Left Atrial Abnormality Research Articles

Left Atrial Dilation and Risk of One-Year Readmission after Embolic Stroke of Undetermined Source

Background: Structural left atrial and ventricular abnormalities on the electrocardiogram (ECG) and transthoracic echocardiogram (TTE) at the time of ischemic stroke have been associated with morbidity and mortality. Yet, the prognostic impact of the same in embolic stroke of undetermined source (ESUS), a relevant subtype of ischemic stroke with a unique pathophysiology, has not been well studied to date. Our aim was to assess the predictive impact of left atrio-ventricular ECG and TTE abnormalities on one-year hospital readmission after ESUS from an ongoing single center prospective stroke registry in the U.S. Methods: We identified 369 ESUS patients who had at least 1 year of complete follow-up between 2013 and 2018. We examined the association of abnormal left atrio-ventricular findings on ECG and TTE, as well as basic demographic and clinical characteristics, measured at index admission with time to 1-year hospital readmission using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards regression. Results: Recurrent ischemic stroke and cardiovascular causes constituted 60% of all readmissions. Patients with left atrial dilation on TTE were more likely to readmitted within 1 year (HR 1.51; 95% CI, 1.04–2.21). Bundle branch block, pathologic Q-wave, and troponin elevation curves diverged, but were not significantly associated with readmission (log-rank p=0.34, p=0.08, p=0.42, respectively). Conclusions: Following ESUS, left atrial dilation on TTE was associated with 1-year overall hospital readmission, of which cardiovascular and cerebrovascular ischemic events, and heart failure were a notable proportion. Our data support ongoing studies of atrial cardiopathy in ESUS patients.

Electrocardiogram and left atrial abnormality: Design of an observational study to clarify diagnostic criteria.

BackgroundThe criteria applied for diagnosis of left atrial (LA) abnormality using electrocardiogram (ECG) have high specificity but low sensitivity. In fact, some authors have suggested classifying P‐wave anomalies associated with LA abnormality and interatrial block as “atrial abnormalities.” The most widely known ECG criteria for LA abnormality include P‐wave duration, morphology and voltage of P wave in inferior leads, presence of P‐wave terminal force in V1 (PtfV1), and P‐wave axis and area. PtfV1 has also been reported to vary according to misplacement of the V1 and V2 electrodes.MethodsThe objective of this observational cohort study is to determine the degree of correlation between ECG criteria for LA abnormality and left atrium volume and functionality, as determined by speckle tracking echocardiography. The study also aims to investigate the correlation between these echocardiographic parameters and PtfV1 value by placing the V1 and V2 electrodes in the second, third, and fourth intercostal spaces.Results and ConclusionsOur results could help to clarify whether the decrease in left atrial deformity, which is currently considered a surrogate target of fibrosis, correlates better with ECG criteria for LA abnormality than atrial volumes.

Electrocardiographic and Echocardiographic Findings in Patients Older than 60 Years: A One Year Pilot Study

Background: Cardiovascular disease (CVD) is the most frequent diagnosis in elderly people and is the leading cause of death in both men and women older than 65 years of age. Age-related vulnerability to CVD is compounded by the cumulative effect of the normal aging process and cardiovascular risk factors over a lifetime. The study assessed the prevalence of electrocardiographic and echocardiographic abnormalities in patients older than 60 years at the geriatric unit of the University of Port-Harcourt Teaching Hospital.
 Methods: A cross-sectional study was conducted over 50 patients admitted to the geriatric ward over one year. The subjects underwent blood pressure and anthropometric parameters clinical examinations. Evaluation of the cardiovascular system was done using resting electrocardiogram and echocardiography.
 Results: The mean age of the subjects was 68.3±6.3 years with a female preponderance. Out of the 50 studied patients, 44 were admitted with a diagnosis of heart failure (HF). Preserved ejection fraction was present in 27 out of the 44 patients admitted for HF. Forty-seven patients had an abnormal LV geometry ranging from concentric remodeling to eccentric LV hypertrophy. Diastolic dysfunction was present in majority of the respondents 42 (84%). Resting ECG showed varying degrees of rhythm disturbances. Sinus tachycardia, bradycardia and left anterior fascicular blocks were the most prevalent rhythm disorders. Electrocardiographic LVH and left atrial abnormalities were present in 21 and 27 patients respectively. Prolonged QTc was present in only 4 patients.
 Conclusion: Electrocardiographic and ultrasound abnormalities are common in elderly patients and this also reflects the high prevalence of CVD in these groups of patients. Thus, resting ECG and ultrasound should routinely be incorporated as one of the baseline assessments for elderly patients to identify potentially serious heart conditions and also serves as a basis for comparison during subsequent hospitalization.

