation parameters were preserved during aging. Compared to WT controls, middle-aged PAK1-/- female mice demonstrated worsening of cardiac function involving a greater enlargement of the left atrium, ventricular hypertrophy, and diastolic dysfunction. Moreover, with aging PAK1-/- female mice, unlike male PAK1-/- mice, exhibited increased adiposity with increased accumulation of visceral adipose tissue. Our data provide evidence for the significance of PAK1 signaling as an element in the preservation of cardiac function and adipose tissue homeostasis in females during aging.

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

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

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

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

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

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

The Impact of Obesity on Nighttime Blood Pressure Dipping

Background and objectives: It is commonly known that obesity not only increases arterial hypertension (HT) risk but also impacts on the response to antihypertensives. This study aimed to assess blood pressure (BP) parameters based on Ambulatory Blood Pressure Measurement (ABPM) in obese patients. Materials and Methods: The study group consisted of 128 patients with obesity (BMI ≥ 30 kg/m²), with an average age of 43.25 years (±12.42), including 55 males and 73 females. They were divided into 2 groups: 1-with BMI ≥ 30 kg/m² and <40 kg/m², 2-with BMI ≥ 40 kg/m². Each patient underwent 24-h blood pressure monitoring. The average 24-h, daytime and nighttime systolic and diastolic pressure, as well as 24-h mean heart rate and % of nocturnal dip, were assessed. Results: Mean BMI in group 1 was 34.73 kg/m² (±2.96), and in group 2 it was 47.6 kg/m² (±6.3). Group 1 was significantly older than group 2 (46.5 vs. 39 years old). The analysis of ABPM revealed significantly higher BP values in all measurements in group 2 (i.e., systolic blood pressure (SBP) 24 h median = 132 mmHg; diastolic blood pressure (DBP) 24 h median = 84 mmHg). The nocturnal dip was greater in group 1 (8.95%). Mean 24-h heart rate was also higher in group 2 (median = 76 beats/min) than group 1 (median = 67.5 beats/min). More than half of patients in group 2 had been previously treated for HT, and based on ABPM, new HT was diagnosed in 6 patients from group 1 and 14 patients from group 2. Three groups of patients were identified based on nighttime dip: dipper, non-dipper, and reverse-dipper. No patient of the extreme dipper type was found. Group 2 comprised of significantly more patients of the reverse-dipper type. Conclusions: Patients with extreme morbid obesity frequently exhibit HT of the reverse-dipping pattern. This type is often linked with a higher risk of more advanced cardiovascular illness.

ECG Indices Poorly Predict Left Ventricular Hypertrophy and Are Applicable Only in Individuals With Low Cardiovascular Risk

Background: Left ventricular hypertrophy (LVH) is an important risk factor for cardiovascular events. The electrocardiography (ECG) has poor sensitivity, but it is commonly used to detect LVH.

AIM

To evaluate the diagnostic efficacy of known ECG indicators to recognize LVH in subgroups with different cardiovascular risk levels. Methods: 676 volunteers were included.

RESULTS

We found that 10.2% of the analyzed population had LVH based on echocardiography. Individuals with LVH were older, had a higher body mass index, higher systolic blood pressure, lower heart rate, higher parameters of insulin resistance, higher cardiovascular risk, and android-type obesity. Variables that remained independently associated with LVH were QRS duration, left atrial volume index, troponin T, and hemoglobin A1c. The receiver operating characteristics (ROC) curve analysis of the Sokolow-Lyon index did not show a significant predictive ability to diagnose LVH in the whole study population including all cardiovascular risk classes. The ROC curves analysis of Cornell and Lewis indices showed a modest predictive ability to diagnose LVH in the general population and in a low cardiovascular class.

CONCLUSIONS

There is a need for new, simple methods to diagnose LVH in the general population in order to properly evaluate cardiovascular risk and introduce optimal medical treatment of concomitant disease.

