Left atrial mechanics evaluated by two-dimensional strain analysis: alterations in essential hypertension.

BACKGROUND: Hypertension is a cardiovascular risk factor that predisposes to cardiac structural alterations namely increased left ventricular (LV) wall thickness, reduced LV compliance and diastolic dysfunction, with consequent left atrial (LA) dilation and functional impairment. In this article, we evaluated differences in left atrial structure and function using two-dimensional speckle tracking echocardiography in patients with hypertension compared with controls. METHODS: This was a retrospective cross-sectional study of 208 hypertensive patients and 157 controls who underwent a comprehensive transthoracic echocardiogram. Patients with hypertension were stratified by the presence of left ventricular hypertrophy (LVH). RESULTS: Non-LVH hypertension patients had lower left atrial reservoir strain (LAS RES ) (34.78 ±â€Š29.78 vs. 29.78 ±â€Š6.08; P  = 0.022) and conduit strain (LAS CD ) (19.66 ±â€Š7.29 vs. 14.23 ±â€Š4.59; P  = 0.014) vs. controls despite similar left atrial volumes (LAV) . Left atrial contractile strain (LAS CT ) was not significantly different between non-LVH hypertension patients and controls (15.12 ±â€Š3.77 vs. 15.56 ±â€Š3.79; P  = 0.601). Left atrial mechanical dispersion was significantly higher in the LVH group compared with the non-LVH hypertension group (42.26 ±â€Š13.01 vs. 50.06 ±â€Š14.95; P  = 0.009). In multivariate regression analysis, LVH correlated with left atrial mechanical dispersion ( P  = 0.016). An age-hypertension interaction independently correlated with LAS CT ( P  < 0.001). CONCLUSION: Hypertension results in functional left atrial changes even before development of LV hypertrophy and structural left atrial changes with increased left atrial volume. We demonstrate both a likely hypertension-associated left atrial myopathy that prevents age-related compensatory increase in left atrial contractile function, and impact of LVH in hypertension on left atrial dyssynchrony.

Alterations in Left Atrial Strain in Breast Cancer Patients Immediately Post Anthracycline Exposure.

AIMS: With improved diagnosis and treatments, a greater percentage of breast cancer patients are achieving long-term survival. Consequently, long-term cardiotoxicity secondary to chemotherapy has become more prevalent, warranting improved cardiac surveillance. We evaluated changes in left atrial (LA) strain in breast cancer patients immediately post anthracycline (AC) therapy to assess its utility as a marker of diastolic dysfunction. METHODS: This was a prospective cohort study of 128 consecutive human epidermal growth factor receptor 2 (HER2)-negative breast cancer patients who underwent transthoracic echocardiography prior to and immediately post AC treatment. Traditional left ventricular (LV) systolic and diastolic parameters and LA volumes were evaluated; additionally, LV global longitudinal strain (LV GLS) and LA phasic strain were measured. RESULTS: All patients had normal LV ejection fraction (>53%) post AC, though LV GLS was significantly reduced. Peak E and é velocities were reduced post AC, with no change in LA volumes. LA reservoir strain (LASRES 34.8% vs 31.5%, p<0.001) and conduit strain (LASCD 17.2% vs 14.4%, p<0.001) were significantly lower post AC and correlated modestly with LV diastolic parameters. Reduction in LA strain post AC was evident even in patients with preserved LV systolic and diastolic function. More patients demonstrated alteration in diastolic function (≥15% reduction in LASRES from baseline) (32%) compared to alteration in systolic function (≥15% reduction in LV GLS) (23%). CONCLUSIONS: LA strain is a promising marker of early diastolic dysfunction. We demonstrate its potential utility in surveillance of breast cancer patients treated with AC.

Echocardiographic Assessment in Patients Recovered from Acute COVID-19 Illness.

