Assessment of Atrial Electromechanical Delay and Left Atrial Mechanical Functions in Patients with Ulcerative Colitis

Inflammatory bowel disease and cardiac function: a systematic review of literature with meta-analysis

Background

Morphological and functional cardiac involvement is rarely described in patients with inflammatory bowel disease (IBD) but there is evidence that they have an increased risk of cardiovascular (CV) events despite the lower prevalence of traditional CV risk factors.

Objectives

Our systematic review and meta-analysis examined the relationship between IBD and cardiac function, namely the incidence of heart failure (HF) and subclinical echocardiographic changes.

Data sources and methods

Two medical databases, PubMed and Scopus, were systematically searched up to September 2022 to identify all studies reporting HF and/or echocardiographic changes in IBD patients.

Results

The qualitative analysis comprised a total of 18 studies (14 retrospective and 4 prospective studies) involving 59,838 patients. IBD was associated with subtle systolic and diastolic alterations, vascular dysfunction, increased risk for HF hospitalizations, and globally worse CV outcomes. Nine studies were included in the meta-analysis. In the IBD population, we found statistically significant reduced early to late diastolic transmitral flow (E/A), higher E to early diastolic mitral annular tissue velocity (E/e'), and decreased global longitudinal strain. Increased left atrial diameter and area were also present in IBD patients but no statistical significance was reached. Inter-atrial and right intra-atrial conduction delays were observed.

Conclusion

The IBD population has an increased risk for left ventricular and atrial dysfunction, vascular changes, arrhythmias, and HF hospitalization. Screening with sensitive imaging like speckle tracking echocardiography could identify early subclinical changes. IBD is in fact a CV risk factor and tight inflammation control may reduce CV risk.

Atrial Fibrillation, Atrial Myopathy, and Thromboembolism: The Additive Value of Echocardiography and Possible New Horizons for Risk Stratification

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, and it is associated with increased stroke and dementia risk. While the established paradigm attributes these complications to blood stasis within the atria and subsequent thrombus formation with cerebral embolization, recent evidence suggests that atrial myopathy (AM) may play a key role. AM is characterized by structural and functional abnormalities of the atria, and can occur with or without AF. Moving beyond classifications based solely on episode duration, the 4S-AF characterization has offered a more comprehensive approach, incorporating patient's stroke risk, symptom severity, AF burden, and substrate assessment (including AM) for tailored treatment decisions. The "ABC" pathway emphasizes anticoagulation, symptom control, and cardiovascular risk modification and emerging evidence suggests broader benefits of early rhythm control strategies, potentially reducing stroke and dementia risk and improving clinical outcomes. However, a better integration of AM assessment into the current framework holds promise for further personalizing AF management and optimizing patient outcomes. This review explores the emerging concept of AM and its potential role as a risk factor for stroke and dementia and in AF patients' management strategies, highlighting the limitations of current risk stratification methods, like the CHA2DS2-VASc score. Echocardiography, particularly left atrial (LA) strain analysis, has shown to be a promising non-invasive tool for AM evaluation and recent studies suggest that LA strain analysis may be a more sensitive risk stratifier for thromboembolic events than AF itself, with some studies showing a stronger association between LA strain and thromboembolic events compared to traditional risk factors. Integrating it into routine clinical practice could improve patient management and targeted therapies for AF and potentially other thromboembolic events. Future studies are needed to explore the efficacy and safety of anticoagulation in AM patients with and without AF and to refine the diagnostic criteria for AM.

Cardiovascular manifestations of inflammatory bowel diseases and the underlying pathogenic mechanisms

