Left Ventricular Mass Index Research Articles

Relationship between NT-proBNP, echocardiographic abnormalities and functional status in patients with subclinical diabetic cardiomyopathy

Abstract Background Persons with diabetes are at risk for developing a cardiomyopathy through several pathophysiological mechanisms independent of traditional risk factors for heart failure. Among those with so-called diabetic cardiomyopathy (DbCM), the relationship between natriuretic peptides, cardiac structural abnormalities and functional capacity is largely unknown. Purpose This study aimed to evaluate associations between NT-proBNP concentrations, clinical characteristics, echocardiographic findings, health status and activity, and outcomes from cardiopulmonary exercise testing Methods The Aldose Reductase Inhibition for Stabilization of Exercise Capacity in Heart Failure Trial (ARISE-HF) trial is evaluating the effects of AT-001, a novel aldose-reductase inhibitor in participants with DbCM without a prior history of heart failure (1). Participants were included if they had a known diagnosis of type 2 diabetes and age ≥60 (or ≥45 with a duration of diabetes of ≥10 years or estimated glomerular filtration rate ≤60 mL/min/1.73m2). Participants were required to have evidence of one of: structural cardiac abnormality, elevated cardiac biomarkers, or impaired exercise tolerance, defined as a peak oxygen uptake (VO2) ≤75% of predicted. In this prespecified subgroup analysis of the ARISE-HF trial, 685 participants with baseline echocardiography data, laboratory investigations, and functional assessment were included. Participants were stratified by N-terminal pro-B type natriuretic peptide (NT-proBNP) quartiles, and correlation with echocardiographic and functional parameters were assessed using Spearman correlation test. Results The mean age of participants was 67.4 years and 50% were female. The mean duration of type 2 diabetes was 14.5 years with a mean hemoglobin A1c of 6.98. The median NT-proBNP was 71 (Q1, Q3: 33, 135) ng/L. No association was observed between NT-proBNP concentrations and echocardiographic parameters of either diastolic or systolic dysfunction including global longitudinal strain, left ventricular ejection fraction, left ventricular mass index, left atrial volume index, E/e’, or right ventricular systolic pressure (Figure 1). In contrast, NT-proBNP was significantly correlated with components of the Kansas City Cardiomyopathy Questionnaire (P<0.001), the Physical Activity Scale in the Elderly (P=0.004), duration of cardiopulmonary exercise testing (P<0.001), peak VO 2 (P<0.001), and ratio of minute ventilation/carbon dioxide production (P=0.002; Figure 2). Conclusion Among highly selected patients with subclinical DbCM, elevated NT-proBNP concentrations are associated with worse health status, lower activity levels, and reduced functional capacity, but not with cardiac structural abnormalities. These findings suggest that regardless of cardiac structural abnormalities, biomarker concentrations reflect important deterioration in functional capacity in affected individuals.

Left atrial reservoir strain as a prognostic indicator for cardiovascular events after mitral valvuloplasty

Abstract Background In patients after mitral valvuloplasty (MVP), assessing valve function and heart failure (HF) is crucial for prognostic predictions. Left ventricular diastolic function assessed by transthoracic echocardiography (TTE) plays an important role in the evaluation of HF in general practice. However, post-mitral valve surgery patients are excluded from the left ventricular diastolic function assessment guidelines proposed by the American Society of Echocardiography in 2016 due to their low correlation with left ventricular diastolic function indices. On the contrary, the left atrial reservoir strain (LARS) before MVP is considered as a prognostic factor, reflecting left atrial dysfunction caused by mitral regurgitation. Nevertheless, there are limited reports on the relationship between LARS and cardiovascular (CV) events after MVP. Purpose The study aims to investigate the utility of LARS in predicting CV events after MVP. Methods The study included 249 patients who underwent TTE between January 2011 and January 2023 after MVP at our hospital. Patient background data, including NYHA classification, medical history, medications, blood tests, and TTE data, were collected at the time of follow-up TTE. LARS, left ventricular global longitudinal strain (LV-GLS), and right ventricular free wall strain (RV-FWSL) analysis were performed using a vender-independent external strain analysis software for all patients in the cohort. The primary endpoints were cardiovascular death and HF rehospitalization. The predictor of cardiovascular events was assessed using the Cox proportional hazards model and Kaplan-Meier curve (KMC). Results The mean age was 61±14 years, and 159 patients (64%) were male. The median time from surgery to TTE was 4.8 (1.0-6.8) years, 32 patients (13%) had events within 8.5 (3.7-10.8) years after TTE. The event groups had higher age, NYHA classification, and NT-pro BNP compared to the non-event group. TTE parameters such as left ventricular mass index, left ventricular end-diastolic volume and end-systolic volume were larger, and LV-GLS and LARS were significantly lower in the event group. In multivariate Cox proportional hazards models showed that LARS was also a prognostic indicator even after adjustment for several variables (Table 1). The KMC showed that LARS was associated with events regardless of left atrial volume index (Log-rank p <0.001, chi-square:31.03) (Figure 1). Conclusion LARS was strongly associated with CV events after MVP. We consider LARS to be a useful prognostic indicator after MVP.

Exploring heart failure prevalence and overlooked dimensions: a comprehensive NT Pro-BNP study in high-risk primary care patients