Coronavirus (COVID-19) infections have spread rapidly worldwide and posed an immense public health problem. COVID-19 infection can affect the cardiovascular system both acutely and in patients followed up some period after COVID-19 infection. The aim of this study was to evaluate left ventricular (LV) and right ventricular (RV) function by echocardiography in COVID-19 recovered patients (hospitalized and non-hospitalized). Forty-two patients who recovered from COVID-19 but had ongoing symptoms were included in this retrospective observational cross-sectional study. Patients were followed-up at a median time of 112 days from confirmed COVID-19 diagnosis and a comprehensive echocardiogram was performed. COVID-19 patients were age- and sex-matched to healthy controls. Traditional TTE parameters and advanced echocardiographic parameters including two-dimensional LV global longitudinal strain (GLS) and RV free wall strain (FWS) were measured. LV volumes and LV ejection fraction were similar in COVID-19 patients and controls; however, LV GLS was significantly worse in the COVID-19 group (p = 0.002). Similarly, RV volumes and traditional RV function parameters were similar, but RV FWS (p = 0.009) and RV global strain (p = 0.015) were reduced. Alterations in LV and RV strain were observed in both hospitalized and non-hospitalized patients. In the subset of COVID-19 patients without any co-morbidities (n = 30), LV GLS remained reduced compared to controls. According to multivariate analysis, COVID-19 infection was the only independent determinant of reduced LV GLS (p = 0.012), while COVID-19 infection, diastolic blood pressure, and RV fractional area change were determinants of RV FWS. In this observational study, prior COVID-19 infection demonstrated LV dysfunction in patients with persistent symptoms. Abnormal LV strain was evident in both hospitalized and non-hospitalized patients, suggesting that these changes are independent of the severity of COVID-19 infection at presentation. The use of LV GLS in COVID-19 patients could have potential clinical utility to support the indication for cardiac magnetic resonance imaging in patients with possible COVID-19 related myocarditis. Future longitudinal studies are needed to evaluate its correlation with adverse cardiovascular events.

What underlies sex differences in heart failure onset within the first year after a first myocardial infarction?

Background: Women are more likely to develop heart failure (HF) after myocardial infarction. However, diagnosis and reperfusion are often delayed. Objectives: To compare the prevalence of HF after primary percutaneous coronary intervention (PPCI)-treated ST segment myocardial infarction (STEMI) between sexes and to study its associations with comorbidities, infarct size, and left ventricular (LV) systolic and diastolic dysfunctions (DD). Methods: The patients with PPCI-treated anterior STEMI, from the CIRCUS study cohort, were followed up for 1 year and HF events were recorded. Evaluation of ejection fraction (LVEF) and DD were performed at baseline and at 1 year. The elevated LV filling pressure (LVFP) included Grades 2 and 3 DD. Results: Of the 791 patients from the CIRCUS study, 135 were women. At 1 year, the proportion of patients who developed HF was 21% among men and 34% among women (p = 0.001). In the subset of 407 patients with available diastolic parameters, the rate of HF was also higher in women. HF during the initial hospitalization was comparable between the sexes. However, women had a higher incidence of rehospitalization for HF within the first year after STEMI (14.1% vs. 4.1%, p = 0.005). Women were older with a higher prevalence of hypertension. The infarct size and LVEF were similar between the sexes. Elevated LVFP was observed more frequently in women than in men during the initial hospitalization and at 1 year (26% vs. 12%, p = 0.04, and 22% vs. 12%, p = 0.006, respectively). Interestingly, only initial elevated LVFP (HR 5.9, 95% CI: 2.4-14.5, p < 0.001), age, and hypertension were independently associated with rehospitalization for HF. Conclusions: After PPCI-treated anterior STEMI, despite comparable infarct size and LVEF, women presented a higher proportion of rehospitalization for HF than men. That was likely due to a greater DD associated with older age and hypertension.

Left atrial strain in cardiac surveillance of bone marrow transplant patients with prior anthracycline exposure.

