Can transesophageal echocardiography be safely omitted in patients scheduled for elective ablation of atrial arrhythmias? Data based on the LATTEE registry.

BACKGROUND: According to the present guidelines, transesophageal echocardiography (TEE) before scheduled catheter ablation (CA) for atrial arrhythmias (atrial fibrillation [AF] or atrial flutter [AFL]) is not deemed obligatory for optimally anticoagulated patients. However, daily clinical practice significantly differs from the recommendations. AIMS: That study aimed to identify transthoracic echocardiographic parameters that could be useful in revealing patients without left atrial thrombus (LAT), thereby contributing to avoiding unnecessary TEE before scheduled CA. METHODS: This is a sub-analysis of a multicenter, prospective, observational study - LATTEE registry. A total of 1346 patients referred for TEE before scheduled CA of AF/AFL were included. RESULTS: LAT was present in 44 patients (3.3%) and absent in the remaining 1302, who were younger, more likely to have paroxysmal AF, and displayed sinus rhythm during TEE. Additionally, they exhibited a lower incidence heart failure, diabetes, systemic connective tissue disease, and chronic obstructive pulmonary disease. Furthermore, they had a lower CHA2DS2-VASc score and a higher prevalence of direct oral anticoagulants. Echocardiographic parameters, including left ventricular ejection fraction (LVEF) > 65%, left atrial diameter (LAD) < 40 mm, left atrial area (LAA) < 20 cm2, left atrial volume (LAV) < 113 ml, and left atrial volume index (LAVI) < 51 ml/m2, demonstrated 100% sensitivity and 100% negative predictive value for the LAT absence, and weremet by 417 patients. Additional echocardiographic indices: LVEF/LAD > 1.4, LVEF/LAVI > 1.6 and LVEF/LAA > 2.7 identified an additional 57 patients, bringing the total predicted LAT-free patients to 474 (35%). CONCLUSIONS: Simple echocardiographic parameters could help identify individuals for whom TEE could be safely omitted before scheduled for elective CA due to atrial arrhythmias.

Heart failure with preserved ejection fraction: diagnostic value of HFA-PEFF score, H2FPEF score, and the diastolic stress echocardiography.

INTRODUCTION: The aim of our study was to compare 3 diagnostic pathways: diastolic stress echocardiography (DSE) based on the ASE/EACVI 2016 guidelines, the 2018 H2FPEF score, and the 2019 HFA-PEFF algorithm, in patients suspected of heart failure with preserved ejection fraction (HFpEF). MATERIAL AND METHODS: The study group included 80 consecutive patients with a clinical suspicion of HFpEF. The H2FPEF and HFA-PEFF scores and serum NT-proBNP concentrations were assessed in all the patients before they were sent for DSE. RESULTS: The DSE-based pathway confirmed HFpEF in 17 (21%) patients, the HFA-PEFF algorithm in 43 (54%), and H2FPEF scoring in 4 (5%) patients. The ROC analysis showed that HFA-PEFF score > 5 predicts a DSE-positive test with a sensitivity of 70.5% and a specificity of 65%, (AUC = 0.711, p = 0.002) with a negative predictive value of 89.1% and positive predictive value of 35.3%. The H2FPEF score > 3 had a negative predictive value of 90%, a positive predictive value of 29.8%, and predicted positive DSE result with a sensitivity of 82.3% but rather poor specificity of 47.6% (AUC = 0.692, p = 0.004). Both H2FPEF and HFA-PEFF showed similar predictive values (AUC) in the prediction of positive DSE test (p = ns). CONCLUSIONS: The HFA-PEFF score overestimated the rate of HFpEF in comparison to DSE and the H2FPEF score. The H2FPEF and HFA-PEFF scores showed only modest predictive values of the positive DSE and had a diagnostic power to rule out the HFpEF.

Echocardiography and Cardiac Magnetic Resonance in the Assessment of Left-Ventricle Remodeling: Differences Implying Clinical Decision.

