Comparison of M-mode and two-dimensional echocardiographic algorithms used to estimate left ventricular mass: the Coronary Artery Risk Development in Young Adults Study

Electrocardiographic manifestations in female team handball players: analyzing ECG changes in athletes

Introduction

Long-term intense training leads to structural, functional, and electrical remodeling of the heart. How different sports affect the heart has not been fully investigated, particularly for female athletes. The aim of the present study was to investigate the morphology of 12-lead resting electrocardiogram (ECG) in elite female handball players compared to non-athlete female subjects. Potential changes will be explored to see if they could be explained by differences in cardiac dimensions and exercise hours.

Materials and methods

A cross-sectional study of 33 elite female team handball players compared to 33 sex and age-matched, non-athletic controls (age range 18-26 years) was performed. All participants underwent a resting 12-lead ECG and an echocardiographic examination. ECG variables for left ventricular hypertrophy and durations were evaluated and adjusted for cardiac dimensions and exercise hours using ANCOVA analysis. A linear regression analysis was used to describe relation between echocardiographic and ECG measures and exercise hours.

Results

The female handball players had larger cardiac dimensions and significantly lower heart rate and QTc duration (Bazett's formula) as well as increased QRS and QT durations compared to controls. The 12-lead sum of voltage and the 12-lead sum of voltage ∗ QRS were significantly higher among handball players. Changes in ECG variables reflecting the left ventricle could in part be explained by left ventricular size and exercise hours. Correlation with exercise hours were moderately strong in most of the echocardiographic measures reflecting left ventricular (LV), left ventricular mass (LVM), left atrium (LA) and right atrium (RA) size. Poor to fair correlations were seen in the majority of ECG measures.

Conclusions

Female team handball players had altered ECGs, longer QRS and QT durations, higher 12-lead sum of voltage and 12-lead sum of voltage ∗ QRS as well as shorter QTc (Bazett's formula) duration compared to non-athletic controls. These findings could only partly be explained by differences in left ventricular size. Despite larger atrial size in the athletes, no differences in P-wave amplitude and duration were found on ECG. This suggest that both structural, and to some degree electrical remodeling, occur in the female team handball players' heart and highlight that a normal ECG does not rule out structural adaptations. The present study adds knowledge to the field of sports cardiology regarding how the heart in female team handball players adapts to this type of sport.

Increased left ventricular remodelling index in paradoxical low-flow severe aortic stenosis with preserved left ventricular ejection fraction compared to normal-flow severe aortic stenosis

INTRODUCTION

Patients with paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular ejection fraction (LVEF) appear distinct from normal-flow (NF) patients, showing worse prognosis, more concentric hypertrophy and smaller left ventricular (LV) cavities. The left ventricular remodelling index (LVRI) has been demonstrated to reliably discriminate between physiologically adapted athlete's heart and pathological LV remodelling.

METHODS

We studied patients with index echocardiographic diagnosis of severe AS (aortic valve area <1 cm2) with preserved LVEF (>50%). The LVRI was determined by the ratio of the LV mass to the end-diastolic volume, as previously reported, and was compared between patients with LF and NF AS. Patients were prospectively followed up for at least 3 years, and clinical outcomes were examined in association with LVRI.

RESULTS

Of the 450 patients studied, 112 (24.9%) had LF AS. While there were no significant differences in baseline clinical profile between LF and NF patients, LVRI was significantly higher in the LF group. Patients with high LVRI (>1.56 g/mL) had increased all-cause mortality (log-rank 9.18, P = 0.002) and were more likely to be admitted for cardiac failure (log-rank 7.61, P = 0.006) or undergo aortic valve replacement (log-rank 18.4, P < 0.001). After adjusting for the effect of age, hypertension, aortic valve area and mean pressure gradient on multivariate Cox regression, high LVRI remained independently associated with poor clinical outcomes (hazard ratio 1.64, 95% confidence interval 1.19-2.25, P = 0.002).

CONCLUSION

Pathological LV remodelling (increased LVRI) was more common in patients with LF AS, and increased LVRI independently predicts worse clinical outcomes.

A new method to quantify left ventricular mass by 2D echocardiography

Increased left ventricular mass (LVM) is a strong independent predictor for adverse cardiovascular events, but conventional echocardiographic methods are limited by poor reproducibility and accuracy. We developed a novel method based on adding the mean wall thickness from the parasternal short axis view, to the left ventricular end-diastolic volume acquired using the biplane model of discs. The participants (n = 85) had various left ventricular geometries and were assessed using echocardiography followed immediately by cardiac magnetic resonance, as reference. We compared our novel two-dimensional (2D) method to various conventional one-dimensional (1D) and other 2D methods as well as the three-dimensional (3D) method. Our novel method had better reproducibility in intra-examiner [coefficients of variation (CV) 9% vs. 11–14%] and inter-examiner analysis (CV 9% vs. 10–20%). Accuracy was similar to the 3D method (mean difference ± 95% limits of agreement, CV): Novel: 2 ± 50 g, 15% vs. 3D: 2 ± 51 g, 16%; and better than the “linear” 1D method by Devereux (7 ± 76 g, 23%). Our novel method is simple, has considerable better reproducibility and accuracy than conventional “linear” 1D methods, and similar accuracy as the 3D-method. As the biplane model forms part of the standard echocardiographic protocol, it does not require specific training and provides a supplement to the modern echocardiographic report.