BACKGROUND: Bone marrow transplantation (BMT) has significantly improved survival rates in various hematological malignancies. However, this has led to an increased prevalence of long-term cardiotoxicity, particularly in those with prior anthracycline (AC) therapy. OBJECTIVES: To evaluate changes in left atrial (LA) volume and function, including LA strain, in BMT patients with prior AC exposure and evaluate its utility as a marker of diastolic dysfunction. METHODS: This was a cross-sectional analysis of 79 BMT patients with prior AC exposure who underwent a comprehensive surveillance transthoracic echocardiogram compared to age-matched healthy volunteers. Left ventricular (LV) and LA parameters were evaluated between the 2 groups. BMT patients were stratified using traditional measures of diastolic function and additionally utilizing LA strain. RESULTS: LV systolic dysfunction with reduced LVEF (13/79) or global longitudinal strain (29/79) was present in BMT patients. There were no differences in LA volumes between the two groups. LA reservoir strain (30.1 ± 11.2% vs 34.1 ± 9.6%, p < 0.001) and LA conduit strain (13.6 ± 8.4% vs 17.0 ± 10.5%, p < 0.001) were reduced in the BMT group compared to controls. LA reservoir strain had modest correlation with mitral annular e' velocity (r = 0.468, p < 0.001). Using current diastolic function guidelines, 26/79 BMT patients had evidence of diastolic dysfunction. However, utilizing LA reservoir strain, an additional 35 patients were identified. CONCLUSIONS: LA strain can identify early diastolic dysfunction in BMT patients with prior AC treatment. With diastolic dysfunction known to precede systolic dysfunction post AC, changes in LA reservoir strain may identify more patients with cardiac dysfunction, prompting increased surveillance and treatment.

The utility of strain imaging in the cardiac surveillance of bone marrow transplant patients.

OBJECTIVE: To evaluate the utility of two-dimensional multiplanar speckle tracking strain to assess for cardiotoxicity post allogenic bone marrow transplantation (BMT) for haematological conditions. METHODS: Cross-sectional study of 120 consecutive patients post-BMT (80 pretreated with anthracyclines (BMT+AC), 40 BMT alone) recruited from a late effects haematology clinic, compared with 80 healthy controls, as part of a long-term cardiotoxicity surveillance study (mean duration from BMT to transthoracic echocardiogram 6±6 years). Left ventricular global longitudinal strain (LV GLS), global circumferential strain (LV GCS) and right ventricular free wall strain (RV FWS) were compared with traditionl parameters of function including LV ejection fraction (LVEF) and RV fractional area change. RESULTS: LV GLS (-17.7±3.0% vs -20.2±1.9%), LV GCS (-14.7±3.5% vs -20.4±2.1%) and RV FWS (-22.6±4.7% vs -28.0±3.8%) were all significantly (p=0.001) reduced in BMT+AC versus controls, while only LV GCS (-15.9±3.5% vs -20.4±2.1%) and RV FWS (-23.9±3.5% vs -28.0±3.8%) were significantly (p=0.001) reduced in BMT group versus controls. Even in patients with LVEF >53%, ~75% of patients in both BMT groups demonstrated a reduction in GCS. CONCLUSION: Multiplanar strain identifies a greater number of BMT patients with subclinical LV dysfunction rather than by GLS alone, and should be evaluated as part of post-BMT patient surveillence. Reduction in GCS is possibly due to effects of preconditioning, and is not fully explained by AC exposure.

Rapid Access Chest Pain Clinics: An Australian Cost-Benefit Study.

OBJECTIVE: Chest pain is a large health care burden in Australia and around the world. Its management requires specialist assessment and diagnostic tests, which can be costly and often lead to unnecessary hospital admissions. There is a growing unmet clinical need to improve the efficiency and management of chest pain. This study aims to show the cost-benefit of rapid access chest pain clinics (RACC) as an alternative to hospital admission. DESIGN: Retrospective cost-benefit analysis for 12 months. SETTING: RACCs in three Sydney tertiary referral hospitals. MAIN OUTCOME MEASURES: Cost per patient. RESULTS: Hospitals A, B and C implemented RACCs but each operating with slightly different staffing, referral patterns, and diagnostic services. All RACCs had similar costs per patient of AUD$455.25, AUD$427.12 and AUD$474.45, hospitals A, B and C respectively, and similar cost benefits per patient of AUD$1,168.75, AUD$1,196.88 and AUD$1,149.55, respectively. At least 28%, 26% and 29% of these RACC patients for hospitals A, B, and C, respectively, would have otherwise had to have been admitted to hospital for the model to be cost-beneficial. CONCLUSION: This study shows that a RACC model of care is cost-beneficial in the state of NSW as an alternative strategy to inpatient care for managing chest pain. Scaling up to a national level could represent an even larger benefit for the Australian health system.

