Background A pattern of reduced basal longitudinal strain (BLS) is often observed in hypertension (HT) and with altered left ventricular (LV) geometry. Whether this pattern is associated with poor outcome is unclear. We hypothesized that BLS becomes incrementally more impaired in the transition from HT to LV hypertrophy (LVH) and is a predictor of outcome. Methods We investigated 1,096 participants from a community-based cohort study who had an echocardiogram with speckle tracking performed. Regional strain was calculated as: BLS, midventricular and apical strain. The participants were stratified by LV geometry: LVH vs. non-LVH (LVH defined as left ventricular mass index >116 g/m2 for men and >96g/m2 for women). Outcome was major adverse cardiovascular events (MACE) defined as incident myocardial infarction, heart failure, and cardiovascular death. Results BLS and midventricular strain were significantly reduced when comparing normal participants without HT to participants with HT, whereas only BLS was reduced when comparing participants with HT to those with LVH (figure). Overall, patients with LVH showed both reduced BLS and midventricular strain (BLS: −17.5 vs −19.2%, p<0.001; midventricular strain: −19.2 vs. −19.9%, p=0.007 for LVH and non-LVH, respectively) compared to non-LVH, whereas apical strain was similar between groups. During a median follow-up of 12.9 years (13.5; 14.9 years) there were 139 events. Only BLS was reduced in patients with MACE (BLS: −18.0 vs −19.1%, p=0.002) compared to patients without outcome. Both BLS and midventricular strain were univariable predictors of MACE in patients with LVH (BLS: HR=1.20 [1.04; 1.20], p=0.002; midventricular strain: HR=1.08 [1.00; 1.17], p=0.049) but not in patients without LVH (BLS: HR=1.02 [0.97; 1.08], p=0.46; midventricular strain: HR=1.01 [0.94; 1.07], p=0.88). Both measures were independent predictors after multivariable adjustment for clinical risk factors: age, gender, smoking, hypertension, and cholesterol (BLS: HR=1.08 [1.00; 1.16, p=0.048; midventricular strain: HR=1.10 [1.00; 1.20], p=0.049). Regional strain by HT and LV geometry Conclusion BLS and midventricular strain, but not apical strain, becomes incrementally impaired in the transition from normal to LVH, and is associated with poor outcome. In regional strain analyses, BLS provides the highest predictive value for outcome in patients with LVH. Acknowledgement/Funding None
Background Several biomarkers independently predict outcome following ST-segment elevation myocardial infarction (STEMI). We hypothesized that combining information from multiple circulating biomarkers with numerous pathophysiological pathways may improve biomarker risk stratification following a STEMI. Method This was a prospective study of 735 patients with STEMI treated with primary percutaneous coronary intervention. Seventeen biomarkers were drawn before revascularization, including adrenalin, noradrenalin, C-reactive protein (CRP), neutrophil gelatinase-associated lipocalin (NGAL), pro-atrial natriuretic peptide (pro-ANP), alfa-defensin, adiponectin, troponin I, hemoglobin, thrombocyte, and total leukocyte count. The primary outcome was a composite of cardiovascular death or heart failure (CVD/HF) identified by national registries. In the effort to identify the best model, the population was randomly split into two equally sized groups, a derivation cohort and a validation cohort. We used classification and regression tree (CART) analysis to develop a risk model. The identified risk model was hereafter applied to the whole cohort. Results Mean age was 63 years, 74% were male and 33% had hypertension. During a median follow-up time of 5.0 years (3.2; 5.0), we observed 185 primary events. After including all biomarkers in the initial model, the CART analysis created a risk model including pro-ANP, NGAL, and CRP (Figure 1a). The risk of CVD/HF increased incrementally with increasing risk group (Figure 1b). The risk remained significantly higher in groups 3 and 4 after multivariable adjustments (hazard ratio (HR)=3.38 [95% confidence interval (CI): 1.60; 7.16] p=0.001 and HR=6.55 [95% CI: 2.73; 15.76] p<0.001, respectively) when compared with group 1. Figure 1 Conclusion We developed a risk model based on multiple biomarkers (NGAL, CRP, and pro-ANP) determined from a CART analysis which may ease risk stratification after STEMI. Acknowledgement/Funding Sif Rasmussen received a scholarship grant from Herlev & Gentofte Hospital and the P. Carl Petersens Fond during preparation of this manuscript.
Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): he Innovation Fund Denmark (grant no.: 12-135225), The Research Foundation for the Capital Region of Denmark, The Danish Heart Foundation (grant no.: 11-04-R83-A3363-22625 and 18-R125-A8534-22083), Aalborg University Talent Management Programme, Arvid Nilssons Fond, Skibsreder Per Henriksen, R. og Hustrus Fond, and Medtronic Background Left atrial (LA) speckle tracking is a novel technique that provides detailed information on atrial function. Its utility for predicting subclinical atrial fibrillation (SCAF) is, however, not well-established. Purpose To investigate whether LA speckle tracking measures are associated with SCAF as detected by long-term continuous rhythm monitoring. Methods This was an echocardiographic substudy of a randomized controlled clinical trial that enrolled elderly individuals (≥70 years) with a CHADS2-score≥2 to either no intervention or implantation of a loop recorder (Reveal LINQ) to detect SCAF (≥6 minutes). A subset of the participants receiving a loop recorder was included in this analysis. An echocardiographic examination was performed, which included conventional measurements and LA speckle tracking. LA speckle tracking allowed for assessment of reservoir, conduit, and contraction strain. Multivariable proportional hazards Cox regression was applied to adjust for the clinical risk score (CHARGE-AF) and net reclassification index (NRI) was used to assess prognostic improvement of this score. Incidence rate curves were constructed using Poisson models. Results Overall, 976 participants were eligible for analysis. Median follow-up time was 3 years (interquartile range: 1.7-4.0 years), during which 284 (29%) were diagnosed with SCAF. The mean age was 74 years, 56% were male, median CHA2DS2-VASc-score was 4. A dilated LA (LA volume≥34ml/m2) was observed in 152 (16%). LA speckle tracking revealed that both LA reservoir strain and contraction strain were univariable predictors of SCAF (HR = 1.05 (1.03-1.06) and HR = 1.07 (1.05-1.10), p < 0.001, per 1% decrease), such that decreasing reservoir and contraction strain were linearly associated with an increased risk of SCAF (figure). LA conduit strain was not a predictor of SCAF. These findings were unchanged after adjusting for the CHARGE-AF score, and both LA strain measures significantly improved the NRI when added to the CHARGE-AF score by 23% and 33%, respectively. Even in participants with normal LA size, both reservoir and contraction strain were independent predictors of SCAF after multivariable adjustment (HR = 1.03 (1.01-1.05), p = 0.001 and HR = 1.06 (1.04-1.09), p < 0.001, per 1% decrease). Conclusion Decreasing left atrial reservoir and contraction strain are independently associated with an increased risk of SCAF as detected by long-term continuous monitoring and provide incremental prognostic value in addition to clinical risk score. Abstract Figure.
Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Background Assessment of maximal LA volume (LAVmax) is recommended in imaging guidelines but evidence suggests additional value of functional LA measures. How extended measures of LA function associate to left ventricular filling pressure has not been fully explored. Purpose To investigate the association between functional LA measures and left ventricular end-diastolic pressure (LVEDP) Methods Patients suspected of coronary artery disease referred for angiography had simultaneous left heart catheterization performed for invasive pressure measurements. LVEDP > 12mmHg was considered elevated. LA measurements by echocardiography included: LAVmax, minimal LA volume (LAVmin), total LA emptying fraction (total LAEF), passive LA emptying fraction (passive LAEF), and active LA emptying fraction (active LAEF). Results Of 43 patients, 28 (65%) had elevated LVEDP. These patients more frequently had coronary vessel disease (VD) and impaired LA mechanics by all accounts except by LAVmax. All LA measures except LAVmax were associated with LVEDP in unadjusted linear regression analyses, however, only LA emptying fractions remained associated with LVEDP after adjusting for age and VD (2.6 (1.2-4.0) mmHg increase, p = 0.001, per 5% decrease in total LAEF; 1.4 (0.1-2.8) mmHg increase, p = 0.040, per 5% decrease in active LAEF; 1.8 (0.1-3.4) mmHg increase, p = 0.038, per 5% decrease in passive LAEF). In logistic regression, passive LAEF was significantly associated with elevated LVEDP (figure), and this was also the case after adjusting for age and VD (OR = 1.11 (1.01-1.21), p = 0.023, per 1% decrease). Similar findings were made in subgroup analyses among patients without dilated LA and patients without conventional indicators of elevated filling pressure. Conclusion Left ventricular end-diastolic pressure is significantly associated with LA functional measures but not LA volumes. Additionally, passive LAEF is associated with elevated LVEDP. Future studies examining LA function should include all components of LAEF. Abstract Figure.
Background Patients undergoing coronary artery bypass grafting (CABG) surgery face an elevated long-term risk of ischemic stroke. Left atrial (LA) mechanics including LA strain are known to predict both stroke and atrial fibrillation in other populations. Evidence is conflicting with regards to the clinical significance of postoperative atrial fibrillation (POAF) and its role in the association between LA mechanics and ischemic stroke is unclear. Purpose The aim of the study was to investigate the association between LA reservoir strain and long-term ischemic stroke in patients undergoing CABG surgery and whether the presence of POAF modified this relationship. Methods Patients undergoing isolated CABG were included from 2006–2011 as part of a retrospective cohort study. Echocardiography was performed prior to surgery. We included patients with available LA reservoir strain measurements, while patients with known atrial fibrillation and moderate to severe valvular disease were excluded. The primary endpoint was ischemic stroke. The association between LA reservoir strain and ischemic stroke was investigated in uni- and multivariable Cox proportional hazards regression models including adjustment for POAF. Poisson regression was used to create a restricted cubic spline model of the continuous association between LA reservoir strain and risk of ischemic stroke. Results We included 542 patients in the analysis. Mean age was 67.3±8.9 years, 89 (16.4%) were female, and median EuroSCORE II was 1.31 (IQR 0.93–1.96). Patients with LA reservoir strain <27.2% (median) were older, more likely to have diabetes, and had a higher EuroSCORE II. In total, 96 patients (17.7%) developed POAF. During a median follow-up period of 3.7 years (IQR 2.7–4.8 years), 21 (3.9%) patients experienced ischemic stroke. In univariable modeling, LA reservoir strain was significantly associated with ischemic stroke (HR 1.10 (95% CI 1.03–1.18, p=0.003) per 1% absolute decrease). After adjustment for EuroSCORE II, LA volume index (LAVi) and prior stroke, LA reservoir strain remained a significant predictor of ischemic stroke (HR 1.09 (95% CI 1.02–1.17, p=0.011) per 1% absolute decrease and HR 4.24 (95% CI 1.37–13.10, p=0.012) for < vs. >median). Adding POAF as a covariate did not alter the significance of LA reservoir strain in the model. In addition, POAF did not modify the association between LA reservoir strain and POAF (p for interaction = 0.07). The association between LA reservoir strain and ischemic stroke persisted in multiple sensitivity analyses including restricting the analysis to patients with normal left atrial volumes (LAVi <34 ml/m2), patients without POAF, and when excluding patients who developed atrial fibrillation during follow-up. Conclusion In patients undergoing CABG, LA reservoir strain was an independent long-term predictor of ischemic stroke. The predictive value of LA reservoir strain was unaffected by the presence of POAF. Funding Acknowledgement Type of funding sources: None.
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