Effects of intensive blood pressure control on left ventricular hypertrophy in aortic valve disease.

BACKGROUND: Hypertension adds to the pressure overload on the left ventricle (LV) in combination with aortic valve (AV) disease, but the optimal blood pressure (BP) targets for patients with AV disease remain unclear. We tried to investigate whether intensive BP control reduces LV hypertrophy in asymptomatic patients with aortic stenosis (AS) or aortic regurgitation (AR). METHODS: A total of 128 hypertensive patients with mild to moderate AS (n = 93) or AR (n = 35) were randomly assigned to intensive therapy, targeting a systolic BP <130 mm Hg, or standard therapy, targeting a systolic BP <140 mm Hg. The primary end point was the change in LV mass from baseline to the 24-month follow-up. Secondary end points included changes in severity of AV disease, LV volumes, ejection fraction and global longitudinal strain (GLS). RESULTS: The treatment groups were generally well balanced regarding the baseline characteristics. The mean (±SD) age of the patients was 68 ± 8 years and 48% were men. The mean BP was 145 ± 12/81 ± 10 mm Hg at baseline. Medication at baseline was similar between the 2 groups. The 2 treatment strategies resulted in a rapid and sustained difference in systolic BP (P < .05). At 24-month, the mean systolic BP was 129 ± 12 mm Hg in the intensive therapy group and 135 ± 14 mm Hg in the standard therapy group. No patient died or underwent AV surgery during follow-up in either of the groups. LV mass was changed from 189.5 ± 41.3 to 185.6 ± 41.5 g in the intensive therapy group (P = .19) and from 183.8 ± 38.3 to 194.0 ± 46.4 g in the standard therapy group (P < .01). The primary end point of change in LV mass was significantly different between the intensive therapy and the standard therapy group (-3.9 ± 20.2 g vs 10.3 ± 20.4 g; P = .0007). The increase in LV mass index was also significantly greater in the standard therapy group (P = .01). No significant differences in secondary end points (changes in severity of AV disease, LV volumes, ejection fraction and GLS) were observed between the treatment groups. CONCLUSIONS: Among hypertensive patients with AV disease, intensive hypertensive therapy resulted in a significant reduction in LV hypertrophy, although progression of AV disease was similar between the treatment groups. CLINICAL TRIAL REGISTRATION: http://ClinicalTrials.gov (Number NCT03666351).

Identifying fragile calcifications of the aortic valve in transcatheter aortic valve replacement: iodine concentration of aortic valvular calcification by spectral CT.

OBJECTIVE: To demonstrate the relationship between spectral computed tomography (CT) measured iodine concentration and strength of aortic valvular calcification (AVC) in patients with aortic valve stenosis (AVS). METHODS: A retrospective study was performed on patients who underwent transcatheter aortic valve replacement (TAVR) for symptomatic AVS and underwent both pre and postprocedural electrocardiogram gated CT scans using a spectral CT system. Preprocedural CT was used to evaluate the volume and iodine concentration (IC) in the AVC. Postprocedural CT data were used to calculate the volume reduction percentage (VRP) of AVC. Multiple linear regression analysis was used to identify the independent variables related to the VRP in AVCs. RESULTS: A total of 94 AVCs were selected from 22 patients. The mean volume and IC of the AVCs before TAVR were 0.37 mL ± 0.15 mL and 7 mg/mL ± 10.5 mg/mL, respectively. After TAVR, a median VRP of all 94 AVCs was 18.5%. Multiple linear regression analysis showed that the IC was independently associated with the VRP (coefficient = 1.64, p < 0.001). When an optimal IC cutoff point was set at 4 mg/mL in the assessment of a fragile AVC which showed the VRP was > 18.5%, the sensitivity was 63%; specificity, 91%; positive predictive value, 88%; and negative predictive value, 71%. CONCLUSIONS: When using spectral CT to prepare the TAVR, measuring the IC of the AVC may be useful to assess the probability of AVC deformity after TAVR. KEY POINTS: • A dual-layer detector-based spectral CT enables quantifying iodine of contrast media in the aortic valve calcification (AVC) on contrast-enhanced CT images. • The AVC including iodine of contrast media on contrast-enhanced CT image may have loose compositions, associated with the deformity of AVC after TAVR. • Measuring the iodine concentration in AVC may have the potential to assess the probability of AVC deformity, which may be associated with the outcome and complications after TAVR.2.

