Prognostic relevance of left atrial function and stiffness in heart failure with preserved ejection fraction patients with and without diabetes mellitus

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

AIMS

The optimal echocardiographic predictors of cardiovascular outcome in heart failure (HF) with preserved ejection fraction (HFpEF) are unknown. We aimed to identify independent echocardiographic predictors of cardiovascular outcome in patients with HFpEF.

METHODS AND RESULTS

Systematic literature search of three electronic databases was conducted from date of inception until November 2022. Hazard ratios (HRs) and their 95% confidence intervals (CIs) for echocardiographic variables from multivariate prediction models for the composite primary endpoint of cardiovascular death and HF hospitalization were pooled using a random effects meta-analysis. Specific subgroup analyses were conducted for studies that enrolled patients with acute versus chronic HF, and for those studies that included E/e', pulmonary artery systolic pressure (PASP), renal function, natriuretic peptides and diuretic use in multivariate models. Forty-six studies totalling 20 056 patients with HFpEF were included. Three echocardiographic parameters emerged as independent predictors in all subgroup analyses: decreased left ventricular (LV) global longitudinal strain (HR 1.24, 95% CI 1.10-1.39 per 5% decrease), decreased left atrial (LA) reservoir strain (HR 1.30, 95% CI 1.13-1.1.50 per 5% decrease) and lower tricuspid annular plane systolic excursion (TAPSE) to PASP ratio (HR 1.17, 95% CI 1.07-1.25 per 0.1 unit decrease). Other independent echocardiographic predictors of the primary endpoint were a higher E/e', moderate to severe tricuspid regurgitation, LV mass index and LA ejection fraction, although these variables were less robust.

CONCLUSIONS

Impaired LV global longitudinal strain, lower LA reservoir strain and lower TAPSE/PASP ratio predict cardiovascular death and HF hospitalization in HFpEF and are independent of filling pressures, clinical characteristics and natriuretic peptides. These echocardiographic parameters reflect key functional changes in HFpEF, and should be incorporated in future prospective risk prediction models.

Beyond Blood Sugar: How Left Atrium Strain Predicts Cardiac Outcomes in Type 2 Diabetes

Speckle tracking echocardiography is an innovative imaging technique that evaluates myocardial motion, including the function of the left atrium (LA). The assessment of the left atrium's function across its dimensions can have diagnostic and prognostic roles in various cardiovascular conditions. Left atrial strain has been recognized as a valuable predictor of mortality and cardiovascular incidents in the general population across various conditions. For individuals with type 2 diabetes mellitus (T2DM), left atrial dysfunction, as gauged by speckle tracking echocardiography, appears particularly prognostic. Parameters such as peak atrial longitudinal strain (PALS) and left atrial stiffness have been linked with heightened risks of severe cardiovascular events, including atrial fibrillation (AF), heart failure (HF) hospitalizations, or mortality. Consequently, recognizing left atrial dysfunction early is crucial for accurate diagnosis, guiding treatment choices, comprehensive patient management, and prognosis evaluation. Using two-dimensional (2D) speckle tracking echocardiography, results from recent studies report that treatment with empagliflozin significantly enhanced LA function in patients with type 2 diabetes mellitus, improving left atrial strain (LAS) contraction and reservoir values. Furthermore, treatments with glucagon-like peptide-1 (GLP)-1 receptor agonists and sodium-glucose cotransporter-2 (SGLT-2) inhibitors were shown to improve LA reservoir strain more effectively than insulin alone, suggesting their potential in reducing cardiovascular complications in T2DM patients. This narrative review further addresses ongoing challenges and potential enhancements needed to boost the clinical value of left atrium strain, emphasizing its significance in managing and improving outcomes for diabetic patients.