Left atrial enlargement and its association with left atrial strain in university athletes participated in 2015 Gwangju Summer Universiade.

Intensive and repetitive athletic training may result in cardiac geometric changes, but the determinants of left atrial (LA) enlargement (LAE) has been poorly studied. We investigated incidence and determinants of LAE and its association with LA strains in highly trained university athletes. A total of 1073 athletes (451 females, 22.4 ± 2.4 years old) who were able to measure LA size, volume, and strains during 2015 Gwangju Summer Universiade were enrolled. LAE was defined as the increased LA volume index > 42 mL/m2. LA strains, reservoir, conduit, and contractile were measured by 2D speckle tracking method, and LA reservoir strain < 27.6% was considered as abnormal. LAE was developed in 205 athletes (19.1%). In univariate analysis, male [odds ratio (OR) = 1.679], Caucasian (OR = 1.746), non-African descent (OR = 1.804), body muscle mass (OR = 1.056), body fat mass (OR = 0.962), systolic blood pressure (OR = 1.012), heart rate (OR = 0.980), sports type with cardiovascular (CV) demand (OR = 1.474), training time (OR = 1.011), left ventricular (LV) global longitudinal strain (LVGLS, OR = 0.906), and LV stroke volume (LVSV, OR = 1.044) were significantly associated with LAE. In multivariate logistic regression analysis, heart rate (OR = 0.961) and sports type with CV demand (OR = 1.299), LVGLS (OR = 0.865) and LVSV (OR = 1.013) were independent determinants of LAE. Abnormal LA reservoir strain was noted in 56 athletes (5.2%), and the incidence of abnormal value was not different between two groups; 42 athletes (4.8%) in LAE vs. 14 (6.8%) in no LAE group (P = 0.293). LAE was common in university athletes (19.1%) and associated with heart rate, sports type with CV demand, LVGLS, and LVSV. Although LAE was significantly associated with the lower LA reservoir strain, the incidence of abnormal value was very low (5.2%) and indifferent between LAE and no LAE group.

Central role of left atrial dynamics in limiting exercise cardiac output increase and oxygen uptake in heart failure: insights by cardiopulmonary imaging.

In heart failure (HF), the haemodynamic response to exercise in relation to left atrial (LA) dynamics is unexplored. We sought to define whether abnormal LA dynamics during exercise may play a role in cardiac output (CO) limitation and tested its ability to predict outcome. A total of 195 HF patients with reduced (n = 105), mid-range (n = 48), and preserved (n = 42) left ventricular ejection fraction (LVEF) and 46 non-cardiac dyspnoea (NCD) subjects underwent cardiopulmonary imaging with assessment of LA strain and strain rate (sra). HF patients, irrespective of LVEF, exhibited a significantly impaired LA strain and LA sra at rest, during exercise and recovery compared to NCD subjects with a blunted response in CO and right ventricular to pulmonary circulation coupling. LA strain and LA sra during exertion were significantly correlated with peak stroke volume index, peak CO and peak cardiac power output (R = 0.33, 0.48, 0.50 and R = 0.36, 0.51, 0.52 for LA strain and LA sra, respectively; all P < 0.001). In HF, after adjustment for age, gender, left atrial volume index, peak mitral regurgitation > 2, peak LVEF and peak heart rate, a higher LA strain (1% increase) during exercise was associated with a higher peak stroke volume index (mL/m2 ), CO (L/min) and cardiac power output (mmHg L/min) at multivariable analyses (β-coefficients ± standard error = 0.23 ± 0.07, 0.046 ± 0.014 and 0.012 ± 0.004, respectively; P < 0.05). The same associations were found also for LA sra (absolute value) (1/s increase, β-coefficients ± standard error = 1.91 ± 0.68, 0.43 ± 0.14 and 0.12 ± 0.04, respectively; P < 0.05). Exercise LA strain (adjusted hazard ratio 0.94, 95% confidence interval 0.92-0.97, P < 0.001) and LA sra (adjusted hazard ratio 0.60, 95% confidence interval 0.43-0.84, P = 0.003) were associated with a worse outcome after adjusting for age and gender. In HF, LA dynamics may play a key role in exercise CO increase due to an impaired forward (left ventricular filling) and backward (right ventricular to pulmonary circulation uncoupling) combination of mechanisms, irrespective of LVEF. The blunted LA strain and LA sra reserve during exercise are associated with a worse cardiopulmonary performance and outcome.