Introduction: Transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR) are the most important modalities used in clinical practice to assess cardiac chambers. However, different imaging techniques may affect their results and conclusions. The aim of our study was to compare left-ventricle (LV) remodeling assessed using TTE and CMR in the context of various cardiovascular diseases. Methods: A total of 202 consecutive patients sent for an elective cardiovascular diagnosis were scheduled for a 2D TTE and CMR, performed within 2 weeks. The study group was divided and analyzed based on the clinical indications for CMR, including coronary artery disease, heart failure, native aortic valve regurgitation or paravalvular leak after aortic valve replacement, or cardiomyopathies. Results: The mean LV mass index (LVMi) values calculated using TTE were significantly larger (127.1 ± 44.5 g/m²) compared to the LVMi assessed using CMR (77.1 ± 26.2 g/m²; p < 0.001). The LV end-diastolic volumes assessed using TTE were underestimated for all the study patients (78.6 ± 43 mL vs. 100.5 ± 39 mL; p < 0.0001) and subgroups, but a statistical trend was observed in patients with cardiomyopathy. Those differences in single parameters led to differences in LV remodeling and the final treatment decision. CMR and TTE provided similar conclusions on LV systolic dysfunction in 68% of the patients. Conclusions: Our results showed that the greater the degree of LV remodeling and dysfunction, the greater the difference between the modalities. Therefore, CMR should be introduced into routine clinical practice, especially for patients undergoing LV remodeling, which may change clinical decisions in a considerable number of cases.

Artificial intelligence in detecting left atrial appendage thrombus by transthoracic echocardiography and clinical features: the Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry.

AIMS: Transoesophageal echocardiography (TOE) is often performed before catheter ablation or cardioversion to rule out the presence of left atrial appendage thrombus (LAT) in patients on chronic oral anticoagulation (OAC), despite associated discomfort. A machine learning model [LAT-artificial intelligence (AI)] was developed to predict the presence of LAT based on clinical and transthoracic echocardiography (TTE) features. METHODS AND RESULTS: Data from a 13-site prospective registry of patients who underwent TOE before cardioversion or catheter ablation were used. LAT-AI was trained to predict LAT using data from 12 sites (n = 2827) and tested externally in patients on chronic OAC from two sites (n = 1284). Areas under the receiver operating characteristic curve (AUC) of LAT-AI were compared with that of left ventricular ejection fraction (LVEF) and CHA2DS2-VASc score. A decision threshold allowing for a 99% negative predictive value was defined in the development cohort. A protocol where TOE in patients on chronic OAC is performed depending on the LAT-AI score was validated in the external cohort. In the external testing cohort, LAT was found in 5.5% of patients. LAT-AI achieved an AUC of 0.85 [95% confidence interval (CI): 0.82-0.89], outperforming LVEF (0.81, 95% CI 0.76-0.86, P < .0001) and CHA2DS2-VASc score (0.69, 95% CI: 0.63-0.7, P < .0001) in the entire external cohort. Based on the proposed protocol, 40% of patients on chronic OAC from the external cohort would safely avoid TOE. CONCLUSION: LAT-AI allows accurate prediction of LAT. A LAT-AI-based protocol could be used to guide the decision to perform TOE despite chronic OAC.

Echocardiographic functional determinants of survival in heart failure with abnormal ejection fraction.

Background and Aims: Patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (EF) have a heterogeneous prognosis, and assessment of coronary physiology with coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) may complement established predictors based on wall motion and EF. Methods and results: In a prospective multicenter study design, we enrolled 1,408 HF patients (age 66 ± 12 years, 1,035 men), with EF <50%, 743 (53%) with coronary artery disease, and 665 (47%) with normal coronary arteries. Recruitment (years 2004-2022) involved 8 accredited laboratories, with inter-observer variability <10% for CFV measurement. Baseline CFV (abnormal value >31 cm/s) was obtained by pulsed-wave Doppler in mid-distal LAD. CFVR (abnormal value ≤2.0) was assessed with exercise (n = 99), dobutamine (n = 100), and vasodilator stress (dipyridamole in 1,149, adenosine in 60). Inducible myocardial ischemia was identified with wall motion score index (WMSI) stress > rest (cut-off Δ ≥ 0.12). LV contractile reserve (CR) was identified with WMSI stress < rest (cutoff Δ ≥ 0.25). Test response ranged from score 0 (EF > 30%, CFV ≥ 32 cm/s, CFVR > 2.0, LVCR present, ischemia absent) to score 5 (all steps abnormal). All-cause death was the only endpoint. Results. During a median follow-up of 990 days, 253 patients died. Independent predictors of death were EF (HR: 0.956, 95% CI: 0.943-0.968, p < 0.0001), CFV (HR: 2.407, 95% CI: 1.871-3.096, p < 0.001), CFVR (HR: 3.908, 95% CI: 2.903-5.260, p < 0.001), stress-induced ischemia (HR: 2.223, 95% CI: 1.642-3.009, p < 0.001), and LVCR (HR: 0.524, 95% CI: 0.324-.647, p = 0.008). The annual mortality rate was lowest (1.2%) in patients with a score of 0 (n = 61) and highest (31.9%) in patients with a score of 5 (n = 15, p < 0.001). Conclusion: High resting CFV is associated with worse survival in ischemic and nonischemic HF with reduced EF. The value is independent and additive to resting EF, CFVR, LVCR, and inducible ischemia.