A review of echocardiograms in hypertensive patients greater than 60 years in a community based family medicine program

Background: Heart disease as a result of Hypertension is known to occur. Anatomical and functional changes of the heart can easily be detected by echocardiography, which is a safe and readily available study. Objectives: The aims of this study were to evaluate the prevalence of common echocardiographic changes in chronic hypertensive patients and to compare these changes in male and female populations. Design/methods: The study was a community-based cross-sectional study, on 227 hypertensive patients, 60 years and older, seen in St. Joseph's Family Medicine at Clifton, with integrated clinical and echocardiographic data. Results: Study population consisted of 227 hypertensive patients, over the age of 60 years who had echocardiography done. Overall 92.5% of the echocardiograms had abnormal findings including but not limited to TR, Diastolic dysfunction, MR, and LVH. There was significant difference between the rate of MR in male and female population. Conclusion: A variety of echocardiographic abnormalities can be found in hypertensive patients. Drug selection in hypertension should be driven by the underlying cardiac pathology. Certain drugs have more effectiveness for diastolic dysfunction, LVH, systolic dysfunction and pulmonary hypertension and are superior choices when these conditions are present. Echocardiogram is a non-invasive and easily available tool in order to help us to select the best treatment strategy to optimize hypertensive control in the challenging group of elderly patients. The results of our study should influence us to liberally use echocardiography in these patients to guide treatment decision and drug selection. Abbreviations: LVH: left ventricular hypertrophy; MR: mitral valve regurgitation; TR: tricuspidvalve regurgitation; LVD: left ventricular dilation; LVEF: left ventricular ejection fraction.

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.

Prevalence of left atrial enlargement and its risk factors in general Chinese population

Background

Left atrial enlargement (LAE) has been proven to be significantly related to stroke and cardiovascular diseases. In China, few studies related to LAE have been conducted, especially in the general population. To the best of our knowledge, our study is the first to explore the prevalence of LAE and associated risk factors in the general Chinese population.

Methods

This study included a total of 11,956 subjects aged ≥35 years. All participants completed a questionnaire, and underwent complete physical examination, electrocardiogram (ECG) and echocardiogram. We defined LAE as a LA diameter exceeding 4.0 cm in men and 3.8 cm in women. We conducted a multivariable logistic regression analysis and a linear regression analysis to identify independent factors of LAE.

Results

The overall prevalence of LAE was 6.43 % for subjects aged over 35 years. The prevalence of LAE was 6.78 % in women and 6.02 % in men. The major risk factors of LAE were female sex (odds ration [OR]: 1.229, β: 0.197), advancing age (OR: 1.015, β: 0.036), high systolic blood pressure (OR: 2.331, β: 0.185), high body mass index (BMI) (OR: 3.956, β: 0.373), diabetes (OR: 1.498, β: 0.030), high left ventricular myocardial index (OR: 1.003, β: 0.073), and low left ventricular ejection fraction, low heart rate, and low estimated glomerular filtration rate. Additionally, the association between BMI and LAE was the most obvious.

Conclusions

Female sex, advancing age, high systolic blood pressure, high BMI, diabetes, high left ventricular myocardial index, low estimated glomerular filtration rate, low left ventricular ejection fraction, and low heart rate were proven to be risk factors of LAE.

Biomarkers of cardiomyocyte injury and stress identify left atrial and left ventricular remodelling and dysfunction: A population-based study

BACKGROUND/OBJECTIVES

The validation of effective screening tools for the identification of patients with subclinical myocardial remodelling is a major clinical need. Thus, we explored the associations of circulating biomarkers of cardiomyocyte injury and stress with subclinical cardiac remodelling and dysfunction, and with biomarkers reflecting collagen turnover.

METHODS

We randomly recruited 727 subjects from a general population (51.2% women; mean age 51.3 years). Measurements included echocardiographic left atrial (LA) and left ventricular (LV) structure and function, quantification of high sensitivity cardiac Troponin T (hs-cTnT), NT-proBNP, and biomarkers of collagen types I and III turnover.

RESULTS

In unadjusted and adjusted analyses, the prevalence of LA enlargement (LAE), LV hypertrophy (LVH) and LV diastolic dysfunction (LVDD) increased with higher hs-cTnT (P ≤ 0.031). NT-proBNP was independently associated with LVDD (P=0.009). Both biomarkers combined yielded significant integrated discrimination and net reclassification improvements (P ≤ 0.014 and P ≤ 0.009, respectively) for LAE, LVH and LVDD, over the conventional risk factors, and were independently and positively associated with biomarkers of collagen type I turnover. In a sensitivity analysis, after excluding participants with previous cardiac diseases, our findings remained consistent.

CONCLUSIONS

Our population-based study suggested that subclinical LV and LA remodelling were associated with hs-cTnT, and that, in combination with NT-proBNP, hs-cTnT showed incremental diagnostic utility over the conventional risk factors. Both biomarkers were associated with biomarkers of collagen type I turnover. Thus, biomarkers of cardiomyocyte microinjury and hemodynamic stress may stimulate fibrosis-related mechanisms and facilitate the diagnosis of subclinical LA and LV remodelling and dysfunction in the general population.

