Echocardiography and Electrocardiography in Detecting Atrial Cardiomyopathy: A Promising Path to Predicting Cardioembolic Strokes and Atrial Fibrillation.

(1) Background: Atrial cardiomyopathy constitutes an intrinsically prothrombotic atrial substrate that may promote atrial fibrillation and thromboembolic events, especially stroke, independently of the arrhythmia. Atrial reservoir strain is the echocardiography marker with the most robust evidence supporting its prognostic utility. The main aim of this study is to identify atrial cardiomyopathy by investigating the association between left atrial dysfunction in echocardiography and P-wave abnormalities in the surface electrocardiogram. (2) Methods: This is a community-based, multicenter, prospective cohort study. A randomized sample of 100 patients at a high risk of developing atrial fibrillation were evaluated using diverse echocardiography imaging techniques, and a standard electrocardiogram. (3) Results: Significant left atrial dysfunction, expressed by a left atrial reservoir strain < 26%, showed a relationship with the dilation of the left atrium (p < 0.001), the left atrial ejection fraction < 50% (p < 0.001), the presence of advanced interatrial block (p = 0.032), P-wave voltage in lead I < 0.1 mV (p = 0.008), and MVP ECG score (p = 0.036). (4) Conclusions: A significant relationship was observed between left atrial dysfunction and the presence of left atrial enlargement and other electrocardiography markers; all of them are non-invasive biomarkers of atrial cardiomyopathy.

Blood-biomarkers and devices for atrial fibrillation screening: Lessons learned from the AFRICAT (Atrial Fibrillation Research In CATalonia) study.

BACKGROUND AND OBJECTIVE: AFRICAT is a prospective cohort study intending to develop an atrial fibrillation (AF) screening program through the combination of blood markers, rhythm detection devices, and long-term monitoring in our community. In particular, we aimed to validate the use of NT-proBNP, and identify new blood biomarkers associated with AF. Also, we aimed to compare AF detection using various wearables and long-term Holter monitoring. METHODS: 359 subjects aged 65-75 years with hypertension and diabetes were included in two phases: Phase I (n = 100) and Phase II (n = 259). AF diagnosis was performed by baseline 12-lead ECG, 4 weeks of Holter monitoring (NuuboTM), and/or medical history. An aptamer array including 1310 proteins was measured in the blood of 26 patients. Candidates were selected according to p-value, logFC and biological function to be tested in verification and validation phases. Several screening devices were tested and compared: AliveCor, Watch BP, MyDiagnostick and Fibricheck. RESULTS: AF was present in 34 subjects (9.47%). The aptamer array revealed 41 proteins with differential expression in AF individuals. TIMP-2 and ST-2 were the most promising candidates in the verification analysis, but none of them was further validated. NT-proBNP (log-transformed) (OR = 1.934; p<0.001) was the only independent biomarker to detect AF in the whole cohort. Compared to an ECG, WatchBP had the highest sensitivity (84.6%) and AUC (0.895 [0.780-1]), while MyDiagnostick showed the highest specificity (97.10%). CONCLUSION: The inclusion and monitoring of a cohort of primary care patients for AF detection, together with the testing of biomarkers and screening devices provided useful lessons about AF screening in our community. An AF screening strategy using rhythm detection devices and short monitoring periods among high-risk patients with high NT-proBNP levels could be feasible.

Risk of Atrial Fibrillation, Ischemic Stroke and Cognitive Impairment: Study of a Population Cohort ≥65 Years of Age.

PURPOSE: To evaluate a model for calculating the risk of AF and its relationship with the incidence of ischemic stroke and prevalence of cognitive decline. MATERIALS AND METHODS: It was a multicenter, observational, retrospective, community-based study of a cohort of general population ≥6ct 35 years, between 01/01/2016 and 31/12/2018. Setting: Primary Care. Participants: 46,706 people ≥65 years with an active medical history in any of the primary care teams of the territory, information accessible through shared history and without previous known AF. Interventions: The model to stratify the risk of AF (PI) has been previously published and included the variables sex, age, mean heart rate, mean weight and CHA2DS2VASc score. Main measurements: For each risk group, the incidence density/1000 person/years of AF and stroke, number of cases required to detect a new AF, the prevalence of cognitive decline, Kendall correlation, and ROC curve were calculated. RESULTS: The prognostic index was obtained in 37,731 cases (80.8%) from lowest (Q1) to highest risk (Q4). A total of 1244 new AFs and 234 stroke episodes were diagnosed. Q3-4 included 53.8% of all AF and 69.5% of strokes in men; 84.2% of all AF and 85.4% of strokes in women; and 77.4% of cases of cognitive impairment. There was a significant linear correlation between the risk-AF score and the Rankin score (p < 0.001), the Pfeiffer score (p < 0.001), but not NIHSS score (p 0.150). The overall NNS was 1/19. CONCLUSION: Risk stratification allows identifying high-risk individuals in whom to intervene on modifiable risk factors, prioritizing the diagnosis of AF and investigating cognitive status.

