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The impact of aging on cardiac function is not fully elucidated. Speckle-tracking echocardiography can unmask subclinical cardiac dysfunction.This study investigated the impact of healthy aging on left ventricular (LV), right ventricular (RV), and left atrial (LA) performance and their relationship with serum B-type natriuretic peptide (BNP) levels in a sample of the general population without prevalent cardiovascular risk factors and structural heart disease.Speckle-tracking echocardiography was performed to assess LV global longitudinal strain (LVGLS), RV free wall strain, and LA phasic strain in 481 normal weight healthy participants who underwent extensive cardiovascular examination. Elevated BNP was defined as BNP37.82 pg/ml for men and50.86 pg/ml for women, which was the 90th percentile of BNP value distribution in the study population.Mean age was 60 ± 12 years (range: 24 to 86 years), and 46% of the participants were men. The earliest alteration of age-related cardiac performance was observed in LA reservoir and conduit strain starting from decade 5, followed by elevated E/e' from decade 6. LVGLS decreased starting from decade 7, whereas there were no significant differences in RV strain, LV ejection fraction, or LV mass index across the decades. In the multivariable linear regression analyses, age was an independent predictor of decreased LVGLS (standardized β = 0.21; p 0.001) and decreased LA phasic strain (standardized β = -0.40 and -0.61 for reservoir and conduit strain; both p 0.001). Age and LA strain were significantly associated with elevated BNP values (adjusted odds ratios: 1.10 and 0.93; both p 0.05, respectively), independent of ventricular morphology and function.Decreases in LA reservoir and conduit strain are the earliest markers of age-related cardiac remodeling, and LA reservoir strain is an independent predictor of elevated serum BNP level, with both possibly being markers of increased risk of heart failure in older adults.

Objectives The purpose of this study was to assess the independent effect of increased body size on left ventricular (LV) diastolic function. Background Obese and overweight persons are at increased risk of heart failure. Left ventricular diastolic dysfunction is an asymptomatic condition associated with future heart failure. It is unclear whether obesity and overweight are independently associated with LV diastolic dysfunction. Methods The LV diastolic function was evaluated in 950 participants from the CABL (Cardiovascular Abnormalities and Brain Lesions) study by traditional and tissue Doppler imaging. Peak early transmitral diastolic flow velocity (E), late transmitral diastolic flow velocity (A), and early diastolic mitral annulus velocity (E′) were measured, and E/A and E/E′ were calculated. The study sample was divided into 3 groups: normal weight (body mass index [BMI] Results In multivariate analyses, BMI was independently associated with higher E, A, and E/E′, an indicator of LV filling pressure (all p ≤ 0.01). Overweight and obese had lower E′ (both p Conclusions Increased BMI was associated with worse LV diastolic function independent of LV mass and associated risk factors. The increased risk of LV diastolic dysfunction in both overweight and obese persons may partially account for the increased risk of heart failure associated with both conditions.

Objectives This study sought to improve global vascular risk prediction with behavioral and anthropometric factors. Background Few cardiovascular risk models are designed to predict the global vascular risk of myocardial infarction, stroke, or vascular death in multiethnic individuals, and existing schemes do not fully include behavioral risk factors. Methods A randomly derived, population-based, prospective cohort of 2,737 community participants free of stroke and coronary artery disease was followed up annually for a median of 9.0 years in the NOMAS (Northern Manhattan Study) (mean age 69 years, 63.2% women, 52.7% Hispanic, 24.9% African American, and 19.9% white). A global vascular risk score (GVRS) predictive of stroke, myocardial infarction, or vascular death was developed by adding variables to the traditional Framingham cardiovascular variables based on the likelihood ratio criteria. Model utility was assessed through receiver-operating characteristics, calibration, and effect on reclassification of subjects. Results Variables that significantly added to the traditional Framingham profile included waist circumference, alcohol consumption, and physical activity. Continuous measures for blood pressure and fasting blood sugar were used instead of hypertension and diabetes. Ten-year event-free probabilities were 0.95 for the first quartile of GVRS, 0.89 for the second quartile, 0.79 for the third quartile, and 0.56 for the fourth quartile. The addition of behavioral factors in our model improved prediction of 10-year event rates compared with a model restricted to the traditional variables. Conclusions A GVRS that combines traditional, behavioral, and anthropometric risk factors; uses continuous variables for physiological parameters; and is applicable to nonwhite subjects could improve primary prevention strategies.

Objective To assess the effect of hypercoagulability on the risk of stroke in patients with aortic plaques.

