Prediction of AF in Heart Failure With Preserved Ejection Fraction: Incremental Value of Left Atrial Strain

OBJECTIVES

This study sought to identify the factors associated with incident atrial fibrillation (AF) in a well-characterized heart failure with preserved ejection fraction (HFpEF) population, with special focus on left atrial (LA) strain.

BACKGROUND

AF is associated with HFpEF, with adverse consequences. Effective risk evaluation might allow the initiation of protective strategies.

METHODS

Clinical evaluation and echocardiography, including measurements of peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA volume index (LAVI), were obtained in 170 patients with symptomatic HFpEF (mean age, 65 ± 8 years), free of baseline AF. AF was identified by standard 12-lead electrocardiogram, review of relevant medical records (including Holter documentation), and surveillance with a portable single-lead electrocardiogram device over 2 weeks. Results were validated in the 103 patients with HFpEF from the Karolinska-Rennes (KaRen) study.

RESULTS

Over a median follow-up of 49 months, incident AF was identified in 39 patients (23%). Patients who developed AF were older; had higher clinical risk scores, brain natriuretic peptide, creatinine, LAVI, and LV mass; lower LA strain and exercise capacity; and more impaired LV diastolic function. PACS, PALS, and LAVI were the most predictive parameters for AF (area under receiver-operating characteristic curve: 0.76 for PACS, 0.71 for PALS, and 0.72 for LAVI). Nested Cox regression models showed that the predictive value of PACS and PALS was independent from and incremental to clinical data, LAVI, and E/e' ratio. Classification and regression trees analysis identified PACS ≤12.7%, PALS ≤29.4%, and LAVI >34.3 ml/m² as discriminatory nodes for AF, with a 33-fold greater hazard of AF (p < 0.001) in patients categorized as high risk. The classification and regression trees algorithm discriminated high and low AF risk in the validation cohort.

CONCLUSIONS

PACS and PALS provide incremental predictive information about incident AF in HFpEF. The inclusion of these LA strain components to the diagnostic algorithm may help guide screening and further monitoring for AF risk in this population.

Comparison of left ventricular longitudinal systolic function parameters in the prediction of adverse outcome in heart failure with preserved ejection fraction

AIMS

Several different diagnostic parameters can be used to assess left ventricular (LV) longitudinal systolic function, but no studies comparing their predictive value have been conducted. We sought to compare the prognostic value of LV long-axis function parameters at rest and exercise using the population with heart failure with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

Clinical and biochemical variables were collected at baseline in 201 patients with HFpEF. Echocardiography was performed at rest and immediately after exercise, with measurement of mitral annular plane systolic excursion, systolic tissue velocity (s'), global longitudinal strain (GLS), and global longitudinal strain rate (GLSR). Participants were followed for 48 (24-60) months for heart failure hospitalization and cardiovascular death. Seventy-four patients (36.8%) met the study endpoint. Cox regression analysis revealed that after adjustment for Meta-Analysis Global Group in Chronic Heart Failure risk score, brain natriuretic peptide (BNP), and peak VO₂ , heart failure hospitalization and cardiovascular death were significantly associated with GLS at rest [hazard ratio (HR) 0.91; 95% confidence interval (CI) 0.84-0.98; P = 0.016], GLS after exercise (HR 0.84; 95% CI 0.77-0.91; P < 0.001), and GLSR after exercise (HR 0.13; 95% CI 0.04-0.48; P = 0.002). The addition of each of the following: exercise GLS and GLSR and resting GLS to the base model including Meta-Analysis Global Group in Chronic Heart Failure, BNP, and peak VO₂ improved predictive power for the study endpoint [net reclassification improvement (NRI) = 49%, P < 0.001; NRI = 42%, P = 0.004; and NRI = 38%, P = 0.009, respectively]. Exercise GLS was the only longitudinal parameter significantly improving c-statistics of the base model (0.68 vs. 0.73; P = 0.047).

CONCLUSIONS

Echocardiographic parameters of LV longitudinal function are not equipotential in predicting adverse outcomes in HFpEF. LV deformation indices, especially assessed with exercise, show the highest predictive utility independent from and incremental to clinical data and BNP.

Application of strain and other echocardiographic parameters in the evaluation of early and long-term clinical outcomes after cardiac surgery revascularization

Background

Coronary artery bypass graft (CABG) surgery is an effective therapeutic strategy for coronary heart disease (CHD). Myocardial longitudinal strain echocardiography with 2D speckle tracking could obtain ventricular function with better accuracy and reliability than the left ventricular ejection fraction.

The aim of the study was to assess changes in left ventricular function in patients before and after surgical revascularization for a 24-month period of observation, using echocardiography with speckle tracking strain imaging. We searched for echocardiographic predictors of poor early and long-term outcome after CABG.

Methods

We enrolled 69 patients scheduled for elective coronary bypass grafting. Patients were divided into groups based on pre-operative systolic and diastolic parameters, depending on the GLS value and the E’ Lat and E/E’ value. The correlation between these parameters and early and long-term outcomes was analyzed.