Association between the number of pregnancies and cardiac target organ damages: a cross-sectional analysis of data from the Korean women's chest pain registry (KoROSE).

BACKGROUND: Pregnancy increases long-term cardiovascular risk after childbirth, but the mechanisms are unclear. This study was performed to investigate the association between the number of pregnancies and several cardiac target organ damage (TOD) in middle-aged and elderly women. METHODS: Using the database of the nation-wide registry, a total of 1,137 women (mean age 63.0 ± 10.9 years) with stable chest pain undergoing invasive coronary angiography (CAG) were analyzed. Information on the number of pregnancies was obtained through a questionnaire. Obstructive coronary artery disease (CAD), left ventricular (LV) mass index (LVMI) and LV septal annular (e') velocity were assessed as indicators of cardiac TOD. RESULTS: Women with higher number of pregnancies (≥ 3) were older (66.3 ± 9.6 vs. 57.4 ± 10.7 years; P < 0.001), had more cardiovascular risk factors, and took more cardiovascular medications than those with lower number of pregnancies (< 3). In multivariable analyses, higher number of pregnancies (≥ 3) was associated with obstructive CAD (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.21-2.17; P = 0.001), a higher LVMI (> 95 g/m2) (OR, 1.46; 95% CI, 1.08-1.98; P = 0.013) and a lower septal e' velocity (< 7 cm/s) (OR, 1.55; 95% CI, 1.12-2.14; P = 0.007) even after controlling for potential confounders. As the number of pregnancies increased, the prevalence of CAD and LVMI increased, and the septal e' velocity gradually decreased (P < 0.001 for each). CONCLUSIONS: In women with chest pain undergoing invasive CAG, higher number of pregnancies was associated with multiple cardiac TOD. Parity information should be checked when assessing a woman's cardiovascular risk.

Aortic Annulus Detection Based on Deep Learning for Transcatheter Aortic Valve Replacement Using Cardiac Computed Tomography.

BACKGROUND: To propose a deep learning architecture for automatically detecting the complex structure of the aortic annulus plane using cardiac computed tomography (CT) for transcatheter aortic valve replacement (TAVR). METHODS: This study retrospectively reviewed consecutive patients who underwent TAVR between January 2017 and July 2020 at a tertiary medical center. Annulus Detection Permuted AdaIN network (ADPANet) based on a three-dimensional (3D) U-net architecture was developed to detect and localize the aortic annulus plane using cardiac CT. Patients (N = 72) who underwent TAVR between January 2017 and July 2020 at a tertiary medical center were enrolled. Ground truth using a limited dataset was delineated manually by three cardiac radiologists. Training, tuning, and testing sets (70:10:20) were used to build the deep learning model. The performance of ADPANet for detecting the aortic annulus plane was analyzed using the root mean square error (RMSE) and dice similarity coefficient (DSC). RESULTS: In this study, the total dataset consisted of 72 selected scans from patients who underwent TAVR. The RMSE and DSC values for the aortic annulus plane using ADPANet were 55.078 ± 35.794 and 0.496 ± 0.217, respectively. CONCLUSION: Our deep learning framework was feasible to detect the 3D complex structure of the aortic annulus plane using cardiac CT for TAVR. The performance of our algorithms was higher than other convolutional neural networks.

Current Status of Pharmacologic and Nonpharmacologic Therapy in Heart Failure with Preserved Ejection Fraction.

Heart failure with preserved ejection fraction (HFpEF) is a significantly symptomatic disease and has a poor prognosis similar to that of heart failure with reduced ejection fraction (HFrEF). Contrary to HFrEF, HFpEF is difficult to diagnose, and the recommended diagnostic algorithm of HFpEF is complicated. Several therapies for HFpEF have failed to reduce mortality or morbidity. HFpEF is thought to be a complex and heterogeneous systemic disorder that has various phenotypes and multiple comorbidities. Therefore, therapeutic strategies of HFpEF need to change depending on the phenotype of the patient. This review highlights the pharmacologic and nonpharmacologic treatment of HFpEF.