Abstract Background Heart failure (HF) is a prevalent syndrome linked to significant morbidity and mortality, especially in those with comorbid conditions like diabetes, hypertension, and atherosclerotic cardiovascular disease. Early detection and intervention are crucial. Natriuretic peptides, particularly NT-proBNP, are promising biomarkers for identifying at-risk individuals, but their use in primary care settings is not fully understood. Methods This prospective cohort study enrolled 874 participants aged 40 and above with documented risk factors for HF, such as diabetes mellitus, hypertension, metabolic syndrome, obesity, atherosclerotic cardiovascular disease, genetic variants for cardiomyopathy, or exposure to cardiotoxic agents. NT-proBNP levels were measured in blood samples collected at primary care clinics, and participants underwent comprehensive cardiac evaluations at a referral hospital. Clinical characteristics, laboratory findings, electrocardiography, and echocardiography results were recorded. Results The study included 874 patients with at least one risk factor for HF, with a mean age of 62.5 ± 9.1 years and 51.9% female. According to the 2022 AHA/ACC/HFSA HF Guideline, 69.1% were Stage A HF, 21.9% Stage B HF, and 9% Stage C HF. Clinical characteristics, laboratory and echocardiographic findings are shown in Picture 1. The majority had hypertension (71.1%), while other prevalent comorbidities included diabetes mellitus (43.4%), dyslipidemia (35.2%), obesity (27.1%), and atherosclerotic cardiovascular disease (26.2%). Laboratory findings showed a significant decrease in HbA1C, eGFR, LDL, triglycerides, and hemoglobin from Stage A to C HF. Median NT-proBNP levels rose from Stage A to C HF (46.4 pg/mL in Stage A, 219 pg/mL in Stage B, and 268.5 pg/mL in stage C), with 84.8% of Stage B HF patients exhibiting elevated levels. NT-proBNP levels were correlated positively with left atrial volume index, left ventricular mass index, age, E/e’, and estimated systolic pulmonary artery pressure levels. Conversely, NT-proBNP levels showed a negative correlation with estimated glomerular filtration rate and left ventricular ejection fraction. Among Stage C patients, 92.4% had HFpEF. The Picture 2 depicted the study's design and outcomes, providing a comprehensive visual representation. Conclusion NT-proBNP screening in primary care settings identified a substantial proportion of individuals with undiagnosed HF, particularly those in Stage B and Stage C. The high prevalence of HFpEF underscores the need for comprehensive evaluation and management strategies targeting this population. Early detection facilitated by NT-proBNP screening may lead to timely interventions and improved outcomes in individuals at risk for HF.

Impact of systolic coronary flow reversal in patients with aortic stenosis: assessment with transthoracic echocardiography

Abstract Background In patients with aortic stenosis (AS), increased systolic wall stress due to increased afterload reduces systolic coronary flow, often leading to systolic coronary flow reversal (SFR) in epicardial coronary arteries. Purpose We used transthoracic echocardiography (TTE) to evaluate severity of AS, left ventricular function, and coronary flow, and investigated echocardiographic indicators associated with SFR. Methods We prospectively evaluated consecutively presenting patients who visited our valvular heart disease outpatient clinic or were admitted to our hospital for investigation of AS (July 2023 to February 2024). Based on ESC guidelines, severity of AS and the left ventricular function were assessed with TTE. At the same time, TTE was used to measure distal left anterior descending coronary artery flow. SFR was defined as the presence of a reversal coronary flow component in systole. Based on the presence or absence of SFR in coronary flow measurements, patients were classified into SFR+ or SFR− groups. The inclusion criteria were AS of moderate or greater severity, and the exclusion criteria were known coronary stenosis and the inability to assess coronary flow. Results Enrolled 28 patients were classified into SFR+ (7 patients) and SFR − (21 patients) groups. Comparing baseline characteristics between the SFR+ and SFR− groups, although there were no significant differences in left ventricular indicators such as left ventricular mass index, left ventricular ejection fraction, stroke volume index, and E/e’ between the two groups, left ventricular global longitudinal strain was significantly lower in the SFR+ group (12.0±3.1%, 14.9±3.0%, p=0.026) (Table 1). Regarding indexes of AS assessment, aortic valve peak velocity and aortic valve mean pressure gradient values were significantly higher in the SFR+ group than in the SFR − group ([475±68 cm/s, 379±55 cm/s, p<0.001] and [56.2±16.5 mm Hg, 34.8±10.5 mm Hg, p<0.001], respectively) (Table 1). Representative cases show Figure 1. Conclusion The presence of SFR in patients with AS assessed using TTE may be a simple echocardiographic index that may be associated with potential decline in left ventricular function and progression of AS.

Anemia in patients with chronic kidney disease and its association with cardiac abnormalities

Abstract Introduction Chronic kidney disease (CKD) is a pathology characterized by multisystemic comorbidities, predominantly associated with cardiovascular disease and anemia. However, the precise association between the degree of anemia and the development of cardiac abnormalities in patients with CKD undergoing hemodialysis remains unclear. Purpose To determine the association between the degree of anemia and cardiac abnormalities in patients with CKD receiving hemodialysis treatment. Methods A cross-sectional multicenter study that included individuals with CKD undergoing hemodialysis was conducted. Electronic medical records containing information regarding medical conditions and pertinent laboratory parameters was collected, and cardiac function was determined using echocardiography. A Spearman rank correlation analysis was conducted to evaluate the associated between the degree of anemia and echocardiographic parameters, with significant set at p <0.05. Results Ninety-nine individuals were included, with a median age of 48 years. The population was categorized based on hemoglobin (Hb) levels into non/mild anemia (Hb >10 mg/dL) and moderate/severe anemia (Hb <9.9 mg/dL) groups (table). Significant differences were observed in left ventricle (LV) posterior wall thickness (10mm in non/mild vs. 11mm in moderate/severe, p<0.015), left atrial (LA) volume (34 mL/m2 in non/mild vs. 39 mL/m2 in moderate/severe, p<0.007) and left ventricular ejection fraction (LVEF) (59% in non/mild vs. 55% in moderate/severe, p<0.025). Negative correlations (figure) were observed between Hb levels and LV mass index (r= -0.21, p= 0.03) and pulmonary artery systolic pressure (PASP)(r= -0.27, p= 0.006). Conclusion The degree of anemia demonstrated an association with cardiac abnormalities, as evidenced by alterations in echocardiographic parameters such as LVEF, LA volume and PSAP. This study underscores the importance of further prospective investigations to enhance early identification and stratification of anemia in patients with CKD aiming to mitigate further cardiac complications.Clinical demographics tableScatter plots with correlation graphs

Echocardiographic predictors of cardiovascular outcome in heart failure with preserved ejection fraction