Biomarkers Predict In-Hospital Major Adverse Cardiac Events in COVID-19 Patients: A Multicenter International Study.

BACKGROUND: The COVID-19 pandemic carries a high burden of morbidity and mortality worldwide. We aimed to identify possible predictors of in-hospital major cardiovascular (CV) events in COVID-19. METHODS: We retrospectively included patients hospitalized for COVID-19 from 10 centers. Clinical, biochemical, electrocardiographic, and imaging data at admission and medications were collected. Primary endpoint was a composite of in-hospital CV death, acute heart failure (AHF), acute myocarditis, arrhythmias, acute coronary syndromes (ACS), cardiocirculatory arrest, and pulmonary embolism (PE). RESULTS: Of the 748 patients included, 141(19%) reached the set endpoint: 49 (7%) CV death, 15 (2%) acute myocarditis, 32 (4%) sustained-supraventricular or ventricular arrhythmias, 14 (2%) cardiocirculatory arrest, 8 (1%) ACS, 41 (5%) AHF, and 39 (5%) PE. Patients with CV events had higher age, body temperature, creatinine, high-sensitivity troponin, white blood cells, and platelet counts at admission and were more likely to have systemic hypertension, renal failure (creatinine ≥ 1.25 mg/dL), chronic obstructive pulmonary disease, atrial fibrillation, and cardiomyopathy. On univariate and multivariate analysis, troponin and renal failure were associated with the composite endpoint. Kaplan-Meier analysis showed a clear divergence of in-hospital composite event-free survival stratified according to median troponin value and the presence of renal failure (Log rank p < 0.001). CONCLUSIONS: Our findings, derived from a multicenter data collection study, suggest the routine use of biomarkers, such as cardiac troponin and serum creatinine, for in-hospital prediction of CV events in patients with COVID-19.

Determinants of Exercise Capacity Following ST-Elevation Myocardial Infarction (STEMI).

BACKGROUND: Abnormal left ventricular systolic and diastolic function and reduced exercise capacity are associated with worse prognosis following ST-elevation myocardial infarction (STEMI). However, evidence is lacking on the determinants of exercise capacity following STEMI. We sought to determine the impact of systolic and diastolic dysfunction on exercise capacity and outcomes following first-ever STEMI. METHODS: In a retrospective analysis of 139 consecutive STEMI patients who had a transthoracic echocardiogram following STEMI and completed exercise treadmill testing, the primary outcome was to identify clinical and echocardiographic determinants of exercise capacity, and the secondary outcome was to identify determinants of major adverse cardiac events (MACEs). RESULTS: Mean number of metabolic equivalents (METs > 8) was used as a cut-off. Age, female sex, anterior infarction, abnormal diastolic function, minimum left atrial indexed volume (LAVImin) ≥ 18 mL/m2, average e', and E/e' were associated with METs ≤ 8, but not left ventricular ejection fraction (LVEF). On multivariate analysis, LAVImin (OR 4.3, 95%CI 1.3-14.2; p = 0.017), anterior infarction (OR 2.6, 95%CI 1.2-5.9; p = 0.022), and abnormal diastolic function (OR 3.73, 95%CI 1.7-8.4; p = 0.001) were independent predictors of METs ≤ 8. On Kaplan-Meier analysis, METs ≤ 8 (p = 0.01) and abnormal diastolic function (p = 0.04) were associated with MACEs (median follow-up 2.3 years). METs ≤ 8 was an independent predictor of MACEs (HR 3.4, 95%CI 1.2-9.8; p = 0.02). CONCLUSIONS: Following first-ever STEMI, increased LAVImin, anterior infarction, and abnormal diastolic function were independent predictors of reduced exercise capacity. Furthermore, reduced exercise capacity was an independent predictor of MACEs. These results highlight important prognostic and therapeutic implications related to abnormal diastolic function in STEMI patients that are distinct from those with LV systolic impairment.

Changes in left atrial phasic strain and mechanical dispersion: Effects of age and gender.

