Criteria For Left Atrial Enlargement Research Articles

ODP151 Hypothyroidism and Cardiac Remodeling in Ischemic Strokes

Abstract Hypothyroidism has been shown to increase the risk of developing cardiovascular disease (CVD), yet the mechanism is not well described. Previous studies correlated hyperlipidemia, diastolic hypertension, and smoking with impaired thyroid function, which serve as independent risk factors for CVD. Our study seeks to understand the prevalence of hypothyroidism in ischemic strokes. We hypothesize that hypothyroidism may exacerbate the severity of co-morbidities accelerating cardiac remodeling and risk for ischemic strokes. Our multi-center retrospective study constructed a database of 646 patients who were admitted over a three year period for a primary diagnosis of ischemic stroke. Detailed chart review excluded patients with known risk factors for ischemic strokes including: atrial-fibrillation, atrial-flutter, prior stroke, carotid artery stenosis, thromboembolic disease, and an active cancer diagnosis. Cardiac remodeling was identified by the hallmark finding of left atrial enlargement (LAE) on transthoracic echocardiogram (TTE) with severity determined as a composite measurement of either left atrial diameter (LAD) or left atrial volume index (LAVI). Inclusion criteria were met by 482 patients (75%), where 349 (54%) were female, 435 (67%) were Caucasian, 390 (60%) had hypertension, 360 (56%) had hyperlipidemia, 291 (45%) were previous or current tobacco users, and 199 (31%) had diabetes. Our preliminary analysis found that 83 (13%) of patients had a diagnosis of hypothyroidism. Of note, TTE reports available for 225 (35%) of patients, wherein 74 (33%) of patients met at least one criteria for LAE. Our initial findings support further subgroup analysis to characterize the significance of hypothyroidism as a comorbidity in the development of ischemic strokes. Further research may identify the individual contribution of hypothyroidism to the severity of cardiac remodeling, as well as the impact of treatment for hypothyroidism in stroke risk reduction. Our preliminary analysis found 74 (48%) of patients met at least one criteria for LAE. Presentation: No date and time listed

Abstract 559: Left Atrial Enlargement In Primary Cryptogenic Strokes Without Atrial Fibrillation

The relationship between left atrial enlargement (LAE) and primary cryptogenic stroke (PCS) remains a mystery. Previous literature found the severity of LAE to be an independent risk factor in cases of PCS, recurrent ischemic strokes, and paroxysmal atrial fibrillation. Our study seeks to further characterize potential risk factors for patients with PCS in the absence of atrial fibrillation. Our multi-center retrospective study constructed a database of 646 patients identified with a diagnosis of cerebral infarction over a three year period. Detailed chart review excluded all patients with known etiologies for PCS including: atrial fibrillation, atrial flutter, prior stroke, systolic heart failure, carotid artery stenosis, thromboembolic disease, previous anticoagulation, or an active cancer diagnosis. Diagnosis of LAE utilized a composite of criteria for transthoracic echocardiogram (TTE) measurements including left atrial diameter (LAD) and left atrial volume index (LAVI). All study criteria were met by 154 patients (24%) for analysis, where baseline characteristics included: 79 (51%) male, 104 (67.5%) Caucasian, 108 (70%) diagnosis of hypertension, 80 (52%) previous or current tobacco users, and 47 (31%) diagnosis of diabetes. Our preliminary analysis found 74 (48%) of patients met at least one criteria for LAE. The mean LAD for patients with and without LAE was 4.1cm and 3.4 cm, respectively (SD .87 vs .55, p<.0001). The mean LAVI for patients with and without LAE was 29.68 mL/m 2 and 18.44 mL/m 2 , respectively (SD 7.37 vs 5.13, p<.0001). Our findings support the significance of LAE as a risk factor for cases of PCS. Multiple risk factors were identified in our study population that reflect the importance of preventative counseling for patients with hypertension, hyperlipidemia, histories of tobacco use, and diabetes. Further research may elucidate whether LAE alone or in the setting of comorbidities warrant universal screening practices or prophylactic therapies to prevent cases of PCS.

Diagnostic accuracy of different electrocardiographic and radiographic criteria for left atrial enlargement as assessed by cardiac magnetic resonance

Diagnostic accuracy of different electrocardiographic and radiographic criteria for left atrial enlargement as assessed by cardiac magnetic resonance

149 Ethnic differences in performance of the 2010 European Society of Cardiology criteria for ECG interpretation in athletes

BackgroundPhysical activity is associated with ECG phenotypes that may overlap with those observed in conditions predisposing to sudden cardiac death. In 2005 the study group of sports cardiology produced guidelines...