Inflammatory bowel disease (IBD), consisting of ulcerative colitis and Crohn's disease, mainly affects the gastrointestinal tract but is also known to have extraintestinal manifestations because of long-standing systemic inflammation. Several national cohort studies have found that IBD is an independent risk factor for the development of cardiovascular disorders. However, the molecular mechanisms by which IBD impairs the cardiovascular system are not fully understood. Although the gut-heart axis is attracting more attention in recent years, our knowledge of the organ-to-organ communication between the gut and the heart remains limited. In patients with IBD, upregulated inflammatory factors, altered microRNAs and lipid profiles, as well as dysbiotic gut microbiota, may induce adverse cardiac remodeling. In addition, patients with IBD have a three- to four times higher risk of developing thrombosis than people without IBD, and it is believed that the increased risk of thrombosis is largely due to increased procoagulant factors, platelet count/activity, and fibrinogen concentration, in addition to decreased anticoagulant factors. The predisposing factors for atherosclerosis are present in IBD and the possible mechanisms may involve oxidative stress system, overexpression of matrix metalloproteinases, and changes in vascular smooth muscle phenotype. This review focuses mainly on 1) the prevalence of cardiovascular diseases associated with IBD, 2) the potential pathogenic mechanisms of cardiovascular diseases in patients with IBD, and 3) adverse effects of IBD drugs on the cardiovascular system. Also, we introduce here a new paradigm for the gut-heart axis that includes exosomal microRNA and the gut microbiota as a cause for cardiac remodeling and fibrosis.

Inflammatory bowel disease and atrial fibrillation: a contemporary overview

Atrial fibrillation is the most common arrhythmia in clinical practice and it is associated with increased morbidity and mortality. Atrial fibrillation is linked with inflammatory signaling while inflammation and oxidative stress promote atrial remodeling promoting the development and perpetuation of the arrhythmia. On the other hand, inflammatory bowel disease (IBD) is considered a chronic inflammatory condition with flares and remissions. IBD has been associated with an increased risk of atherosclerotic cardiovascular disease but its relationship with atrial fibrillation has not been studied well. Recent epidemiological evidence indicates an association between IBD and atrial fibrillation, especially during flares/hospitalizations. This brief review provides a concise overview of all available data regarding the association between IBD and atrial fibrillation including the predictive role of electrocardiographic and echocardiographic markers. Several unresolved issues including the thromboembolic risk in this setting and the potential role of antiinflammatory interventions are also discussed.

Review article: Risk of cardiovascular events in patients with inflammatory bowel disease receiving small molecule drugs

BACKGROUND

In the context of an ageing inflammatory bowel disease (IBD) population, cardiovascular comorbidities become particularly relevant. Novel small molecule drugs (SMDs) for the treatment of moderate-to-severe IBD have been recently approved, including Janus kinase (JAK) inhibitors and sphingosine-1-phosphate receptor (S1P) modulators. Data from rheumatoid arthritis population have raised concerns about the risk of cardiovascular events with the use of tofacitinib, which was extrapolated to other immune-mediated diseases and other JAK inhibitors. S1P receptor modulation has been associated with potential cardiovascular events, especially bradycardia and cardiac conduction abnormalities.

AIM

To review the incidence of cardiovascular events with the use of SMDs in patients with IBD and to provide practical recommendations on mitigation strategies.

METHODS

Published literature was reviewed; recommendations were synthesised by experts in both cardiovascular diseases and IBD.

RESULTS

Evidence from the IBD population does not indicate a higher risk of cardiovascular events with tofacitinib and other JAK inhibitors. The risk is higher in patients with intermediate to high cardiovascular risk. S1P modulators may be associated with a dose-dependent, first-dose effect, transient risk of conduction abnormalities (bradycardia and AV block). Screening and monitoring of cardiovascular risk factors should be done in all patients with IBD. Risk stratification for cardiovascular disease should be performed before starting treatment with SMDs.

CONCLUSIONS

Available evidence of both JAK inhibitors and S1P modulators indicates a reassuring safety profile of SMDs from the cardiovascular perspective in the overall IBD population. Efforts should be made to identify patients with IBD at a higher risk of cardiovascular events.

Assessment of atrial conduction times in patients with frequent premature ventricular complex

Background

Premature ventricular complex (PVC) is a frequent finding in the general population. The atrial conduction time (ACT) is the period between the electrocardiographic P wave and the atrial mechanical contraction, and its prolongation indicates an atrial electromechanical delay (EMD). In our study, we compared atrial conduction parameters by echocardiographic methods between patients with frequent PVC and healthy control subjects.

