1
|
Pedersson PR, Skaarup KG, Lassen MCH, Olsen FJ, Iversen AZ, Jørgensen PG, Biering-Sørensen T. Left atrial strain is associated with long-term mortality in acute coronary syndrome patients. Int J Cardiovasc Imaging 2024; 40:841-851. [PMID: 38365994 PMCID: PMC11052866 DOI: 10.1007/s10554-024-03053-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/08/2024] [Indexed: 02/18/2024]
Abstract
To investigate the long-term prognostic value of the left atrial (LA) strain indices - peak atrial longitudinal strain (PALS), peak conduit strain (PCS), and peak atrial contractile strain (PACS) in acute coronary syndrome (ACS) patients in relation to all-cause mortality. This retrospective study included ACS patients treated with percutaneous coronary intervention (PCI) and examined with echocardiography. Exclusion criteria were non-sinus rhythm during echocardiography, missing images, and inadequate image quality for 2D speckle tracking analysis of the LA. The endpoint was all-cause death. Multivariable Cox regression which included relevant clinical and echocardiographic measures was utilized to assess the relationship between LA strain parameters and all-cause mortality. A total of 371 were included. Mean age was 64 years and 76% were male. Median time to echocardiography was 2 days following PCI. During a median follow-up of 5.7 years, 83 (22.4%) patients died. Following multivariable analysis, PALS (HR 1.04, 1.01-1.06, p = 0.002, per 1% decrease) and PCS (HR 1.05, 1.01-1.09, p = 0.006, per 1% decrease) remained significantly associated with all-cause mortality. PALS and PCS showed a linear relationship with the outcome whereas PACS was associated with the outcome in a non-linear fashion such that the risk of death increased when PACS < 18.22%. All LA strain parameters remained associated with worse survival rate when restricting analysis to patients with left atrial volume index < 34 ml/m2. Reduced LA function as assessed by PALS, PCS, and PACS were associated with an increased risk of long-term mortality in patients with ACS.
Collapse
Affiliation(s)
- Philip Rüssell Pedersson
- Department of Cardiology, Copenhagen University Hospital-Herlev & Gentofte, Gentofte Hospitalsvej 8 3Th, Post 835, DK-2900, Copenhagen, Denmark.
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Kristoffer Grundtvig Skaarup
- Department of Cardiology, Copenhagen University Hospital-Herlev & Gentofte, Gentofte Hospitalsvej 8 3Th, Post 835, DK-2900, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mats Christian Højbjerg Lassen
- Department of Cardiology, Copenhagen University Hospital-Herlev & Gentofte, Gentofte Hospitalsvej 8 3Th, Post 835, DK-2900, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital-Herlev & Gentofte, Gentofte Hospitalsvej 8 3Th, Post 835, DK-2900, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Allan Zeeberg Iversen
- Department of Cardiology, Copenhagen University Hospital-Herlev & Gentofte, Gentofte Hospitalsvej 8 3Th, Post 835, DK-2900, Copenhagen, Denmark
| | - Peter Godsk Jørgensen
- Department of Cardiology, Copenhagen University Hospital-Herlev & Gentofte, Gentofte Hospitalsvej 8 3Th, Post 835, DK-2900, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev & Gentofte, Gentofte Hospitalsvej 8 3Th, Post 835, DK-2900, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
2
|
Lange A, Palka V, Bian C, Huntress H, Morgan J, Allwood S, Swann R, Palka P. Left heart remodelling in hypertensive patients: a comprehensive echocardiography and computed tomography study. Front Cardiovasc Med 2023; 10:1295537. [PMID: 38075969 PMCID: PMC10704463 DOI: 10.3389/fcvm.2023.1295537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/03/2023] [Indexed: 09/25/2024] Open
Abstract
OBJECTIVES This study aimed to assess left heart remodelling changes in hypertension, excluding underlying ischaemic heart disease, utilising computed tomography coronary angiography (CTCA) and transthoracic echocardiography (TTE). METHODS A total of 178 patients (mean age 60 ± 9 years, 53% female) were enrolled in the study: Group 1 consisted of patients with essential hypertension (n = 96, Group 1), and Group 2 served as age-matched controls (n = 82, Group 2). All participants underwent both CTCA and TTE. TTE measurements included left ventricle (LV) concentricity and function and left atrial (LA) volume and function. Using both CTCA and TTE, we measured LV diastasis volume (LVdias) and LA diastasis volume (LAdias). RESULTS LV mass index and LV mass/height2.7 were similar in both the groups. However, Group 1 had a higher prevalence of concentric LV remodelling, characterised by a larger mean LV wall thickness, increased relative wall thickness ratio, and a reduced ratio of LV end-diastolic volume (LVED) index to mean wall thickness (55 ± 14 vs. 65 ± 15, p = 0.0007). Group 1 showed higher LAdias and LA minimal volumes, while LA reservoir function was lower in Group 2. The LVdias/LAdias ratio was lower in Group 1 compared to Group 2 (TTE 1.77 ± 0.61 vs. 2.24 ± 1.24, p = 0.0025, CTCA 1.50 ± 0.23 vs. 1.69 ± 0.41, p = 0.0002). A composite score based on four combined TTE parameters, namely, LVED index/mean wall thickness ≤57, ratio of early diastolic mitral inflow to mitral annular tissue velocities (E/e') >8, LVdias/LAdias ≤1.62, and LA reservoir function ≤0.58, yielded the highest discriminatory power (area under the curve-AUC = 0.772) for distinguishing patients with hypertensive heart disease (HHD). Collectively, we refer to these parameters as the LEDA score, with each parameter scored as one point. For LEDA scores of 0, 1, 2, 3, 4, the probability of underlying HHD was 0%, 23%, 59%, 80%, and 95%, respectively. Furthermore, a CTCA-derived LVdias/LAdias ≤1.76, considered as a single parameter, demonstrated modest accuracy in differentiating patients with HHD (AUC = 0.646). CONCLUSIONS The TTE LEDA score, based on four parameters, namely, LVED index/mean wall thickness, E/e', LVdias/LAdias, and LA reservoir function, proved to be the most effective in defining left heart remodelling in hypertension.