Objectives We sought to assess the risk of ischemic stroke from a patent foramen ovale (PFO) in the multiethnic prospective cohort of northern Manhattan. Background Patent foramen ovale has been associated with increased risk of ischemic stroke, mainly in case-control studies. The actual PFO-related stroke risk in the general population is unclear. Methods The presence of PFO was assessed at baseline by using transthoracic 2-dimensional echocardiography with contrast injection in 1,100 stroke-free subjects older than 39 years of age (mean age 68.7 +/- 10.0 years) from the Northern Manhattan Study (NOMAS). The presence of atrial septal aneurysm (ASA) also was recorded. Subjects were followed annually for outcomes. We assessed PFO/ASA-related stroke risk after adjusting for established stroke risk factors. Results We detected PFO in 164 subjects (14.9%); ASA was present in 27 subjects (2.5%) and associated with PFO in 19 subjects. During a mean follow-up of 79.7 +/- 28.0 months, an ischemic stroke occurred in 68 subjects (6.2%). After adjustment for demographics and risk factors, PFO was not found to be significantly associated with stroke (hazard ratio 1.64, 95% confidence interval [CI] 0.87 to 3.09). The same trend was observed in all age, gender, and race-ethnic subgroups. The coexistence of PFO and ASA did not increase the stroke risk (adjusted hazard ratio 1.25, 95% CI 0.17 to 9.24). Isolated ASA was associated with elevated stroke incidence (2 of 8, or 25%; adjusted hazard ratio 3.66, 95% CI 0.88 to 15.30). Conclusions Patent foramen ovale, alone or together with ASA, was not associated with an increased stroke risk in this multiethnic cohort. The independent role of ASA needs further assessment in appositely designed and powered studies.

ObjectivesThis study sought to determine the effect of lipoprotein(a), or Lp(a), levels and apolipoprotein(a), or apo(a), sizes on endothelial function and to explore ethnic differences in their effects.BackgroundAlthough high levels of Lp(a) have been shown to confer increased cardiovascular risk in Caucasians, its significance in non-Caucasian populations is uncertain. The pathogenic role of the apo(a) component of Lp(a) is also unclear.MethodsThe relationship of Lp(a) levels and apo(a) sizes to endothelial function was examined in a multiethnic cohort of 89 healthy subjects (age 42 ± 9 years; 50 men, 39 women) free of other cardiac risk factors. Endothelium-dependent, flow-mediated dilation (FMD) and endothelium-independent, nitrate-induced dilation (NTG) were assessed by ultrasound imaging of the brachial artery.ResultsPlasma Lp(a) levels were lowest in Caucasians (18.3 ± 21.1 mg/dl, n = 40); intermediate in Hispanics (30.2 ± 30.5 mg/dl, n = 21); and highest in African Americans (68.8 ± 46.0 mg/dl, n = 28). Lipoprotein(a) levels were found to correlate inversely to FMD (r = −0.33, p < 0.005) but not to NTG (r = 0.06, p = 0.60). This association remained significant after adjusting for gender (p = 0.002). In addition, subjects with small apo(a) size of ≤22 kringle 4 repeats had significantly lower FMD than those with large apo(a) (2.23 ± 2.37% vs. 6.26 ± 4.29%, p < 0.0001), irrespective of Lp(a) levels.ConclusionsThese findings support an independent role of Lp(a) in atherogenesis, an effect that is particularly evident in African Americans. The proatherogenic property of Lp(a) can be attributed in part to its apo(a) component.

OBJECTIVES The purpose of the study was to assess the mechanism responsible for increased stroke risk in patients with atrial septal aneurysm (SA) and patent foramen ovale (PFO), and to determine the efficacy of medical therapy for preventing stroke recurrence or death. BACKGROUND Atrial septal aneurysm and PFO are associated with stroke. However, the mechanism for this association is undefined, and the efficacy of medical therapy has not been investigated in a randomized fashion. METHODS The Patent foramen ovale In Cryptogenic Stroke Study (PICSS) evaluated transesophageal echocardiography findings in patients enrolled in the Warfarin-Aspirin Recurrent Stroke Study, a randomized double-blind trial to evaluate the efficacy of warfarin compared with aspirin. RESULTS Large PFO and prominent eustachian valve (EV) or right atrial (RA) filamentous strands were found more frequently in patients with SA compared with those without SA (37.7% vs. 10.9%, p < 0.001 and 59.4% vs. 43.1%, p = 0.02). Patients with SA and PFO had no significant difference in time to recurrent stroke or death compared with those having neither (hazard ratio [HR] 1.08, 95% confidence interval [CI] 0.49 to 2.38, p = 0.84; two-year event rates 15.9% vs. 14.5%). Patients with SA, PFO, and RA anatomy predisposing to paradoxical embolization also had no difference compared with those without these findings (HR 1.22, 95% CI 0.43 to 3.47, p = 0.71; two-year event rates 18.2% vs. 14.2%). There was no significant difference in time to recurrent stroke or death between the patients treated with warfarin or aspirin (HR 1.00, 95% CI 0.22 to 4.47, p = 1.0; two-year event rates 16.0% vs. 15.8%). CONCLUSIONS Atrial septal aneurysm is associated with the presence of large PFO and prominent EV or RA filamentous strands. On medical therapy, patients with SA and PFO did not experience increased risk of adverse events, and there was no difference between treatment results for warfarin and for aspirin.