Abstract Background The optimal echocardiographic predictors of cardiovascular outcome in heart failure with presereved ejection fraction (HFpEF) are unknown. Purpose We aimed to identify independent echocardiographic predictors of cardiovascular outcome in patients with HFpEF. Methods Systematic literature search of three electronic databases was conducted from date of inception until November 2022. Hazard ratios (HRs) and their 95% confidence intervals (CIs) for echocardiographic variables from multivariate prediction models for the composite primary endpoint of cardiovascular death and heart failure (HF) hospitalization were pooled using a random effects meta-analysis. Specific subgroup analyses were conducted for studies that enrolled patients with acute versus chronic HF, and for those studies that included E/e’, pulmonary artery systolic pressure (PASP), renal function, natriuretic peptides and diuretic use in multivariate models. Results Forty-six studies totalling 20,056 patients with HFpEF were included. Three echocardiographic parameters emerged as independent predictors in all subgroup analyses: Decreased left ventricular (LV) global longitudinal strain (HR 1.24, 95% CI 1.10-1.39 per 5% decrease), decreased left atrial (LA) reservoir strain (HR 1.30, 95% CI 1.13-1.1.50 per 5% decrease) and lower tricuspid annular plane systolic excursion (TAPSE) to PASP ratio (HR 1.17, 95% CI 1.07-1.25) per 0.1 unit decrease). Other independent echocardiographic predictors of the primary endpoint were a higher E/e’, moderate to severe tricuspid regurgitation, LV mass index and LA ejection fraction, although these variables were less robust. Conclusion Impaired LV global longitudinal strain, lower LA reservoir strain and lower TAPSE/PASP ratio predict cardiovascular death and HF hospitalization in HFpEF and are independent of filling pressures, clinical characteristics and natriuretic peptides. These echocardiographic parameters reflect key functional changes in HFpEF, and should be incorporated in future prospective risk prediction models.

Assessment of impact of left ventricular flow state on myocardial blood flow using positron emission tomography and echocardiography

Abstract Background The relationship between left ventricular (LV) mass and myocardial blood flow (MBF) has been recognized as an important physiological measure of myocardial perfusion to match global metabolic demand. However, there is little information on the association between LV flow state and MBF. Purpose To investigate impact of LV flow state on MBF. Methods The study included 104 patients undergoing cardiac positron emission tomography (PET) and echocardiography for chest pain and/or dyspnoea. CT attenuation corrected rest/regadenoson stress 13N-ammonia myocardial perfusion imaging was acquired with a PET CT camera. All images were acquired in 3-D list mode. Sixteen dynamic frames were reconstructed and analyzed with QPET software to obtain rest quantitative MBF measurements adjusted for rate-pressure product in ml/min/g, with a myocardial flow reserve (MFR) derived as the ratio of stress MBF/resting MBF. All patients had no ischaemia or infarction with LV ejection fraction ≥55%. Echocardiography was performed within 6 months of PET in clinically stable conditions allowing for. SV was measured by Doppler echocardiography using the continuity equation and was indexed by body surface area (SVi). The patients were divided to normal flow group (NFS: SVi > 35 ml/m2) and low flow group (LFS: SVi≤35 ml/m2). Results The mean SVi was 40 ml/m2 for NFS and 29 ml/m2 for LFS (p<0.001). LFS group was younger (57 ± 11 vs. 67 ± 11 years, p<0.001) with higher body mass index (43±8 vs. 37±8 kg/m2, p<0.001) and lower resting MBF (0.84±0.22 vs. 1.02±0.34 ml/min/g, p<0.01) than NFS groups. There were no significant differences of hypertension (81% vs. 82%, p> 0.05), LV mass index (82±21 vs. 88±82 g/m2, p>0.05), LVEF (63% vs. 65%, p>0.05) between LFS and NFS groups. SVi was positively associated with MBF as a whole group (r= 0.38, p<0.01). However, this significant association was only observed in NFS group (r=0.62, p <0.001), but not in LFS group (r=0.048, p= 0.46, Figure). Conclusion LFS expressed low MBF and the dissociation between SVi and MBF in comparison with NFS group suggesting potential alterations in relationships between myocardial work (SV) and oxygen consumption (MBF) in LFS. Further studies are warranted to investigate the pathophysiology behind the findings and to correlate with a long-term clinical outcome.

Additive effect of metabolic dysfunction-associated fatty liver disease on left ventricular function and global strain in type 2 diabetes mellitus patients: a 3.0 T CMR feature tracking study

Abstract Purpose Type 2 diabetes mellitus (T2DM) represents the most prevalent form of diabetes, exerting a significant influence on cardiovascular health. Concurrently, metabolic dysfunction-associated fatty liver disease (MAFLD) is closely linked to heightened cardiac dysfunction risk. Our study aimed to explore the additive effect of MAFLD on left ventricular (LV) deformation among T2DM patients, utilizing cardiac magnetic resonance (CMR) feature tracking technology. Methods This study retrospectively included 270 patients with T2DM, comprising 110 individuals with MAFLD and 160 without, alongside 80 age- and sex-matched healthy controls, all of whom underwent CMR examination. Parameters derived from CMR encompass those related to LV function and global strain metrics. LV global strain parameters include global radial peak strain (GRPS), longitudinal peak strain (GLPS), and circumferential peak strain (GCPS), peak systolic strain rate (PSSR), and peak diastolic strain rate (PDSR), measured across radial, circumferential, and longitudinal directions. Intergroup analysis, employing the Mann-Whitney U test, was utilized to compare LV function and global strain parameters. Results The LV function parameters, including LV end-diastolic volume (LVEDV), LVEDV index, LV end-systolic volume (LVESV), LVESVI, LV mass, and LV mass index, displayed a progressive augmentation from controls through T2DM patients without MAFLD, to those with MAFLD. In parallel, LVEF showed a declining trajectory across these groups. In contrast, LVSV and LVSVI were comparable among the three groups. In a similar vein, when examining global strain parameters derived from CMR, a significant and progressive deterioration is observed across the groups. GRPS, GCPS and GLPS, along with PSSR and PDSR in radial, circumferential, and longitudinal directions, manifest a pronounced decline moving from control subjects to T2DM patients without MAFLD, and further deteriorating in those with T2DM and MAFLD (All p-values < 0.05). To assess the effect of MAFLD severity on global peak strain, patients with T2DM and MAFLD were stratified into two groups: a mild MAFLD group (N=77) and a moderate to severe MAFLD group (N=33). Although there was a noticeable decline in GRPS, GCPS and GLPS, as well as in PSSR and PDSR across the three groups—from those without MAFLD to those with mild and then moderate to severe MAFLD—the observed differences did not reach statistical significance. The absence of statistical significance is likely due to the small sample sizes of the groups categorized by severity of MAFLD. Conclusions This study revealed that MAFLD has additive worsening effects on LV function and LV global strains in T2DM patients evaluated by CMR. Besides, moderate to severe MAFLD, compared to mild MAFLD, exhibits worse global strain parameters. Early detection and intervention of MAFLD might improve the prognosis of T2DM patients.