Association between epicardial adipose tissue, high-sensitivity C-reactive protein and myocardial dysfunction in middle-aged men with suspected metabolic syndrome.

BACKGROUND: As body fat composition and metabolism differ between men and women, we evaluated sex-related differences in the association among epicardial adipose tissue (EAT), secretome profile, and myocardial function of subjects with suspected metabolic syndrome. METHODS: We evaluated 277 participants (men, n = 140; 56.1 ± 4.7 years) who underwent conventional echocardiography and two-dimensional speckle tracking from the Seoul Metabolic Syndrome cohort. EAT was measured from the right ventricular free wall perpendicular to the aortic annulus at end systole. Global longitudinal strain (GLS) was obtained from 18 apical segments. Apolipoprotein A1, apolipoprotein B, adiponectin, and high-sensitivity C-reactive protein (hs-CRP) levels were measured using immunoturbidimetry assay. RESULTS: Mean age, body mass index, and hs-CRP level did not differ by sex. Waist circumference, fasting blood glucose level, and triglyceride/high-density lipoprotein cholesterol ratio were higher, and apolipoprotein AI and adiponectin levels were lower in men. No significant difference in mean EAT thickness was found (7.02 ± 1.81 vs. 7.13 ± 1.70 mm, p = 0.613). Men had a higher left ventricular (LV) mass index and lower GLS. EAT thickness was associated with hs-CRP level in men alone (ß = 0.206, p = 0.015). LV mass index (ß = 2.311, p = 0.037) and function represented by e' (ß = - 0.279, p = 0.001) and GLS (ß = - 0.332, p < 0.001) were independently associated with EAT thickness in men alone. CONCLUSIONS: In middle-aged subjects with suspected metabolic syndrome, EAT was associated with inflammation represented by hs-CRP level, LV mass, and subclinical myocardial dysfunction only in men, suggesting that the inflammatory activity of EAT induced myocardial remodeling and dysfunction in middle-aged subjects but was attenuated in women. Trial registration NCT02077530 (date of registration: November 1, 2013).

Association of epicardial adipose tissue with coronary spasm and coronary atherosclerosis in patients with chest pain: analysis of data collated by the KoRean wOmen'S chest pain rEgistry (koROSE).

Epicardial adipose tissue (EAT) represents a cardio-metabolic risk factor; it secretes several adipokines related to coronary atherosclerosis. However, the precise relationship between EAT and coronary vasospasm is unknown. This study aimed to investigate the relationship between EAT and coronary vasospasm using data from the KoRean wOmen'S chest pain rEgistry (koROSE). This study included 551 patients (female/male = 366/185; mean age = 60.2 ± 10.2 years) who presented with chest pain at an outpatient clinic, and who subsequently underwent echocardiography and coronary angiography. Coronary artery stenosis (CAS >50% narrowing of at least one coronary artery) was detected in 223 patients (40.5%). The remaining 328 patients underwent the coronary spasm provocation test. Coronary spasm was defined as >90% narrowing induced by intra-coronary acetylcholine or ergonovine injection. EAT thickness was measured using transthoracic echocardiography according to American society of echocardiography recommendations. The mean EAT thickness was higher in the patients with CAS than in those without (8.09 ± 2.51 versus 6.88 ± 2.54 mm, P = 0.001) after adjusting for factors potentially influencing EAT thickness. Coronary vasospasm by provocation test was detected in 128 patients. The EAT thickness was higher in the patients with spasm than in those without (7.65 ± 2.52 versus 6.40 ± 2.45 mm, P < 0.001) but was not statistically different from that of the patients with CAS (P = 0.43). The EAT thickness had an independent relationship with CAS [odds ratio (OR) 1.166, 95% confidence interval (CI) 1.07-1.27, P < 0.001] and coronary vasospasm [OR 1.276, 95% CI 1.14-1.43, P < 0.001] after adjusting for clinical cardiovascular risk factors. EAT thickness is associated with coronary vasospasm and coronary atherosclerosis. The pathophysiology of coronary spasm may be similar to that of coronary atherosclerosis and could be an indicator of coronary stenosis.