Objectives The goal of this study was to determine whether the risk of ischemic stroke associated with increased left ventricular mass (LVM) is modified by physical activity (PA). Background Increased LVM is associated with an increased risk for stroke. Physical activity can decrease the risk of stroke and may have variable effects on LVM. Methods We used a case-control study design in a multiethnic population in northern Manhattan, New York, to study 394 case subjects who had a first ischemic stroke and 413 stroke-free control subjects. All subjects were interviewed and two-dimensional echocardiograms obtained to determine LVM. Results A sharp increase in risk of ischemic stroke was seen in the highest quartile of LVM (odds ratio [OR]: 6.14 [95% confidence interval {CI}: 3.04 to 12.38]). Thus, increased LVM was defined by the highest quartile of LVM. In multivariate analysis, the effect of increased LVM on the risk of stroke was significantly decreased by the presence of any level of PA versus no PA (OR: 1.59 [95% CI: 0.99 to 2.57] p Conclusions Increased LVM is associated with an increased risk of stroke, especially among sedentary patients. Physical activity decreases the risk of stroke among patients with increased LVM to a level comparable to that of patients without increased LVM. Recommending PA may be a nonpharmacologic tool to reduce the stroke risk, especially among patients with increased LVM.

In this issue of the Journal , Lee et al. ([1][1]) report findings from 1,367 consecutive cases of coronary artery bypass grafting (CABG) performed between 2004 and 2007 at the Asan Medical Center in Seoul, South Korea, all of whom underwent pre-operative magnetic resonance angiography (MRA) of the

To the Editor: Left ventricular (LV) hypertrophy is a risk factor for cardiovascular disease ([1–3][1]) and ischemic stroke ([4–6][2]). Current data suggest that genetic factors and traditional cardiovascular risk factors contribute to left ventricular mass (LVM) and LV hypertrophy. Several

Objectives The purpose of this study was to evaluate the relationship between patent foramen ovale (PFO), ischemic stroke, and subclinical cerebrovascular disease in the general population. Background PFO is found more frequently in stroke patients than in stroke-free controls. However, the PFO-related stroke risk in the general population is not well established, and the relationship between PFO and silent brain infarcts (SBI) is not known. Methods PFO presence was assessed by transthoracic echocardiography with saline contrast injection in 1,100 stroke-free individuals over age 39 of a community-based sample followed for a mean of 11 years. In addition, 360 participants underwent brain magnetic resonance imaging (MRI) for SBI detection. We evaluated the risk of stroke associated with PFO after adjusting for established stroke risk factors and examined the odds of having SBI among those with and without PFO. Results PFO was present in 164 participants (14.9%). Over a mean follow-up of 11.0 ± 4.5 years, 111 ischemic strokes occurred (10.1%), 15 (9.2%) in the PFO+ and 96 (10.3%) in the PFO− groups. The 12.5-year cumulative risk of stroke was 10.1% (standard error: 2.5%) in the PFO+ and 10.4% (standard error: 1.1%) in the PFO− group (p = 0.46). The adjusted hazard ratio for PFO and stroke was 1.10 (95% confidence interval [CI]: 0.64 to 1.91). In the MRI subcohort, PFO was not associated with SBI (adjusted odds ratio: 1.15, 95% CI: 0.50 to 2.62). Conclusions In this community-based cohort, PFO was not associated with an increased risk of clinical stroke or subclinical cerebrovascular disease.