Echocardiographic evaluation of cardiac remodelling in a cohort of patients with heart failure and reduced ejection fraction treated with dapagliflozin

Abstract Background Several mechanisms have been proposed to explain SGLT2 inhibitors’ (SGLT2i) beneficial effects in patients with heart failure (HF), but their exact mode of action in this setting is not fully understood. Pivotal randomised clinical trials regarding this class of drugs in HF setting have not reported echocardiographic data regarding potential cardiac positive remodelling. Objectives To assess the effects of dapagliflozin treatment initiation on cardiac remodelling in patients with HF and reduced ejection fraction (HFrEF), with a focus on left ventricular performance and atrial volumetry. Methods In this retrospective observational study, we analysed data from 94 patients with HFrEF in whom dapagliflozin had been prescribed as part of HF treatment optimization. Inclusion criteria were: age > 18 years; ongoing optimal medical therapy (OMT) for HF according to 2021 ESC HF guidelines (except for SGLT2i); transthoracic echocardiogram within 30 days of baseline assessment demonstrating a left ventricular (LV) ejection fraction (EF) <40%; comprehensive assessment at 6 months with clinical, laboratory and echocardiographic data. Results Patients (mean age 71.7 ± 9.8, 76% males, coronary artery disease as HFrEF main aetiology in 66%) showed significant cardiac remodelling after dapagliflozin initiation, specifically in terms of stroke volume index (SVi, +9.7 ml/m2, p<0.001), LVEF (+5.1%, p<0.001), LV end-diastolic volume (LV EDV) index (-8.4 ml/m2, p<0.001), left atrial (LA) volume index (-3.9 ml/m2, p=0.026), and LV mass index (LVMi, -12.9 gr/m2, p=0.004). BNP tended to significantly decrease (-168.6 ng/L, p=0.025). Percentage of patients with an indication for ICD implantation in primary prevention went from 36.2% to 8.5%, p<0.001. We did not observe significant differences in terms of mitral regurgitation (MR) grading at follow-up (in particular, the proportion of patients with severe MR remained approximately stable: 7% vs 4%, p=0.86). We did not observe any change in diastolic function measured by E/e’ ratio (mean difference -0.6; 95% CI -2.2 to 0.9, p=0.41). Conclusions Treatment with dapagliflozin resulted in positive remodelling in our cohort of patients with HFrEF in terms of chamber volumes, contractility parameters (and this was not explained by an improvement in MR severity) and LVMi. There was a significant decrease in natriuretic peptide as well as in the proportion of patients with primary prevention ICD indication. Our findings highlight the need of further data to fully elucidate the exact mechanism that leads to LA and LV positive remodelling with SGLT2i.Figure 1.Change in TTE Parameters

Left ventricular late diastolic strain rate predicts cardiovascular mortality in patients with heart failure with reduced ejection fraction

Abstract Background Left ventricular (LV) strain rate measures provide detailed information regarding LV contraction and filling pressures. These include global systolic strain rate (GSRs), early and late diastolic strain rates (GSRe and GSRa), and ratio of transmitral early filling velocity to GSRe (E/GSRe). Purpose To investigate the prognostic value of strain rate measures with regard to cardiovascular mortality in patients with heart failure with reduced ejection fraction (HFrEF). Methods The study population was retrospectively included from a HF clinic and consisted of patients with LV ejection fraction (LVEF) ≤45%. Echocardiography was obtained within 1 year of referral. The study endpoint was cardiovascular mortality, which was analysed using univariable and adjusted Cox proportional hazards models. Incremental prognostic information was assessed using Harrell’s C-index and continuous net reclassification improvement (NRI). Cubic spline analysis was used to dichotomise variables at a hazard ratio (HR) of 1 for better interpretability. Results The final study population consisted of 1160 patients with HFrEF (mean age 68±11.8 years, 72.7% male, LV ejection fraction (LVEF) 28.6±9.9%). During follow-up (median 10.1 years, IQR: 4.7-13.0), 333 (28.7%) met the outcome. Subjects who met the outcome generally had higher age and prevalence of male sex, a higher burden of comorbidities, and more severely impaired conventional echocardiographic parameters. All four strain rate measures were significantly associated with cardiovascular mortality (GSRs: HR 16.88 95% CI [8.42, 33.84] per 1 s-1 increase, GSRe: HR 0.29 [0.18, 0.47] per 1 s-1 increase, E/GSRe ratio: HR 1.31 [1.22, 1.41] per 1 unit increase, GSRa: HR 0.15 95% CI [0.23, 0.65] per 1 s-1 increase, p<0.0001 for all). However, only GSRa remained an independent predictor in multivariable Cox regression after adjustment for clinical risk factors including sex, age, mean arterial pressure, heart rate, body mass index, cigarette pack years, diabetes mellitus, total cholesterol, ischemic heart disease, and echocardiographic factors including LVEF, global longitudinal strain, tricuspid annular plane systolic excursion, LV mass index, LV internal diameter index, E/e’ ratio and left atrial volume index (HR 0.39 [0.23,0.65], p=0.0003). Furthermore, GSRa provided incremental prognostic information to a model containing all aforementioned parameters (Harrell’s C-index 0.789 vs. 0.792 and continuous NRI 0.158). GSRa was dichotomised at 0.5 s-1, and a Kaplan-Meier curve stratified according to this was plotted (log rank p<0.0001)(Figure 2). Conclusion GSRa is an independent predictor of cardiovascular mortality in patients with HFrEF after multivariable adjustment. GSRa provides incremental prognostic value over conventional echocardiographic measures in risk stratification of HFrEF patients. Our results suggest an increased risk of cardiovascular mortality associated with a GSRa below 0.5 s-1.Figure 1:Spline of HR according to GSRaFigure 2:Kaplan-Meier curve