Collapse
Affiliation(s)
| | - Viktoria Palka
- Queensland Cardiovascular Group, Brisbane, QLD, Australia
- Faculty of Humanities, University of Queensland, Brisbane, QLD, Australia
| | - Chris Bian
- Queensland Cardiovascular Group, Brisbane, QLD, Australia
| | - Harry Huntress
- Queensland Cardiovascular Group, Brisbane, QLD, Australia
| | - Jill Morgan
- Queensland Cardiovascular Group, Brisbane, QLD, Australia
| | - Sean Allwood
- Queensland Cardiovascular Group, Brisbane, QLD, Australia
| | - Rohan Swann
- Queensland Cardiovascular Group, Brisbane, QLD, Australia
| | | |
Collapse
|
3
|
Souza JB, Sousa MG, Laurinavicius AG, Hygídio DDA, Vilela ADA, Colombo FC, Assef JE. Advanced echocardiography techniques (AETs) to assess left atrial structure and function in individuals with resistant hypertension. Echocardiography 2023; 40:792-801. [PMID: 37395940 DOI: 10.1111/echo.15646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 05/26/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023] Open
Abstract
AIMS Resistant hypertension (RH) is a challenging phenotype within the hypertension (HTN) spectrum, requiring careful assessment and follow-up. Evaluation of left atrial function may be clinically informative, but is usually neglected. Advanced Echocardiography Techniques (AETs), such as Strain Analysis and three-dimensional echocardiography (3D ECHO) may be useful complementary tools to assess atrial function in patients with RH. METHODS AND RESULTS Ninety-six eligible adult patients were categorized into three groups: resistant hypertensive (RH), controlled hypertensive (CH), and normotensive (N), and underwent AETs to identify morphofunctional changes in the left atrium (LA) across different HTN phenotypes. The LA reservoir strain was significantly lower among RH than in N and CH patients (p < .001). Accordingly, LA conduit strain showed a gradient through the groups: higher among N, followed by CH and RH patients (p = .015). LA contraction strain was higher among CH than in N and RH patients (p = .02). Maximum indexed, pre-A, and minimum atrial volumes obtained by 3D ECHO showed differences between N and the others (p < .001), but not between CH and RH. N patients showed a higher fraction of passive emptying of the LA than the others (p = .02), with no difference between CH and RH. Total emptying of the LA only differed between N and RH patients, while active emptying of the LA showed no difference between the groups (p = .82). CONCLUSION The left atrium may present early functional changes in response to HTN, which are detectable by AETs. AETs, especially S-LA, allowed to identify markers of atrial myocardial damage in both RH and CH patients.
Collapse
|
4
|
Pavasini R, Fabbri G, Di Ienno L, Deserio MA, Sanguettoli F, Bianchi N, Zucchetti O, D'Aniello E, Papi A, Spadaro S, Contoli M, Campo G. Left atrial pressure in patients with respiratory failure due to SARS-CoV-2 infection and supraventricular arrythmias. J Cardiovasc Med (Hagerstown) 2022; 23:414-416. [PMID: 35013049 DOI: 10.2459/jcm.0000000000001291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero-Universitaria Di Ferrara, Cona
| | - Gioele Fabbri
- Cardiology Unit, Azienda Ospedaliero-Universitaria Di Ferrara, Cona
| | - Luca Di Ienno
- Cardiology Unit, Azienda Ospedaliero-Universitaria Di Ferrara, Cona
| | | | | | - Nicola Bianchi
- Cardiology Unit, Azienda Ospedaliero-Universitaria Di Ferrara, Cona
| | | | | | - Alberto Papi
- Respiratory Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Intensive Care Unit, Azienda Ospedaliero Universitaria di Ferrara
| | - Marco Contoli
- Respiratory Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero-Universitaria Di Ferrara, Cona
| |
Collapse
|
5
|
Sonaglioni A, Cara MD, Nicolosi GL, Eusebio A, Bordonali M, Santalucia P, Lombardo M. Rapid Risk Stratification of Acute Ischemic Stroke Patients in the Emergency Department: The Incremental Prognostic Role of Left Atrial Reservoir Strain. J Stroke Cerebrovasc Dis 2021; 30:106100. [PMID: 34525440 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106100] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/20/2021] [Accepted: 08/31/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES To determine the prognostic value of positive global left atrial strain (LA-GSA+), measured by two-dimensional speckle tracking echocardiography (2D-STE) in a population of acute ischemic stroke (AIS) patients without atrial fibrillation (AF), in the setting of Emergency Department (ED). METHODS All consecutive AIS patients with sinus rhythm on ECG and without AF history entered this prospective study. All patients underwent complete blood tests and transthoracic echocardiography implemented with 2D-STE analysis of LA strain parameters within 6-12 h after symptoms onset. At 6-months follow-up, we evaluated the composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. RESULTS A total of 102 AIS patients (76.4 ± 10.8 yrs, 47% males) were prospectively included. LA-GSA+ was markedly reduced in AIS patients (20.8 ± 7.7%), without any statistically significant difference between the stroke subtypes. At 6-months follow-up, 7 deaths and 27 re-hospitalizations occurred. On multivariate Cox regression analysis, variables independently associated with outcome were: LA-GSA+ (per unit) (HR 0.29, 95% CI 0.19-0.39) and C-reactive protein (CRP) (per 0.1 mg/dl) (HR 1.45, 95% CI 1.15-1.75) as continuous variables; statin therapy (HR 0.45, 95%CI 0.28-0.62), and type 2 diabetes (HR 1.65, 95% CI 1.15-2.35) as categorical variables. A LA-GSA+ ≤20.0% predicted the occurrence of the above-mentioned outcome at 6-months follow-up with 94% sensitivity and 81% specificity (AUC=0.84). Interestingly, GSA+ showed a strong inverse correlation with CRP levels (r = -0.86). CONCLUSIONS A LA-GSA+ ≤20% reflects a more advanced atrial cardiomyopathy and might provide a rapid and reliable prognostic risk stratification of AIS patients without AF history in the setting of ED.
Collapse
Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, MultiMedica IRCCS, San Giuseppe Hospital, Milan, Italy.
| | - Marianna Di Cara
- Emergency Medicine Unit, MultiMedica IRCCS, San Giuseppe Hospital, Milan, Italy
| | | | - Alessandro Eusebio
- Emergency Medicine Unit, MultiMedica IRCCS, San Giuseppe Hospital, Milan, Italy
| | - Marco Bordonali
- Emergency Medicine Unit, MultiMedica IRCCS, San Giuseppe Hospital, Milan, Italy
| | - Paola Santalucia
- Department of Neurology, MultiMedica IRCCS, San Giuseppe Hospital, Milan, Italy
| | - Michele Lombardo
- Department of Cardiology, MultiMedica IRCCS, San Giuseppe Hospital, Milan, Italy
| |
Collapse
|
6
|
Alsharqi M, Huckstep OJ, Lapidaire W, Williamson W, Mohamed A, Tan CMJ, Kitt J, Burchert H, Telles F, Dawes H, Foster C, Lewandowski AJ, Leeson P. Left atrial strain predicts cardiovascular response to exercise in young adults with suboptimal blood pressure. Echocardiography 2021; 38:1319-1326. [PMID: 34185918 DOI: 10.1111/echo.15149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 11/30/2022] Open
Abstract
AIMS To investigate the left ventricular response to exercise in young adults with hypertension, and identify whether this response can be predicted from changes in left atrial function at rest. METHODS A total of 127 adults aged 18-40 years who completed clinical blood pressure assessment and echocardiography phenotyping at rest and during cardiopulmonary exercise testing, were included. Measurements were compared between participants with suboptimal blood pressure ≥120/80mm Hg (n = 68) and optimal blood pressure <120/80mm Hg (n = 59). Left ventricular systolic function during exercise was obtained from an apical four chamber view, while resting left atrial function was assessed from apical four and two chamber views. RESULTS Participants with suboptimal blood pressure had higher left ventricular mass (p = 0.031) and reduced mitral E velocity (p = 0.02) at rest but no other cardiac differences. During exercise, their rise in left ventricular ejection fraction was reduced (p = 0.001) and they had higher left ventricular end diastolic and systolic volumes (p = 0.001 and p = 0.001, respectively). Resting cardiac size predicted left ventricular volumes during exercise but only left atrial booster pump function predicted the left ventricular ejection fraction response ( β = .29, p = 0.011). This association persisted after adjustment for age, sex, body mass index, and mean arterial pressure. CONCLUSION Young adults with suboptimal blood pressure have a reduced left ventricular systolic response to exercise, which can be predicted by their left atrial booster pump function at rest. Echocardiographic measures of left atrial function may provide an early marker of functionally relevant, subclinical, cardiac remodelling in young adults with hypertension.