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

Background. Left atrial (LA) enlargement is a powerful risk factor for cardiovascular diseases; little information is available about its prevalence and correlates in subjects free of overt cardiac disease seen in echocardiographic practice. Aim. We evaluated the prevalence of LA enlargement (LAE) and the relationship with left ventricular (LV) mass and diastolic function in subjects with preserved LV systolic function referred to an echocardiographic study for routine clinical indications. Methods. 1104 subjects (mean age 58 ± 16 years, 46% men, 57% hypertensives) underwent a comprehensive echo-Doppler examination. LAE and LV hypertrophy (LVH) were defined as LA volume index (LAVI) >29 ml/m2 and LV mass index (LVMI) >50 g/h2.7, respectively. Abnormalities of LV relaxation and LV filling were diagnosed by age-related thresholds of lateral annular velocity (Ei) and by early mitral flow velocity to Ei ratio (E/Ei) ≥16, respectively. Results. Overall, 10% of echocardiographic examinations fulfilled the criteria for LAE, 46% for LVH, 45% for altered LV relaxation and 5% for altered LV filling index. LVH progressively increased from 25% to 75% across LAVI quartiles. More patients in the highest quartile exhibited abnormal indexes of LV relaxation and LV filling compared with lower quartiles. In multivariate analysis, LV mass index (β = 0.408), age (β = 0.188), E/Ei ratio (β = 0.140) and Ei (β = 0.140) emerged as major correlates of LAE (p at least <0.01 for all). Conclusions. LAE is a frequent finding in patients with preserved systolic function seen in current practice; this abnormality is strongly related to LVH and to diastolic dysfunction. Early detection of LAE may identify patients at higher cardiovascular risk and promote appropriate prevention strategies.

Relation of Electrocardiographic Criteria for Left Atrial Enlargement to Two-Dimensional Echocardiographic Left Atrial Volume Measurements

Left atrial (LA) enlargement by 2-dimensional (2-D) echocardiography predicts adverse cardiovascular outcomes. Electrocardiographic (ECG) criteria for LA enlargement are based on M-mode echocardiographic LA diameter, which is inferior to 2-D-derived LA volumes. This study compared established ECG criteria for LA enlargement with atrial volume obtained by 2-D echocardiography to determine if traditional ECG criteria accurately represent LA chamber enlargement, therefore offering a low-cost screening tool. A total of 261 randomly selected patients who underwent electrocardiography and 2-D echocardiography were enrolled. ECG parameters and electronically derived P-wave medians were analyzed with electronic calipers for maximal accuracy. LA volumes by 2-D echocardiography were measured with Simpson's method of discs, with enlargement defined as 32 ml/m(2). Sensitivity and specificity tables and receiver-operating characteristic curves were constructed for each criterion. Univariate and multivariate analyses were performed for predictors of 2-D echocardiographic LA enlargement. LA enlargement was present in 43% of patients. ECG P-wave duration was the most sensitive for the detection of LA enlargement (69%) but had low specificity (49%). Conversely, a biphasic P wave was the most specific (92%) but had low sensitivity (12%). The maximum area under the receiver-operating characteristic curve for any criterion was 0.64, too low to be of clinical utility. In conclusion, established ECG criteria for LA enlargement do not reliably reflect LA enlargement and lack sufficient predictive value to be useful clinically. These results suggest that P-wave abnormalities should be noted as nonspecific LA abnormalities, with the term "LA enlargement" no longer used.

Electrocardiographic Diagnosis of Left Atrial Enlargement

Established scalar electrocardiographic criteria for left atrial enlargement are based on abnormalities of the P-terminal force, total P-wave duration, and the relationship of total P-wave duration to PR-interval duration. These electrocardiographic signs may also result from left atrial hypertension, left atrial hypertrophy, and interatrial conduction defects. This article describes the scalar electrocardiographic criteria for left atrial enlargement in current use, and provides a critical appraisal of their efficacy in diagnosis.

Relationship between Doppler left ventricular diastolic filling indexes and the electrocardiographic criteria for left atrial enlargement

Traditional electrocardiographic (ECG) criteria for left atrial enlargement (LAE) emphasize the increased amplitude and width of the corresponding component of the hypertrophied atrium. Although a correlation exists between LAE and ECG criteria, a cause-and-effect relationship has not been conclusively demonstrated. Because the diastolic properties of the left ventricle directly influence left atrial emptying, these properties might also influence the ECG diagnosis of LAE. Therefore, the authors hypothesized that the ECG criteria for LAE are influenced by diastolic properties of the left ventricle as defined by Dopplerderived parameters.