Early detection of left atrial and bi-ventricular myocardial strain abnormalities by MRI feature tracking in normotensive or hypertensive T2DM patients with preserved LV function

BackgroundPrevious studies have found that impaired global myocardial systolic strain is associated with cardiovascular events in T2DM patients. However, the effect of hypertension (HT) on left atrial (LA), right ventricular (RV) and left ventricular (LV) myocardial deformation in hypertensive T2DM patients has not been fully studied by cardiac magnetic resonance feature tracking (CMR-FT). Our aim was to assess LA, RV and LV strain in T2DM patients with T2DM-HT and without hypertension using CMR-FT and to determine the underlying relationships with clinical parameters.MethodsA total of 27 T2DM patients, 23 T2DM-HT patients and 31 controls were studied. LA, LV and RV strain was evaluated using CMR-FT. The clinical and biochemical parameters of the patients were collected.ResultsThe T2DM patients had reduced LA global circumferential strain (LAGCS), radial strain (LAGRS), longitudinal strain (LAGLS) and right ventricular longitudinal strain (RVGLS) compared with the controls (LAGCS: 27.2 ± 2.1% vs 33.5 ± 2.4%; LAGRS: − 28.6 ± 1.1% vs − 31.9 ± 1.3%; LAGLS: 24.3 ± 1.3% vs 31.4 ± 1.5; RVGLS: − 21.4 ± 1.2% vs − 26.3 ± 1.1%, p < 0.05 for all). The T2DM-HT patients had greater LAGCS, LAGRS and LAGLS than the T2DM patients (LAGCS: 40.4 ± 3.8% vs 27.2 ± 2.1%; LAGRS: − 36.8 ± 2.0% vs − 28.6 ± 1.1%; LAGLS: 32.3 ± 2.4% vs 24.3 ± 1.3%, p < 0.05 for all). In the diabetic patients, LAGCS was associated with microalbuminuria levels (standardized ß = − 0.289, p = 0.021), and LAGCS, LAGRS and LAGLS were correlated with diuretic treatment (standardized ß =0.440, − 0.442, and 0.643, p < 0.05 for all).ConclusionsCMR-FT may be considered a promising tool for the early detection of abnormal LA and RV myocardial strain. LA and RV strain values are impaired in T2DM patients. The amelioration of LA strain might be associated with hypertensive compensation or antihypertensive treatment, which requires to be confirmed in larger trials.

Electrocardiographic Left Atrial Abnormality and B-Type Natriuretic Peptide in a General Japanese Population: NIPPON DATA2010.

Aims: P-wave terminal force in lead V1 (PTFV1) is an electrocardiogram marker of increased left atrial pressure and may be a noninvasive and early detectable marker for future cardiovascular events in the general population compared to serum B-type natriuretic peptide (BNP) concentration. The clinical significance of PTFV1 in the contemporary general population is an area of unmet need. We aimed to demonstrate the correlation between PTFV1 and BNP concentrations in a contemporary representative Japanese population.Methods: Among 2,898 adult men and women from 300 randomly selected districts throughout Japan (NIPPON DATA2010), we analyzed 2,556 participants without cardiovascular disease (stroke, myocardial infarction, and atrial fibrillation). Elevated BNP was defined as a value of ≥ 20 pg/mL based on the definition from the Japanese Circulation Society guidelines.Results: In total, 125 (4.9%) participants had PTFV1. Participants with PTFV1 were older with a higher prevalence of hypertension, major electrocardiographic findings, and elevated BNP concentrations (13.5 [6.9, 22.8] versus 7.8 [4.4, 14.5] pg/mL; P < 0.001). After adjustment for confounders, PTFV1 was correlated with elevated BNP (odds ratio, 1.66; 95% confidence interval, 1.05–2.62; P = 0.030). This correlation was consistent among various subgroups and was particularly evident in those aged < 65 years or those without a history of hypertension.Conclusions: In the contemporary general population cohort, PTFV1 was independently related to high BNP concentration. PTFV1 may be an alternative marker to BNP in identifying individuals at a higher risk of future cardiovascular events in the East Asian population.

LEFT ATRIAL STRUCTURE AND FUNCTION OF THE AMYLOIDOGENIC V122I TRANSTHYRETIN VARIANT IN ELDERLY AFRICAN AMERICANS

AIMS African-American carriers of the transthyretin (TTR) valine-to-isoleucine substitution (V122I) are at increased risk of heart failure, yet many have relatively subtle abnormalities of left ventricular (LV) function. We sought to explore the influence of this mutation on left atrial (LA) structure and function in this population. METHODS AND RESULTS We assessed 1225 genotyped African-Americans (age range, 67-89 years) participating in the Atherosclerosis Risk in Communities study who underwent echocardiography and were in sinus rhythm at study Visit 5 (2011 to 2013). Six LA parameters [LA maximum/minimum volume index, ejection fraction, and LA reservoir, conduit, and contractile longitudinal strains (LS)] were compared between V122I TTR variant carriers (n = 46) and non-carriers (n = 1179). LA minimum volume index was significantly greater and LA contractile LS was worse in carriers than non-carriers (19.5 ± 10.6 mL/m2 vs. 16.3 ± 8.4 mL/m2 ; 15.0 ± 5.8% vs. 16.8 ± 5.7%, respectively, both P < 0.05). Carriers had a significantly higher number of LA abnormalities than non-carriers (1.8 ± 2.2 vs. 1.1 ± 1.6, P = 0.009). The number of subjects with at least four LA abnormalities was significantly increased among carriers compared with non-carriers (27% vs. 12%; odds ratio 2.43; 95% confidence interval 1.06-5.58 after adjusting for age, sex, body mass index, and LV wall thickness and global LS). CONCLUSIONS Left atrial enlargement and dysfunction were common in V122I TTR carriers with sinus rhythm than non-carriers, suggesting that abnormalities of LA function may represent early markers of subclinical disease in these individuals.