Collapse
Affiliation(s)
- Maryam Alsharqi
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Department of Cardiac Technology, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Odaro J Huckstep
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Winok Lapidaire
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Wilby Williamson
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Afifah Mohamed
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Department of Diagnostic Imaging & Applied Health Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Cheryl M J Tan
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jamie Kitt
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Holger Burchert
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Fernando Telles
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Helen Dawes
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Charlie Foster
- Centre for Exercise, Nutrition & Health Sciences, School of Policy Studies, University of Bristol, Bristol, UK
| | - Adam J Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Paul Leeson
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
7
|
Incremental prognostic value of global left atrial peak strain in women with new-onset gestational hypertension. J Hypertens 2020; 37:1668-1675. [PMID: 30950977 DOI: 10.1097/hjh.0000000000002086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Left atrial strain and strain rate parameters, measured by bidimensional-speckle tracking echocardiography, have been proposed as predictors of atrial fibrillation, stroke, congestive heart failure and cardiovascular death. However, they have not yet been tested in hypertensive disorders of pregnancy. The aim of this study was to assess the prognostic role of global left atrial peak strain (GLAPS) in a population of pregnant women with new-onset hypertension in a medium-term follow-up. METHODS Twenty-seven consecutive women with new-onset hypertension after 20 weeks pregnancy and 23 age-matched, race-matched and gestational week-matched consecutive normotensive pregnant women were enrolled in this prospective study. All participants underwent a complete echocardiographic study with bidimensional-speckle tracking echocardiography and carotid examination. At 1-year follow-up, we evaluated the occurrence of persistent hypertension. RESULTS In comparison with normotensive women, those hypertensive had a higher burden of cardiovascular risk factors, similar left atrial volume indexed (P = 0.14), but severely impaired left atrial strain (P < 0.0001) and strain rate values (P < 0.0001). At 1-year follow-up, persistent hypertension was documented in 59.3% of patients. At the univariate Cox analysis, the variables associated with the occurrence of the investigated outcome in all hypertensive pregnancies were SBP (hazard ratio 1.04, P = 0.04), DBP (hazard ratio 1.11, P = 0.01), mean arterial pressure (hazard ratio 1.09, P = 0.01) values and the GLAPS value (hazard ratio 0.85, P = 0.0019). The latter was significantly associated with the investigated outcome both in preeclamptic (hazard ratio 0.84, P = 0.02) and nonpreeclamptic pregnant women (hazard ratio 0.83, P = 0.04). The receiver operating characteristics curve analysis highlighted that a GLAPS value of 23.5% or less predicted persistent hypertension with sensitivity of 100% and specificity of 90.90%. CONCLUSION In hypertensive pregnant women a GLAPS value of 23.5% or less reveals a greater severity of atrial cardiomyopathy and might predict postpregnancy persistent hypertension.
Collapse
|
8
|
Vincenti A, Genovesi S, Sonaglioni A, Binda G, Rigamonti E, Lombardo M, Anzà C. Mechanical atrial recovery after cardioversion in persistent atrial fibrillation evaluated by bidimensional speckle tracking echocardiography. J Cardiovasc Med (Hagerstown) 2019; 20:745-751. [PMID: 31483328 DOI: 10.2459/jcm.0000000000000864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Atrial fibrillation induces reversible electrical and mechanical modifications (atrial remodeling). Atrial stunning is a mechanical dysfunction with preserved bioelectrical function, occurring after successful atrial fibrillation electrical cardioversion (ECV). Two-dimensional speckle tracking echocardiography is a new technology for evaluating atrial mechanical function. We assessed atrial mechanical function after ECV with serial two-dimensional speckle tracking echocardiography evaluations. The investigated outcome was left atrium mechanical recovery within 3 months. METHODS A total of 36 patients [mean age 73 (7.9) years, 23 males] with persistent atrial fibrillation underwent conventional transthoracic and transesophageal echocardiography before ECV. Positive global atrial strain (GSA+) was assessed at 3 h, 1, 2, 3, 4 weeks and 3 months after ECV. Mechanical recovery was defined as the achievement of a GSA+ value of 21%. RESULTS Independent predictors of GSA+ immediately after ECV (basal GSA+) were E/e' ratio and left atrial appendage anterograde flow velocity. During the follow-up, 25% of patients suffered atrial fibrillation recurrence. In 12/36 patients (33%) left atrium mechanical recovery was detected (mechanical recovery group), while in 15/36 (42%) recovery did not occur (no atrial mechanical recovery group). At univariate analysis, the variables associated with recovery, were basal GSA+ (P = 0.015) and maximal velocity left atrial appendage (P = 0.022). Female sex (P = 0.038), N-terminal pro-B type natriuretic peptide (P = 0.013), E/e' (P = 0.042) and the indexed left atrium volume (P = 0.019) were associated with the lack of left atrium mechanical recovery. CONCLUSION In almost half of the patients, the left atrium did not resume mechanical activity within the 3 months after ECV, despite sinus rhythm recovery. The left atrium of these patients was larger, stiffer and their E/E' was higher, suggesting a higher endocavitary pressure compared with mechanical recovery patients. These findings might suggest an increased thromboembolic risk.
Collapse
Affiliation(s)
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano.,Nephrology Unit, San Gerardo Hospital, Monza
| | | | - Giulia Binda
- Department of Cardiology, Ospedale San Giuseppe MultiMedica
| | | | | | - Claudio Anzà
- Cardiovascular Department, MultiMedica IRCCS, Milano, Italy
| |
Collapse
|
9
|
Olsen FJ, Møgelvang R, Jensen GB, Jensen JS, Biering-Sørensen T. Relationship Between Left Atrial Functional Measures and Incident Atrial Fibrillation in the General Population. JACC Cardiovasc Imaging 2019; 12:981-989. [DOI: 10.1016/j.jcmg.2017.12.016] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/12/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
|
10
|
Cameli M, Mandoli GE, Lisi E, Ibrahim A, Incampo E, Buccoliero G, Rizzo C, Devito F, Ciccone MM, Mondillo S. Left atrial, ventricular and atrio-ventricular strain in patients with subclinical heart dysfunction. Int J Cardiovasc Imaging 2019; 35:249-258. [PMID: 30251175 DOI: 10.1007/s10554-018-1461-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/19/2018] [Indexed: 01/09/2023]
Abstract
Arterial hypertension (AH) and diabetes mellitus (DM) are the most common causes of heart deterioration because of their high prevalence in the population. The aim of this study was to evaluate peak left atrial (LA), longitudinal strain (PALS), left ventricular (LV), longitudinal strain (LS) and global atrial-ventricular strain (GAVS), by speckle-tracking echocardiography (STE), in asymptomatic patients with AH or/and DM and normal LA, LV size and ejection fraction (EF), to analyze their capability to detect early subclinical dysfunction. We enrolled 162 patients affected by AH and/or DM with normal indexed LA volume, LV end-diastolic diameter and a LVEF > 52% (females) or > 54% (males) (60 hypertensives, 52 diabetics and 50 both) and 60 healthy controls. All subjects underwent standard and advanced STE. PALS, LS and GAVS were measured. GAVS was calculated as the algebraic sum of absolute PALS and LS values in four- and two-chambers views. LS, although with lower values in hypertensives, diabetics and both, did not show significant differences between groups. PALS and GAVS were significantly reduced in AH (31.9 ± 10.3% and 49.7 ± 11.2%, respectively) and DM (26.2 ± 7.1% and 42.6 ± 9.8%) compared to controls, and even more if the two coexisted (20.4 ± 6.5% and 37.1 ± 8.4%). PALS had the highest statistical significance and was able to identify subclinical damage independently from LS value. PALS was reduced in patients with AH and/or DM without alteration of standard echo indexes. The value of PALS was independent from LS and was sufficient to identify heart dysfunction in an earlier stage.