Pulmonary Artery Acceleration Time in Young Adulthood and Cardiovascular Outcomes Later in Life: The Coronary Artery Risk Development in Young Adults Study

BACKGROUND

Lower pulmonary artery acceleration time (PAcT) is correlated with higher pulmonary artery pressure. The aim of this study was to test the hypothesis that PAcT measured in young adulthood would be associated with future cardiovascular outcomes.

METHODS

In the Coronary Artery Risk Development in Young Adults year 5 examination (1990-1991), PAcT was measured as the time interval from onset to peak flow velocity at the pulmonary valve annulus on Doppler echocardiography. The primary outcome was a composite of fatal or nonfatal cardiovascular disease events: myocardial infarction, non-myocardial infarction acute coronary syndrome, coronary revascularization, congestive heart failure, stroke, transient ischemic attack, carotid artery disease, and peripheral arterial disease.

RESULTS

PAcT was obtained in 4,171 participants (mean age, 30 ± 4 years, 55% women, 51% white). PAcT groups obtained using linear spline methodology were as follows: group I, PAcT ≥ 196 msec (n = 122); group II, PAcT < 196 and ≥115 msec (n = 3,195); and group III, PAcT < 115 msec (n = 854). During follow-up (median, 24.9 years), the primary outcome occurred in 216 participants (5.2%); 66 of 854 (7.7%) of those with PAcT < 115 msec, 149 of 3,195 (4.7%) of those with intermediate PAcT level, and one of 122 (0.8%) of those with PAcT ≥ 196 msec. In a fully adjusted model, the lowest and intermediate PAcT groups had hazard ratios of 8.3 (95% CI, 1.1-62.1; P = .04) and 6.8 (95% CI, 0.9-50.5; P = .06), respectively, in comparison with the highest PAcT group.

CONCLUSIONS

PAcT is useful for better identifying young adults at higher risk for cardiovascular events, who may benefit from a strict control of modifiable cardiovascular risk factors.

Diagnostic value of Tei index for acute myocardial infarction in patients presenting to emergency department with ischemic chest pain and correlation with Hs-troponin

Background:

Acute myocardial infarction is one of the most common causes of mortality in developed countries, and high-sensitive troponin test usually becomes positive within 3 h from the onset of symptoms. Myocardial perfusion index (Tei index) is a parameter measured during the echocardiographic examination.

Objectives:

The aim of this study is to investigate the diagnostic value of the Tei index for early diagnosis of acute myocardial infarction in the emergency department and to evaluate the correlation between the Tei index and Hs-Troponin value.

Materials and Methods:

A total of 129 cases were evaluated, and patients were divided into two groups according to their final diagnosis as “acute myocardial infarction (non-ST segment elevation myocardial infarction)” and “non-acute myocardial infarction” groups. Baseline and third-hour Hs-Troponin levels and Tei index values were determined, and their correlation was analyzed.

Results:

A total of 84 cases were diagnosed with acute myocardial infarction (non-ST segment elevation myocardial infarction), 84.5% had positive Tei index results at the time of admission while the remaining 45 patients were diagnosed as non-acute myocardial infarction and only 48.9% of them had positive Tei index. The diagnostic value of the Tei index and Hs-troponin were calculated as 79.8% and 60%; 67.9% and 60%, respectively. Also, we found that a 0.02 or more increase in the Tei index value has a 97.6 sensitivity and 97.5 specificity for the diagnosis of non-ST segment elevation myocardial infarction. A weak correlation was found between the Tei index and Hs-Troponin values in the acute myocardial infarction group (r = 0.425) and a negative correlation in non-acute myocardial infarction patients at presentation.

Conclusion:

It is suggested that the use of Tei index might be used as a supportive measure for the early diagnosis of acute myocardial infarction, and the deterioration of Tei index seems to be more significant than Hs-Troponin especially in ruling out acute myocardial infarction.

Left ventricular myocardial performance index in prediabetic patients without coronary artery disease

INTRODUCTION

Prediabetes is a high-risk condition for diabetes mellitus type 2, which is an important public health issue. The myocardial performance index (MPI) is a noninvasive Doppler measurement of global ventricular function. We evaluated the MPI and left ventricular (LV) function in prediabetic patients who did not have coronary artery disease.

METHODS

In total, 80 prediabetics (34 females and 46 males) and an equal number of sex-matched healthy volunteers (35 females and 45 males) were enrolled prospectively. All subjects underwent laboratory analyses and echocardiographic examinations, including MPI measurements.