Left Atrial Phasic Function in Type 2 Diabetes Mellitus Patients with Preserved Left Ventricular Ejection Fraction Assessed by Feature Tracking CMR Imaging

Purposes: Type 2 diabetes mellitus (T2DM) patients are associated with left atrial (LA) function abnormalities. This study aimed to assess LA phasic function in T2DM patients using FT-CMR imaging. Materials and methods: One hundred consecutive Chinese T2DM patients and 20 controls underwent CMR imaging were prospectively enrolled. LA phasic function was determined by volumetric and strain analysis. Total strain (εs) and peak positive strain rate (SRs), passive strain (εe) and peak early negative strain rate (SRe), active strain (εa) and peak late negative strain rate (SRa) were measured reflecting LA reservoir, conduit, and pump function, respectively. Results: LA reservoir, conduit function were decreased in T2DM, while LA pump function were only numerically higher than controls regardless of LA size. The ROC analysis showed superiority of strain parameters (AUC of εs: 0.852, εe: 0.802, p < 0.001 for both) than traditional LAEF parameters (AUC of total LAEF: 0.671, p = 0.014; passive LAEF: 0.642, p = 0.042) to differentiate T2DM from controls. Multivariate regression analysis showed age was independent determinant of εs and εe, DM duration and LV global longitudinal strain (GLS) were independent determinants of εe and εa. Conclusions: Aside from LA pump function, LA reservoir and conduit function determined on FT-CMR are impaired in T2DM patients compared with controls regardless of LA size. Strain parameters are superior in differentiating T2DM from controls. LA phasic function evaluated using FT-CMR may add important information in clinical decisions.

Left Atrial Volumetric and Deformation Analysis in Adult Patients with Dextro-Transposition of the Great Arteries (Insights from the CSONGRAD Registry and MAGYAR-Path Study)

Background: In complete or dextro-transposition of the great arteries (dTGA), the aorta and the pulmonary artery are transposed. The present study was designed to examine dTGA-associated left atrial (LA) volumetric and functional abnormalities in adult patients late after repair and to compare their results to those of healthy controls. Methods: The present study consisted of 15 dTGA patients (30.3 ± 8.1 years, 9 males), the patients had Mustard (n = 8) or Senning (n = 7) procedure performed. Their results were compared to those of 36 age- and gender-matched healthy subjects (28.7 ± 1.5 years, 24 males). Results: Increased maximum LA volume and reduced LA emptying fractions respecting the cardiac cycle could be demonstrated in our dTGA patients. LA stroke volumes representing all LA functions were significantly reduced. Peak LA circumferential, longitudinal, and area strains and LA circumferential, longitudinal, and area strains measured at atrial contraction were reduced in our dTGA patients. Most LA strains were reduced in patients having Mustard surgery compared to controls and patients undergoing Senning operation. Conclusions: Significant LA volumetric and functional abnormalities could be demonstrated in adult patients with dTGA late after repair. Senning procedure seems to have more beneficial long-term effects on LA volumetric and functional features as compared to the Mustard procedure.

Abstract TMP91: Pre-Sepsis P-wave Terminal Force in Lead V1 (PTFV1) as a Predictor of Atrial Fibrillation, In-Hospital Mortality, and Cognition in Sepsis Patients