Collapse
MESH Headings
- Aged
- Arterial Pressure
- Asymptomatic Diseases
- Atrial Function, Left
- Biomechanical Phenomena
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/diagnostic imaging
- Diabetes Mellitus, Type 2/physiopathology
- Diabetic Cardiomyopathies/diagnostic imaging
- Diabetic Cardiomyopathies/etiology
- Diabetic Cardiomyopathies/physiopathology
- Early Diagnosis
- Echocardiography, Doppler, Pulsed
- Female
- Humans
- Hypertension/complications
- Hypertension/diagnostic imaging
- Hypertension/physiopathology
- Male
- Middle Aged
- Myocardial Contraction
- Predictive Value of Tests
- Risk Factors
- Ventricular Dysfunction, Left/diagnostic imaging
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left
Collapse
Affiliation(s)
- Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy.
| | - Giulia Elena Mandoli
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Edoardo Lisi
- Department of Mathematics, Imperial College, London, UK
| | - Aladino Ibrahim
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Eufemia Incampo
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Gianluigi Buccoliero
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Cosimo Rizzo
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Fiorella Devito
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Sergio Mondillo
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| |
Collapse
|
11
|
Prognostic value of global left atrial peak strain in patients with acute ischemic stroke and no evidence of atrial fibrillation. Int J Cardiovasc Imaging 2018; 35:603-613. [PMID: 30377893 DOI: 10.1007/s10554-018-1485-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/24/2018] [Indexed: 12/18/2022]
Abstract
Prognostic stratification of acute ischemic stroke (AIS) patients without atrial fibrillation (AF) remains a challenge. Two-dimensional speckle tracking echocardiography (2D-STE) has recently been introduced for dynamic evaluation of left atrial function. However only few data are actually available regarding the application of 2D-STE in AIS patients. The aim of our study was to assess the prognostic role of global left atrial peak strain (GLAPS), measured by 2D-STE, in AIS patients without AF history. Eighty-five AIS patients (mean age 74.1 ± 12.1 years, 49 males) with normal sinus rhythm on ECG and without AF history were enrolled in the prospective study. All patients underwent a complete echocardiographic study with 2D-STE. At 1 year follow-up, we evaluated the occurrence of a composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. GLAPS was markedly reduced in AIS patients (15.71 ± 4.70%), without any statistically significant difference between the stroke subtypes. At 1-year follow-up, 14 deaths and 17 hospital readmissions were detected in AIS subjects. On a multivariate Cox model, variables independently associated with the occurrence of the composite endpoint were the "Rankin in" Scale (HR 1.69, p = 0.001), GFR (HR 0.98, p = 0.03) and the GLAPS value (HR 0.78, p < 0.0001). A GLAPS value ≤ 15.5% predicted the composite endpoint with sensitivity of 100% and specificity of 80%. A GLAPS value ≤ 15.5% reflects a more advanced atrial cardiomyopathy and might provide a reliable and useful prognostic risk stratification of AIS patients without AF history.
Collapse
|
12
|
Hennawy B, El Kilany W, Galal H, Mamdouh A. Role of speckle tracking echocardiography in detecting early left atrial dysfunction in hypertensive patients. Egypt Heart J 2018; 70:217-223. [PMID: 30190649 PMCID: PMC6123346 DOI: 10.1016/j.ehj.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/21/2018] [Indexed: 12/03/2022] Open
Abstract
Background Arterial hypertension adversely affects left atrial (LA) size and function, effect on function may precede effect on size. Many techniques were used to assess LA function but with pitfalls. Objectives Early detection of left atrial dysfunction with speckle tracking echocardiography in hypertensive patients with normal left atrial size. Patients and methods The study was conducted on 50 hypertensive patients and 50 age matched normotensive controls, all with normal LA volume index and free from any other cardiovascular disease that may affect the LA size or function. They were all subjected to history taking, clinical examination and echocardiographic study with assessment of LA functions [total LA stroke volume, LA expansion index by conventional 2D echocardiography and Global peak atrial longitudinal strain by speckle tracking (PALS)], left ventricular (LV) systolic and diastolic functions, and LV mass. Results Different indices of LA dysfunction (Total LA stroke volume, LA expansion index and global PALS) were significantly lower in the hypertensive group despite the normal LA volume index in all the studied subjects. The presence of diabetes mellitus (DM) and higher grade of LV diastolic dysfunction were significantly associated with lower global PALS. The higher age, systolic blood pressure (BP), body mass index (BMI), LA volume index, and LV mass index and the lower LA expansion index were associated with lower global PALS. Conclusion Speckle tracking echocardiography is a useful novel technique in detecting LA dysfunction in hypertension even before LA enlargement occurs.
Collapse
Key Words
- BMI, body mass index
- BP, blood pressure
- DM, diabetes mellitus
- HR, heart rate
- Hypertension
- LA, left atrium
- LASV, LA stroke volume
- LV, left ventricle
- Left atrial dysfunction
- Left atrium
- PALS, peak atrial longitudinal strain
- ROI, region of interest
- STE, speckle-tracking echocardiography
- Speckle tracking
Collapse
Affiliation(s)
- Bassam Hennawy
- Cardiology Department, Ain Shams University Hospital, Cairo, Egypt
| | - Wael El Kilany
- Cardiology Department, Ain Shams University Hospital, Cairo, Egypt
| | - Haitham Galal
- Cardiology Department, Ain Shams University Hospital, Cairo, Egypt
| | - Ahmed Mamdouh
- Cardiology Department, Ain Shams University Hospital, Cairo, Egypt
| |
Collapse
|
13
|
Yu S, Zhang Y. Assessment of left atrial function: Another window to detect early cardiac impairment? J Clin Hypertens (Greenwich) 2017; 19:1105-1107. [PMID: 29067770 DOI: 10.1111/jch.13109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Shikai Yu
- The Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi Zhang
- The Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| |
Collapse
|
14
|
Olsen FJ, Bertelsen L, de Knegt MC, Christensen TE, Vejlstrup N, Svendsen JH, Jensen JS, Biering-Sørensen T. Multimodality Cardiac Imaging for the Assessment of Left Atrial Function and the Association With Atrial Arrhythmias. Circ Cardiovasc Imaging 2017; 9:CIRCIMAGING.116.004947. [PMID: 27729358 DOI: 10.1161/circimaging.116.004947] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Several cardiac imaging modalities are able to visualize the left atrium (LA) and, therefore, allow for quantification of both structural and functional properties of this cardiac chamber. In echocardiography, only the maximal LA volume is included in the assessment of diastolic function at the current moment. Numerous studies, however, have shown that functional measures may be superior to the maximal LA volume in several aspects and to possess clinical value even in the absence of structural abnormalities. Such functional measures could prove particularly useful in the setting of predicting atrial fibrillation, which will be a point of focus in this review. Pivotal cardiac magnetic resonance imaging studies have revealed high correlation between LA fibrosis and risk of atrial fibrillation recurrence after catheter ablation, and subsequent multimodality imaging studies have uncovered an inverse relationship between LA reservoir function and degree of LA fibrosis. This has sparked an increased interest into the application of advanced imaging modalities, including both speckle tracking echocardiography and tissue tracking by cardiac magnetic resonance imaging. Even though increasing evidence has supported the use of functional measures and proven its superiority to the maximal LA volume, they have still not been adopted in clinical guidelines. The reason for this discrepancy may rely on the fact that there is little to no agreement on how to technically perform deformation analysis of the LA. Such technical considerations, limitations, and alternate imaging prospects will be addressed in this review.