Methods

The study included 54 patients with PVC and 54 healthy volunteers. Atrial conduction parameters were measured with echocardiographic examination. The time difference between the p wave and the Am wave was measured in the septal, lateral, and tricuspid annulus regions. The interatrial EMD, left atrial intra-atrial delay, and the right atrial intra-atrial delay were calculated from these measurements. The groups were compared for demographic and electrocardiographic features and echocardiographic parameters.

Results

Left intra-atrial EMD, right intra-atrial EMD, and interatrial EMD were significantly longer in the patient group (p = .001, p < .001, p < .001, respectively). PA lateral, PA septal, and PA tricuspid durations were significantly prolonged in the patient group (all p < .001). All ACT parameters were significantly prolonged in patients with PVC QRS duration of 150 ms and above (all p < .001). All ACT parameters were prolonged in PVCs of right ventricular origin than those of left ventricular origin (all p < .001). ACT parameters were prolonged in patients with a coupling interval time below 485 ms (all p < .001).

Conclusions

Atrial conduction times are prolonged in patients with frequent PVC.

Is there any link between atrial arrhythmias and inflammatory bowel disease?

BACKGROUND

Inflammation plays an important role in the development of cardiovascular disease, including atherosclerosis and arrhythmia. The aim of this study was to evaluate atrial conduction times (ACTs) in patients with inflammatory bowel disease (IBD) in which systemic chronic inflammation is evident.

METHODS

In this cross-sectional, prospective, single-center study, 79 IBD patients (51 ulcerative colitis; 28 Crohn's disease) and 70 healthy controls were included. Atrial electromechanical properties were measured by recording simultaneous surface electrocardiography (ECG) with transthoracic echocardiography (ECHO) and tissue Doppler imaging methods. The relationship between age, disease duration, and ACT was evaluated.

RESULTS

There were significantly increased conduction durations of lateral-PA (time interval from the onset of the P-wave on surface ECG to the beginning of the late diastolic wave), septal-PA, tricuspid-PA, and interatrial-electromechanical delay (IA-EMD), right intraatrial EMD, and left intraatrial (LI-EMD) durations in IBD patients (P < 0.001). In IBD patients, there was a positive correlation with age, lateral PA, septal PA, tricuspid PA, IA-EMD, and LI-EMD (P < 0.05). A positive correlation was found between disease duration and only lateral PA and tricuspid PA (P < 0.05).

CONCLUSION

In IBD patients, prolonged ACT consists a potential risk for severe atrial arrhythmias. ECG and ECHO screening can be useful in identifying risk groups in IBD patients and taking precautions for future cardiac complications.

Mendelian randomization as an approach to assess causal effects of inflammatory bowel disease on atrial fibrillation

Background: Despite growing evidence indicating that patients with inflammatory bowel disease (IBD) have an increased risk of atrial fibrillation (AF), owing to the potential biases of confounding effects and reverse causation, the specific relationship between IBD and AF remains controversial. The aim of this study is to determine whether there is a causal effect of IBD on AF.

Methods: A two-sample Mendelian randomization (MR) study was performed to evaluate the causal effect of IBD on AF. Statistical summaries for the associations between single nucleotide polymorphisms (SNPs) and traits of interest were obtained from independent consortia with European populations. The dataset of IBD was acquired from genome-wide association studies (GWAS), including more than 75,000 cases and controls. A GWAS with 60,620 AF cases and 970,216 controls was used to identify genetic variation underlying AF. The causal effect was estimated using the multiplicative random effects inverse-variance weighted method (IVW), followed by sensitivity analysis.

Results: Using 81 SNPs, there was no evidence to suggest an association between genetically predicted IBD and risk of AF with multiplicative random-effects IVW MR analysis (odds ratio = 1.0000, 95% confidence interval: 0.9994 1.0005, p = 0.88).

Conclusion: As opposed to current assumptions, no substantial evidence was found to support a causal role of IBD in the development of AF.

Quantifying Risk Factors for Atrial Fibrillation: Retrospective Review of a Large Electronic Patient Database

BACKGROUND

Despite the numerous comorbidities associated with atrial fibrillation (AF), the relative risk has been varying and not well-documented.

AIM

To quantify the risk of diseases associated with AF.