Sex differences in the long-term outcomes of moderate rheumatic mitral stenosis

Abstract Background There are limited data on the sex differences in the long-term outcomes of moderate mitral stenosis (MS). Purpose This study aimed to investigate sex differences in long-term outcomes of moderate AS. Methods From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry of 3,140 patients, we included patients with moderate MS (1.5 < mitral valve area ≤ 2.0 cm2) between January 2000 and December 2021 who had not undergone previous percutaneous of surgical treatment of MS. Primary outcomes were a composite of all-cause death, heart failure (HF) hospitalization, ischemic stroke, and mitral valve intervention. We analyzed clinical and echocardiographic variables based on sex. Results A total of 788 patients (mean 62.2 ± 12.9 years, women 74.5%) were followed over a mean duration of 7.0 ± 6.0 years. During follow-up, 287 patients (36.4%) experienced primary outcomes. Women (n=587) had more atrial fibrillation (AF) (p=0.022), higher left ventricular (LV) ejection fraction (EF) (p<0.001), and smaller LV chamber (LV mass index; p<0.001) compared to men. Primary outcomes did not differ for both sexes (p=0.285). However, on the analysis of both sexes according to right ventricular systolic pressure (RVSP), men with elevated RVSP had poorer outcomes (p<0.001) but women did not differ (p=0.238) (Figure 1). On the multivariate Cox regression analysis, elevated RVSP was the only factor that was independently associated with poorer outcomes (hazard ratio [HR], 1.30 [95% CI, 1.10-1.05], p=0.005) in men. However, in women, several factors including older age (HR 1.02, 95% CI 1.00-1.03, p=0.012), presence of AF (HR 2.40, 95% CI 1.66-3.48, p<0.001), decreased LV EF (HR 0.98, 95% CI 0.97-1.00, p=0.007), and higher mean diastolic pressure gradient (HR 1.09, 95% CI 1.01-1.17, p=0.027) showed the independent association with poorer outcome, but not in RVSP (Figure 2). Conclusions In moderate MS, RVSP showed a significant prognostic role in men, but in women, various comorbidities other than that were associated with prognosis. Therefore, different follow-up strategy using specific parameters for each gender would be needed.

Left atrial morpho-functional parameters and their correlation with other phenotypic and functional characteristics of hypertrophic cardiomyopathy

Abstract Background Left atrial (LA) volume index (LAVI), LA reservoir strain (LARS) and total atrial conduction time (TACT) (estimated by tissue Doppler imaging) are morphological and functional parameters reflecting LA structural and electrical remodeling, connected to atrial fibrillation development and heart failure progression in various substrates. In hypertrophic cardiomyopathy (HCM), correlation of the above-mentioned parameters with other disease characteristics is not fully investigated. Purpose Aim of this study was to estimate the prevalence of atrial myopathy characteristics such as increased LAVI, impaired LARS and elongated TACT in a cohort of HCM patients without AF history and investigate their correlation with other phenotypic and functional characteristics of the disease such as left ventricular (LV) hypertrophy magnitude, fibrosis extent and diastolic dysfunction grade. Methods We included 100 HCM patients (54±21 years, 75% male, maximum wall thickness 19±3.4mm) without history of atrial fibrillation who have consecutively undergone 2D-speckle tracking echocardiography and cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). TACT and LARS measurement is shown on left panel. Burden of fibrosis (percentage of LV mass) was defined by LGE extent (>5 standard deviations compared to nulled myocardium) in CMR slices. Results All HCM patients had preserved EF (60±7.5%), while 28 (28%) presented outflow tract obstruction and 10 (10%) diastolic dysfunction stage≥2. LGE was observed in 64 patients (64%) occupying 8±5% of left ventricular (LV) mass. Mean TACT was 140±22 msec, with LAVI being 32±16 mL/m2 and LARS 26±14%. Among HCM demographic, phenotypic and functional characteristics tested, age and LV mass index were found to be the only independent regressors of TACT (r=0.54, p<0.0005 and r=0.44, p=0.002 respectively, right upper panel), while E/E’ (r=-0.44, p=0.003) and fibrosis extent (r=0.36, p=0.02) were the strongest predictors of LARS and LAVI values respectively (right lower panel). Conclusions Atrial myopathy parameters seem to correlate with various morphological and functional characteristics of HCM. Atrial electro-mechanical delay assessed through TDI based TACT correlates significantly with LVMI, whereas LARS and LAVI are strong regressors of elasticity properties, partially expressed through diastolic function and underlying fibrosis.

Trajectories of weight and their impact on cardiac remodeling and function 16 years after bariatric surgery

Abstract Introduction Obesity is a major risk factor for heart failure, particularly heart failure with preserved left ventricular (LV) ejection fraction. Surgical treatment of obesity have significant beneficial short-term effects on weight loss and on cardiac function; its long-term impact on cardiac remodeling and function remains largely unknown. Purpose We examine the long-term effect of bariatric surgery on cardiac remodeling and function in adults with preserved LV ejection fraction. Methods Forty-four individuals with severe obesity [body mass index (BMI) ≥35kg/m2] and preserved LV ejection fraction (≥50%) who underwent bariatric surgery (biliopancreatic diversion with duodenal switch [BPD-DS]) were included. Anthropometric measurements and echocardiography were obtained at baseline, 12 months and 16 years follow-up. Results Mean age of participants (71% female) was 44 ± 8 years and body mass index (BMI) 49.6 ± 6.1 kg/m2. Bariatric surgery led to marked weight reduction and significant improvements in obesity-related metabolic conditions/comorbidities (hypertension, dyslipidemia, type 2 diabetes). Mean percentage of weight loss at 12 months was 37.1 ± 7.0 %. Percentage of weight regain at 16 years averaged 8.9 ± 35.0 %. Bariatric surgery was associated with a significant reduction in indexed LV mass and LV hypertrophy (p <0.01), and improvement in LV diastolic function parameters (p <0.01) at 12 months. In many participants, cardiac remodeling parameters deteriorated at 16 years follow-up compared to the echocardiographic measurements taken at 12 months post-surgery. Prevalence of LV diastolic dysfunction increased at 16 years (81 vs. 38%; p<0.001), even after adjusting for age. Weight regain at 16 years (regaining >10% of weight lost; n=25; 57%) was not found to be associated with a worsening in cardiac remodeling compared to those who maintained weight loss, except for indexed LV mass (-9.3 ± 10.6 vs. -5.5 ± 7.8 g/m2.7; p=0.04) and LV end-diastolic diameter (-5.4 ± 4.0 vs. -3.5 ± 3.3 cm; p=0.01). Conclusion Bariatric surgery (BPD-DS) leads to durable long-term weight loss. Weight regain following bariatric surgery does not appear to have adverse effect on cardiac remodeling and function. Surgical treatment of obesity may be an effective and safe way to prevent clinical cardiac dysfunction and heart failure related to obesity.