Collapse
Affiliation(s)
- Flemming Javier Olsen
- From the Department of Cardiology, Herlev & Gentofte Hospital (F.J.O., J.S.J., T.B.-S.), Department of Cardiology, Rigshospitalet (L.B., M.C.d.K., N.V., J.H.S.), Department of Cardiology, Department of Clinical Physiology, Nuclear Medicine & PET, Cluster for Molecular Imaging, Rigshospitalet (T.E.C.), and Institute of Clinical Medicine, Faculty of Health and Medical Sciences (J.H.S., J.S.J.), University of Copenhagen, Denmark; and Department of Radiology, Cardio-Vascular Imaging Division (T.E.C.) and Department of Medicine, Cardiovascular Medicine Division (T.B.-S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Litten Bertelsen
- From the Department of Cardiology, Herlev & Gentofte Hospital (F.J.O., J.S.J., T.B.-S.), Department of Cardiology, Rigshospitalet (L.B., M.C.d.K., N.V., J.H.S.), Department of Cardiology, Department of Clinical Physiology, Nuclear Medicine & PET, Cluster for Molecular Imaging, Rigshospitalet (T.E.C.), and Institute of Clinical Medicine, Faculty of Health and Medical Sciences (J.H.S., J.S.J.), University of Copenhagen, Denmark; and Department of Radiology, Cardio-Vascular Imaging Division (T.E.C.) and Department of Medicine, Cardiovascular Medicine Division (T.B.-S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Martina Chantal de Knegt
- From the Department of Cardiology, Herlev & Gentofte Hospital (F.J.O., J.S.J., T.B.-S.), Department of Cardiology, Rigshospitalet (L.B., M.C.d.K., N.V., J.H.S.), Department of Cardiology, Department of Clinical Physiology, Nuclear Medicine & PET, Cluster for Molecular Imaging, Rigshospitalet (T.E.C.), and Institute of Clinical Medicine, Faculty of Health and Medical Sciences (J.H.S., J.S.J.), University of Copenhagen, Denmark; and Department of Radiology, Cardio-Vascular Imaging Division (T.E.C.) and Department of Medicine, Cardiovascular Medicine Division (T.B.-S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Thomas Emil Christensen
- From the Department of Cardiology, Herlev & Gentofte Hospital (F.J.O., J.S.J., T.B.-S.), Department of Cardiology, Rigshospitalet (L.B., M.C.d.K., N.V., J.H.S.), Department of Cardiology, Department of Clinical Physiology, Nuclear Medicine & PET, Cluster for Molecular Imaging, Rigshospitalet (T.E.C.), and Institute of Clinical Medicine, Faculty of Health and Medical Sciences (J.H.S., J.S.J.), University of Copenhagen, Denmark; and Department of Radiology, Cardio-Vascular Imaging Division (T.E.C.) and Department of Medicine, Cardiovascular Medicine Division (T.B.-S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Niels Vejlstrup
- From the Department of Cardiology, Herlev & Gentofte Hospital (F.J.O., J.S.J., T.B.-S.), Department of Cardiology, Rigshospitalet (L.B., M.C.d.K., N.V., J.H.S.), Department of Cardiology, Department of Clinical Physiology, Nuclear Medicine & PET, Cluster for Molecular Imaging, Rigshospitalet (T.E.C.), and Institute of Clinical Medicine, Faculty of Health and Medical Sciences (J.H.S., J.S.J.), University of Copenhagen, Denmark; and Department of Radiology, Cardio-Vascular Imaging Division (T.E.C.) and Department of Medicine, Cardiovascular Medicine Division (T.B.-S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jesper Hastrup Svendsen
- From the Department of Cardiology, Herlev & Gentofte Hospital (F.J.O., J.S.J., T.B.-S.), Department of Cardiology, Rigshospitalet (L.B., M.C.d.K., N.V., J.H.S.), Department of Cardiology, Department of Clinical Physiology, Nuclear Medicine & PET, Cluster for Molecular Imaging, Rigshospitalet (T.E.C.), and Institute of Clinical Medicine, Faculty of Health and Medical Sciences (J.H.S., J.S.J.), University of Copenhagen, Denmark; and Department of Radiology, Cardio-Vascular Imaging Division (T.E.C.) and Department of Medicine, Cardiovascular Medicine Division (T.B.-S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jan Skov Jensen
- From the Department of Cardiology, Herlev & Gentofte Hospital (F.J.O., J.S.J., T.B.-S.), Department of Cardiology, Rigshospitalet (L.B., M.C.d.K., N.V., J.H.S.), Department of Cardiology, Department of Clinical Physiology, Nuclear Medicine & PET, Cluster for Molecular Imaging, Rigshospitalet (T.E.C.), and Institute of Clinical Medicine, Faculty of Health and Medical Sciences (J.H.S., J.S.J.), University of Copenhagen, Denmark; and Department of Radiology, Cardio-Vascular Imaging Division (T.E.C.) and Department of Medicine, Cardiovascular Medicine Division (T.B.-S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Tor Biering-Sørensen
- From the Department of Cardiology, Herlev & Gentofte Hospital (F.J.O., J.S.J., T.B.-S.), Department of Cardiology, Rigshospitalet (L.B., M.C.d.K., N.V., J.H.S.), Department of Cardiology, Department of Clinical Physiology, Nuclear Medicine & PET, Cluster for Molecular Imaging, Rigshospitalet (T.E.C.), and Institute of Clinical Medicine, Faculty of Health and Medical Sciences (J.H.S., J.S.J.), University of Copenhagen, Denmark; and Department of Radiology, Cardio-Vascular Imaging Division (T.E.C.) and Department of Medicine, Cardiovascular Medicine Division (T.B.-S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
15
|
Peng J, Laukkanen JA, Zhao Q, Wang L, Zhang X, Li G. Association of left atrial enlargement with ventricular remodeling in hypertensive Chinese elderly. Echocardiography 2017; 34:491-495. [PMID: 28247527 DOI: 10.1111/echo.13484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND It is not well known whether left atrial (LA) enlargement is associated with left ventricular (LV) remodeling in Asian subjects with preserved LV ejection fraction (LVEF ≥50%). Therefore, we studied whether LA enlargement is related to ventricular remodeling in hypertensive Chinese elderly with preserved LVEF. METHODS Data of 480 hypertensive Chinese elderly (age from 65 to 94 years) with LVEF ≥50% were consecutively included in the study. RESULTS We observed a total of 248 patients (51.7%) with increased LA size. Univariate analysis showed that LA size was positively related to duration of hypertension, prevalence of coronary heart disease and atrial fibrillation, interventricular septal thickness, LV posterior wall thickness, LV end-diastolic and end-systolic diameter, LV mass index, right ventricular (RV) diameter and aortic diameter; meanwhile, LA size was inversely related to LVEF and relative wall thickness of LV. Multivariate regression analysis showed that LA enlargement was positively related to duration of hypertension (P=.012) and RV diameter (P<.001). CONCLUSIONS Left atrial enlargement is independently associated with a longer duration of hypertension and RV dilative remodeling in hypertensive elderly with preserved LVEF. LA enlargement is an early sign of RV eccentric remodeling in hypertensive elderly.