Prognostic Significance of Left Atrial Enlargement in a General Population

We estimated the risk of cardiovascular events, cardiovascular mortality, and all-cause mortality associated with left atrium (LA) enlargement alone or combined with echocardiographic left ventricular hypertrophy (LVH) in 1785 representatives of the general population of Monza recruited for the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study. LA enlargement was assessed by measuring LA diameter via echocardiography. LA enlargement was defined as a LA diameter >2.3 cm/m 2 , whereas LVH was defined as a left ventricular mass index ≥114 g/m 2 and 99 g/m 2 in men and women, respectively. Death certificates and hospital diagnoses were collected over an average 148 months follow-up. During follow-up, there were 175 deaths (of which 59 for cardiovascular causes) and 139 cardiovascular fatal and nonfatal events. Compared with subjects with neither LA enlargement nor LVH, subjects with isolated LA enlargement exhibited a significant increase in the adjusted risk of combined fatal and nonfatal cardiovascular events (hazard ratio, 2.0; confidence interval, 1–4.1; P =0.04), although not of cardiovascular death or all-cause death. The adjusted (for baseline covariates, including ambulatory blood pressure) risk of fatal and nonfatal cardiovascular events, cardiovascular death, and all-cause death was significantly increased also in subjects with isolated LVH (hazard ratio, 2.2, 3.4, 2.1, respectively; P =0.001 for all), whereas no further increase was seen in subjects with both LA and left ventricular abnormalities. Thus, like LVH, LA enlargement is an independent long-term predictor of cardiovascular events. The cardiovascular risk, however, is not further increased when LA enlargement is superimposed on an increase of LV mass.

Maternal educational level and blood pressure, aortic stiffness, cardiovascular structure and functioning in childhood: the generation R study

BACKGROUND

In adults, low level of education was shown to be associated with higher blood pressure levels and alterations in cardiac structures and function. It is currently unknown whether socioeconomic inequalities in arterial and cardiac alterations originate in childhood. Therefore, we investigated the association of maternal education with blood pressure levels, arterial stiffness, and cardiac structures and function at the age of 6 years and potential underlying factors.

METHODS

The study included 5,843 children participating in a prospective cohort study in the Netherlands. Maternal education was assessed at enrollment. Blood pressure, carotid-femoral pulse wave velocity, left atrial diameter, aortic root diameter, left ventricular mass, and fractional shortening were measured at the age of 6 years.

RESULTS

Children with low educated (category 1) mothers had higher systolic (2.80mm Hg; 95% confidence interval (CI) = 1.62-2.94) and diastolic (1.80mm Hg; 95% CI = 1.25-2.35) blood pressure levels compared with children with high educated (category 4) mothers. The main explanatory factors were the child's body mass index (BMI), maternal BMI, and physical activity. Maternal education was negatively associated with fractional shortening (P trend = 0.008), to which blood pressure and child's BMI contributed the most. No socioeconomic gradient was observed in other arterial and cardiac measurements.

CONCLUSIONS

Socioeconomic inequalities in blood pressure are already present in childhood. Higher fractional shortening among children from low socioeconomic families might be a first cardiac adaptation to higher blood pressure and higher BMI. Interventions should be aimed at lowering child BMI and increasing physical activity among children from low socioeconomic families.

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.

Correlation of echocardiographic left atrial abnormality with myocardial ischemia during myocardial perfusion assessment in the presence of known left ventricular hypertrophy

Left atrial (LA) abnormality, an easily quantifiable parameter of left ventricular (LV) diastolic dysfunction, has been associated with cardiovascular risk similar to that of LV hypertrophy. The correlation between LV hypertrophy and LA abnormality among patients undergoing myocardial perfusion (MP) study has not been described. We prospectively studied 78 consecutive patients with LV hypertrophy who underwent MP study after screening for electrocardiographic and echocardiographic LA abnormality over a 6-month period. Of those, 48 had a positive MP imaging result, and 30 did not. LA size (p = 0.002) and P-wave duration (p = 0.017) were significantly increased in the former. The differential change in LA size (no defect = 35 ± 4, mild = 36 ± 5, moderate = 38 ± 5, severe = 44 ± 5 mm; p <0.0001) and P-wave duration (no defect = 107 ± 14, mild = 110 ± 17, moderate = 113 ± 15, severe = 127 ± 22 ms; p = 0.003) was greatest when the MP study defect exceeded moderate severity. In conclusion, the presence of LA abnormality could assist during MP study interpretation among patients with LV hypertrophy when such markers appear to be correlated with the severity of the MP study defect.

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.