Association between objectively-measured sleep duration and early cardiac and hepatic imaging changes in adolescents: insights from the EnIGMA study

Abstract Introduction Inadequate sleep duration (SD) has been associated with adverse cardiovascular (CV) events in adults and adiposity in all life stages. Furthermore, previous cross-sectional studies have shown a possible association between self-reported SD and cardiac structural alterations as detected with echocardiography and cardiovascular magnetic resonance (MR), even in young healthy people. However, there is a lack of longitudinal studies demonstrating an association between objectively-measured SD and structural cardiac alterations. Purpose To assess the association between SD and MR-derived cardiac and hepatic parameters in adolescents. Methods This study used longitudinal data collected as part of the SI! Program for Secondary Schools trial in Spain (2017-2021), which enrolled 1326 participants (mean age: 12.5±0.5 years at baseline). Measurements were taken at three different time-points: baseline, 2-year follow-up and 4-year follow-up. SD and physical activity were assessed by accelerometry for seven consecutive days at each follow-up. The participants were offered to undergo a MR scan in the final follow-up as part of the Early imaging markers of unhealthy lifestyles in adolescents (EnIGMA) study. The imaging protocol included a cine SSFP to provide images for chamber size and function, myocardial tagging acquisitions to assess myocardial strain, T1 and T2 mapping sequences to provide precise myocardial relaxation time properties, and a liver mDixonQuant sequence to obtain liver fat content, using a 3-T scanner. The cumulative effect of the independent variable (SD) and the covariates was assessed using the area under the curve (AUC) method, calculating the integral of the curve parameters during the follow-up period for each subject. To facilitate interpretation, AUC values were divided by the years of follow-up. The participants were included in the analysis if they had available data for SD in at least 2 of the 3 time-points. The association between SD and the MR parameters was assessed by linear regression models. Results 109 participants (61 girls [56.0%]; mean age=16.0±0.5 years) were included in this study. Indexed left ventricular (LV) mass, as well as indexed end-diastolic biventricular volumes were higher in boys than in girls (Figure 1). SD AUC (hours/day) was independently and inversely associated with indexed LV mass and liver fat fraction in the unadjusted and adjusted (age, gender, physical activity, body mass index percentile, and systolic and diastolic blood pressure percentiles AUCs) models (Figure 2). There were no significant associations between the SD AUC and other MR-derived parameters. Conclusion Shorter SD is independently associated with initial stages of cardiac remodeling and liver fat accumulation as assessed with state-of-the-art MR as early as in adolescence. Considering these results, health promotion programs should be implemented early in life emphasizing the importance of good sleep habits.Participant characteristicsAssociation between SD and MR

Chronic inflammation is associated with impaired cardiac structure and function in patients with inflammatory arthritis: the ARTCADIA Study

Abstract Background Inflammation as an underlying cause of cardiac dysfunction has been underscored in recent years. Patients with inflammatory arthritis (IA) are at risk of being exposed to a high degree of chronic and systemic inflammation. It is therefore important to investigate whether high inflammatory burden impacts cardiac structure and function in patients with IA. Purpose To examine the impact of long-term inflammation on measures of cardiac structure and function in individuals with rheumatoid arthritis (RA) and axial Spondyloarthritis (axSpA), collectively referred to as IA, in a large cohort. Methods In a prospective cohort study, outpatients with a diagnosis of IA were included over two years during their biannual rheumatological routine appointment. In total, 1,285 participants were included. Participants were evaluated at a cardiology research center where echocardiography was performed following a pre-defined protocol. To evaluate chronic inflammation, C-reactive protein (CRP) was averaged from clinical outpatient visits registered in a rheumatological database. Uni- and multivariable linear regressions were used to examine the relationship between echocardiographic measures and log-transformed CRP. Results Among the 1,285 participants, 903 (70%) were diagnosed with RA, 358 (28%) with axSpA, and 24 (2%) with other forms of IA. Mean age was 60 ± 13 years, 64% were female. The median number of outpatient visits was 30 (Interquartile range (IQR): 18 - 48), median disease duration was 12 (IQR: 6 - 20) years, and the median outpatient CRP was 5.7 (IQR: 3.7 – 9.8) mg/L. 519 (40%) patients had hypertension (HT), 113 (9%) diabetes mellitus (DM), 76 (5.9%) ischemic heart disease (IHD) and 35 (2.5%) heart failure (HF). Mean left ventricular (LV) ejection fraction was 54.6 ± 5.7%, mean numerical global longitudinal strain (GLS) was 17.8 ± 2.4%, mean LV mass index (LVMi) was 73 ± 18 g/m2 and mean tricuspid annular plane systolic excursion (TAPSE) was 2.5 ± 0.4 cm. In univariable analyses, higher levels of CRP were significantly associated with lower GLS, p < 0.001; higher E/e’, p = 0.001; higher LVMi, p < 0.001 and lower TAPSE, p = 0.005 (Figure). The associations remained significant after adjusting for clinical characteristics including disease duration, age, sex, blood pressure, body mass index, physical activity, pack-years of smoking, cholesterol, HT, DM, heart rate, atrial fibrillation, IHD and HF (p < 0.05 for all associations). We observed no significant interactions between the IA diagnosis and inflammation across the significant echocardiographic measures. Conclusion In a large cohort of patients with IA, increasing levels of chronic inflammation determined by outpatient CRP was associated with impaired measures of cardiac structure and function and remained significant after adjusting for clinical characteristics. The prognostic and clinical implication of these findings needs to be explored in future studies.Linear regression splines

Echocardiographic and clinical features of patients developing prosthesis-patient mismatch after TAVI: insights from an international multicenter registry