Left ventricular diastolic dysfunction (LVDD) is frequent in the elderly, and is an independent predictor of mortality, cardiovascular events, and heart failure development. Ambulatory blood pressure (ABP) is a better predictor of target organ damage and cardiovascular events than office BP. We

The CHA2DS2-Vasc score was developed to predict stroke and other adverse clinical events in patients with atrial fibrillation. There is also interest in assessing its performance in patients with systolic heart failure (HF) in sinus rhythm, such as those enrolled in the WARCEF trial. CHA2DS2-Vasc

Objectives . This study attempted to document the incidence of pulmonary vein complications and their potential relation to clinical outcome in patients after lung transplantation. Background . Several case reports have documented the presence of pulmonary venous thrombosis causing graft failure in patients after lung transplantation. Because the presentation of these complications mimics that of other postoperative problems, the true incidence of pulmonary vein abnormalities remains unclear. Transesophageal echocardiography is ideally suited to examine the pulmonary veins in the postoperative setting. Methods . Twenty-one consecutive patients undergoing lung transplantation at our institution underwent transesophageal echocardiography within 32 days of transplantation (mean [± SD] 6.5 ± 7.8 days). Special attention was placed on visualizing the pulmonary veins. Results . Six (29%) of the 21 patients were noted to have abnormalities of the pulmonary veins in the vicinity of the anastomotic site. After follow-up of 30 days, 4 of these patients (67%) had significant cardiovascular morbidity, and 2 died, compared with 1 (7%) of 15 patients with normal pulmonary veins (p = 0.03). The degree of obstruction of the pulmonary vein appeared to correlate with short-term outcome. Conclusions . Abnormalities of the pulmonary veins are common after lung transplantation and are easily identified by transesophageal echocardiography. Occlusive thrombi appear to be detrimental to short-term outcome.

The purpose of this study was to assess the independent effect of increased body size on left ventricular (LV) diastolic function.Obese and overweight persons are at increased risk of heart failure. Left ventricular diastolic dysfunction is an asymptomatic condition associated with future heart failure. It is unclear whether obesity and overweight are independently associated with LV diastolic dysfunction.The LV diastolic function was evaluated in 950 participants from the CABL (Cardiovascular Abnormalities and Brain Lesions) study by traditional and tissue Doppler imaging. Peak early transmitral diastolic flow velocity (E), late transmitral diastolic flow velocity (A), and early diastolic mitral annulus velocity (E') were measured, and E/A and E/E' were calculated. The study sample was divided into 3 groups: normal weight (body mass index [BMI]25.0 kg/m(2)), overweight (BMI 25.0 to 29.9 kg/m(2)), and obese (BMI ≥30 kg/m(2)).In multivariate analyses, BMI was independently associated with higher E, A, and E/E', an indicator of LV filling pressure (all p ≤ 0.01). Overweight and obese had lower E' (both p0.01) and higher E/E' (both p0.01) than normal weight participants. The E/A was lower in obese subjects than in normal weight subjects (p0.01). The risk of diastolic dysfunction was significantly higher in overweight subjects (adjusted odds ratio: 1.52, 95% confidence interval: 1.04 to 2.22) and obese subjects (adjusted odds ratio: 1.60, 95% confidence interval: 1.06 to 2.41) compared to normal weight subjects.Increased BMI was associated with worse LV diastolic function independent of LV mass and associated risk factors. The increased risk of LV diastolic dysfunction in both overweight and obese persons may partially account for the increased risk of heart failure associated with both conditions.

This study sought to improve global vascular risk prediction with behavioral and anthropometric factors.Few cardiovascular risk models are designed to predict the global vascular risk of myocardial infarction, stroke, or vascular death in multiethnic individuals, and existing schemes do not fully include behavioral risk factors.A randomly derived, population-based, prospective cohort of 2,737 community participants free of stroke and coronary artery disease was followed up annually for a median of 9.0 years in the NOMAS (Northern Manhattan Study) (mean age 69 years, 63.2% women, 52.7% Hispanic, 24.9% African American, and 19.9% white). A global vascular risk score (GVRS) predictive of stroke, myocardial infarction, or vascular death was developed by adding variables to the traditional Framingham cardiovascular variables based on the likelihood ratio criteria. Model utility was assessed through receiver-operating characteristics, calibration, and effect on reclassification of subjects.Variables that significantly added to the traditional Framingham profile included waist circumference, alcohol consumption, and physical activity. Continuous measures for blood pressure and fasting blood sugar were used instead of hypertension and diabetes. Ten-year event-free probabilities were 0.95 for the first quartile of GVRS, 0.89 for the second quartile, 0.79 for the third quartile, and 0.56 for the fourth quartile. The addition of behavioral factors in our model improved prediction of 10-year event rates compared with a model restricted to the traditional variables.A GVRS that combines traditional, behavioral, and anthropometric risk factors; uses continuous variables for physiological parameters; and is applicable to nonwhite subjects could improve primary prevention strategies.

