Longitudinal Assessment of Left Atrial Remodeling in Patients With Chronic Severe Aortic Regurgitation.

BACKGROUND: There are significant sex and age differences in left ventricular (LV) remodeling that may lead to disparity in outcomes when used to inform the timing of aortic regurgitation (AR) intervention. OBJECTIVES: The aim of this study was to examine whether left atrial (LA) parameters might represent better criteria than LV parameters to inform the timing of AR intervention. METHODS: Using data on patients with moderate to severe or severe AR with serial echocardiography (2010-2016), the longitudinal trends in left atrial volume index (LAVI) and left atrial reservoir strain (LAr) were evaluated by sex and age. The incremental utility of these parameters in predicting adverse events over LV parameters was also determined. RESULTS: In 525 patients (25.7% women) with 1,687 echocardiograms over a median follow-up period of 2.0 years (Q1-Q3: 1.0-3.6 years), there was significant increase in LAVI (1.0 mL/m2 per year [95% CI: 0.76-1.2 mL/m2 per year]) and decrease in LAr (-1.3% per year [95% CI: -1.6% to -0.92%]), without a significant interaction by sex or age category (P for interaction ≥ 0.17). In addition, both LAVI and LAr were significant predictors of adverse events independent of LV parameters. The optimal discriminatory thresholds were 37 mL/m2 for LAVI and 35% for LAr. These thresholds were similar across categories of sex and age. Within the relatively short-term follow-up, surgery was associated with survival benefit among patients with LAVI ≥37 mL/m2 (HR: 0.33 [95% CI: 0.15-0.72]; P = 0.006) but was not statistically significant among patients with LAVI <37 mL/m2 (HR: 0.46 [95% CI: 0.18-1.17]; P = 0.09). Similarly, surgery was associated with survival for the subgroup with LAr ≤35% but not among those with LAr >35%. CONCLUSIONS: Unlike LV remodeling, LA remodeling demonstrates a similar rate of progression between categories of sex and age among patients with AR. In addition, LA parameters provide incremental prognostic value over LV parameters.

Impact of Age and Sex on Left Ventricular Remodeling in Patients With Aortic Regurgitation.

BACKGROUND: Current guidelines for aortic regurgitation (AR) recommend the same linear left ventricular (LV) dimension for intervention regardless of age and sex. OBJECTIVES: The purpose of this study was to evaluate the impact of age and sex on the degree of LV remodeling and outcomes. METHODS: We included consecutive patients with severe AR who were serially monitored by echocardiogram between 2010 and 2016. The 2 main endpoints were as follows: 1) LV end-systolic volume indexed to body surface area (LVESVi) and LV end-diastolic volume indexed to body surface area; and 2) adverse events (AE). We evaluated the longitudinal rate of LV remodeling and determined the association between LV volume and AE by age and sex. RESULTS: A total of 525 adult patients (26% women) with a median echocardiogram follow-up of 2.0 years (IQR: 1.0-3.6 years) were included. At baseline, older patients (age ≥60 years) had smaller LV volumes compared with younger patients (age <60 years), eg, the mean LVESVi was 27.3 mL/m2 vs 32.3 mL/m2, respectively. Similarly, women had smaller LV volumes compared with men (mean LVESVi was 23.3 mL/m2 vs 32.4 mL/m2). On serial evaluation, older patients and women maintained smaller LV volumes compared with younger patients and men, respectively. There were 210 (40%) AE during follow-up. The optimal discriminatory threshold for AE varies by age and sex, eg, the LVESVi threshold was highest for young men (50 mL/m2), intermediate for older men (35 mL/m2), and lowest for women (27 mL/m2). CONCLUSIONS: On serial evaluation, older patients and women with chronic AR maintained smaller LV volumes than younger patients and men, respectively, and develop AE at lower LV volumes.

Predictive validity of pre-admission assessments on medical student performance.

OBJECTIVES: To examine the predictive validity of pre-admission variables on students' performance in a medical school in Saudi Arabia. METHODS: In this retrospective study, we collected admission and college performance data for 737 students in preclinical and clinical years. Data included high school scores and other standardized test scores, such as those of the National Achievement Test and the General Aptitude Test. Additionally, we included the scores of the Test of English as a Foreign Language (TOEFL) and the International English Language Testing System (IELTS) exams. Those datasets were then compared with college performance indicators, namely the cumulative Grade Point Average (cGPA) and progress test, using multivariate linear regression analysis. RESULTS: In preclinical years, both the National Achievement Test (p=0.04, B=0.08) and TOEFL (p=0.017, B=0.01) scores were positive predictors of cGPA, whereas the General Aptitude Test (p=0.048, B=-0.05) negatively predicted cGPA. Moreover, none of the pre-admission variables were predictive of progress test performance in the same group. On the other hand, none of the pre-admission variables were predictive of cGPA in clinical years. Overall, cGPA strongly predict-ed students' progress test performance (p<0.001 and B=19.02). CONCLUSIONS: Only the National Achievement Test and TOEFL significantly predicted performance in preclinical years. However, these variables do not predict progress test performance, meaning that they do not predict the functional knowledge reflected in the progress test. We report various strengths and deficiencies in the current medical college admission criteria, and call for employing more sensitive and valid ones that predict student performance and functional knowledge, especially in the clinical years.