Multiple Phenotypes of Chronic Coronary Syndromes Identified by ABCDE Stress Echocardiography.

BACKGROUND: Regional wall motion abnormality is considered a sensitive and specific marker of ischemia during stress echocardiography (SE). However, ischemia is a multifaceted entity associated with either coronary artery disease (CAD) or angina with normal coronary arteries, a distinction difficult to make using a single sign. The aim of this study was to evaluate the diagnostic potential of the five-step ABCDE SE protocol for CAD detection. METHODS: From the 2016-2022 Stress Echo 2030 study data bank, 3,229 patients were selected (mean age, 66 ± 12 years; 2,089 men [65%]) with known CAD (n = 1,792) or angina with normal coronary arteries (n = 1,437). All patients were studied using both the ABCDE SE protocol and coronary angiography, within 3 months. In step A, regional wall motion abnormality is assessed; in step B, B-lines and diastolic function; in step C, left ventricular contractile reserve; in step D, coronary flow velocity reserve in the left anterior descending coronary artery; and in step E, heart rate reserve. RESULTS: SE response ranged from a score of 0 (all steps normal) to a score of 5 (all steps abnormal). For CAD, rates of abnormal results were 347 for step A (19.4%), 547 (30.5%) for step B, 720 (40.2%) for step C, 615 (34.3%) for step D, and 633 (35.3%) for step E. For angina with normal coronary arteries, rates of abnormal results were 81 (5.6%) for step A, 429 (29.9%) for step B, 432 (30.1%) for step C, 354 (24.6%) for step D, and 445 (31.0%) for step E. The dominant "solitary phenotype" was step B in 109 patients (9.1%). CONCLUSIONS: Stress-induced ischemia presents with a wide range of diagnostic phenotypes, highlighting its complex nature. Using a comprehensive approach such as the advanced ABCDE score, which combines multiple markers, proves to be more valuable than relying on a single marker in isolation.

Rest and Stress Left Atrial Dysfunction in Patients with Atrial Fibrillation.

BACKGROUND: Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS) but sometimes occult at rest and elicited by stress. AIM: This study sought to assess LA volume and function at rest and during stress across the spectrum of AF. METHODS: In a prospective, multicenter, observational study design, we enrolled 3042 patients [age = 64 ± 12; 63.8% male] with known or suspected CCS: 2749 were in sinus rhythm (SR, Group 1); 191 in SR with a history of paroxysmal AF (Group 2); and 102 were in permanent AF (Group 3). All patients underwent stress echocardiography (SE). We measured left atrial volume index (LAVI) in all patients and LA Strain reservoir phase (LASr) in a subset of 486 patients. RESULTS: LAVI increased from Group 1 to 3, both at rest (Group 1 = 27.6 ± 12.2, Group 2 = 31.6 ± 12.9, Group 3 = 43.3 ± 19.7 mL/m2, p < 0.001) and at peak stress (Group 1 = 26.2 ± 12.0, Group 2 = 31.2 ± 12.2, Group 3 = 43.9 ± 19.4 mL/m2, p < 0.001). LASr progressively decreased from Group 1 to 3, both at rest (Group 1 = 26.0 ± 8.5%, Group 2 = 23.2 ± 11.2%, Group 3 = 8.5 ± 6.5%, p < 0.001) and at peak stress (Group 1 = 26.9 ± 10.1, Group 2 = 23.8 ± 11.0 Group 3 = 10.7 ± 8.1%, p < 0.001). Stress B-lines (≥2) were more frequent in AF (Group 1 = 29.7% vs. Group 2 = 35.5% vs. Group 3 = 57.4%, p < 0.001). Inducible ischemia was less frequent in SR (Group 1 = 16.1% vs. Group 2 = 24.7% vs. Group 3 = 24.5%, p = 0.001). CONCLUSIONS: In CCS, rest and stress LA dilation and reservoir dysfunction are often present in paroxysmal and, more so, in permanent AF and are associated with more frequent inducible ischemia and pulmonary congestion during stress.