Electrocardiographic diagnosis of left ventricular hypertrophy in the presence of left bundle branch block

The presence of left bundle branch block (LBBB) on 12-lead ECG may obscure the diagnosis of other ECG abnormalities including left ventricular hypertrophy (LVH). We retrospectively reviewed ECGs of patients with LBBB and LVH as determined by echocardiography to evaluate several ECG parameters as predictors of LVH. ECG evaluation included precordial voltage as measured by the sum of the S wave in leads V 1 or V 2 plus R wave in lead V 6, QRS duration, mean frontal plane QRS axis, R wave amplitude in lead aV L, intrinsicoid deflection, and the presence or absence of criteria for left atrial enlargement. In the presence of LBBB and LVH, precordial voltage was significantly greater ( p < 0.001), QRS duration more prolonged ( p < 0.001), and left atrial enlargement more frequently present ( p < 0.001) than when LVH was not present. There was no difference in limb lead voltage, intrinsicoid deflection, or mean frontal plane QRS axis. Furthermore, the criterion of SV 2 + RV 6 > 4.5 mV demonstrated a sensitivity of 86% and a specificity of 100%. We conclude that a voltage criterion of SV 2 + RV 6 > 4.5 mV is diagnostic of LVH in the presence of LBBB; furthermore, QRS duration of > 160 msec plus left atrial enlargement strongly supports the diagnosis of LVH.

Sensitivity and specificity of commonly used electrocardiographic criteria for left atrial enlargement determined by m-mode echocardiography

To assess the sensitivity and specificity of 6 commonly used electrocardiographic criteria for left atrial (LA) enlargement, the rest ECGs of 99 patients in normal sinus rhythm were analyzed. Fifty-seven of the patients had LA enlargement and 42 had a normal LA dimension as determined by M-mode echocardiography. The 6 criteria studied and their respective sensitivities and specificities were as follows: (1) duration of the negative phase of the P wave in lead V 1 >40 ms: sensitivity, 83%; specificity, 80%; (2) notched P wave in any standard lead with an interpeak duration >40 ms: sensitivity, 15%; specificity, 100%; (3) P terminal force (depth X duration of the terminal portion of the P wave) in lead V 1 more negative than —0.04 mm·s: sensitivity, 69%; specificity 93%; (4) depth of the negative phase of the P wave in lead V 1 >- 1 mm: sensitivity, 60%; specificity, 93%; (5) total P-wave duration >110 ms in any standard lead: sensitivity, 33%; specificity, 88%; (6) total P wave duration/P-R interval duration >1.6: sensitivity, 31%; specificity, 64%. Combining 2 or more of these criteria did not substantially improve sensitivity and specificity.

Assessment of electrocardiographic criteria for left atrial enlargement in childhood

Ninety children, aged 1 day to 18 years (median 7 months), with electrocardiographic or echocardiographic evidence of left atrial (LA) enlargement were selected to determine if electrocardiographic criteria accurately reflected increased LA dimension as determined by echocardiography. Four cardiac defects known to produce LA enlargement were chosen: ventricular septal defect (24 patients), patent ductus arteriosus (25 patients), cardiomyopathy (27 patients) and mitral regurgitation (14 patients). Different electrocardiographic criteria for LA enlargement were assessed. The data indicated that the overall sensitivity and predictive value of the ECG to detect LA enlargement were 40 and 85%, respectively. The ECG and echocardiogram failed to agree in 62% of the patients. The most predictive variable for LA enlargement was the presence of a notched P wave in the limb leads with a large negative terminal deflection in lead V 1. The sensitivity of ECG was highest in patients with chronic LA overload status, in mitral regurgitation (77%), cardiomyopathy (50%) and ventricular septal defect (54% ). The results show that in the pediatric population, electrocardiographic criteria are moderately predictive for LA enlargement but not as sensitive as generally believed.

173 ELECTROCARDIOGRAPHIC-ECHOCARDIOGRAPHIC CORRELATION OF ATRIAL ENLARGEMENT DURING CHILDHOOD

Electrocardiographic(ECG) criteria for left atrial enlargement (LAE) are considered to accurately reflect left atrial dimensions. No data are available correlating left atrial size (LAS) and ECG criteria for LAE in children. ECG and echocardiograms (Echo) of ninety-five patients(pts) (age-1 day to 18y, median 7mos.)were studied to determine if LAE as manifested by four different ECG criteria accurately reflect LAE as determined by LAS and LA/AO ratio on echo, clinical and catheterization data. Four cardiac defects known to cause LAE were selected for study. There were 27 pts with ventricular septal defect(Group 1); 15 pts with mitral insufficiency(Group 2); 25 pts with patent ductus arteriosus(Group 3); and 28 pts with cardiomyopathy(Group 4). Our results show that 1)in pts with no ECG criteria for LAE 67% and 96% had increased LAS and LA/AO ratio on echo respectively. 2)in pts with LAE on ECG 67% and 73% had increased LAS and LA/AO ratio on echo. 3)66% and 57% of pts with increased LAS and LA/AO ratio by echo showed LAE by ECG. 4)with increasing magnitude of LAS by echo, LAE by ECG became more predictive. Overall sensitivity, and predictive value of LAE by ECG criteria were 66% and 67% and for the groups, Gr 1: 100%, 33%, Gr 2: 75%, 90%, Gr 3: 21%, 100%, Gr 4: 81%, and 81% respectively. We conclude that current ECG criteria for LAE in children are not as sensitive or predictive as previously suggested.