Introduction: Enlarged P-wave terminal force in lead V1 (PTFV1) &gt;5000 μV*ms is a long-term predictor of the left atrial abnormality such as atrial fibrillation (AF), cognitive dysfunction, and stroke at age ≤ 60. Sepsis patients are at high risk of cardiac dysfunction, AF, stroke, and impaired cognition acutely and longitudinally, but predictive value pre-sepsis PTFV1 has not been studied. Hypothesis: Higher PTFV1 before sepsis onset is associated with AF events, left atrial enlargement, mortality, and 1-year cognitive impairment in patients who developed sepsis. Methods: Patients with acute sepsis were prospectively screened and enrolled in an observational study years 2015-2019. Of the 360 consented, 287 had pre-sepsis electrocardiograms (ECG), and 272 were evaluable. PTFV1 was measured using the Mitutoyo 500-195-30CAL Absolute Digimatic Caliper. Left atrial diameter index (LADI) pre-sepsis and post enrollment were recorded (median of 2 days [interquartile range (IQR) 1-13]). Occurrence of AF was assessed on the next available ECG, 3 days [IQR 1-11] post-enrollment. Cognitive function at 1-year follow-up was assessed by the mini-mental state examination (MMSE) and the Hopkins Verbal Learning test (HVLT). Statistical significance was evaluated using linear and logistic univariate regression. Results: In this cohort, the median age was 63 years [IQR 53-71], 44% women. The median PTVF1, LADI at pre-sepsis and follow up were 3219 μV*ms [IQR 0 - 5487], 1.86 cm/mm 2 [IQR 1.58 - 2.14], and 1.89 cm/mm 2 [IQR 1.59 - 2.17], respectively. Pre-sepsis PTFV1 was &gt; 5,000 μV*ms in 32%. Elevated PTFV1 at age ≥ 60 was not associated with AF (p=0.06) or in-hospital mortality (p=0.17). Similarly, high PTFV1 at age &lt; 60 was not associated in-hospital mortality (p=0.50), and only 3 in this cohort had AF. There was no association with pre-sepsis LADI (p=0.55), follow-up LADI (p=0.70), MMSE (p=0.35), or HVLT (p=0.78) and PTFV1. Conclusions: Here, PTFV1 values were not associated with AF or measures of cognitive impairment. While our findings differ from other longitudinal studies, the early time interval and setting of sepsis in our study is unique. Future studies will include multivariate analysis and evaluation of long term outcome measures linked to PTFV1 such as stroke.

310 Computed Tomography Pulmonary Venogram Characteristics of Patients Undergoing Hybrid Atrial Fibrillation Ablation

Computed tomography pulmonary venogram can provide anatomic information of the left atrium, left atrial appendage and pulmonary veins that assist in planning radiofrequency catheter ablation for atrial fibrillation. 26 patients underwent computed tomography pulmonary venograms prior to their hybrid atrial fibrillation ablation. Left atrial abnormalities, lack of left atrial appendage opacification, pulmonary vein ostial diameters and variant anatomy were recorded. The mean pulmonary vein cross-sectional diameters were as follows:•Right superior pulmonary vein were 20.2±4.8mm x 17.8±4.3mm;•Right inferior pulmonary vein 19.6±3.9mm;•Left superior pulmonary vein 19.4±3.3mm x 16.1±2.9mm; and•Left inferior pulmonary veins 20.3±6.4mm x 16.4±3.5mm. There were 7 pulmonary vein variants. 3 patients had a common left pulmonary vein with a mean cross-sectional diameter of 33±2.6mm x 25.3±4 mm. 4 patients had right middle pulmonary veins with a mean cross-sectional diameter of 9±1.4mm x 8.5±1mm. There were no left atrial abnormalities. The left atrial appendages were well opacified. The pulmonary vein characteristics and variant anatomy were obtained. 29% of patients had variant anatomy, which is similar to the documented rates in the literature, with the most common variant being the right middle pulmonary vein.

Association of Abnormal P-Wave Indices With Dementia and Cognitive Decline Over 25Years: ARIC-NCS (The Atherosclerosis Risk in Communities Neurocognitive Study).

BackgroundAbnormal P‐wave indices (PWIs)—reflecting underlying left atrial abnormality—are associated with increased risk of stroke independent of atrial fibrillation. We assessed whether abnormal PWIs are associated with incident dementia and greater cognitive decline, independent of atrial fibrillation and ischemic stroke.Methods and ResultsWe included 13 714 participants (mean age, 57±6 years; 56% women; 23% black) who were followed for dementia through the end of 2015. (Abnormal P‐wave terminal force in lead V1, ≥4000 μV×ms), abnormal P‐wave axis (>75° or <0°), prolonged P‐wave duration (>120 ms), and advanced interatrial block were determined from ECGs at visits 2 to 4. Dementia was adjudicated by an expert panel using data from cognitive tests and hospitalization International Classification of Diseases codes. Cognitive function was measured longitudinally using 3 neuropsychological tests. Cox proportional hazards models were used to assess the association between time‐dependent abnormal PWIs with incident dementia. Linear regression models were used to evaluate PWIs with cognitive function over time. At the conclusion of the study, 19%, 16%, 28%, and 1.9% of participants had abnormal P‐wave terminal force in lead V1, abnormal P‐wave axis, prolonged P‐wave duration, and advanced interatrial block, respectively. During mean follow‐up of 18 years, there were 1390 (10%) dementia cases. All abnormal PWIs except advanced interatrial block were associated with an increased risk of dementia even after adjustment for incident atrial fibrillation and stroke: multivariable hazard ratio of abnormal P wave terminal force in lead V1=1.60, 95% CI, 1.41 to 2.83; abnormal P‐wave axis, hazard ratio =1.36, 95% CI, 1.17 to 2.57; prolonged P‐wave duration, hazard ratio=1.60, 95% CI, 1.42 to 1.80. Only abnormal P‐wave terminal force in lead V1 was associated with greater decline in global cognition.ConclusionsAbnormal PWIs are independently associated with an increased risk of dementia. This novel finding should be replicated in other cohorts and the underlying mechanisms should be evaluated.