Lipid-Lowering Treatment and the Lipid Goals Attainment in Patients with a Very High Cardiovascular Risk.

Hypercholesterolemia is the main cardiovascular (CV) risk factor with a large body of evidence. Our aim was to assess the achievement of the main therapeutic goal of Low-Density Lipoprotein Cholesterol (LDL-C) in patients with a very high CV risk and a high-dose statin therapy. The study group consisted of 1413 consecutive patients hospitalised at the Upper-Silesian Medical Centre in Katowice due to acute myocardial infarction (AMI) treated with atorvastatin ≥ 40 mg or rosuvastatin ≥ 20 mg. The lipid profile was performed on admission and within 12 months after AMI. The main therapeutic goal was defined as LDL-C < 55 mg%. The study group (n = 1413) included 979 males (69.3%) with arterial hypertension (83.3%), diabetes (33.5%), peripheral artery disease (13.6%) and nicotinism (46.2%). In the study group, only 61 patients (4.3%) were additionally taking ezetimibe. During hospitalisation, the primary LDL-C goal was found in only 186 patients (13.2%). Subsequently, a follow-up lipidogram within 12 months was performed in 652 patients (46%), and the therapeutic goal was achieved in 255 patients (39%). There were 258 (18.26%) patients who died within 12 months after myocardial infarction. The lowest mortality rate was found in the subgroup of patients with LDL-C < 55 mg% during follow-up (11.02%). The primary lipid goal attainment among patients with a high-dose statin and a very high CV risk is low and far from the expected rate. Patients hospitalised for AMI should be given a combination of statin and ezetimibe more frequently. Low LDL-C levels measured at follow-up predict a lower risk of death at 12-month follow-up in a large group of patients.

Treatment goal attainment for secondary prevention in coronary patients with or without diabetes mellitus - Polish multicenter study POLASPIRE.

Introduction: Cardiovascular disease is still a leading cause of death in Poland and across Europe. The aim of this study was to assess the attainment of the main treatment goals for secondary cardiovascular prevention in coronary patients with or without diabetes mellitus (DM) in Poland. Material and methods: The study group included 1026 patients (65.5 ±9 y.o.; males: 72%) included at least 6 months after the index hospitalisation for myocardial infarction, unstable angina, elective percutaneous coronary intervention or coronary artery bypass surgery. The target and treatment goals were defined according to the 2016 European Society of Cardiology guidelines on cardiovascular prevention. Results: Patients with DM (n = 332; 32%) were slightly older compared to non-diabetic (n = 694) individuals (67.2 ±7 vs. 64.6 ±9 years old; p < 0.0001). The DM goal was achieved in 196 patients (60%). The rate of primary (LDL: 51% vs. 35%; p < 0.0001) and secondary (non-HDL: 56% vs. 48%; p < 0.02) goal attainment was higher in DM(+) compared to DM(-) patients. The rate of target blood pressure was lower in DM(+) than in normoglycemic patients (52% vs. 61% at < 140/90 mm Hg, p < 0.01. As expected, goal achievement of normal weight (9.5% vs. 19%; p < 0.0001) and waist circumference (7% vs. 15%; p < 0.001) was lower in diabetic patients and the rate of regular physical activity was similar (DM+ 12% vs. DM- 14%; p = ns). Finally, there was no difference in active smokers (DM+ 23% vs. DM- 22%; p = ns). Conclusions: Great majority of Polish patients in secondary prevention do not achieve treatment goals. Although lipid goals attainment is better in DM and the rate of smokers is similar, the management of all risk factors needs to be improved.

A distinct septal pattern of late gadolinium enhancement specific for COVID-induced myocarditis: A multicenter cardiovascular magnetic resonance study.