Sudden Cardiac Death Risk Stratification in Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) poses a significant clinical challenge, with sudden cardiac death (SCD) emerging as one of the leading causes of mortality. Despite advancements in cardiovascular medicine, predicting and preventing SCD in HFpEF remains complex due to multifactorial pathophysiological mechanisms and patient heterogeneity. Unlike heart failure with reduced ejection fraction, where impaired contractility and ventricular remodeling predominate, HFpEF pathophysiology involves heavy burden of comorbidities such as hypertension, obesity, and diabetes. Diverse mechanisms, including diastolic dysfunction, microvascular abnormalities, and inflammation, also contribute to distinct disease and SCD risk profiles. Various parameters such as clinical factors and electrocardiogram features have been proposed in SCD risk assessment. Advanced imaging modalities and biomarkers offer promise in risk prediction, yet comprehensive risk stratification models specific to HFpEF ar0e lacking. This review offers recent evidence on SCD risk factors and discusses current therapeutic strategies aimed at reducing SCD risk in HFpEF.

Left atrial stiffness is in correlation with left atrial reservoir strain in pediatric patients with mitral regurgitation

BACKGROUND

Left atrial stiffness index (LASI), defined as the ratio of early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') to peak atrial strain, reflects reduced left atrial (LA) compliance and represents an emerging marker that can be used for noninvasive measurement of fibrosis of LA in patients with mitral regurgitation (MR).

OBJECTIVE

To investigate the impact of chronic MR in children and adolescents on the remodeling and function of the LA, quantified through strain parameters and diastolic function.

METHODS

The study included fifty patients (n= 50) diagnosed with primary and secondary chronic MR lasting at least 5 years. The echocardiographic recordings were performed by a third party, two cardiologists actively engaged in echocardiography on a daily basis.

RESULTS

Older participants had higher values of the LASI (r= 0.467, p= 0.001). Participants with higher LASI values had a smaller LA reservoir (r= 0.784, p= 0.0001) and smaller LA conduit values (r=-0.374, p= 0.00). Participants with higher LASI values had a larger LA diameter (r= 0.444, p-value= 0.001) and higher average E/e' ratio (r= 0.718, p= 0.0001). There was a significant difference (p= 0.04) in the LASI among participants based on the MR jet area (< 20.85% ⩾ 20.85%), LASI was higher in participants with an area greater than 20.85%. Differences in other parameters such as LA reservoir, LA conduit, LA contractile were not statistically significant.

CONCLUSION

Increased LA stiffness is associated with diminished atrial compliance and reservoir capacity, and LASI has a potential to as an early marker for assessing disease severity and progression in pediatric MR.

Inflammation and Coagulation are Two Interconnected Pathophysiological Pathways in Atrial Fibrillation Pathogenesis

Introduction

Atrial fibrillation (AF) is associated with elevated levels of clotting factors such as tissue factor (TF) and factor XII (FXII). Various inflammation markers, such as interleukin-6 (IL-6), tumor necrosis factor-α (TNF- α), and high-sensitive C-reactive protein (hs-CRP), have also been associated with AF. This study explores the relationship between inflammation markers and coagulation activity, including their impact on heart structural changes in these patients.

Methods

We observed 283 patients with nonvalvular AF who underwent a complete examination at admission, but only 183 patients have successful cardioversion. As a control group, similar patients without AF were examined. The markers of the coagulation and inflammation were studied by ELISA on the analyzer "Stat Fax 303 Plus". Studies were conducted using l statistical package SPSS 13.0.

Results

It was revealed that patients with AF had significantly higher levels of hs-CRP, IL-6, and TNF-α and had elevated levels of TF and FXII compared with control group. The moderate correlations were observed between IL-6 and left atrial diameter (LAD), IL-6 and LA stiffness, hs-CRP and left atrial volume (LAV), TF and LAV.

Conclusion

We have demonstrated that patients with AF have the relationship between elevated levels of inflammatory markers and coagulation activity, which contributes to structural atrial remodeling.