METHODS

Population-based retrospective analysis in IBM Explorys (1999-2019), an electronic database with over 63 million patients in the United States. Odds ratios were calculated between AF and other diseases. AF patients were also stratified by age, gender, and race to assess trends of AF in different demographic groups.

RESULTS

1,812,620 patients had AF in the database. Congestive heart failure had the highest association with AF (OR 42.95). Cardiomyopathy, coronary artery disease, hypertension, and myocardial infarction all had odds greater than 15. Anemia of chronic disease and chronic kidney disease had odds greater than 18, the highest for chronic inflammatory conditions. Other conditions commonly associated with AF were found to have odds less than 8, including hyperthyroidism, alcohol use, and sleep apnea. Helicobacter pylori infection had the lowest odds at 1.98.

CONCLUSIONS

Epidemiologic information could be integrated with current clinical algorithms to more rapidly identify patients at risk of AF.

Usefulness of tissue Doppler-derived atrial electromechanical delay for identifying patients with paroxysmal atrial fibrillation

Background

Tissue Doppler imaging (TDI)-derived atrial electromechanical delay (AEMD) has been reported to be useful for detecting paroxysmal atrial fibrillation (PAF). However, its usefulness remains unknown when analyzed along with patients seemingly at high-risk for AF as controls. From this standpoint, we investigated whether AEMD would be of use for identifying patients with PAF.

Methods

We retrospectively analyzed TDI recordings to obtain AEMD in 63 PAF patients. Thirty-three patients with multiple cardiovascular risk factors (MRFs) but without history of AF and 50 healthy individuals served as disease and healthy controls, respectively. AEMD was defined as the time-interval between the electrocardiogram P-wave and the beginning of the spectral TDI-derived A’ for the septal (septal EMD) and lateral (lateral EMD) sides of the mitral annulus.

Results

There was no significant difference in the left atrial volume index between PAF patients and disease controls (28 ± 9 mL/m² vs. 27 ± 5 mL/m²). PAF patients had longer AEMD, particularly for the lateral EMD (75 ± 23 ms), compared with disease (62 ± 22 ms, P = 0.009) and healthy (54 ± 24 ms, P < 0.001) controls. Multivariate logistic regression analysis revealed that the lateral EMD (OR 1.25, 95%CI 1.03–1.52, P = 0.023), along with the left atrial volume index (OR 2.25, 95%CI 1.44–3.51, P < 0.001), was one of the significant independent associates of identifying PAF patients.

Conclusions

This cross-sectional study indicates that even analyzed together with MRFs patients, AEMD remains useful for identifying patients at risk for AF. Our results need to be confirmed by a large-scale prospective study.

Atrial peak longitudinal strain may be predictive of pancolitis in patients with ulcerative colitis

BACKGROUND

Ulcerative colitis is a chronic idiopathic inflammatory bowel disease of the colon that is characterized by a relapsing and remitting course. Previous studies have shown that arterial stiffness, carotid intima media thickness, atrial electromechanical delay, and global longitudinal strain suggested subclinical cardiovascular disorders in ulcerative colitis patients. The aims of our study was to evaluate the left atrial function of patients with ulcerative colitis by using speckle tracking echocardiography, and to assess the relationship between echocardiographic variables and the extent of the disease.

METHODS

We recruited 51 outpatients with ulcerative colitis in remission phase and 52 healthy volunteers. The ulcerative colitis patients were evaluated by for the extent of the disease by endoscopy at the initial diagnosis.

RESULTS

E/E_m , left atrial volume, and left atrial stiffness index were higher, and peak atrial longitudinal strain was lower in pancolitis than in non-pancolitis patients. In the multivariate logistic regression test, peak atrial longitudinal strain and E/E_m were found to be independent predictors for pancolitis.

CONCLUSION

Early detection of myocardial abnormalities by conventional echocardiography and speckle tracking echocardiography, which is a simple and non-invasive technique, may be useful for giving insights to the extent of the disease in ulcerative colitis patients.

Increased risk of atrial fibrillation in patients with inflammatory bowel disease: A nationwide population-based study

BACKGROUND

Inflammatory bowel disease (IBD), a chronic inflammatory disease of the gastrointestinal tract, could play a role in the pathophysiology of atrial fibrillation (AF).