Editors' note: Atrial cardiopathy in patients with embolic strokes of unknown source and other stroke etiologies

In the article “Atrial cardiopathy in patients with embolic strokes of unknown source and other stroke etiologies,” Jalini et al. reported atrial cardiopathy in 26.6% of patients meeting the criteria for embolic stroke of unknown source (ESUS) vs 12.1% of patients with large artery atherosclerosis and 16.9% of those with small vessel disease in a cross-sectional study of 846 consecutive patients with ischemic stroke. They also found that patients with ESUS were younger, less hypertensive, and had higher cholesterol and low-density protein levels but fewer left ventricular or atrial abnormalities compared with yet another group with cardioembolism. In response, Drs. Lattanzi and Silvestrini note that they recently found an inverse association between abnormally increased P-wave terminal force in lead V1 (a marker of atrial cardiopathy) and paradoxical or artery-to-artery embolic sources in patients with ESUS. Patients with anterior circulation ESUS more often had ipsilateral (vs contralateral) internal carotid artery plaques with more concerning atherosclerotic findings, whereas younger patients with ESUS had higher incidence of patent foramen ovale (PFO) and lower rates of other vascular risk factors or markers of cardiopathy or atherosclerosis. Stating that ESUS is thus a heterogeneous entity, they encourage the identification of such distinct phenotypes to help guide secondary prevention and potentially targeted interventions. In their reply, the authors agree that the ESUS definition seems too broad and that factors such as PFO, aortic arch, and nonstenotic carotid plaques that were not addressed in their study are important embolic sources in subgroups of patients with ESUS. They note that ongoing trials in subgroups of patients with ESUS will further inform secondary prevention in this population. In the article “Atrial cardiopathy in patients with embolic strokes of unknown source and other stroke etiologies,” Jalini et al. reported atrial cardiopathy in 26.6% of patients meeting the criteria for embolic stroke of unknown source (ESUS) vs 12.1% of patients with large artery atherosclerosis and 16.9% of those with small vessel disease in a cross-sectional study of 846 consecutive patients with ischemic stroke. They also found that patients with ESUS were younger, less hypertensive, and had higher cholesterol and low-density protein levels but fewer left ventricular or atrial abnormalities compared with yet another group with cardioembolism. In response, Drs. Lattanzi and Silvestrini note that they recently found an inverse association between abnormally increased P-wave terminal force in lead V1 (a marker of atrial cardiopathy) and paradoxical or artery-to-artery embolic sources in patients with ESUS. Patients with anterior circulation ESUS more often had ipsilateral (vs contralateral) internal carotid artery plaques with more concerning atherosclerotic findings, whereas younger patients with ESUS had higher incidence of patent foramen ovale (PFO) and lower rates of other vascular risk factors or markers of cardiopathy or atherosclerosis. Stating that ESUS is thus a heterogeneous entity, they encourage the identification of such distinct phenotypes to help guide secondary prevention and potentially targeted interventions. In their reply, the authors agree that the ESUS definition seems too broad and that factors such as PFO, aortic arch, and nonstenotic carotid plaques that were not addressed in their study are important embolic sources in subgroups of patients with ESUS. They note that ongoing trials in subgroups of patients with ESUS will further inform secondary prevention in this population.

Diastolic Dysfunction in Patients With Human Immunodeficiency Virus Receiving Antiretroviral Therapy: Results From the CHART Study