Evaluation of sex differences in the relationship between diastolic dysfunction and thromboembolism using propensity score analysis.

BACKGROUND: Female sex is a risk factor for thromboembolism (TE) in atrial fibrillation (AF); however, the underlying mechanisms are unclear. We postulated that left ventricular (LV) diastolic dysfunction (LVDD) could be associated with increased thromboembolic risk in women. METHODS: From a retrospective cohort, 158 patients (female : male = 79:79) with nonvalvular AF were propensity score-matched for age, presence of diabetes, hypertension, coronary artery disease, congestive heart failure, embolic history, AF type, and AF duration. Cardiac size and function and central aortic stiffness parameters were evaluated. Diastolic function was classified as normal, indeterminate, and LVDD according to recent guidelines. Surrogate markers for thromboembolism (dense spontaneous echo contrast and thrombus) were evaluated using transesophageal echocardiography. RESULTS: Surrogate markers for TE showed a trend to be more frequent in women than in men (21.5% vs 11.4%, P = .086). LVDD was more prevalent in women than in men (22.8% vs 2.5%, P < .001); however, the prevalence of indeterminate diastolic function was not different between sexes (26.6% vs 20.3%, P = .453). Surrogate markers for TE were detected mostly in women with LVDD. LV diastolic parameters showed a restrictive pattern, and aortic stiffness parameters were worse in women than in men. Women with LVDD had increased aortic stiffness compared to women with indeterminate and normal function, whereas aortic stiffness did not differ among men in all groups. Significant relations between LV diastolic function and aortic stiffness parameters were observed only in women. CONCLUSION: LVDD due to increased aortic stiffness could be related to a higher thromboembolic risk in women with AF.

Epicardial adipose tissue is related to cardiac function in elderly women, but not in men.

BACKGROUND AND AIM: Epicardial adipose tissue (EAT) is easily quantifiable visceral adipose tissue that is closely associated with cardiometabolic disease including heart failure with preserved left ventricular (LV) ejection fraction. As body fat distribution and metabolism are different between men and women, we evaluated the sex difference in EAT thickness and its relationship to cardiac function. METHODS AND RESULTS: A total of 152 consecutive patients (76 men) with mean age of 62 ± 9 years were enrolled. Conventional echocardiography was performed and EAT thickness was measured perpendicularly on the right ventricular free wall at end systole. Mean EAT thickness in all patients was 6.5 ± 2.0 mm. EAT thickness was associated with patient age, body mass index, and the presence of hypertension. EAT thickness was not different by sex in patients younger than 60 years (men, 6.4 ± 2.0 mm; women, 6.2 ± 1.8 mm, p = 0.716); however, among patients aged 60 years or older, EAT thickness was significantly greater in women than men (men, 6.0 ± 1.7 mm; women 7.7 ± 2.1 mm, p < 0.001). LV function represented by E/e' and s' was significantly related to EAT thickness only in women (E/e', ß = 0.330, p = 0.002; lateral s', ß = -0.225, p = 0.042). CONCLUSION: EAT thickness was greater in women than men after 60 years old and its relationship with LV function was significant only in women. Greater increase in EAT thickness in elderly women after menopause might partially account for this difference.

Layer-specific dyssynchrony and its relationship to the change of left ventricular function in hypertensive patients.