[Clinical, electrical and echocardiographic characteristics of patients with advanced interatrial block]. / Características clínicas, eléctricas y ecocardiográficas de los pacientes con bloqueo interauricular avanzado.

El haz de Bachmann se compone de un conjunto de fibras miocárdicas paralelas y especializadas, responsables del 80% de la conducción interauricular. Discurre por las paredes anterosuperiores auriculares, y su afectación da lugar al bloqueo interauricular (BIA); éste puede ser: a) parcial (BIA-p) si la conducción está retrasada (en el ECG produce una onda P ≥ 120 ms) o b) avanzado (BIA-a) si está del todo interrumpida y la despolarización auricular izquierda (AI) ocurre en dirección retrógrada caudocraneal (la onda P es ≥ 120 ms y bifásica +/- en las derivaciones inferiores II, III y VF)1.

Differential characteristics of the typical and atypical advanced interatrial block.

Objetivo: Se denomina bloqueo interauricular avanzado (BIA) a la existencia de una onda P ≥ 120 ms y bifásica +/- en las derivaciones inferiores (II-III-VF) del electrocardiograma (ECG) de superficie, el cual constituye un factor predictivo significativo del desarrollo de fibrilación auricular. En fecha reciente se han descrito cuatro patrones de BIA atípicos (BIA-At) con base en la morfología y la duración de la onda P, sin conocer si comparten patogenia y características clínicas similares. Método: Estudio observacional, descriptivo y retrospectivo de pacientes, visitados en el Servicio de Cardiología, en ritmo sinusal y con BIA. Las variables analizadas se obtuvieron de la historia clínica informatizada. El análisis de la onda P se efectuó al aumentar el tamaño del electrocardiograma y mediante calipers electrónicos. El análisis estadístico se realizó con SPSS 19.0, con nivel de significación de p < 0.05. Resultados: Se incluyó a 75 pacientes con media de edad de 74.4 ± 11.7 años, con 62.7% de varones. Se compararon los grupos de pacientes con BIA típico (BIA-T) y BIA-At. El primero se relacionó con la existencia de diabetes mellitus (p = 0.001), enfermedad renal crónica estadio ≥ 3 (p = 0.036), bloqueo auriculoventricular (p = 0.006) y una menor fracción de expulsión ventricular media (p = 0.025); no hubo diferencias respecto de la prevalencia de fibrilación auricular/flúter o accidente cerebrovascular. Sólo la diabetes se acompañó de riesgo de ser un BIA-T (OR: 6.4; p = 0.002; IC 95%: 2.0-21.1). Conclusiones: La diabetes mellitus constituye el único factor de riesgo de que un BIA sea típico. Los pacientes con BIA-T y BIA-At presentan similar prevalencia de fibrilación auricular y accidente cerebrovascular, por lo que son objeto de un mismo tratamiento clínico. Objective: It is called advanced interatrial block (IAB) to the existence of a P wave ≥ 120 ms and biphasic ± in the lower leads II-III-VF of the surface electrocardiogram (ECG), which constitutes a significant predictive factor for the development of atrial fibrillation. Recently, four patterns of atypical aIAB (At-IAB) have been described based on the morphology and duration of the P wave, but it's unknown if they share the same pathogenesis and clinical characteristics. Method: An observational, descriptive and retrospective study was performed with patients, visited in cardiology, who have a sinus rhythm and with aIAB. The analyzed variables were obtained from the computerized clinical history. The analysis of the P wave was made by increasing the size of the ECG and by electronic calipers. Statistical analysis was performed with SPSS 19.0; level of significance: p < 0.05. Results: A total of 75 patients with an average age of 74.4 ± 11.7 years and with a 62.7% males, were included. It was compared the group of patients with typical aIAB (T-aIAB) and with At-aIAB. The first one was associated with the existence of diabetes mellitus (p = 0.001), chronic kidney disease stage ≥ 3 (p = 0.036), atrioventricular block (p = 0.006) and a lower mean ventricular ejection fraction (p = 0.025); there were no differences regarding the prevalence of atrial fibrillation/flutter or stroke. Only diabetes was associated with the risk of T-aIAB (odds ratio: 6.4; p = 0.002; 95% confidence interval: 2.0-21.1). Conclusions: Diabetes mellitus is the only risk factor for an aIAB to be typical. Patients with T-aIAB and At-aIAB have a similar prevalence of atrial fibrillation and stroke, so they must follow the same clinical management.