BACKGROUND: COVID-19 is a great medical challenge as it provokes acute respiratory distress and has pulmonary manifestations and cardiovascular (CV) consequences. AIMS: This study compared cardiac injury in COVID-19 myocarditis patients with non-COVID-19 myocarditis patients. METHODS: Patients who recovered from COVID-19 were scheduled for cardiovascular magnetic resonance (CMR) owing to clinical myocarditis suspicion. The retrospective non-COVID-19 myocarditis (2018-2019) group was enrolled (n = 221 patients). All patients underwent contrast-enhanced CMR, the conventional myocarditis protocol, and late gadolinium enhancement (LGE). The COVID study group included 552 patients at a mean (standard deviation [SD]) age of 45.9 (12.6) years. RESULTS: CMR assessment confirmed myocarditis-like LGE in 46% of the cases (68.5% of the segments with LGE <25% transmural extent), left ventricular (LV) dilatation in 10%, and systolic dysfunction in 16% of cases. The COVID-19 myocarditis group showed a smaller median (interquartile range [IQR]) LV LGE (4.4% [2.9%-8.1%] vs. 5.9% [4.4%-11.8%]; P <0.001), lower LV end-diastolic volume (144.6 [125.5-178] ml vs. 162.8 [136.6-194] ml; P <0.001), limited functional consequence (left ventricular ejection fraction, 59% [54.1%-65%] vs. 58% [52%-63%]; P = 0.01), and a higher rate of pericarditis (13.6% vs. 6%; P = 0.03) compared to non-COVID-19 myocarditis. The COVID-19-induced injury was more frequent in septal segments (2, 3, 14), and non-COVID-19 myocarditis showed higher affinity to lateral wall segments (P <0.01). Neither obesity nor age was associated with LV injury or remodeling in subjects with COVID-19 myocarditis. CONCLUSIONS: COVID-19-induced myocarditis is associated with minor LV injury with a significantly more frequent septal pattern and a higher pericarditis rate than non-COVID-19 myocarditis.

Adiposity, fat depots and the prediction of stroke.

BACKGROUND: Despite the progress in research, the utility of clinical assessment for the prediction of stroke is limited. The aim herein, was to evaluate the predictive values of major ultrasound indexes of carotid artery and fat depots for stroke in patients with high and very high cardiovascular (CV) risk. METHODS: The study group included 364 patients (age: 61.3 ± 7.2 years old) with typical CV risk factors scheduled for elective coronary angiography (2012-2013). A comprehensive baseline assessment included the following ultrasound indexes: carotid artery intima-media thickness (IMT), extra-media thickness (EMT), epicardial (EFT) and pericardial fat thickness (PFT), abdominal subcutaneous (ASF) and visceral fat (AVF) and combined periarterial adipose tissue intima-media adventitia (PATIMA) index. Afterwards, all patients were followed for 80.9 ± 7.1 months. RESULTS: There were 23 strokes and 25 cases with new-onset atrial fibrillation during follow-up. Receiver operating characteristics (ROC) analysis showed, that selected clinical parameters (age, waist circumference [WC], waist-hip ratio [WHR]) and ultrasound indexes (EFT: area under curve [AUC] 0.672, p < 0.01 and PATIMA index: AUC 0.658, p < 0.01) were predictive for stroke. However, their predictive values showed no significant differences (p = NS). The baseline body mass index (BMI) was the only parameter, which showed a prediction for new-onset atrial fibrillation (BMI > 33 kg/m2: sensitivity 65%, specificity 76%). CONCLUSIONS: It was found that age, WC and echocardiographic EFT revealed significant predictive values for stroke. Both WC and EFT showed a very high NPV suggesting that they should be implemented into the clinical practice as a tool affirming a very low risk of stroke.

Cardiac Magnetic Resonance Findings in Patients Recovered from COVID-19 Pneumonia and Presenting with Persistent Cardiac Symptoms: The TRICITY-CMR Trial.

The prevalence and clinical consequences of coronavirus disease 2019 (COVID-19)-related non-ischemic cardiac injury are under investigation. The main purpose of this study was to determine the occurrence of non-ischemic cardiac injury using cardiac magnetic resonance (CMR) imaging in patients with persistent cardiac symptoms following recovery from COVID-19 pneumonia. We conducted a single-center, cross-sectional study. Between January 2021 and May 2021, we enrolled 121 patients with a recent COVID-19 infection and persistent cardiac symptoms. Study participants were divided into those who required hospitalization during the acute phase of SARS-CoV-2 infection (n = 58; 47.9%) and those non-hospitalized (n = 63; 52.1%). Non-ischemic cardiac injury (defined as the presence of late gadolinium enhancement (LGE) lesion and/or active myocarditis in CMR) was detected in over half of post-COVID-19 patients (n = 64; 52.9%). LGE lesions were present in 63 (52.1%) and active myocarditis in 10 (8.3%) post-COVID-19 study participants. The majority of LGE lesions were located in the left ventricle at inferior and inferolateral segments at the base. There were no significant differences in the occurrence of LGE lesions (35 (60.3%) vs. 28 (44.4%); p = 0.117) or active myocarditis (6 (10.3%) vs. 4 (6.3%); p = 0.517) between hospitalized and non-hospitalized post-COVID-19 patients. However, CMR imaging revealed lower right ventricular ejection fraction (RVEF; 49.5 (44; 54) vs. 53 (50; 58) %; p = 0.001) and more frequent presence of reduced RVEF (60.3% vs. 33.3%; p = 0.005) in the former subgroup. In conclusion, more than half of our patients presenting with cardiac symptoms after a recent recovery from COVID-19 pneumonia had CMR imaging abnormalities indicating non-ischemic cardiac injury. The most common finding was LGE, while active myocarditis was detected in the minority of patients. CMR imaging abnormalities were observed both in previously hospitalized and non-hospitalized post-COVID-19 patients. Further research is needed to determine the long-term cardiovascular consequences of COVID-19 infection and the optimal management of patients with suspected post-COVID-19 non-ischemic cardiac injury.