Left ventricular (LV) remodeling in systemic arterial hypertension causes electrical conduction delay and impairs synchronous contraction, which may contribute to the development of heart failure. This study aimed to assess the change of LV mechanics in hypertension by layer-specific dyssynchrony. One hundred and twenty-one patients with primary hypertension and LV ejection fraction >50 % (mean age, 62 ± 10 years) and 31 normotensive controls (mean age, 63 ± 9 years) were prospectively included. Layer-specific dyssynchrony index (DI) was defined as standard deviation of time interval (TI) from the onset of Q wave to peak longitudinal strain obtained from 18 segments in each endocardial, myocardial, and epicardial layer. The global TI between the onset of Q wave to peak global longitudinal strain in each layer was obtained and the time difference (TD) of global TI between layers was calculated. DIs were significantly different in three layers (P < 0.001 in both groups), and were significantly greater in hypertensive patients than in controls except epicardial DI. End diastolic filling pressure and LV global longitudinal strain were related with endocardial DI. TD between endocardium and myocardium was greater in hypertensive patients than in controls (P = 0.001). Layer-specific DI revealed delayed contraction in each layer and between layers in hypertensive patients, which were apparent in endocardium and between endocardium and myocardium. Increased layer-specific DIs were associated with subclinical LV dysfunction, although LV ejection fraction was preserved. These may be helpful to understand layer-specific mechanical property of LV myocardium and for early detection of subclinical impairment of myocardial function.

Clinical Significance of Dynamic Left Ventricular Outflow Tract Obstruction During Dobutamine Stress Echocardiography in Women With Suspected Coronary Artery Disease.

BACKGROUND: Although dobutamine stress echocardiography (DSE) is frequently associated with dynamic left ventricular outflow tract obstruction (DLVOTO), little is known about its clinical significance in women with suspected coronary artery disease (CAD). METHODS AND RESULTS: One hundred and two female patients (57±10 years) who underwent DSE as part of the Korean women's chest pain registry study were included. Doppler echocardiography was performed during DSE to assess the presence of DLVOTO. Patients with DLVOTO (n=52) were older than those without DLVOTO (n=50; P=0.001). Hypertension was more prevalent in patients with DLVOTO (P=0.02). Patients with DLVOTO had smaller LV diameter, but higher LV mass index and relative wall thickness (P<0.05 for all). LV diastolic function (as reflected by late diastolic velocity, deceleration time of early diastolic velocity [E], and ratio of E velocity to early diastolic mitral annular velocity), was worse in patients with DLVOTO (P<0.05 for all). Patients with DLVOTO had shorter exercise time (P=0.02) and lower amount of work (P=0.04) than patients without DLVOTO. DSE-provoked DLVOTO was not related to the presence of CAD in these patients. CONCLUSIONS: In Korean women with suspected CAD, DSE-provoked DLVOTO is correlated with LV concentric remodeling and LV diastolic dysfunction, and may be associated with limited exercise tolerance and symptoms of chest pain.

Acute changes of left ventricular hemodynamics and function during percutaneous coronary intervention in patients with unprotected left main coronary artery disease.

Percutaneous coronary interventions (PCIs) are increasingly being used to treat unprotected left main coronary artery (ULMCA) lesions. However, research is sparse on the acute changes of left ventricular (LV) hemodynamics and function during PCI in patients with ULMCA stenosis. We aimed to assess the acute changes of LV function using speckle-tracking imaging during PCI in these patients. Fifteen consecutive patients who underwent elective PCI for ULMCA stenosis were enrolled. Echocardiographic studies and pressure measurement were performed at baseline, during PCI and after PCI. LMCA occlusion with a first balloon inflation induced a marked reduction in the peak positive derivative of LV pressure (dP/dt max), LV global longitudinal strain (GLS), and systolic and diastolic strain rates, and a marked increase in LV end-diastolic pressure (EDP) (all P < 0.01). During the second inflation, the degrees of LV hemodynamic and functional changes were similar to those of the first inflation, even with a higher inflation pressure. During the third inflation, the values of GLS and dP/dt max were higher than those of the second inflation (P = 0.03 and P = 0.05, respectively). After optimal PCI, dP/dt max, LVEDP, and strain parameters were improved to baseline values. LV hemodynamics and function were considerably impaired with the first ballooning during PCI for ULMCA stenosis. However, the degrees of LV hemodynamic and functional changes decreased with each successive balloon inflation, which can be explained by ischemic preconditioning. After all procedures were safely completed, LV systolic function was improved without LV diastolic stunning.

Association of inflammation, myocardial fibrosis and cardiac remodelling in patients with mild aortic stenosis as assessed by biomarkers and echocardiography.