Evaluation of the Relationship Between Diabetic Retinopathy and the Development of Left Atrial Stiffness in Patients with Diabetes Mellitus

OBJECTIVE

Based on several studies, atrial remodeling results in an increase in left atrial (LA) stiffness, which is indicative of a worsened reservoir function. A typical microvascular consequence of diabetes mellitus (DM) is diabetic retinopathy. Therefore, the objective of this study was to assess the factors that might be related to LA stiffness in DM patients.

MATERIALS AND METHODS

There were 200 DM patients in the study population. The LA stiffness value of 0.33 led to the division of the patients into 2 groups. According to these groups, the parameters to predict the development of the LA stiffness were investigated.

RESULTS

The patient population's median age was 54.7 ± 9.4 years, and of them, 105 (52.5% of the population) were men. Retinopathy was substantially linked with LA stiffness. Interventricular septum thickness (B coefficient: 0.261, 95% CI 0.128; 0.394; P < .001), mitral annular plane systolic excursion (B coefficient: -0.350, 95% CI -0.489; -0.2212; P < 0.001), and retinopathy (B coefficient: 0.644, 95% CI 0.307; 0.983; P < .001) were identified as independent predictors of the progression of LA stiffness by the linear regression model.

CONCLUSION

The results of the current investigation demonstrated a correlation between higher LA stiffness values and the presence of diabetic retinopathy in diabetic patients.

Association of complication of type 2 diabetes mellitus with hemodynamics and exercise capacity in patients with heart failure with preserved ejection fraction: a case-control study in individuals aged 65-80 years

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a frequently observed complication in patients with heart failure with preserved ejection fraction (HFpEF). Although a characteristic finding in such patients is a decrease in objective exercise capacity represented by peak oxygen uptake (peakVO₂), exercise capacity and its predictors in HFpEF with T2DM remain not clearly understood. This case-control study aimed to investigate the association between exercise capacity and hemodynamics indicators and T2DM comorbidity in patients with HFpEF aged 65-80 years.

METHODS

Ninety-nine stable outpatients with HFpEF and 50 age-and-sex-matched controls were enrolled. Patients with HFpEF were classified as HFpEF with T2DM (n = 51, median age, 76 years) or without T2DM (n = 48, median age, 76 years). The peakVO₂ and ventilatory equivalent versus carbon dioxide output slope (VE vs VCO₂ slope) were measured by cardiopulmonary exercise testing. The peak heart rate (HR) and peak stroke volume index (SI) were measured using impedance cardiography, and the estimated arteriovenous oxygen difference (peak a-vO₂ diff) was calculated with Fick's equation. The obtained data were compared among the three groups using analysis of covariance adjusted for the β-blocker medication, presence or absence of sarcopenia, and hemoglobin levels in order to determine the T2DM effects on exercise capacity and hemodynamics in patients with HFpEF.

RESULTS

In HFpEF with T2DM compared with HFpEF without T2DM and the controls, the prevalence of sarcopenia, chronotropic incompetence, and anemia were significantly higher (p < 0.001). The peakVO₂ (Controls 23.5 vs. without T2DM 15.1 vs. with T2DM 11.6 mL/min/kg), peak HR (Controls 164 vs. without T2DM 132 vs. with T2DM 120 bpm/min), peak a-vO₂ (Controls 13.1 vs without T2DM 10.6 vs with T2DM 8.9 mL/100 mL), and VE vs VCO₂ slope (Controls 33.2 vs without T2DM 35.0 vs with T2DM 38.2) were significantly worsened in patients with HFpEF with T2DM (median, p < 0.001). There was no significant difference in peak SI among the three groups.

CONCLUSIONS

Our results suggested that comorbid T2DM in patients with HFpEF may reduce exercise capacity, HR response, peripheral oxygen extraction, and ventilation efficiency. These results may help identify cardiovascular phenotypes of HFpEF complicated with T2DM and intervention targets for improving exercise intolerance.