Results

Preoperative EF was preserved in 86, 95% (60) patients. Pre-operative reduced GLS was observed in 73.91% (51) of patients and severely reduced in 31.88% (22).

In the first post-operative 6-month period, we observed a significant decrease in the GLS. The GLS was a predictor of early postoperative outcome for intubation time, the inotropes use and length of ICU stay. Diastolic dysfunction was a predictor of the greater inotrope requirements.

Conclusions

Global longitudinal strain and diastolic dysfunction parameters are a good predictors of worse early outcome after CABG.

Preoperative thromboelastometry for the prediction of increased chest tube output in cardiac surgery: A retrospective study

Bleeding following cardiac surgery is a serious event with potentially life-threatening consequences. Preoperative recognition of coagulation abnormalities and detection of cardiopulmonary bypass (CPB) related coagulopathy could aid in the start of preventive treatment strategies that minimize perioperative blood loss. Most algorithms that analyze thromboelastometry coagulation tests in elective cardiac surgery do not include test results performed before surgery. We evaluated preoperative rotational thromboelastometry test results for their ability to predict blood loss during and after cardiac surgery.A total of 114 adult patients undergoing cardiac surgery with CPB were included in this retrospective analysis. Each patient had thromboelastometry tests done twice: preoperatively, before the induction of anesthesia and postoperatively, 10 minutes after heparin reversal with protamine after decannulation.Patients were placed into 1 of 2 groups depending on whether preoperative thromboelastometry parameters deviated from reference ranges: Group 1 [N = 29; extrinsically activated test (EXTEM) or INTEM results out of normal range] or Group 2 (N = 85; EXTEM and INTEM results within the normal range). We observed that the total amount of chest tube output was significantly greater in Group 1 than in Group 2 (700 mL vs 570 mL, P = .03). At the same time, the preoperative values of standard coagulation tests such as platelet count, aPTT, and INR did not indicate any abnormalities of coagulation.Preoperative coagulation abnormalities diagnosed with thromboelastometry can predict increased chest tube output in the early postoperative period in elective adult cardiac surgery. Monitoring of the coagulation system with thromboelastometry allows rapid diagnosis of coagulation abnormalities even before the start of the surgery. These abnormalities could not always be detected with routine coagulation tests.

Unchanged plasma levels of the soluble urokinase plasminogen activator receptor in elective coronary artery bypass graft surgery patients and cardiopulmonary bypass use

OBJECTIVE AND DESIGN

The soluble urokinase plasminogen activator receptor (suPAR) has been recently recognized as a potential biological marker of various disease states, but the impact of a major surgical intervention on the suPAR level has not yet been established. The aim of our study was to investigate if the induction of a systemic inflammatory reaction in response to cardiopulmonary bypass would be accompanied by an increase in the plasma suPAR level.

METHODS AND SUBJECTS

Patients undergoing coronary artery bypass grafting under cardiopulmonary bypass (CPB) were added. Based on the baseline suPAR level, patients were divided into group 1 (suPAR within normal range) or group 2 (suPAR above range). Blood was collected before the induction of anesthesia and 6 and 24 hours after surgery. Plasma suPAR, IL-6, IL-8, TNF-α, troponin I, NT-proBNP, and NGAL were quantified to assess the impact of surgical trauma on these markers.

RESULTS

The baseline suPAR level was within the normal range in 31 patients (3.3 ng/mL), and elevated in 29 (5.1 ng/mL) (p<0.001). Baseline mediators of systemic inflammatory reaction concentrations (IL-6, TNF-α, and IL-8) and organ injury indices (troponin I, NT-proBNP, and NGAL) were low and increased after surgery in all patients (p<0.05). The surgery did not cause significant changes in the suPAR level either at 6 or 24 hours after, however the difference between groups observed at baseline remained substantial during the postoperative period.

CONCLUSIONS

There was no change in the suPAR level observed in patients subjected to elective cardiac coronary artery bypass surgery and CPB, despite activation of a systemic inflammatory reaction.

Applying the PARiHS framework in a knowledge dissemination initiative

This paper describes the process of facilitating knowledge dissemination using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, including articulation of findings, barriers, implications, and recommendations. Advanced practice nurses (APNs) are in a unique position to facilitate the dissemination of evidence-based knowledge to front-line staff in health care organizations. At a community acute care hospital in Toronto, Ontario, the collaborative competency of an APN was used to develop partnerships with three units in order to implement interprofessional knowledge dissemination via education sessions. The goal was to increase nurses' knowledge of best practices and, consequently, improve outcomes for nephrology patients under their care. The PARiHS framework was used to facilitate the process of knowledge dissemination. The framework consists of three elements: evidence, context, and facilitation. In order for the implementation of a project to be successful, it is necessary to understand the context of the organization. Implications and recommendations for advance practice nurses will be described.