AIM

To investigate the association between IBD and AF development.

METHODS

We performed a population-based cohort study using records in the Korean National Health Insurance Services database between 2010 and 2014. A total of 37696 patients with IBD (12349 with Crohn’s disease and 25397 with ulcerative colitis) were identified. The incidence rate of newly diagnosed AF in patients with IBD was compared with that in a 3 times larger cohort of 113088 age- and sex-matched controls without IBD.

RESULTS

During 4.9 ± 1.3 years of follow-up, 1120 patients newly diagnosed with AF (348 in the IBD group and 772 in controls) were identified. After adjustments using multivariable Cox proportional hazards, patients with IBD were at a 36% [95% confidence interval (CI) 20%-54%] higher risk of AF than controls. The association between IBD and the development of AF was stronger in younger than in older patients. Patients without cardiovascular risk factors showed a higher risk of AF primarily. Additionally, patients receiving immun-omodulators [Hazard ration (HR) 1.46, 95%CI 1.31-1.89], systemic corticosteroids (HR 1.37, 95%CI 1.10-1.71), or biologics agents (HR 2.38, 95%CI 1.51-3.75) were at higher risk of AF than patients without them.

CONCLUSION

IBD significantly increased the risk of AF, and the impact of IBD on developing AF was in patients with moderate to severe disease.

Gastrointestinal and liver diseases and atrial fibrillation: a review of the literature

Atrial fibrillation (AF) is the most common arrhythmia worldwide and is associated with significant morbidity and mortality. A number of risk factors have been associated with AF, though few studies have explored the association between gastrointestinal and liver diseases and AF. Additionally, AF and treatment for AF may predispose to gastrointestinal and liver diseases. We review the current literature on the bidirectional associations between gastrointestinal and liver diseases and AF. We highlight the gaps in knowledge and areas requiring future investigation.

Evaluation of Left Atrial Electromechanical Delay and Left Atrial Phasic Functions in Surgical Early Menopause Patients

BACKGROUND

This study evaluated the atrial electromechanical delay (AEMD) and the left atrial (LA) mechanical functions in patients with surgical early menopause.

METHODS

A total of 62 patients were included in the study: 33 patients with surgical early menopause and 29 age- and sex-matched healthy controls. The duration distance from the start of the P wave to the beginning of the A wave for the lateral mitral annulus, septal mitral annulus, and lateral tricuspid annulus was assessed by tissue Doppler echocardiography. The differences in these durations were used to calculate the inter- and intra-atrial mechanical delays. LA volumes were evaluated using the biplane area-length technique, and LA mechanical function values were measured.

RESULTS

The baseline laboratory and clinical characteristics were similar between the two groups. Surgical early menopause patients displayed increased static atrial electromechanical connection (PA′) times for the septal mitral annulus and lateral tricuspid annulus compared to the controls. However, the lateral mitral annulus, the inter-atrial, the intra-LA, and the right atrial EMD PA′ times were not significantly altered in surgical early menopause patients compared to controls. Importantly, the LA volume index (28.1 ± 8.17 vs. 24.89 ± 7.96 mL/m², p = 0.019), the maximal LA volume (49.6 ± 14.1 vs. 42.9 ± 16.1 mL, p = 0.004), the minimal LA volume (18.4 ± 7.0 vs. 15.2 ± 9.0 mL, p = 0.022), and the atrial precontraction LA volume (31.0 ± 10.9 vs. 24.9 ± 10.1 mL, p = 0.006) were higher in the patients with surgical early menopause compared to the controls. The LA reservoir, conduit and pumping functions and the total, passive, and active emptying volumes were all comparable between the two groups (p = 0.09; 0.06; 0.68; 0.06; 0.48; 0.07, respectively).

CONCLUSIONS

Patients with surgical early menopause demonstrated impaired atrial electrical delay and electromechanical functions.