Left atrial diameter and albumin with renal outcomes in chronic kidney disease

BACKGROUND AND AIM

Echocardiographic left atrial diameter (LAD) has been documented to be an independent predictor of adverse cardiovascular outcomes in various populations. An enlarged left atrium is frequently noted in chronic kidney disease (CKD). We examined the association between albumin and indexed LAD (indexed to height) and assessed whether the combination of indexed LAD and albumin was independently associated with renal outcomes in patients with CKD stages 3-5.

METHODS

This longitudinal study enrolled 395 patients, who were classified into four groups according to median values of indexed LAD (LAD/height) and albumin. The change in renal function was measured by estimated glomerular filtration rate (eGFR) slope. Rapid renal progression was defined as eGFR slope less than -3 ml/min/1.73 m(2)/year. The renal end point was defined as commencement of dialysis.

RESULTS

Albumin was significantly associated with indexed LAD (β = -0.108, P = 0.024). During follow-up period, seventy-four patients started dialysis. After the multivariate analysis, the group with higher indexed LAD and lower albumin was independently associated with rapid renal progression (odds ratio, 7.979; 95% confidence interval [CI], 3.028 to 21.025) and progression to dialysis (hazard ratio, 2.352; 95% CI, 1.078 to 5.131).

CONCLUSIONS

Our findings show that albumin is independently associated with indexed LAD and suggest that the combination of increased indexed LAD and hypoalbuminemia is independently associated with rapid renal progression and progression to dialysis in patients with CKD. Assessments of serum albumin and indexed LAD by echocardiography are useful for predicting the risk for adverse renal outcomes.

Left atrial volume index as a marker of left ventricular diastolic dysfunction in asymptomatic Tanzanian diabetic patients

AIM

To determine the prevalence of left atrial (LA) enlargement and its relation to left ventricular (LV) diastolic dysfunction among asymptomatic diabetic outpatients attending Muhimbili National Hospital in Dar es Salaam, Tanzania.

METHODS

Echocardiography was performed in 122 type 2 and 58 type 1 diabetic patients. Diastolic dysfunction was defined as peak transmitral blood velocity to medial mitral annulus velocity (E/E') ratio ≥ 15. LA volume indexed to body surface area (LAVI) was considered enlarged if ≥ 29 ml/m(2).

RESULTS

Enlarged LAVI and LV diastolic dysfunction were more common in type 2 than in type 1 diabetic patients (44.3 vs 25.9% and 20.5 vs 3.5%, respectively, both p < 0.05). In multivariate linear regression analysis, larger LAVI was associated with LV diastolic dysfunction independent of significant associations with LV mass index and presence of mitral regurgitation in type 2 diabetic patients, while LV mass index, lower ejection fraction and longer duration of diabetes were the main covariates of larger LAVI in type 1 diabetic patients (all p < 0.05).

CONCLUSION

Enlarged LA is common among asymptomatic Tanzanian diabetic patients, and particularly associated with LV diastolic dysfunction in type 2, and with cardiomyopathy and lower systolic function in type 1 diabetic patients.

Left atrial eccentricity in chronic mitral regurgitation: relation to left atrial function

AIMS

The aim of this study was to assess the changes in the left atrial (LA) shape and to identify the determinants of these changes in chronic mitral regurgitation (MR).

METHODS AND RESULTS

We enrolled 125 consecutive patients (56 ± 16 years, 51% men) with chronic MR caused by myxomatous mitral valve disease in sinus rhythm and 45 control patients (54 ± 15 years, 55% men) undergoing transthoracic Doppler echocardiography. The LA eccentricity index (LAEi) and the LA volume index (LAVi) were used to estimate the LA shape and size, respectively. There were significant decreases in LAEi (r= -0.723, P< 0.001) and increases in LAVi (r= 0.642, P< 0.001) with increasing severity of MR. In multivariate stepwise linear regression analysis, regurgitant fraction (RF) was an independent determinant of the LAE, whereas RF, left ventricular (LV) mass index and LV diastolic dysfunction grade were independent determinants of the LA volume. The LAEi was positively related to the velocity of A' in the entire population (r = 0.238, P = 0.002). On the receiver operating characteristic (ROC) curve analysis, LAEi ≤1.30 was the best cut-off value to reflect the LA systolic dysfunction (A' velocity <7 cm/s; area under the curve was 0.78, P < 0.001).

CONCLUSION

LA becomes more spherical with increasing severity of MR, suggesting a decrease in LAE, which is mainly determined by the volume overload. LAE might be closely related to the LA systolic function in chronic MR.