Características diferenciales del bloqueo interauricular avanzado típico y atípico / Differential characteristics of the typical and atypical advanced interatrial block

Resumen Objetivo: Se denomina bloqueo interauricular avanzado (BIA) a la existencia de una onda P ≥ 120 ms y bifásica +/- en las derivaciones inferiores (II-III-VF) del electrocardiograma (ECG) de superficie, el cual constituye un factor predictivo significativo del desarrollo de fibrilación auricular. En fecha reciente se han descrito cuatro patrones de BIA atípicos (BIA-At) con base en la morfología y la duración de la onda P, sin conocer si comparten patogenia y características clínicas similares. Método: Estudio observacional, descriptivo y retrospectivo de pacientes, visitados en el Servicio de Cardiología, en ritmo sinusal y con BIA. Las variables analizadas se obtuvieron de la historia clínica informatizada. El análisis de la onda P se efectuó al aumentar el tamaño del electrocardiograma y mediante calipers electrónicos. El análisis estadístico se realizó con SPSS 19.0, con nivel de significación de p < 0.05. Resultados: Se incluyó a 75 pacientes con media de edad de 74.4 ± 11.7 años, con 62.7% de varones. Se compararon los grupos de pacientes con BIA típico (BIA-T) y BIA-At. El primero se relacionó con la existencia de diabetes mellitus (p = 0.001), enfermedad renal crónica estadio ≥ 3 (p = 0.036), bloqueo auriculoventricular (p = 0.006) y una menor fracción de expulsión ventricular media (p = 0.025); no hubo diferencias respecto de la prevalencia de fibrilación auricular/flúter o accidente cerebrovascular. Sólo la diabetes se acompañó de riesgo de ser un BIA-T (OR: 6.4; p = 0.002; IC 95%: 2.0-21.1). Conclusiones: La diabetes mellitus constituye el único factor de riesgo de que un BIA sea típico. Los pacientes con BIA-T y BIA-At presentan similar prevalencia de fibrilación auricular y accidente cerebrovascular, por lo que son objeto de un mismo tratamiento clínico.

Abstract Objective: It is called advanced interatrial block (IAB) to the existence of a P wave ≥ 120 ms and biphasic ± in the lower leads II-III-VF of the surface electrocardiogram (ECG), which constitutes a significant predictive factor for the development of atrial fibrillation. Recently, four patterns of atypical aIAB (At-IAB) have been described based on the morphology and duration of the P wave, but it’s unknown if they share the same pathogenesis and clinical characteristics. Method: An observational, descriptive and retrospective study was performed with patients, visited in cardiology, who have a sinus rhythm and with aIAB. The analyzed variables were obtained from the computerized clinical history. The analysis of the P wave was made by increasing the size of the ECG and by electronic calipers. Statistical analysis was performed with SPSS 19.0; level of significance: p < 0.05. Results: A total of 75 patients with an average age of 74.4 ± 11.7 years and with a 62.7% males, were included. It was compared the group of patients with typical aIAB (T-aIAB) and with At-aIAB. The first one was associated with the existence of diabetes mellitus (p = 0.001), chronic kidney disease stage ≥ 3 (p = 0.036), atrioventricular block (p = 0.006) and a lower mean ventricular ejection fraction (p = 0.025); there were no differences regarding the prevalence of atrial fibrillation/flutter or stroke. Only diabetes was associated with the risk of T-aIAB (odds ratio: 6.4; p = 0.002; 95% confidence interval: 2.0-21.1). Conclusions: Diabetes mellitus is the only risk factor for an aIAB to be typical. Patients with T-aIAB and At-aIAB have a similar prevalence of atrial fibrillation and stroke, so they must follow the same clinical management.

Results, barriers and enablers in atrial fibrillation case finding: barriers in opportunistic atrial fibrillation case finding-a cross-sectional study.

BACKGROUND: Atrial fibrillation (AF) is often asymptomatic, and screening is not routinely undertaken. OBJECTIVE: Evaluate the feasibility and effectiveness of a population-based case finding program and to identify the enablers of and/or barriers to its implementation. METHODS: We conducted a cross-sectional study of a health care case finding program for AF from 1 January 2016, to 31 December 2017, that included 48 336 people ≥60 years of age in the region of Terresde l'Ebre (Catalonia, Spain). We analysed the effect on the prevalence of AF and, stratified by age, on the incidence of new diagnoses of AF. We assessed the sociodemographic and clinical variables related to the realization of a case finding. RESULTS: A total of 32 090 (62.4%) people were screened for AF. We observed a significant increase in the AF prevalence after 2 years of program intervention (5.9-7.7%; P < 0.001). The detection of new AF cases was significantly higher in the case finding group across the whole of the age range, and 765 (2.6%) new AF cases were diagnosed using case finding. The factors that were significantly associated with an underuse of case finding were: age <70 years, urban residence, institutionalized status, Pfeiffer score ≥2, Charlson score >3 and number of visits <7/year. CONCLUSIONS: A health care program of case finding is feasible and is associated with a significant increase in the prevalence and incidence of AF. The results depend on factors such as the ease of access to health care, age, place of residence and comorbidities.