PURPOSE: Left atrial (LA) function by two-dimensional (2D) strain is an emerging tool with increasing clinical utility. Age and gender are key modulators of strain parameters; however, the specific time course for LA structural and functional changes is not clearly defined. METHODS: A total of 147 healthy individuals (20-69 years) underwent transthoracic echocardiography; subjects were evaluated by age (decade) and gender. LA and left ventricular (LV) volumetric and strain measurements were performed. RESULTS: Left atrial reservoir (ƐR) and conduit strain (ƐCD) with negatively correlated with age (r =-.36; r = -.56; P < .001, respectively) being significantly lower by the 6th and 5th decades, respectively. Contractile strain (ƐCT) positively correlated with age (r = .36; P < .001), being significantly higher by the 6th decade. ƐR and ƐCD were higher in young females (20-34 years) compared to young males (P = .033 and P < .001, respectively). ƐCT was significantly higher in middle-aged adult males (35-50yrs; P = .010), though seen later in females (≥51 years; P = .005). Standard deviation of time to positive strain (SD-TPS) significantly higher by the 5th decade and correlated with age in both males (r = .44; P <.001) and females (r = .40; P = .001). CONCLUSION: We demonstrate that ƐR and ƐCD are lower with age, with differing rates between males and females. As a compensatory mechanism for decline in ƐCD, ƐCT is higher, more notably in males; comparatively, females display a more prominent decline in ƐR and ƐCD with age. Alteration in electromechanical properties occurred in both genders with SD-TPS becoming higher with age.

Comparative Assessments of Left and Right Ventricular Function by Two-Dimensional, Contrast Enhanced and Three-Dimensional Echocardiography with Gated Heart Pool Scans in Patients Following Myocardial Infarction.

Multiple noninvasive imaging modalities are available to measure biventricular function, although limited studies have assessed agreement between modalities in assessing left and right ventricular ejection fraction (LVEF & RVEF) in the same cohort of patients. In this study we prospectively compared the agreement of 2-dimensional echocardiography (2DE), contrast enhanced 2DE, 3-dimensional echocardiography (3DE), and gated heart pool scan (GHPS) measures of LVEF and RVEF in patients with acute ST-elevation myocardial infarction. We recruited 95 consecutive ST-elevation myocardial infarction patients (mean age 61.4 ± 12.0, male: 79.5%) admitted to a major tertiary hospital between July 2016 and May 2018. Despite minimal inter- and intra-observer variability (coefficient of variance < 5% in both categories), substantial discrepancies exist between modalities with Pearson's correlation coefficients ranging from 0.64 to 0.91 for LVEF measurements, and 0.27 to 0.86 for RVEF measurements. Bland-Altman plots demonstrated no systematic bias between modalities. GHPS and 3DE offered the closest agreement for both LVEF and RVEF, demonstrating the greatest correlation coefficient (r = 0.91 and 0.86 respectively), lowest mean absolute differences (4% and 3% respectively), and narrowest Bland-Altman limits of agreement (19% and 18% respectively). Greater than 10% of 2DE and contrast enhanced 2DE scans discordantly showed LVEF values >40% for patients whose LVEF was measured as ≤ 40% by 3DE or GHPS. In conclusion, substantial variation exists between modalities when assessing LVEF and RVEF, although we demonstrate that 3DE and GHPS have the closest agreement. This variability should be considered in clinical management of patients, and modalities should not be used interchangeably in sequential patient follow-up.

Atrial premature activity detected after an ischaemic stroke unveils atrial myopathy.