RESULTS

There was a moderate increase in MPI between healthy controls and prediabetics (P < .001). Prediabetes was strongly associated with MPI (r = .553, P < .001). We found that MPI was associated with prediabetes on multivariate logistic regression analysis (Odds Ratio (OR) = 1.967, 95% confidence interval [CI] = 1.574-2.459, P < .001).

CONCLUSIONS

The results of this study show that systolic functions and LV diastolic parameters were adversely affected in prediabetic patients. Prediabetes is closely associated with subclinical LV systolic and diastolic dysfunction as assessed by MPI.

Genetic association of left ventricular mass assessed by M-mode and two-dimensional echocardiography

BACKGROUND

Left ventricular mass offers prognostic information for assessing cardiovascular disease risk. M-mode and two-dimensional (2D) echocardiographically-derived left ventricular mass values have shown high accuracy and reproducibility; however, no studies to date have compared left ventricular mass genetic association findings on the basis of both the methods. The aim of this study was to compare associations of single-nucleotide polymorphisms (SNPs) from genome-wide association study analyses of left ventricular mass using both methods in the same cohort.

METHODS AND RESULTS

Left ventricular mass was determined using 2D and M-mode echocardiography in 711 patients (390 women); SNP genotype data were obtained using the Genome-wide Human SNP Array 6.0. Genome-wide association study analyses were performed to obtain panels of SNPs associated with left ventricular mass and left ventricular mass index. The unindexed left ventricular mass showed excellent agreement [M-mode: 170 ± 47 vs. 2D: 178 ± 56 g; intraclass correlation coefficient 0.929 (95% confidence interval 0.932, 0.909)]. The presence of left ventricular hypertrophy based on M-mode and 2D-derived left ventricular mass index values showed moderate agreement (kappa = 0.49). Eleven SNPs showed suggestive association with at least two of the four left ventricular mass traits, with one SNP in CDH13 common to all four derived traits.

CONCLUSION

M-mode and 2D echocardiography left ventricular mass measurements in the same cohort identified suggestive genetic associations, both shared and unshared, suggesting common left ventricular mass biology underlying the two measures of left ventricular mass. The combined use of M-mode and 2D echo is a novel approach that may increase the yield of genetic association with left ventricular mass.

Echocardiography-based left ventricular mass estimation. How should we define hypertrophy?

Left ventricular hypertrophy is an important risk factor in cardiovascular disease and echocardiography has been widely used for diagnosis. Although an adequate methodologic standardization exists currently, differences in measurement and interpreting data is present in most of the older clinical studies. Variability in border limits criteria, left ventricular mass formulas, body size indexing and other adjustments affects the comparability among these studies and may influence both the clinical and epidemiologic use of echocardiography in the investigation of the left ventricular structure. We are going to review the most common measures that have been employed in left ventricular hypertrophy evaluation in the light of some recent population based echocardiographic studies, intending to show that echocardiography will remain a relatively inexpensive and accurate tool diagnostic tool.

Three-dimensional echocardiographic measurement of left ventricular mass: comparison with magnetic resonance imaging and two-dimensional echocardiographic determinations in man

This study was performed to compare a novel three-dimensional echocardiography (3DE) system to clinical two-dimensional echocardiography (2DE) and magnetic resonance imaging (MRI) for determination of left ventricular mass (LVM) in humans. LVM is an independent predictor of cardiac morbidity and mortality. Echocardiography is the most widely used clinical method for assessment of LVM, as it is non-invasive, portable and relatively inexpensive. However, when measuring LVM, 2DE is limited by assumptions about ventricular shape which do not affect 3D echo.

METHODS

A total of 25 unselected patients underwent 3DE, 2DE and MRI. Three-dimensional echo used a magnetic scanhead tracker allowing unrestricted selection and combination of images from multiple acoustic windows. Mass by quantitative 2DE was assessed using seven different geometric formulas.

RESULTS

LVM by MRI ranged from 91 to 316 g. There was excellent agreement between 3DE and MRI (r = 0.99, SEE = 6.9 g). Quantitative 2D methods correlated well with but underestimated MRI (r = 0.84-0.92) with SEEs over threefold greater (22.5-30.8 g). Interobserver variation was 7.6% for 3DE vs. 17.7% for 2DE.

CONCLUSIONS

LVM in humans can be measured accurately, relative to MRI, by transthoracic 3D echo using magnetic tracking. Compared to 2D echo, 3D echocardiography significantly improves accuracy and reproducibility.

Left ventricular size determined by electron beam computed tomography predicts significant coronary artery disease and events

A novel method in the measurement of left ventricular (LV) area using noncontrast electron beam computed tomography (EBCT) was introduced and studied as a diagnostic and prognostic marker for coronary artery disease. Larger LV area measured by noncontrast EBCT was significantly associated with angiographic coronary disease and was a better predictor of coronary disease events than log calcium score.