Collapse
Affiliation(s)
- Jing Peng
- Division of Cardiology, Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jari A Laukkanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.,Department of Medicine, Central Finland Central Hospital, Jyväskylä, Finland
| | - Qianping Zhao
- Division of Cardiology, Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liping Wang
- Division of Cardiology, Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xu Zhang
- Division of Cardiology, Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Li
- Division of Cardiology, Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
16
|
Lee JH, Park JH. Role of echocardiography in clinical hypertension. Clin Hypertens 2015; 21:9. [PMID: 26893921 PMCID: PMC4750785 DOI: 10.1186/s40885-015-0015-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/13/2015] [Indexed: 12/17/2022] Open
Abstract
Hypertension is a major and correctable cardiovascular risk factor. The correct diagnosis of hypertension and precise assessment of cardiovascular risk are essential to give proper treatment in patients with hypertension. Although echocardiography is the second-line study in the evaluation of hypertensive patients, it gives many clues suggesting bad prognosis associated with hypertension, including increased left ventricular (LV) mass, decreased LV systolic function, impaired LV diastolic function, and increased left atrial size and decreased function. Along with conventional echocardiographic methods, tissue Doppler imaging, three-dimensional echocardiography, and strain echocardiography are newer echocardiographic modalities in the evaluation of hypertensive patients in the current echocardiographic laboratories. Understanding conventional and newer echocardiographic parameters is important in the diagnosis and assessment of cardiovascular risk in hypertensive patients.
Collapse
Affiliation(s)
- Jae-Hwan Lee
- Department of Cardiology in Internal Medicine, School of Medicine, Chungnam National University Hospital, Chungnam National University, Daejeon, Korea
| | - Jae-Hyeong Park
- Department of Cardiology in Internal Medicine, School of Medicine, Chungnam National University Hospital, Chungnam National University, Daejeon, Korea
| |
Collapse
|
17
|
Xu TY, Sun JP, Lee APW, Yang XS, Ji L, Zhang Z, Li Y, Yu CM, Wang JG. Left atrial function as assessed by speckle-tracking echocardiography in hypertension. Medicine (Baltimore) 2015; 94:e526. [PMID: 25674752 PMCID: PMC4602743 DOI: 10.1097/md.0000000000000526] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We investigated left atrial (LA) function in relation to hypertension using 2-dimensional speckle-tracking echocardiography (STE) in subjects with preserved left ventricular (LV) ejection fraction, while accounting for LA enlargement and LV mass and diastolic function.We performed standard 2-dimensional and Doppler echocardiography and LA volumetric measurements and STE strain imaging in hypertensive patients (systolic/diastolic blood pressure ≥140/90 mmHg, or use of antihypertensive drugs, n = 124) and age- and sex-matched normotensive subjects (n = 124). We measured the peak LA velocity, strain, and strain rate during systole and early and late diastole, respectively. We investigated the associations of interests in the presence or absence of LA enlargement (LA volume index ≥28 mL/m).Hypertensive and normotensive subjects had similar LV ejection fraction and LA diameter (P ≥ 0.22). However, hypertensive compared with normotensive subjects had enlarged LV and impaired diastolic function, and had increased LA volumetric measurements and decreased LA emptying fractions (P < 0.0001). Hypertensive patients also had impaired LA function, as measured by STE velocity, strain, and strain rate in general and in the absence of LA enlargement (P < 0.0001). The differences in LA STE strain rate during LV systole and LA contraction between hypertension and normotension in the absence of LA enlargement remained statistically significant (P < 0.001), after adjustment for age, sex, and LV mass index and E/E'.Hypertension is associated with impaired LA function, as assessed by STE strain imaging technique, even before LA enlargement develops and after LV remodeling is accounted for.
Collapse
Affiliation(s)
- Ting-Yan Xu
- From the Center for Cardiovascular Evaluations, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai (T-YX, YL, J-GW); and Division of Cardiology, S.H. Ho Cardiovascular and Stroke Centre, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China (JPS, AP-WL, XSY, LJ, ZZ, C-MY)
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Badran HM, Faheem N, Elnoamany MF, Kenawy A, Yacoub M. Characterization of Left Atrial Mechanics in Hypertrophic Cardiomyopathy and Essential Hypertension Using Vector Velocity Imaging. Echocardiography 2015; 32:1527-38. [DOI: 10.1111/echo.12885] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Hala Mahfouz Badran
- Cardiology Department; Menoufiya University; Shebin Egypt
- The BAHCM National Program; Aswan Egypt
- Aswan Heart Center; Aswan Egypt
| | - Naglaa Faheem
- Cardiology Department; Menoufiya University; Shebin Egypt
- The BAHCM National Program; Aswan Egypt
| | | | - Asma Kenawy
- Cardiology Department; Menoufiya University; Shebin Egypt
| | - Magdi Yacoub
- The BAHCM National Program; Aswan Egypt
- Aswan Heart Center; Aswan Egypt
- Imperial College; London United Kingdom
| |
Collapse
|
19
|
Yang L, Qiu Q, Fang SH. Evaluation of left atrial function in hypertensive patients with and without left ventricular hypertrophy using velocity vector imaging. Int J Cardiovasc Imaging 2014; 30:1465-71. [PMID: 25005684 DOI: 10.1007/s10554-014-0485-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/02/2014] [Indexed: 12/31/2022]
Abstract
To study left atrial deformation characteristics using Velocity vector imaging (VVI) in hypertensive patients with and without left ventricular hypertrophy (LVH), and to explore its value for detection of left atrial dysfunction in these patients. Sixty-four patients with essential hypertension were divided into normal left ventricular geometry (LVN, 37 cases) and LVH (27 cases) groups, according to their left ventricular mass index. Twenty-five age-matched healthy participants were included as control group. Two-dimensional dynamic images of the apical four- and two-chamber echocardiographic views were obtained, and strain/strain rate (SR) curves of eight atrial segments were derived by VVI software. Peak systolic strain (ε(sys)), systolic SR (SRs), early and late diastolic SR (SRe, SRa) were measured and calculated. Peak early diastolic mitral inflow and annulus velocities were also measured and their ratio (E/E') calculated. Compared with the control group, SRe decreased and SRa increased significantly in LVH group (P < 0.05), while no significant difference was found between LVN and control groups with respect to SRe, SRa, SRs and ε(sys) (P > 0.05). Also, no significant difference was observed in SRe, SRa, SRs and ε(sys) between LVH and LVN groups (P > 0.05). SRe and SRa correlated significantly with E/E' (r = -0.634, r = 0.609; both P < 0.001). Strain/SR parameters derived from VVI may reflect decreased conduit, increased booster pump function of the left atrium in hypertensive patients with LVH and correlate with left ventricular diastolic function.