Cardiovascular Manifestations of Inflammatory Bowel Disease: Pathogenesis, Diagnosis, and Preventive Strategies

Inflammatory bowel disease (IBD) refers to a group of chronic inflammatory diseases that targets mainly the gastrointestinal tract. The clinical presentation of IBD includes both gastrointestinal manifestations and extraintestinal manifestations (EIM). The reported cardiovascular manifestations in IBD patients include pericarditis, myocarditis, venous and arterial thromboembolism, arrhythmias, atrioventricular block, heart failure, endocarditis, valvulopathies, and Takayasu arteritis. The aim of this article is to review the available literature about the possible pathogenic mechanisms and determine preventive measures capable of reducing the incidence and severity of the cardiovascular manifestations. In IBD patients, the incidence of cardiovascular manifestations is low, but higher than that in the general population. Therefore, clinicians should pay attention to any new modification that might indicate cardiovascular involvement in IBD patients, and they should consider chronic inflammatory diseases in patients with cardiac conditions without an evident cause. Considering the role of inflammation in the development of cardiovascular manifestations, the management should include prevention of flares and maintenance of remission for as long as possible. Preventive measures should also include active screening and strict control of the cardiovascular risk factors in all IBD patients.

Speckle Tracking Stress Echocardiography Uncovers Early Subclinical Cardiac Involvement in Pediatric Patients with Inflammatory Bowel Diseases

Inflammatory bowel disease (IBD) is an established risk factor for cardiovascular disease (CVD). However, whether cardiac consequences present early in IBD is unknown. This is the first study in children aiming to unmask altered myocardial mechanics in IBD. We enrolled 50 consecutive normotensive children with Crohn’s disease (CD) (n = 28) or ulcerative colitis (UC) (n = 22). The study groups consisted of 18 patients with active inflammatory disease (mean age 14.6 ± 2.5 years) and 32 children with IBD in remission (14.3 ± 2.3 years). 60 age- and gender-matched children served as healthy controls. Speckle tracking stress echocardiography (STE) was used to assess left ventricular (LV) myocardial strain and strain rate. Circumferential strain rate was significantly decreased in children with active IBD (−1.55 ± 0.26 s⁻¹) and IBD in remission (−1.49 ± 0.26 s⁻¹) versus healthy controls (1.8 ± 0.4 s⁻¹) both at rest (p < 0.001) and during exercise (p = 0.021). Moreover, longitudinal strain rate, circumferential strain and E/E′ ratio were significantly impaired in IBD. Pediatric patients with IBD feature subclinical signs of LV systolic and diastolic myocardial impairment early in the course of CD and UC. This may not be reversible even when IBD is clinically controlled. Patients with IBD should be regularly screened for signs of CVD.

Assessment of left atrial mechanical functions and atrial electromechanical delay in Juvenile idiopathic arthritis by tissue Doppler echocardiography

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a systemic chronic inflammatory disease. Studies using tissue Doppler imaging (TDI) for the evaluation of cardiac functions of children with JIA are limited. Thus, this study was conducted to evaluate Left ventricular function, left atrial mechanical functions and atrial electromechanical delay in JIA.

METHODS

This study was carried out as a across sectional study. A total of 34 patients with active JIA and 34 controls were included. Atrial electromechanical delay and left atrial (LA) mechanical functions in addition to systolic and diastolic left ventricular (LV) functions were measured by using conventional echocardiography and TDI. Assessment of disease activity was done using Juvenile arthritis disease activity score (JADAS-27).

RESULTS

JIA patients had abnormal atrial electromechanical coupling as established from prolonged lateral mitral annulus (PA lateral), septal mitral annulus (PA septum), inter-atrial and intra-atrial electromechanical delays compared with healthy controls. Left ventricular filling abnormalities were found characterized by a reduced E/A ratio (1.07 ± 0.56 vs. 1.48 ± 0.16, p = 0.01). E/Em was significantly higher in patients with JIA (7.58 ± 1.79 vs. 4.74 ± 1.45, p = 0.003) denoting impaired diastolic function. Left atrial mechanical functions assessment showed significantly decreased LA passive emptying fraction, increased LA active emptying fraction and LA total emptying volume in JIA patients (p = 0.01, p = 0.01, p = 0.03 respectively).

CONCLUSION

Atrial electromechanical coupling intervals, and LA mechanical functions were impaired which can be considered as an early form of subclinical cardiac involvement in JIA patients. Significant diastolic functional abnormalities exist in JIA.