Abstract Background The impact of prosthesis-patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI) is controversial. Purpose Our study aims to evaluate the impact of PPM on mortality and clinical-echocardiographic progression of cardiac damage in a "real world" cohort of patients at intermediate and low surgical risk and to characterize its main predictors. Methods 963 patients who underwent TAVI procedure between 2017 and 2021, from an international multicenter observational registry, were included in this analysis. Multiparametric echocardiographic data were analyzed at 1-year follow-up (FU). Clinical and echocardiographic features were stratified by presence of PPM and PPM severity, as per the most current international recommendations (VARC-3 criteria). Results 18% of patients developed post-TAVI PPM, (7.7% of the whole cohort severe). At baseline, 50.3% of patients with PPM were male (vs 46.2% in the cohort without PPM, p=0.33), aged 82y (interquartile range (IQR) 79-85y) vs 82y (IQR 78-86y; p=0.46), and 55.6% had Balloon-Expandable valves implanted (vs 46.8% of patients without PPM, p=0.04); they had smaller left ventricular outflow tract (LVOT) diameter (20mm, IQR 19-21 vs 20mm, IQR 20-22, p=0.02), reduced Stroke Volume index (SVi) (34.2 vs 38 ml/m2, p<0.01) and transaortic flow rate (190.6 vs 211 ml/s, p<0.01). At pre-discharge FU patients with PPM had more paravalvular aortic regurgitation (AR) (moderate/severe AR 15.8% vs 9.2%, p<0.01). At a median FU of 1.46 years (IQR 1-4), there was no evidence of a significant impact of PPM on overall mortality (15.3% vs 13.1%, p=0.46) nor on rehospitalization rate for heart failure (4.3% vs 8.0%, p=0.10). At 1-year FU, maladaptive alterations of left ventricular parameters were found in patients with PPM, with a significant increase in endsystolic diameter (ESD) (33 vs 28mm, p=0.03) and a statistically non-significant increase in LV mass index (121 vs 106g/m2, p=0.07). Interestingly, trajectory parameters of patients with PPM from baseline to 1-year FU showed a reduced cardiac remodeling compared to patients without PPM, including no LVEF improvement (p=0.88), absent reduction of LV end-diastolic volume (p=0.70), indexed LV mass (p=0.31), ESD (p=0.48) and pulmonary artery systolic pressure (p=0.82), and an increase of basal RV diameter (p<0.001). Patients with moderate/severe PPM had worse NYHA functional class at 1 year (NYHA III-IV 13% vs 7.8%, p=0.03). Independent predictor of PPM at multivariable logistic regression was male gender (OR=1.93, p=0.04); while SVi (OR=0.86, p<0.001), prosthetic size >23mm (OR=0.62, p=0.03) and LVOT diameter (OR=0.79, p=0.02) had protective effect. Conclusions There was no evidence of a short- or medium-term impact of PPM on mortality. However, clinical-echocardiographic evaluations demonstrated a PPM-related pattern of early ventricular maladaptive alterations associated with a significant deterioration in NYHA class at 1 year.

Cardiac structural, functional remodelling, and perfusion impairments across the spectrum of aortic stenosis

Abstract Background Aortic stenosis (AS) accounts for substantial global morbidity and premature mortality even in moderate AS (Mod-AS). Whilst myocardial remodeling response is considered critical in the adverse prognosis of Mod-AS, the precise mechanisms remain poorly understood. We aimed to prospectively assess myocardial remodeling, perfusion and energetics differences in Mod-AS and severe AS (Severe-AS). Methods Fifty-two Severe-AS and 25 Mod-AS patients and 18 demographically-matched controls underwent cardiovascular magnetic resonance and phosphorus-magnetic resonance spectroscopy to define left ventricular (LV) mass and function, global longitudinal shortening (GLS), rest and adenosine-stress myocardial blood flow (MBF), myocardial perfusion reserve (MPR), layer-specific perfusion metrics (subendocardial [Endo], subepicardial [Epi] MBF and MPR, and Endo-Epi-MBF ratio [Endo/Epi]), myocardial scar on late gadolinium enhancement (LGE) imaging, and myocardial energetics (phosphocreatine:ATP ratio [PCr/ATP]). Results Compared to controls, with increasing AS severity, there was progressive increase in LV concentricity (LV mass-index (controls: 46[40,51],Mod-AS:58[51,65],Severe-AS: 70[65,75]g/m2; P<0.0001), and stepwise decline in GLS (controls:19.9[17.6,22.2], Mod-AS:17.7[16.6,18.8], Severe-AS:13.4[12.5,14.4]%; P<0.0001) with significant differences between Mod-AS and Severe-AS in all three comparisons. Both stress MBF(controls:2.1[1.9,2.3],Mod-AS:1.9[1.6,2.2],Severe-AS:1.3[1.2,1.5]ml/min/g; P<0.0001) and MPR(controls:3.3[2.8,3.6],Mod-AS:2.8[2.4,3.2], Severe-AS:1.9[1.8,2.1]; P<0.0001) were only significantly reduced in Severe-AS compared to controls, with significant differences also detected between Mod-AS and Severe-AS. However, stress-endo-MBF (controls:2.0[1.8,2.3], Mod-AS:1.7[1.5,2.0], Severe-AS:1.2[1.1,1.3]ml/min/g; P<0.0001), stress-Endo/Epi(controls:1.00[0.93,1.07],Mod-AS:0.87[0.80,0.94],Severe-AS:0.81[0.75,0.82];P<0.0001), rest-Endo/Epi (controls:1.12[1.10,1.14], Mod-AS:1.06[1.03,1.09], Severe-AS:1.03[1.02,1.06]; P<0.0001) and endo-MPR (controls:3.2[2.7,3.6],Mod-AS:2.5[2.1,2.9],Severe-AS:1.7[1.5,1.8]; P<0.0001) were all significantly reduced in both Mod-AS and Severe-AS. Compared to controls, both AS groups showed significantly lower PCr/ATP (controls:2.2[2.0,2.3],Mod-AS:1.8[1.6,2.0],Severe-AS:1.7[1.6,1.8]; P<0.0001). Only the Severe-AS group had evidence of non-ischemic myocardial scarring on LGE (2.9[0.0,6.2]%), which was detected in 65%(n=34) of patients. AS severity (peak aortic valve velocity) correlated with stress-MBF (r=-0.45, P=0.0003), MPR (r=-0.44, P=0.0005) and GLS (r=-0.47, P=0.0001). Conclusions Moderate and severe-AS are both associated with cardiac concentric hypertrophy, reductions in myocardial energetics, and subendocardial hypoperfusion. Patients with Severe-AS exhibit a more pronounced phenotype with worse LV hypertrophy, contractile dysfunction and myocardial scarring compared to Mod-AS patients.