BACKGROUND: Recent publications suggest that left atrial (LA) myopathy is a potential source of thromboembolism, independent of atrial fibrillation. AIMS: We sought to investigate whether the presence of atrial premature activity after an ischaemic stroke is associated with LA remodelling and dysfunction, and might be a surrogate marker of LA myopathy. METHODS: After an ischaemic stroke or a transient ischaemic attack, patients without known atrial fibrillation or overt heart disease were included prospectively in the study. All patients had a standard workup, including ambulatory Holter electrocardiogram monitoring and transthoracic echocardiography. In some patients, transoesophageal echocardiography was also performed. Anatomical and functional LA remodelling were assessed using minimal and maximal volumes and LA emptying fraction in two-dimensional and three-dimensional echocardiography. Patients were separated into two groups according to the burden of atrial premature complexes (APCs), measured by Holter electrocardiography. RESULTS: Among 148 eligible patients recruited from October 2015 to May 2016, 93 were included in the group with non-frequent APCs (nf-APC:<100 APCs/24hours) and 43 in the group with frequent APCs (f-APC:>100 APCs/24hours). Twelve patients had paroxysmal atrial fibrillation, and were not included in the statistical analysis. Maximal and minimal indexed LA volumes were significantly higher in the f-APC group than in the nf-APC group (P<0.01). LA emptying fraction was worse in the f-APC group than in the nf-APC group. In addition, LA appendage emptying velocity was impaired in the f-APC group, and was correlated with LA remodelling variables, especially LA emptying fraction (r=0.621). CONCLUSIONS: After an ischaemic stroke or a transient ischaemic attack, excessive APCs are associated with LA remodelling. Thus, LA dilatation and dysfunction reflect early LA myopathy, which might itself be responsible for cardioembolic stroke.

Demographic and clinical profile of cardioembolic stroke patients in Western Sydney.

BACKGROUND: Cardioembolism (CE) contributes to a large proportion of ischaemic stroke. AIMS: To evaluate the demographic and clinical profile of CE stroke in Western Sydney. METHODS: A retrospective analysis of ischaemic stroke patients presenting to Westmead Hospital (January-October 2016) was performed. Strokes were classified by TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria into different categories. Clinical and demographic data were collected on all stroke patients, and differences between CE and other stroke causes were identified. RESULTS: Two hundred and twenty-eight consecutive patients (70.9 years; 53% male) were identified. By TOAST criteria, 21 (9%) had large-artery atherosclerosis, 94 (41%) CE, 10 (5%) small-vessel disease, 2 (1%) other aetiology and 101 (44%) undetermined aetiology. A significant proportion of CE stroke patients had cardiovascular risk factors including hypertension (66%), hypercholesterolaemia (50%), diabetes (26%) and ischaemic heart disease (28%). The majority (81%) of patients with CE had atrial flutter/flutter. CE stroke, compared with other types of stroke, was more common in females (56 vs 41%, P = 0.022) and patients with CE stroke were more likely to have previous cerebral ischaemia (34 vs 21%, P = 0.026), suggesting increased recurrence in this group. Of the patients with atrial flutter/flutter (n = 56), the majority (87%) had a high CHA2 DS2 -VASC score (≥2); however, a significant proportion (55.4%) were not on anticoagulation. CONCLUSIONS: Cardioembolic stroke remains a significant burden in Western Sydney, and it is likely that a significant proportion may be preventable, as evidenced by the substantial presence of modifiable cardiovascular risk factors, and inadequate anticoagulation of patients with atrial arrhythmias.

Echocardiographic Strain in Clinical Practice.

The accurate evaluation of left ventricular (LV) function has been central to monitoring of therapy, institution of specific therapeutic interventions and as a prognostic marker for risk stratification in a variety of cardiovascular conditions. However, LV ejection fraction, the most commonly used measure of LV systolic function, is a 'coarse' measure of global LV function, with several limitations. Strain analysis, a measure of myocardial deformation, has come to the forefront more recently as a more sensitive measure of myocardial function than LV ejection fraction. Its utility in detection of early subclinical LV dysfunction, defining regional variation in specific cardiomyopathies, utility to monitor improvement with therapy and as a prognostic marker in a variety of cardiac conditions has led to its increasing use in clinical practice. This review will briefly summarise specific methodological aspects, use in diagnosis and prognostic utility of strain analysis in various cardiovascular conditions.

Rapid Access Cardiology (RAC) Services Within a Large Tertiary Referral Centre-First Year in Review.