Collapse
Affiliation(s)
- Li Yang
- Department of Cardiology, Sun Yat-Sen Memorial Hospital, Sun Yet-Sen University, 107 Yanjiang West Road, Guangzhou, 510120, China,
| | | | | |
Collapse
|
20
|
Liu Y, Wang K, Su D, Cong T, Cheng Y, Zhang Y, Wu J, Sun Y, Shang Z, Liu J, Zhong L, Zou L, Chitian C, Zhang X, Jiang Y. Noninvasive assessment of left atrial phasic function in patients with hypertension and diabetes using two-dimensional speckle tracking and volumetric parameters. Echocardiography 2014; 31:727-735. [PMID: 24354465 DOI: 10.1111/echo.12492] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the left atrial phasic function of hypertensive patients with or without coexisting diabetes using two-dimensional speckle tracking echocardiography (2DSTE)-based strain and strain rate imaging and volumetric parameters. METHODS The study included an isolated hypertension group (HT group) comprising 99 patients, a hypertension and diabetes group (HT + DM group) comprising 65 patients, and 26 age-matched healthy controls. The 2DSTE-based strain and strain rate images were studied, and the following parameters were measured: peak left atrial longitudinal strain (LAS-S ), early diastolic (LAS-E ) and late diastolic (LAS-A ) atrial longitudinal strains, and systolic (LASR-S ), early diastolic (LASR-E ) and late diastolic (LASR-A ) strain rates. RESULTS The LAS-S and LASR-S were lower in the HT group and the HT + DM group compared with the control group (P < 0.001). The LAS-E and LASR-E were lower in the HT group (14.9 ± 5.5% and -1.1 ± 0.4/sec, respectively) than in the control group (22.1 ± 8.3% and -1.7 ± 0.6/sec, respectively) (P < 0.001), and they were further depressed in the HT + DM group (12.3 ± 6.3% and -1.0 ± 0.4/sec, respectively) (P < 0.05). There were no significant differences in LAS-A or LASR-A among the 3 groups (P > 0.05). Multivariate regression analysis revealed that HT and DM were independently related to LAS-E and LASR-E . CONCLUSIONS Hypertension can lead to abnormal left atrial reservoir and conduit functions, and coexisting diabetes can further impair conduit function. 2DSTE-derived strain and strain rate imaging are sensitive methods for evaluating left atrial phasic function.
Collapse
Affiliation(s)
- Yan Liu
- The First Affiliated Hospital of Dalian Medical University, Liaoning, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Ben Aharon I, Bar Joseph H, Tzabari M, Shenkman B, Farzam N, Levi M, Shalgi R, Stemmer SM, Savion N. Doxorubicin-induced vascular toxicity--targeting potential pathways may reduce procoagulant activity. PLoS One 2013; 8:e75157. [PMID: 24073244 PMCID: PMC3779248 DOI: 10.1371/journal.pone.0075157] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 08/12/2013] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Previous study in mice using real-time intravital imaging revealed an acute deleterious effect of doxorubicin (DXR) on the gonadal vasculature, as a prototype of an end-organ, manifested by a reduction in blood flow and disintegration of the vessel wall. We hypothesized that this pattern may represent the formation of microthrombi. We aimed to further characterize the effect of DXR on platelets' activity and interaction with endothelial cells (EC) and to examine potential protectants to reduce DXR acute effect on the blood flow. METHODS The effect of DXR on platelet adhesion and aggregation were studied in vitro. For in vivo studies, mice were injected with either low molecular weight heparin (LMWH; Enoxaparin) or with eptifibatide (Integrilin(©)) prior to DXR treatment. Testicular arterial blood flow was examined in real-time by pulse wave Doppler ultrasound. RESULTS Platelet treatment with DXR did not affect platelet adhesion to a thrombogenic surface but significantly decreased ADP-induced platelet aggregation by up to 40% (p<0.001). However, there was a significant increase in GPIIbIIIa-mediated platelet adhesion to DXR-exposed endothelial cells (EC; 5.7-fold; p<0.001) reflecting the toxic effect of DXR on EC. The testicular arterial blood flow was preserved in mice pre-treated with LMWH or eptifibatide prior to DXR (P<0.01). CONCLUSIONS DXR-induced acute vascular toxicity may involve increased platelet-EC adhesion leading to EC-bound microthrombi formation resulting in compromised blood flow. Anti-platelet/anti-coagulant agents are effective in reducing the detrimental effect of DXR on the vasculature and thus may serve as potential protectants to lessen this critical toxicity.
Collapse
Affiliation(s)
- Irit Ben Aharon
- Institute of Oncology, Davidoff Center and Rabin Medical Center, Petah-Tiqva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
| | - Hadas Bar Joseph
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moran Tzabari
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Shenkman
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel
| | - Nahid Farzam
- Goldschleger Eye Research Institute and Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mattan Levi
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ruth Shalgi
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Salomon M. Stemmer
- Institute of Oncology, Davidoff Center and Rabin Medical Center, Petah-Tiqva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naphtali Savion
- Goldschleger Eye Research Institute and Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
22
|
Sampaio F, Pimenta J, Bettencourt N, Fontes-Carvalho R, Silva AP, Valente J, Bettencourt P, Fraga J, Gama V. Left atrial function is impaired in cirrhosis: a speckle tracking echocardiographic study. Hepatol Int 2013. [PMID: 26202416 DOI: 10.1007/s12072-013-9469-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Abnormalities in left ventricular systolic and diastolic function have been described in patients with cirrhosis. There are no studies on left atrial (LA) function in these patients. We aimed to evaluate LA function in cirrhosis patients using myocardial deformation imaging. METHODS We included 111 hospitalized and ambulatory patients with cirrhosis and 18 healthy controls. A comprehensive echocardiographic evaluation was performed; LA strain was assessed using velocity vector imaging. RESULTS Peak atrial longitudinal strain at the end of ventricular systole was lower in patients [41.9 % (34.4-51.0) vs. 48.0 % (42.0-57.1), p = 0.02]. No differences were found in atrial strain before atrial contraction in patients and controls [17.5 % (14.3-22.4) vs. 20.7 % (14.1-26.3), p = 0.14]. On multivariate linear regression analysis, E' velocity was the only variable independently associated with peak atrial longitudinal strain (R (2) = 47 %). No correlation was found between the LA volume index (LAVI) and peak atrial longitudinal strain (r = -0.136, p = 0.219). Peak atrial longitudinal strain performed better than LAVI in identifying patients with elevated filling pressures (AUC = 0.81 vs. 0.52). CONCLUSIONS Patients with cirrhosis have abnormal atrial reservoir function, which may be related to the same factors associated with impaired ventricular relaxation. LA enlargement in cirrhosis may not reflect elevated filling pressures and should not be used as an isolated marker of diastolic dysfunction. The atrial "pump" function does not seem to be affected in cirrhosis patients.