Underlying Causes of Myocardial Infarction with Nonobstructive Coronary Arteries: Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging Pilot Study.

BACKGROUND: Scientific statements recommend multimodality imaging in myocardial infarction with non-obstructive coronary arteries (MINOCA) to define the underlying cause. AIM: We evaluated the diagnostic yield of intravascular optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) in the MINOCA setting. METHODS: In this prospective, single center, observational pilot study, we enrolled patients with MINOCA without previous coronary interventions. All patients underwent three vessel OCT, followed by CMR. Imaging results were combined to determine the mechanism of MINOCA, when possible. RESULTS: We enrolled 10 patients in this pilot study. Women constituted 50% of the analyzed population. The mean age of patients was 52 years. ST-segment elevation was found in 30% of patients. A possible culprit lesion was identified by OCT in 70% of participants, most commonly plaque rupture or erosion. An ischemic pattern of CMR abnormalities was identified in 70% of participants. Myocarditis and Tako-Tsubo were identified in 30%. A cause of MINOCA was identified in all patients using multimodality imaging, while using OCT alone identification occurred in only 70% of patients. CONCLUSION: In this pilot study, multimodality imaging with OCT and CMR identified potential mechanisms in all patients with a diagnosis of MINOCA, and it has the potential to guide medical therapy for secondary prevention.

Echocardiographic predictors of thrombus in left atrial appendage-The role of novel transthoracic parameters.

Introduction: The left atrium appendage thrombus (LAAT) formation is a complex process. A CHA2DS2-VASc scale is an established tool for determining the thromboembolic risk and initiation of anticoagulation treatment in patients with atrial fibrillation or flutter (AF/AFL). We aimed to identify whether any transthoracic echocardiography (TTE) parameters could have an additional impact on LAAT detection. Methods: That is a sub-study of multicenter, prospective, observational study LATTEE (NCT03591627), which enrolled 3,109 consecutive patients with AF/AFL referred for transesophageal echocardiography (TEE) before cardioversion or ablation. Results: LAAT was diagnosed in 8.0% of patients. The univariate logistic regression analysis [based on pre-specified in the receiver operating characteristic (ROC) analysis cut-off values with AUC ≥ 0.7] identified left ventricular ejection fraction (LVEF) ≤ 48% and novel TTE parameters i.e., the ratios of LVEF and left atrial diameter (LAD) ≤ 1.1 (AUC 0.75; OR 5.64; 95% CI 4.03-7.9; p < 0.001), LVEF to left atrial area (LAA) ≤ 1.7 (AUC 0.75; OR 5.64; 95% CI 4.02-7.9; p < 0.001), and LVEF to indexed left atrial volume (LAVI) ≤ 1.1 (AUC 0.75, OR 6.77; 95% CI 4.25-10.8; p < 0.001) as significant predictors of LAAT. In a multivariate logistic regression analysis, LVEF/LAVI and LVEF/LAA maintained statistical significance. Calculating the accuracy of the abovementioned ratios according to the CHA2DS2-VASc scale values revealed their highest predictive power for LAAT in a setting with low thromboembolic risk. Conclusion: Novel TTE indices could help identify patients with increased probability of the LAAT, with particular applicability for patients at low thromboembolic risk.

Risk factors for left atrial thrombus in younger patients (aged < 65 years) with atrial fibrillation or atrial flutter: Data from the multicenter left atrial thrombus on transesophageal echocardiography (LATTEE) registry.