Echocardiographic left atrial enlargement. Comparison of vectorcardiogram and electrocardiogram for detection

Standard electrocardiograms (ECG) and Frank vectorcardiograms (VCG) were obtained in 43 consecutive patients in sinus rhythm who had echocardiographic evidence of left atrial enlargement (left atrial internal dimension greater than 4.0 cm; x +/- 1SD = 4.7 +/- 0.5 cm). High gain VCG P loop measurements for the study group were: maximal posterior magnitude, 0.11 +/- 0.03 mv; duration, 106 +/- 14 msec and ratio of maximal posterior to maximal anterior P vector magnitudes, 3.2 +/- 1.4. Thirty of 43 (70%) patients with echocardiographic determined left atrial enlargement had VCGs diagnostic of that condition. Utilizing New York Heart Association criteria for left atrial enlargement, 17 of 43 patients (40%) had ECGs which were diagnostic. Fifteen of 43 (35%) subjects manifested both ECG and VCG criteria for left atrial enlargement and only two patients had diagnostic ECGs and normal VCGs. It is concluded that analysis of high gain VCG P loops provides a 30% higher yield for the diagnosis of echocardiographically determined left atrial enlargement when compared with P wave examination on the standard ECG.

Atrial endocardial activation in man electrode catheter technique for endocardial mapping

The sequence of antegrade atrial endocardial activation was evaluated in 49 patients: 24 with a normal P wave configuration, 15 with electrocardiographic criteria for left atrial enlargement and 14 with a variety of supraventricular arrhythmias. In 17 patients, 6 with and 11 without evidence of the Wolff-Parkinson-White syndrome, retrograde atrial activation sequence was analyzed during ventricular premature beats, junctional rhythm or supraventricular tachycardia. The recording sites included the high mid- and low right atrium the right atrioventricular (A-V) junction and the distal coronary sinus or the left atrium. In patients with normal P waves atrial activation began at either the high or the mid-right atrium and proceeded to the low right atrium and A-V junction and then the coronary sinus. A similar sequence of activation was noted In patients with left atrial enlargement, but activation at the coronary sinus was markedly delayed (77 ± 8 [mean ± standard deviation] versus 112 ± 14 msec, P

Radiological Assessment of Left Atrial Size in Infants

IN ADULT cardioroentgenology, evaluation of selective enlargement of the left atrium rests upon many findings. These include visualization of a double density along the right cardiac border, localized prominence in the “cardiac waist” on the left just below the prominence normally occupied by the main pulmonary artery segment (2), obliteration of the aortic pulmonic window, eleva tion of the left main-stem bronchus, and the selective displacement of the esophagus on the cardioesophagram. Application of the adult criteria of left atrial enlargement in the examination of children under two and a half years of age presents serious difficulties familiar to most pediatricians and pediatric radiologists (4). This is not well clarified in the literature except for passing mention of “false left atrial enlargement” (3). In infants (children under two and a half years of age will be referred to as infants in this report), the double density on the right cardiac border is frequently seen in the normal. An enlarged left atrium is more likely to compress the left main-stem bronchus than elevate it. Therefore, cardioesophagography remains the only accurate method of detecting left atrial enlargement in this age group (short of angiocardiography) and requires critical evaluation. Our purpose is to emphasize the criteria for left atrial enlargement in these infants. Materials and Methods One hundred and twenty esophagographic studies, performed in infants for extracardiac reasons, were reviewed. The supine position was used in all cases. Thirty-six of the 120 examinations were selected for analysis because multiple “spots” of the well filled esophagus had been recorded in each instance. In 19 of the 36, segmental indentation on the esophagus suggesting left atrial enlargement was noted on more than one of the spot-films. In 4 a single spot-film recorded localized indentation, and in 13 no localized indentation was noted on the spot-films. Subsequently, 25 children with no heart disease were subjected to cine-esophagography. Analysis of the frames in each study revealed segmental esophageal indentation, varying from 3 to 25 per cent of the frames. In addition, cine-esophagrams were obtained in 25 children with varying congenital heart lesions. In these, independent evaluation of the left atrial size was made from angiocardiography, electrocardiography, and the physiologic data recorded during cardiac catheterization. Discussion The infant's chest is proportionately shorter and wider than the adult's (5), and in infants the general size and configuration of the heart change from inspiration to expiration considerably more than in adults. Segmental esophageal indentation by a normal left atrium occurs when expiration and atrial diastole coincide. The size of the indentation or the esophageal curve varies during the expiratory event.