1. The aim of the present study was to investigate the relationships among inflammation, myocardial fibrosis and cardiac remodelling in patients with mild aortic stenosis (AS), as assessed by biomarkers and echocardiography. 2. We evaluated 32 consecutive patients with mild AS, as well as 30 age- and gender-matched healthy individuals with normal aortic valves as control subjects. 3. Baseline echocardiography showed that the left ventricular (LV) mass index (111.3 ± 26.9 vs 94.5 ± 18.2 g/m(2); P = 0.006) and left atrial (LA) volume index (LAVI 27.5 ± 9.0 vs xx.x ± 5.2 mm(3)/mm(2); P = 0.005) were significantly higher in patients with mild AS. 4. Furthermore, LA enlargement (LAVI > 33 mm(3)/mm(2); 32.4% vs 3.3%; P = 0.003) and elevated LV filling pressure (E/e' > 15; 50.0% vs 23.3%; P = 0.036) were higher in patients with mild AS. 5. In patients with mild AS, stepwise, multivariate linear regression analysis revealed that the LV end-diastolic volume index was independently associated with matrix metalloproteinase (MMP)-1 (ß = 0.371; P = 0.015), that the aortic valve mean pressure gradient was independently associated with MMP-2 (ß = 0.19; P = 0.019), that MMP-2 was independently associated with transforming growth factor-ß (ß = 0.95; P < 0.001) and interleukin (IL)-1 (ß = 0.17; P = 0.019) and that IL-1 was independently associated with tissue inhibitor of matrix metalloproteinase-1 (ß = 0.68; P = 0.001). 6. Myocardial fibrosis in mild AS is independently associated with three factors: LV volume overload, aortic valve pressure overload and inflammation.

Presence of preoperative diastolic dysfunction predicts postoperative pulmonary edema and cardiovascular complications in patients undergoing noncardiac surgery.

OBJECTIVE: The aim of this study was to evaluate the impact of left ventricular diastolic dysfunction on predicting postoperative pulmonary edema and major cardiovascular events (MACE) in patients who underwent low- or intermediate-risk noncardiac surgery. METHODS: A total of 692 patients aged >60 years who underwent transthoracic echocardiography (TTE) before undergoing elective low- or intermediate-risk noncardiac surgery were prospectively enrolled. The medical history and TTE variables were assessed. Each patient was clinically evaluated for postoperative pulmonary edema and MACE. The presence of postoperative pulmonary edema and MACE were evaluated during a 30-day follow-up period after surgery. RESULTS: We identified 166 patients with pulmonary edema and 49 patients with MACE. After adjusting for clinical and TTE variables, multivariate analysis demonstrated that a ratio of early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e') >15, pulmonary artery systolic pressure (PASP) ≥35 mmHg, and left ventricular hypertrophy (LVH) were significantly associated with postoperative pulmonary edema (E/e', P < 0.001: PASP, P = 0.005; LVH, P = 0.017). The multivariate analysis for MACE after adjusting for clinical risk factors indicated that MACE were significantly associated with an E/e' > 15 (P < 0.001). CONCLUSION: E/e' > 15, PASP elevation, and LVH on preoperative TTE predicted postoperative pulmonary edema, and E/e' > 15 predicted MACE in the patients who underwent low- or intermediate-risk noncardiac surgery. Thus, we believe that clinicians need to be cautious when providing perioperative care to patients with high E/e' ratios who are indicated for TTE.

Early changes of left ventricular function in young adults with never-treated hypertension and no left ventricular hypertrophy: relationships to ambulatory blood pressure monitoring.