Diastolic dysfunction (DD) is common and occurs at an earlier age among human immunodeficiency virus-infected (HIV+) individuals, but the mechanisms and consequences of DD among HIV+ individuals are unclear. The Characterization of Heart Function on Antiretroviral Therapy (CHART) study was a multicenter cross-sectional case-control study of treated and virally suppressed HIV+ individuals with (DD+) and without DD (DD-). All patients had normal ejection fraction (>50%), no significant valvular disease, and no history of coronary revascularization or persistent atrial fibrillation. Overall, 94 DD+ and 101 DD- patients were included. DD+ patients were older with higher body mass index (BMI) and more likely to have hypertension, renal dysfunction, and dyslipidemia. Groups were similar with respect to sex, race, CD4 count, and HIV RNA copies. N-terminal pro-B-type natriuretic peptide levels (median 36 [23, 85] vs 26 [12, 49] pg/mL, P < .01) and high-sensitivity troponin I (3.6 [2.6, 5.1] vs 2.5 [1.8, 3.5] pg/mL, P < .01) were higher among DD+ patients. The latter had similar left atrial size, but increased stiffness (conduit strain: 23.5 [17.5, 36.9] vs 30.0 [22.9, 37.0], P < .01) and impaired relaxation (reservoir strain: 39.7 [32.0, 58.0] vs 45.9 [37.0, 60.6], P = .04). On cardiac magnetic resonance, the prevalence of focal fibrosis was higher among DD+ patients (19.0% vs 5.3%, P < .01). DD+ patients demonstrated higher levels of carboxyl-terminal telopeptide of collagen type I (P = .04), and trends toward higher interleukin-6 and oxidized low-density lipoprotein levels (P ≤ .08). Kansas City Cardiomyopathy Questionnaire physical limitation (87.1±21.4 vs 93.1±18.1, P = .01) and symptom frequency scores were lower among DD+ patients (86.0±21.5 vs 92.5±16.8, P = .01). In this contemporary HIV+ population receiving antiretroviral therapy, DD was associated with multiple alterations in cardiac structure and function, including myocardial fibrosis and left atrial abnormalities, and worse quality of life. Further studies are needed to assess longitudinal changes in these parameters and their potential as therapeutic targets to prevent progressive cardiac remodeling and dysfunction in HIV.

Use of echocardiography to stratify the risk of atrial fibrillation: comparison of left atrial and ventricular strain.

Although both left atrial (LA) and ventricular (LV) dysfunction has been accepted as an important risk factor of atrial fibrillation (AF), usefulness of LA and LV strain has not been fully compared for prediction of AF. The aims of this study were to clarify the associations of both LA and LV strain with AF and to compare their predictive values in the risk stratification for AF. We evaluated 531 consecutive patients (median age 67 years, 56% male), with no history of AF who underwent echocardiography after cryptogenic stroke. Standard echocardiographic parameters were measured, and speckle-tracking was used to measure LA (reservoir, pump, and conduit strain) and LV strain (global longitudinal strain, GLS). The baseline clinical and echocardiographic parameters of the patients who developed AF and those who did not were compared. Median 36 months of follow-up, 61 patients (11%) had newly diagnosed AF. LA pump strain and GLS were significantly and independently associated with AF and provided incremental predictive value over clinical and standard echocardiographic parameters. Areas under the receiver-operating curves for GLS (0.841) were comparable to LA pump (0.825) and reservoir (0.851) strain. However, predictive value of both strains was different between patients with and without LA enlargement at the time of transthoracic echocardiography screening. LA strain was more useful than LV strain in patients with normal LA volumes, while LV strain was more useful than LA strain in patients with abnormal LA volumes. Both LA and LV strain are significantly and independently associated with AF and provide incremental predictive value over clinical and standard echocardiographic parameters. However, priorities of strain assessment are different depends on patients' condition at the time of echocardiography.

Interrelation Between Electrocardiographic Left Atrial Abnormality, Left Ventricular Hypertrophy, and Mortality in Participants With Hypertension

Left ventricular hypertrophy (LVH) and left atrial abnormality (LAA) are common correlated complications of hypertension. It is unclear how common for electrocardiographic markers of LAA (ECG-LAA) to coexist with ECG-LVH and how their coexistence impacts their prognostic significance. This analysis included 4,077 participants (61.2 ± 13.0 years, 51.2% women, 48.6% whites) with hypertension from the Third National Health and Nutrition Examination Survey. ECG-LVH was defined by Cornell voltage criteria. ECG-LAA was defined as deep terminal negativity of P wave in V1 >100 µV. Cox proportional hazard analysis was used to examine the associations between various combinations of ECG-LAA and ECG-LVH with all-cause mortality over a median follow-up of 14 years. The baseline prevalence of ECG-LVH, ECG-LAA, and the concomitant presence of both was 3.6%, 2.7%, and 0.34%, respectively. In a multivariable-adjusted model, mortality risk was highest in the group with concomitant ECG-LAA and ECG-LVH (hazard ratio [HR; 95% confidence interval {CI}] 2.69 [1.51, 4.80]), followed by isolated ECG-LAA (HR [95% CI] 1.63 [1.26, 2.12]), and then isolated ECG-LVH (HR [95% CI] 1.40 [1.08, 1.81]), compared with the group without ECG-LAA or ECG-LVH. Effect modification of these results by age and diabetes but not by gender or race was observed. In models with similar adjustment where ECG-LVH and ECG-LAA were entered as 2 separate variables and subsequently additionally adjusted for each other, the mortality risk was essentially unchanged for both variables. In conclusion, in participants with hypertension, ECG-LAA and ECG-LVH are independent markers of poor outcomes, and their concomitant presence carries a higher risk than either marker alone.