Septo sigmoideo: ¿una variante de la hipertrofia ventricular o de la miocardiopatía hipertrófica? / Sigmoid septum: A variant of the ventricular hypertrophy or of the hypertrophic cardiomyopathy?

Resumen Objetivo El septo sigmoideo y la miocardiopatía hipertrófica cursan con hipertrofia ventricular izquierda y, aunque parecen ser entidades distintas, muchas veces plantean problemas de diagnóstico diferencial. Este estudio se ha realizado para evaluar la prevalencia y características del septo sigmoideo ecocardiográfico y sus hallazgos diferenciales con respecto a la miocardiopatía hipertrófica. Métodos Estudio descriptivo, observacional y prospectivo. Se estudiaron 1,770 pacientes mediante ecocardiografía. El septo sigmoideo (hipertrofia focal y aislada del septo interventricular basal ≥ 13 mm en hombres y ≥ 2 mm en mujeres, que supera en ≥ 50% al grosor del septo medio) se clasificó en "tipo 1" (≤ 14 mm) y "tipo 2" (≥ 15 mm). Resultados Hubo 59 casos de septo sigmoideo (prevalencia del 3.3%): 26 (1.5%) pacientes con un tipo 1 (50% hombres) y 33 (1.9%) pacientes con un tipo 2 (72.7% hombres); se detectaron 25 (1.4%) casos de miocardiopatía hipertrófica (76% hombres). El grupo con septo sigmoideo tipo 2 se diferenció de esta última en: su mayor edad (73 ± 10.5 años; p < 0.0001), más hipertensión (84.8%; p < 0.0001), menor filtrado glomerular (73.3 ± 21.4 ml/min; p = 0.007), menor alteración de la repolarización (18.2%; p = 0.004) e índice de Cornell (en hombres; 22.2 ± 11 mm; p = 0.041), más disfunción diastólica (75%; p = 0.0089) y en la morfología y localización de la fibrosis ventricular en resonancia magnética. Conclusión Con respecto a la miocardiopatía hipertrófica, los pacientes con septo sigmoideo tipo 2 son de más edad y generalmente hipertensos; por lo demás, a menudo no presentan claras diferencias en sus características clínicas, electrocardiográficas o ecocardiográficas. Por ello, la resonancia cardíaca resulta de gran ayuda en su diagnóstico diferencial.

Abstract Objective Sigmoid septum and hypertrophic cardiomyopathy presenting with left ventricular hypertrophy and, although they appear to be different entities, often involve problems in the differential diagnosis. This study was carried out to assess the prevalence and characteristics of the echocardiographic sigmoid septum and its differential findings regarding hypertrophic cardiomyopathy. Methods Descriptive, observational and prospective study. A total of 1,770 patients were studied by echocardiography. Sigmoid septum (focal and isolated hypertrophy of the basal interventricular septum ≥ 13 mm in men and ≥ 12 mm in women, exceeding ≥ 50% of the median septum thickness) was classified as "Type 1" (≤ 14 mm) and "Type 2" (≥ 15 mm). Results There were 59 cases of sigmoid septum (prevalence of 3.3%): 26 (1.5%) patients with type 1 (50% male) and 33 (1.9%) patients with type 2 (72.7% male); there were 25 (1.4%) cases of hypertrophic cardiomyopathy (76% male). The group with type 2 sigmoid septum differed from hypertrophic cardiomyopathy in: was older (73 ± 10.5 years; P < .0001), with more hypertension (84.8%; P < .0001), lower glomerular filtering (73.3 ± 21.4 ml/min; P = .007), lower repolarization abnormalities (18.2%; P = .004) and Cornell index (in men, 22.2 ± 11 mm; P = .041), more diastolic dysfunction (75%; P = .0089) and in ventricular morphology and fibrosis location in magnetic resonance. Conclusion Regarding the hypertrophic cardiomyopathy, patients with type 2 sigmoid septum are older and generally hypertensive; otherwise, often they have no clear differences in their clinical, electrocardiographic or echocardiographic characteristics. Therefore, cardiac resonance is helpful in the differential diagnosis.