The number of young adults with hypertension (HT) is increasing. We investigated the changes of left ventricular (LV) function and their relationship to the ambulatory blood pressure monitoring (ABPM) parameters in young adults with never-treated HT and no LV hypertrophy. Consecutive young patients (29.5 ± 5.9 years) with first diagnosed primary HT and sex- and age-matched normotensive controls were enrolled. We excluded patients who had LV hypertrophy. ABPM was performed in all HT patients. LV strain values were obtained by two-dimensional speckle tracking imaging. There was no difference in LV ejection fraction and mass index between HT patients (n = 40) and controls (n = 40). LV global longitudinal strain (GLS) was lower (p = 0.001) and twist was higher (p = 0.002) in HT patients than in controls. LV GLS was significantly correlated to averaged and daytime diastolic BP and its variability and most related to daytime diastolic BP (ß = 0.33, p = 0.03). Patients with high daytime diastolic BP and its variability showed lower GLS (both p = 0.02) and higher twist (both p = 0.04) than patients with low daytime diastolic BP. Early changes of LV function with decreased GLS and increased twist were shown in young HT patients even with no LV hypertrophy and daytime diastolic BP and its variability were related to the impairment of LV function.

The difference of predictors for recurrence after catheter ablation of non-paroxysmal atrial fibrillation according to follow-up period.

The aim of this study was to assess the clinical and echocardiographic predictors for the recurrence of persistent atrial fibrillation (AF) after ablation during a long-term period.A total of 130 patients with persistent AF who had undergone radiofrequency catheter ablation (RFCA) were enrolled. We analyzed the relation between clinical parameters, echocardiographic parameters, and AF recurrences at 6 months, 1 year, and 2 years after ablation.During the 2-year follow-up, AF recurred in 61 patients (46.6%). In the 6 month follow-up, AF recurrence was associated only with total ablation time only. However, during the 1-year and 2-year follow-up periods, the presence of hypertension, impaired left atrial (LA) emptying fraction (eF) (≤ 20%), decreased LA appendage (LAA) emptying velocity (≤ 20 cm/sec), and LAAeF (≤ 20%) were correlated with AF recurrence (odds ratio [OR] = 1.87, 2.45, 1.93, and 2.15 respectively, P = 0.016, 0.004, 0.029, and 0.004 respectively). Among these factors, impaired LAeF was the only independent predictor of AF recurrence in multivariate analysis (OR = 2.81, P = 0.012).In patients with persistent AF who had undergone RFCA, the best predictor of AF recurrence after ablation varied according to the follow-up period. Diminished LA function was the only predictor of recurrence in the 2-year follow-up. Pre-procedural assessment of LA function might be helpful in selecting those patients who would benefit from RFCA.

Epicardial Adipose Tissue and Heart Failure, Friend or Foe?

Heart failure (HF) management guidelines recommend individualized assessments based on HF phenotypes. Adiposity is a known risk factor for HF. Recently, there has been an increased interest in organ-specific adiposity, specifically the role of the epicardial adipose tissue (EAT), in HF risk. EAT is easily assessable through various imaging modalities and is anatomically and functionally connected to the myocardium. In pathological conditions, EAT secretes inflammatory cytokines, releases excessive fatty acids, and increases mechanical load on the myocardium, resulting in myocardial remodeling. EAT plays a pathophysiological role in characterizing both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). In HFrEF, EAT volume is reduced, reflecting an impaired metabolic reservoir, whereas in HFpEF, the amount of EAT is associated with worse biomarker and hemodynamic profiles, indicating increased EAT activity. Studies have examined the possibility of therapeutically targeting EAT, and recent studies using sodium glucose cotransporter 2 inhibitors have shown potential in reducing EAT volume. However, further research is required to determine the clinical implications of reducing EAT activity in patients with HF.

Early menopause is associated with abnormal diastolic function and poor clinical outcomes in women with suspected angina.

Early identification of women at high risk for cardiovascular diseases (CVD), with subsequent monitoring, will allow for improved clinical outcomes and generally better quality of life. This study aimed to identify the associations between early menopause, abnormal diastolic function, and clinical outcomes. This retrospective study included 795 menopausal women from is a nationwide, multicenter, registry of patients with suspected angina visiting outpatient clinic. The patients into two groups: early and normal menopause (menopausal age ≤ 45 and > 45 years, respectively). If participants met > 50% of the diastolic function criteria, they were classified as having normal diastolic function. Multivariable-adjusted Cox models were used to test associations between menopausal age and clinical outcomes including the incidence of major adverse cardiovascular events (MACE), over a median follow-up period of 771 days. Early menopause was associated with increased waist circumference (p = 0.001), diabetes prevalence (p = 0.003), obstructive coronary artery disease (p = 0.005), abnormal diastolic function (p = 0.003) and greater incidences of MACE, acute coronary syndrome, and hospitalization for heart failure. In patients with abnormal diastolic function, early menopause increased MACE risk significantly, with no significant difference in normal diastolic function. These findings highlight early menopause and abnormal diastolic function as being potential risk markers in women for midlife CVD events.