P Wave Indices-Advancing Our Understanding of Atrial Fibrillation-Related Cardiovascular Outcomes.

Atrial fibrillation (AF) is associated with an increased risk of ischemic stroke, heart failure, cognitive decline, dementia, myocardial infarction, sudden cardiac death (SCD), and all-cause death. Although these associations are firmly established, our understanding of the underlying mechanisms remains incomplete. Accumulating evidence suggests that left atrial (LA) abnormality or atrial cardiomyopathy may explain the relationship of AF to the aforementioned outcomes. P-wave indices (PWIs) reflect underlying atrial remodeling. In this mini review, we define representative PWIs, discuss state-of-the-art knowledge on the relationship between abnormal PWIs and AF-related cardiovascular outcomes (focusing on ischemic stroke and sudden cardiac death), and propose directions for future research. Our ultimate goal is to present a practical way forward to advance the emerging field of LA abnormality or atrial cardiomyopathy.

Electrocardiographic findings in peripartum cardiomyopathy.

BackgroundThere is limited data on electrocardiographic (ECG) abnormalities and their prognostic significance in women with peripartum cardiomyopathy (PPCM). We sought to characterize ECG findings in PPCM and explore the association of ECG findings with myocardial recovery and clinical outcomes.HypothesisWe hypothesized that ECG indicators of myocardial remodeling would portend worse systolic function and outcomes.MethodsStandard 12‐lead ECGs were obtained at enrollment in the Investigations of Pregnancy‐Associated Cardiomyopathy study and analyzed for 88 women. Left ventricular ejection fraction (LVEF) was measured by echocardiography at baseline, 6 months, and 12 months. Women were followed for clinical events (death, mechanical circulatory support, and/or cardiac transplantation) until 1 year.ResultsHalf of women had an “abnormal” ECG, defined as atrial abnormality, ventricular hypertrophy, ST‐segment deviation, and/or bundle branch block. Women with left atrial abnormality (LAA) had lower LVEF at 6 months (44% vs 52%, P = 0.02) and 12 months (46% vs 54%, P = 0.03). LAA also predicted decreased event‐free survival at 1 year (76% vs 97%, P = 0.008). Neither left ventricular hypertrophy by ECG nor T‐wave abnormalities predicted outcomes. A normal ECG was associated with recovery in LVEF to ≥50% (84% vs 49%, P = 0.001) and event‐free survival at 1 year (100% vs 85%, P = 0.01).ConclusionsECG abnormalities are common in women with PPCM, but a normal ECG does not rule out the presence of PPCM. LAA predicted lower likelihood of myocardial recovery and event‐free survival, and a normal ECG predicted favorable event‐free survival.

Association of central blood pressure with left atrial structural and functional abnormalities in hypertensive patients: Implications for atrial fibrillation prevention.

Functional and structural abnormalities of the left atrium have been demonstrated to be clinically and prognostically significant in a range of cardiovascular disorders, increasing the risk of atrial fibrillation. Among the potential contributors to these aberrations, central arterial factors remain insufficiently defined. Accordingly, we sought to investigate the determinants of left atrium abnormalities in hypertension, with special focus on central haemodynamics. In this retrospective, cross-sectional study, 263 patients (age 63.8 ± 8.0 years) with uncomplicated hypertension underwent echocardiography including left atrium strain (LAS) and volume analysis, and central haemodynamics assessment using radial tonometry. Patients were grouped depending on LAS and left atrium volume index (LAVI), using externally validated cutpoints (34.1% for LAS and 34 ml/m2 for LAVI). The subset with lower LAS (n = 124) demonstrated higher central (cPP) and brachial pulse pressure (bPP), ventricular- arterial coupling, left ventricular mass index (LVMI) and LAVI, and lower global left ventricular longitudinal strain and early diastolic tissue velocity (e'). Patients with higher LAVI (n = 119) presented higher systolic blood pressure, cPP, bPP, central augmentation pressure, LVMI and E/e' ratio and lower LAS. In multivariable analysis, cPP was independently associated with both LAS (β = -0.22; p = 0.002) and LAVI (β = 0.21; p = 0.003). No independent associations with left atrium parameters were shown for bPP. Higher cPP is detrimentally associated with left atrium structural and functional characteristics, thus providing a possible pathophysiological link with the development of substrate for atrial fibrillation. Prophylaxis of atrial fibrillation might be another argument for consideration in the treatment strategy in hypertension targeted measures addressing central blood pressure.