Latent class analysis reveals a novel phenotype of heart failure that spans the left ventricular ejection fraction range

Abstract Background It is increasingly evident that heart failure (HF) represents a heterogenous syndrome rather than a single clinical entity. The elusiveness of effective therapies for heart failure with preserved ejection fraction (HFpEF) has led to a consensus that our current, unidimensional construct of HF using only left ventricular ejection fraction (LVEF) does not adequately capture the multiplicity of the disease states. The ability to harmonize echocardiographic data from multiple sources has enabled use of unsupervised cluster-based analysis to identify multidimensional cardiac structural phenotypes. Purpose To identify cardiac structural phenotypes of HF across the LVEF spectrum. Methods We harmonized echocardiographic data from eight randomized clinical HF trials (ESCAPE, EXACT-HF, FIGHT, I-PRESERVE, NEAT-HFpEF, RELAX, STICH and TOPCAT), which included both HFrEF and HFpEF populations (total n=4223 echocardiograms). These studies collectively spanned the years 2000 through 2015 and represent a balanced LVEF distribution. Latent class analysis (LCA) was performed iteratively to identify predominant structural phenotypes using LVEF, RV function, LV end diastolic volume, LV mass index, eccentricity, mitral valve deceleration time, and lateral E/e’ ratio. Results LCA identified 4 echocardiographic phenotypes. Three phenotypes skewed toward either high or low EF, but one phenotype demonstrated a relatively even distribution of patients with HFrEF, heart failure with mildly reduced ejection fraction (HFmrEF) and HFpEF (36.0%, 21.4% and 42.7%, respectively). Patients in this phenotype had preserved RV function and left ventricular hypertrophy (97%), of which 56.8% had concentric and 43.2% eccentric LVH. E/e’ was normal in 63% of subjects. A vast majority (91%) of patients had recent-onset HF (diagnosed within the past year). There were no remarkable distinguishing comorbidities. Notable differences in biomarker profile included higher levels of troponin I, cyclic GMP and lower levels of neurohormones (aldosterone, endothelin-1, dopamine, and norepinephrine) than the other phenotypes. Conclusions This is the first cluster-based analysis to identify a quantitative structural HF phenotype of HF that is not distinguished by LVEF. While the underlying pathophysiology is unclear, most patients have recent onset HF and biomarker profiles with relatively low neurohormone activity. These features may reflect a distinct pathophysiology that could indicate a specific, targeted intervention.

Insights from the assessment of anatomic valve orifice area after transcatheter aortic valve implantation using transesophageal echocardiography

Abstract Background Although transthoracic echocardiography (TTE) is the gold standard for evaluating effective valve orifice area (EOA) after transcatheter aortic valve implantation (TAVI), the continuous formula is inherently different from anatomic valve orifice area because it implies a minimum jet width through the aortic valve. It has also been reported that the doppler method with TTE overestimates the mean gradient due to pressure recovery and is even less accurate after TAVI. On the other hand, recent technological developments have improved image resolution, making valve morphology possible using transesophageal echocardiography (TEE). Purpose The purpose of this study was to compare transcatheter aortic valve (TAV) area using TEE and TTE to evaluate whether there is a significant difference in each area and to explore factors that influence the difference in area. Methods Patients who underwent TEE-guided TAVI and SAPIEN3 implantation between February 2019 and March 2023 and had aortic valve evaluation with TTE before discharge were included. We retrospectively evaluated the TAV after TAVI using TTE and TEE. Aortic valve orifice area was calculated by two methods: EOA index (doppler-area: DA) calculated by the continuous doppler formula using TTE and t-AVA index (trace-area: TA) derived by the trace method using TEE. TAV tracing was performed in early systole on the short-axis image of the aortic valve. The TAV tracing was performed by physicians specializing in echocardiography, and multiple physicians were blinded to the same case to eliminate inter-rater error. The percentage change between the two groups was calculated from the difference in area by TTE and TEE, and the 75th percentile of the percentage change was defined as the cutoff value for the group with the large difference in TAV area. Results Patients whose TAV was difficult to observe by TEE were excluded, and 464 patients were finally analyzed. TA was significantly larger than DA (1.56±0.28 cm2/m2 vs 1.18±0.26 cm2, p<0.001) and similar for all TAV sizes. However, even though TA expanded as valve size increased, the largest area of DA was observed in the 26mm TAV, and the 29mm TAV was comparable to the 26mm TAV. Only a weak correlation was shown between DA and TA (correlation coefficient: 0.356). There were 43 cases of moderate prosthetic valve-patient mismatch (PPM: EOA-i<0.85cm) in DA, but only 1 case in TA. In multivariate logistic regression analysis, women (OR 2.25, 95% CI 1.17-4.34, p < 0.015) and LV mass index (OR 1.01, 95% CI 1.00-1.02, p < 0.041) were independent factors for the large difference in TAV area. Conclusion After TAVI, the TAV area with TEE was larger than the EOA-i with TTE, and PPM was rarely seen. Depending on valve size, patient background, and cardiac morphology, there are cases of overestimation of postoperative AS in TTE, which may need to be carefully evaluated in women and patients with larger LV mass index.

Impact of changes in left heart geometry on predicting new-onset atrial fibrillation in patients with hypertension

Abstract Background Hypertension-induced left ventricular hypertrophy (LVH) increases end-diastolic LV pressure and contributes to left atrial enlargement (LAE), which are associated with development of atrial fibrillation (AF). However, the impact of LVH and LAE and their regression following antihypertensive therapy on AF incidence remains unclear. Purpose This study aimed to investigate the impact of changes in the LVH and LAE status on the occurrence of new-onset AF (NOAF). Methods This retrospective analysis included patients with sinus rhythm who underwent echocardiography at hypertension diagnosis and after 6–18 months. LVH was defined as LV mass index >115 g/m2 (men) and >95 g/m2 (women), and LAE was defined as LA volume index >42 ml/m2. LVH and LAE regression was defined as the absence of LVH and LAE on follow-up echocardiography, respectively. The occurrence of NOAF was assessed in relation to changes in LVH and LAE status. Results Among the 1,464 patients included in the study, 163 (11.1%) patients developed NOAF during a median follow-up of 63.8 months (interquartile range, 35.9–128.5 months). On average, 12 electrocardiograms per patient were reviewed for AF detection. New-onset LVH (adjusted HR 1.88, 95% CI 1.20–2.94, P=0.006) and LAE (adjusted HR 1.89, 95% CI 1.05–3.40, P=0.034) were significant predictors of NOAF. Conversely, regression of LVH (adjusted HR 0.51, 95% CI 0.280.91, P=0.022) or LAE (adjusted HR: 0.30, 95% CI 0.15–0.63, P=0.001) after antihypertensive therapy was associated with a reduced risk of NOAF. The risk of NOAF was higher in patients with LVH and LAE together (adjusted HR 4.30, 95% CI 2.81–6.56, P<0.001) than in those with either LVH or LAE, or those with neither, as determined by follow-up echocardiography. Conclusion In patients with hypertension and sinus rhythm, regression of LVH and LAE following antihypertensive therapy is associated with a decreased incidence of NOAF, whereas newly developed LVH or LAE is associated with a higher risk of NOAF. The changes in left heart geometry can serve as a predictive marker for NOAF in patients with hypertension.