Collapse
Affiliation(s)
- Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal.
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal.
| | - Joana Pimenta
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Nuno Bettencourt
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Ana Paula Silva
- Gastroenterology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
| | - João Valente
- Internal Medicine Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
| | - Paulo Bettencourt
- Cardiovascular R&D Unit, University of Porto Medical School, Porto, Al. Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - José Fraga
- Gastroenterology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
| | - Vasco Gama
- Cardiology Department, Centro Hospitalar de Gaia/Espinho, Rua Conceição Fernandes, 4430-502, Vila Nova de Gaia, Portugal
| |
Collapse
|
23
|
Tsai WC, Huang YY, Liu YW, Shih JY, Lin CC, Tsai LM. Changes of Left Atrial Phasic Function Assessed by Speckle Tracking Echocardiography in Untreated Hypertension. J Med Ultrasound 2012. [DOI: 10.1016/j.jmu.2012.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
24
|
Bar-Joseph H, Ben-Aharon I, Tzabari M, Tsarfaty G, Stemmer SM, Shalgi R. In vivo bioimaging as a novel strategy to detect doxorubicin-induced damage to gonadal blood vessels. PLoS One 2011; 6:e23492. [PMID: 21931602 PMCID: PMC3170286 DOI: 10.1371/journal.pone.0023492] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2010] [Accepted: 07/19/2011] [Indexed: 11/19/2022] Open
Abstract
Introduction Chemotherapy may induce deleterious effects in normal tissues, leading to organ damage. Direct vascular injury is the least characterized side effect. Our aim was to establish a real-time, in vivo molecular imaging platform for evaluating the potential vascular toxicity of doxorubicin in mice. Methods Mice gonads served as reference organs. Mouse ovarian or testicular blood volume and femoral arterial blood flow were measured in real-time during and after doxorubicin (8 mg/kg intravenously) or paclitaxel (1.2 mg/kg) administration. Ovarian blood volume was imaged by ultrasound biomicroscopy (Vevo2100) with microbubbles as a contrast agent whereas testicular blood volume and blood flow as well as femoral arterial blood flow was imaged by pulse wave Doppler ultrasound. Visualization of ovarian and femoral microvasculature was obtained by fluorescence optical imaging system, equipped with a confocal fiber microscope (Cell-viZio). Results Using microbubbles as a contrast agent revealed a 33% (P<0.01) decrease in ovarian blood volume already 3 minutes after doxorubicin injection. Doppler ultrasound depicted the same phenomenon in testicular blood volume and blood flow. The femoral arterial blood flow was impaired in the same fashion. Cell-viZio imaging depicted a pattern of vessels' injury at around the same time after doxorubicin injection: the wall of the blood vessels became irregular and the fluorescence signal displayed in the small vessels was gradually diminished. Paclitaxel had no vascular effect. Conclusion We have established a platform of innovative high-resolution molecular imaging, suitable for in vivo imaging of vessels' characteristics, arterial blood flow and organs blood volume that enable prolonged real-time detection of chemotherapy-induced effects in the same individuals. The acute reduction in gonadal and femoral blood flow and the impairment of the blood vessels wall may represent an acute universal doxorubicin-related vascular toxicity, an initial event in organ injury.
Collapse
Affiliation(s)
- Hadas Bar-Joseph
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Irit Ben-Aharon
- Davidoff Center, Rabin Medical Center, Institute of Oncology, Petah-Tiqva, Israel
- * E-mail:
| | - Moran Tzabari
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Galia Tsarfaty
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - Salomon M. Stemmer
- Davidoff Center, Rabin Medical Center, Institute of Oncology, Petah-Tiqva, Israel
| | - Ruth Shalgi
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| |
Collapse
|
25
|
Mondillo S, Cameli M, Caputo ML, Lisi M, Palmerini E, Padeletti M, Ballo P. Early detection of left atrial strain abnormalities by speckle-tracking in hypertensive and diabetic patients with normal left atrial size. J Am Soc Echocardiogr 2011; 24:898-908. [PMID: 21665431 DOI: 10.1016/j.echo.2011.04.014] [Citation(s) in RCA: 318] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND Systemic hypertension and type 2 diabetes mellitus are associated with impaired left atrial (LA) function, but whether LA functional abnormalities also occur in patients with hypertension and diabetes who have normal LA sizes is unknown. The aim of this study was to explore LA strain using speckle-tracking echocardiography in patients with hypertension or diabetes and normal LA size. METHODS LA strain was studied by speckle-tracking echocardiography in 155 patients with hypertension or diabetes with LA volume indexes < 28 mL/m(2) (83 with hypertension, 34 with diabetes, and 38 with both diabetes and hypertension) and 36 age-matched controls. The following indexes were measured: peak atrial longitudinal strain, time to peak atrial longitudinal strain, atrial longitudinal strain during early diastole and late diastole, and peak LA strain rate during ventricular systole, early diastole, and late diastole. RESULTS Peak atrial longitudinal strain was lower in patients with hypertension (29.0 ± 6.5%) and those with diabetes (24.7 ± 6.4%) than in controls (39.6 ± 7.8%) and further reduced in patients with diabetes and hypertension (18.3 ± 5.0%) (P < .0001). Similar results were found for atrial longitudinal strain during early diastole, atrial longitudinal strain during late diastole, and peak LA strain rate during ventricular systole and early diastole (P < .0001 for all). An inverse trend was found for time to peak atrial longitudinal strain, whereas no differences in peak LA strain rate during late diastole were observed. Two-way analysis of variance showed no interactions between hypertension and diabetes. In multivariate analyses, hypertension and diabetes were both independently associated with decreases in all LA strain and strain rate indexes, with the exception of peak LA strain rate during late diastole. CONCLUSIONS LA deformation mechanics are impaired in patients with hypertension or diabetes with normal LA size. The coexistence of both conditions further impairs LA performance in an additive fashion. Speckle-tracking echocardiography may be considered a promising tool for the early detection of LA strain abnormalities in these patients.
Collapse
Affiliation(s)
- Sergio Mondillo
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | | | | | | | | | | | | |
Collapse
|
26
|
Khoo CW, Krishnamoorthy S, Lim HS, Lip GYH. Assessment of left atrial volume: a focus on echocardiographic methods and clinical implications. Clin Res Cardiol 2010; 100:97-105. [PMID: 20821219 DOI: 10.1007/s00392-010-0222-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 08/25/2010] [Indexed: 11/28/2022]
Abstract
Left atrial enlargement is an important predictor of cardiovascular events such as atrial fibrillation, stroke, heart failure and mortality. A number of methods of left atrial size assessment by echocardiography have been reported, from the simple antero-posterior diameter in the parasternal long axis view to the more complex ellipsoid, area-length and Simpson's method of estimating left atrial volume. These different methods of left atrial size assessment, their clinical implications and some common pitfalls are discussed in this review.
Collapse
Affiliation(s)
- Chee W Khoo
- City Hospital, University of Birmingham Centre for Cardiovascular Sciences, Birmingham, B18 7QH, UK
| | | | | | | |
Collapse
|