Prediction of longitudinal clinical outcomes after acute myocardial infarction using a dynamic machine learning algorithm.

Several regression-based models for predicting outcomes after acute myocardial infarction (AMI) have been developed. However, prediction models that encompass diverse patient-related factors over time are limited. This study aimed to develop a machine learning-based model to predict longitudinal outcomes after AMI. This study was based on a nationwide prospective registry of AMI in Korea (n = 13,104). Seventy-seven predictor candidates from prehospitalization to 1 year of follow-up were included, and six machine learning approaches were analyzed. Primary outcome was defined as 1-year all-cause death. Secondary outcomes included all-cause deaths, cardiovascular deaths, and major adverse cardiovascular event (MACE) at the 1-year and 3-year follow-ups. Random forest resulted best performance in predicting the primary outcome, exhibiting a 99.6% accuracy along with an area under the receiver-operating characteristic curve of 0.874. Top 10 predictors for the primary outcome included peak troponin-I (variable importance value = 0.048), in-hospital duration (0.047), total cholesterol (0.047), maintenance of antiplatelet at 1 year (0.045), coronary lesion classification (0.043), N-terminal pro-brain natriuretic peptide levels (0.039), body mass index (BMI) (0.037), door-to-balloon time (0.035), vascular approach (0.033), and use of glycoprotein IIb/IIIa inhibitor (0.032). Notably, BMI was identified as one of the most important predictors of major outcomes after AMI. BMI revealed distinct effects on each outcome, highlighting a U-shaped influence on 1-year and 3-year MACE and 3-year all-cause death. Diverse time-dependent variables from prehospitalization to the postdischarge period influenced the major outcomes after AMI. Understanding the complexity and dynamic associations of risk factors may facilitate clinical interventions in patients with AMI.

Differences in coronary angiographic findings and outcomes between men and postmenopausal women with stable chest pain.

BACKGROUND: Despite the significant increase in cardiovascular events in women after menopause, studies comparing postmenopausal women and men are scarce. METHODS: We analyzed data from a nationwide, multicenter, prospective registry and enrolled 2412 patients with stable chest pain who underwent elective coronary angiography. Binary coronary artery disease (b-CAD) was defined as the ≥50% stenosis of epicardial coronary arteries, including the left main coronary artery. RESULTS: Compared with the men, postmenopausal women were older (66.6 ±â€…8.5 vs. 59.5 ±â€…11.4 years) and had higher high-density lipoprotein cholesterol levels (49.0 ±â€…12.8 vs. 43.6 ±â€…11.6 mg/dl, P  < 0.01). The prevalence of diabetes did not differ significantly ( P  = 0.40), and smoking was more common in men than in postmenopausal women ( P  ≤ 0.01). At enrollment, b-CAD and revascularization were more common in men than in postmenopausal women (50.3% vs. 41.0% and 14.4% vs. 9.7%, respectively; both P  < 0.01). However, multivariate analyses revealed that revascularization [odds ratio (OR): 0.72; 95% confidence interval (CI): 0.49-1.08] was not significantly related to sex and a similar result was found in age propensity-matched population (OR: 0.80; 95% CI: 0.52-1.24). During the follow-up period, the secondary composite cardiovascular outcomes were lower in postmenopausal women than in men (OR: 0.55; 95% CI: 0.31-0.98), also consistent with the result using the age propensity-mated population (OR: 0.33; 95% CI: 0.13-0.85). CONCLUSION: Postmenopausal women experienced coronary revascularization comparable to those in men at enrollment, despite the average age of postmenopausal women was 7 years older than that of men.Postmenopausal women exhibit better clinical outcomes than those of men if optimal treatment is provided.