Background: Our aim was to assess the characteristics and to identify predictors of left atrial thrombus (LAT) in patients under age 65 with atrial fibrillation (AF) or atrial flutter (AFl). Methods: We conducted a subanalysis of a multicenter, prospective, observational study [the LATTEE registry]. Consecutive AF/AFl patients referred for cardioversion or ablation were enrolled. Results: Of the 3,109 patients included in the study, 1,276 were under age 65 (41%). Compared to non-LAT patients, those with LAT (n = 76) had higher CHA2DS2-VASc score (p < 0.001), more frequently had non-paroxysmal AF/AFl (p < 0.001), heart failure (p < 0.001), history of diabetes mellitus (p = 0.001), transient ischemic attack (p = 0.04), coronary artery disease (p = 0.02), and chronic kidney disease (p < 0.001). The LAT patients were also more often smokers (p = 0.004) and were more frequently treated with vitamin K antagonists (VKAs) (p < 0.001). Transthoracic echocardiography revealed a higher left atrial area (p < 0.001), lower left ventricular ejection fraction (LVEF) (p < 0.001), and lower value of LA appendage emptying volume in LAT than in non-LAT patients (p < 0.001). LVEF (OR 2.95; 95% CI: 1.32-6.59, p = 0.008), non-paroxysmal AF/AFl (OR 7.1; 95% CI: 2.05-24.63, p = 0.002) and treatment with VKAs (OR 4.92; 95% CI: 2.48-9.75, p < 0.001) were identified as independent predictors of LAT in younger patients. Conclusions: Our study, which focused on younger patients with AF/AFl, indicated substantial clinical and echocardiographic differences between participants with and without LAT. In the AF/AFl patients younger than age 65, the independent predictors of LAT included non-paroxysmal AF/AFl, lower LVEF, and treatment with VKAs.

Increased Body Mass Index and Risk of Left Atrial Thrombus in Nonvalvular Atrial Fibrillation Patients-Data from the Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) Registry.

An increased body mass index (BMI) is associated with a higher incidence of atrial fibrillation (AF) and a higher risk of thromboembolic complications in AF patients. The aim of this study was to investigate the effect of BMI on the risk of left atrial thrombi (LATs) in patients with nonvalvular AF/atrial flutter (AFl) (NV AF/AFl). Patients diagnosed with NVAF/AFl (between November 2018 and May 2020) were selected from the multicenter, prospective, observational Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry that included AF/AFl patients referred for cardioversion or ablation followed by transesophageal echocardiography. A total of 2816 AF/AFl patients (63.6% males; mean age 65.8 years; mean BMI 29.8 kg/m2) were included in the study. Two hundred and twenty-two of them (7.9%) had LATs. Compared with normal-weight patients, those with BMIs ≥ 25 kg/m2 more frequently presented clinical factors potentially provoking LATs, such as non-paroxysmal AF/AFl (p = 0.04), hypertension (p < 0.001), and diabetes (p < 0.001); had higher CHA2DS2 scores (p < 0.001); and had larger LA dimensions (LA diameter and LA area) (p < 0.001 for both parameters). On the other hand, they showed some features negatively related to thromboembolic risk; for example, they were younger (p < 0.001) and were more often male (p = 0.002). In addition, patients with abnormal BMIs were more likely to be smokers (p = 0.006) and to be treated with oral anticoagulants (p = 0.005). Despite these differences in the prevalence of thromboembolic risk factors, the incidence of LATs was not increased in patients with abnormal body weight (overweight and obese compared to normal-weight patients) in this large real-life cohort of AF/AFl patients. This is probably due to the balanced composition regarding the prevalence of positive and negative thromboembolic risk factors.

Heart failure and the risk of left atrial thrombus formation in patients with atrial fibrillation or atrial flutter.