BACKGROUND: Rapid Access Cardiology (RAC) services are hospital co-located cardiologist-led outpatient clinics providing prompt assessment and management of chest pain. This service model is part of chest pain management in the United Kingdom. However, little data exists on RAC services in Australia. Our aim was to describe the introduction of RAC services to an Australian tertiary centre (utility, safety, and acceptability). METHODS: Referrals were accepted for low-intermediate risk chest pain. Referrer and patient clinical data was collected prospectively in the first year of RAC - 4 February 2015 to 4 February 2016. Data was linked to hospital presentations/admissions to identify readmissions/mortality data. RESULTS: Among 520 patients (55.0% male, mean age 55.2 years), 87.6% were referred from emergency and 68.4% assessed within 5 days. The final diagnosis was new coronary artery disease (CAD) in 7.9%, and 81.3% had ≥2 cardiovascular risk factors (diabetes, hyperlipidaemia, hypertension, overweight/obesity, smoker, pre-existing CAD, and chronic renal failure). On average, 0.8 cardiac tests were ordered per person. In total, 35 (6.7%) had invasive coronary angiograms, with 51.4% having obstructive CAD. Patients reported in surveys (82.8% response rate) that 93.0% "strongly agreed" RAC services were useful to the community. Referrers were also "very satisfied" with RAC (7/17) or "satisfied" (9/17). Furthermore, of 336 referrals, referrers reported without RAC they would admit the patient in 11.3% of cases. There were 4.8% (25/520) unplanned cardiovascular readmissions and 0.6% (3/520) of these were for acute coronary syndromes and no deaths. CONCLUSIONS: Outpatient RAC services are an accepted, effective and safe pathway for management of low-intermediate risk chest pain.

Diastolic function deterioration in type 2 diabetes mellitus: predictive factors over a 3-year follow-up.

Aims: Diastolic dysfunction is frequent in patients with type 2 diabetes mellitus (DM2) and associated with a poor prognosis. This study aimed to describe diastolic function changes over time in DM2 patients and to identify predictive factors of diastolic function deterioration. Methods and results: Diastolic function was assessed by echocardiography according to the EACVI/ASE recommendations at baseline and 3-year follow-up in a prospective cohort of 310 DM2 patients without overt heart disease. Predictors of diastolic function deterioration were identified using logistic regression analysis. During the 3-year follow-up, prevalence of diastolic dysfunction increased from 49% to 67% (P = 0.001). Only 32% of the patients had a normal diastolic function both at baseline and 3 years and 27% of the patients presented diastolic function deterioration. At multivariable analysis, age (OR = 1.05 [1.01-1.09], P < 0.01), retinopathy (OR = 2.00 [1.10-3.63], P = 0.02), and increase in systolic blood pressure during follow-up (OR = 1.03 [1.01-1.04], P < 0.01) were predictive of diastolic function deterioration. Conclusion: Age, retinopathy, and increase in blood pressure over time are associated with an increased risk of diastolic function deterioration in DM2 patients. The presence of these co-factors might help to early identify patients at risk of heart failure.

Left atrial remodelling assessed by 2D and 3D echocardiography identifies paroxysmal atrial fibrillation.

AIMS: Paroxysmal atrial fibrillation (PAF) is common, often silent, and can be difficult to detect. Echocardiographic parameters assessing left atrial (LA) remodelling correlated with atrial fibrosis in permanent AF, but less is known about earlier stages such as PAF. We aimed to evaluate whether 2D and 3D echocardiographic (2DE and 3DE) assessment of LA anatomy and function is able to identify patients with PAF. METHODS AND RESULTS: This case-control study included 102 patients without overt heart disease, 44 patients with PAF. Anatomical remodelling was assessed using indexed maximal, minimal, and pre-atrial contraction volumes. Reservoir, conduit, and pump functions were assessed by volume and strain methods. All parameters were assessed by 2DE and 3DE and were compared between the two groups. Receiver-operating characteristic curves were constructed for each parameter for PAF prediction. PAF patients had bigger LA volumes than non-PAF group. Using 3DE, all atrial functions were impaired in the PAF group, regardless of the parameters used (all P < 0.05), whereas using 2DE, conduit function did not reach significant difference. Areas under the curve (AUCs) for 3D parameters were higher than those for equivalent 2DE parameters. PAF was best predicted by LA minimal indexed volume assessed by 2DE or 3DE (AUC 0.82 and 0.86, respectively) and 3D-LA ejection fraction and area strain (AUC = 0.82 and 0.81, respectively). CONCLUSION: Anatomical and functional LA remodelling assessed by 2DE and 3DE is independently and strongly associated with PAF, suggesting that these parameters can help identify PAF.