AIMS: The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transoesophageal echocardiography (TOE) in patients with atrial fibrillation or atrial flutter (AF/AFl) with reference to the presence of heart failure (HF) and its subtypes. METHODS AND RESULTS: The research is a sub-study of the multicentre, prospective, observational Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry, which comprised 3109 consecutive patients with AF/AFl undergoing TOE prior to direct current cardioversion or catheter ablation. TOE parameters, including presence of LAT, were compared between patients with and without HF and across different subtypes of HF, including HF with preserved (HFpEF), mid-range (HFmrEF), and reduced ejection fraction (HFrEF). HF was diagnosed in 1336 patients (43%). HF patients had higher prevalence of LAT than non-HF patients (12.8% vs. 4.4%; P < 0.001). LAT presence increased with more advanced type of systolic dysfunction (HFpEF vs. HFmrEF vs. HFrEF: 7.4% vs. 10.5% vs. 20.3%; P < 0.001). Univariate analysis revealed that HFrEF (odds ratio [OR] 4.13; 95% confidence interval [95% CI]: 3.13-5.46), but not HFmrEF or HFpEF, was associated with the presence of LAT. Multivariable logistic regression indicated that lower left ventricular ejection fraction (OR per 1%: 0.94; 95% CI 0.93-0.95) was an independent predictor of LAT formation. Receiver operator characteristic analysis showed LVEF ≤48% adequately predicted increased risk of LAT presence (area under the curve [AUC] 0.74; P < 0.0001). CONCLUSION: The diagnosis of HFrEF, but neither HFmrEF nor HFpEF, confers a considerable risk of LAT presence despite widespread utilization of adequate anticoagulation.

Cardiometabolic predictive value of anthropometric parameters, vascular ultrasound indexes, and fat depots in patients at high cardiovascular risk: an 8-year prospective cohort study.

INTRODUCTION: Adiposity has a few phenotypes associated with various levels of risk for diabetes mellitus (DM), but their exact predictive value is not well understood. OBJECTIVES: We aimed to assess the predictive value of anthropometric parameters, vascular ultrasound indexes, and fat depots for long­term cardiometabolic risk. PATIENTS AND METHODS: A total of 150 patients with chronic coronary syndrome (CCS) scheduled for elective coronary angiography were enrolled and a comprehensive clinical and ultrasound assessment of adiposity was performed (2012-2013). Of them, 143 individuals were followed for 8 years for insulin resistance (IR) and / or DM development. RESULTS: At baseline, DM and prediabetes were found in 22% and 8% of the patients, respectively. It was established that 11.7% of the participants died during the follow­up. The rate of DM increased to 46% with a decrease in the prediabetes rate (3.5%). Significant correlations with the Homeostatic Model Assessment of Insulin Resistance and glycated hemoglobin were observed for major anthropometric and ultrasound variables. In the multivariable analysis, independent predictors of IR were preperitoneal fat thickness (PreFT) (per 10mm increase: odds ratio [OR], 1.63; 95% CI, 1.22-2.33; P = 0.003) and body surface area (per 0.1m2 increase: OR, 1.59; 95% CI, 1.11-2.39; P = 0.02). DM was independently predicted by the high­density lipoprotein cholesterol concentration (OR, 0.93; 95% CI, 0.87-0.97; P = 0.005) and body fat mass (OR, 1.09; 95% CI, 1.03-1.17; P = 0.003). CONCLUSIONS: A complex assessment of the adipose tissue in patients with CCS is a valuable method for improving metabolic risk stratification. Some anthropometric and ultrasound parameters, such as PreFT or body surface area, were associated with IR and DM development.

Recollection of Physician Information about Risk Factor and Lifestyle Changes in Chronic Coronary Syndrome Patients.

A patient's compliance to a physician's lifestyle information is essential in chronic coronary syndrome (CCS) patients. We assessed potential characteristics associated with a patient's recollection of physician information and lifestyle changes. This study recruited and interviewed patients (aged ≤ 80 years) 6-18 months after hospitalization due to acute coronary syndrome or elective myocardial revascularization. A physician's information on risk factors was recognized if patients recollected the assessment of their diet, weight management, blood pressure control, cholesterol level, diabetes, and other lifestyle factors by the doctor. Of a total of 946 chronic coronary syndrome patients, 52.9% (501) of them declared the recollection of providing information on more than 80% of the risk factors. A good recollection of risk factor information was associated with the following: a patient's age (OR per year: 0.97; 95% CI: 0.95 to 0.99), obesity (OR: 4.41; 95% CI: 3.09-6.30), diabetes (OR: 4.16; 95% CI: 2.96-5.84), diuretic therapy (OR: 1.41; 95% CI: 1.03-1.91), calcium channel blockers (OR: 1.47; 95% CI: 1.04-2.09), and ACEI/sartan (OR: 0.65; 95% CI: 0.45-0.94) at hospitalization discharge. In terms of goal attainment, better adherence to antihypertensive drugs (OR: 1.80; 95% CI: 1.07-3.03) was observed in the patients with a good compared to a poor recollection of risk factor information. The recollection of physician risk factor information was significantly associated with more comorbidities. Strategies to tailor the conveying of information to a patient's perception are needed for optimal patient-doctor communication.