Our goal was to assess the effect of hypercoagulability on the risk of stroke in patients with aortic plaques.Atherosclerotic plaques in the aortic arch are a risk factor for ischemic stroke. Their relationship with blood hypercoagulability, which might enhance their embolic potential and affect treatment and prevention, is not known.We performed transesophageal echocardiography in 255 patients with first acute ischemic stroke and in 209 control subjects matched by age, gender, and race/ethnicity. The association between arch plaques and hypercoagulability, and its effect on the stroke risk, was assessed with a case-control design. Stroke patients were then followed prospectively to assess recurrent stroke and death.Large (or =4 mm) arch plaques were associated with increased stroke risk (adjusted odds ratio [OR]: 2.4, 95% confidence interval [CI]: 1.3 to 4.6), especially when ulcerations or superimposed thrombus were present (adjusted OR: 3.3, 95% CI: 1.4 to 8.2). Prothrombin fragment F 1.2, an indicator of thrombin generation, was associated with large plaques in stroke patients (p = 0.02), but not in control subjects. Over a mean follow-up of 55.1 +/- 37.2 months, stroke patients with large plaques and F 1.2 over the median value had a significantly higher risk of recurrent stroke and death than those with large plaques but lower F 1.2 levels (230 events per 1,000 person-years vs. 85 events per 1,000 person-years; p = 0.05).In patients presenting with acute ischemic stroke, large aortic plaques are associated with blood hypercoagulability, suggesting a role for coagulation activation in the stroke mechanism. Coexistence of large aortic plaques and blood hypercoagulability is associated with an increased risk of recurrent stroke and death.

In this issue of the Journal , Gaita et al. [(1)][1] report findings from 270 patients, of whom 180 had atrial fibrillation and 90 with similar demographic and clinical characteristics did not have atrial fibrillation. All were free of clinical stroke at the time of the study, and all underwent

The goal of this study was to determine whether the risk of ischemic stroke associated with increased left ventricular mass (LVM) is modified by physical activity (PA).Increased LVM is associated with an increased risk for stroke. Physical activity can decrease the risk of stroke and may have variable effects on LVM.We used a case-control study design in a multiethnic population in northern Manhattan, New York, to study 394 case subjects who had a first ischemic stroke and 413 stroke-free control subjects. All subjects were interviewed and two-dimensional echocardiograms obtained to determine LVM.A sharp increase in risk of ischemic stroke was seen in the highest quartile of LVM (odds ratio [OR]: 6.14 [95% confidence interval [CI]: 3.04 to 12.38]). Thus, increased LVM was defined by the highest quartile of LVM. In multivariate analysis, the effect of increased LVM on the risk of stroke was significantly decreased by the presence of any level of PA versus no PA (OR: 1.59 [95% CI: 0.99 to 2.57] p0.07 vs. 3.53 [95% CI: 1.94 to 6.42] p0.0001). Although PA decreased the risk of stroke in all patients, the effect was stronger in subjects with increased LVM than among those without increased LVM (p = 0.033).Increased LVM is associated with an increased risk of stroke, especially among sedentary patients. Physical activity decreases the risk of stroke among patients with increased LVM to a level comparable to that of patients without increased LVM. Recommending PA may be a nonpharmacologic tool to reduce the stroke risk, especially among patients with increased LVM.

Atrial fibrillation is the most common significant arrhythmia in the general population, with an estimated prevalence of 3% to 4%, which increases to almost 9% after the age of 80 years ([1][1]). Atrial fibrillation increases the risk for death by almost 2-fold and the risk for ischemic stroke by

Heart failure (HF) patients have a high incidence of new-onset atrial fibrillation (AF). Because of the adverse prognostic influence of AF in HF, the identification of patients at high risk of developing AF, while they are still sinus rhythm, may be of great clinical value. The incidence of and

In the U.S., 660,000 new cases of heart failure (HF) are diagnosed each year ([1][1]), a figure that has been steadily increasing. The number of prevalent HF cases is currently estimated at more than 5 million, and 1 in 5 men or women at age 40 years will have HF during their lifetime ([1][1]).

Non-invasive detection of rejection is a major objective in the management of heart transplant recipients. We investigated the utility of 2-dimensional speckle-tracking echocardiography (2D-STE) for detecting allograft rejection. We retrospectively evaluated 170 endomyocardial biopsy specimens from

Objectives. The purpose of this study was to investigate left atrial appendage size, function and thrombus prevalence in patients with atrial “fibrillation-flutter.” Background. Thrombus formation and peripheral embolization in atrial fibrillation are related to left atrial appendage dysfunction. Embolization occurs less frequently in atrial flutter. It is not known whether the atrial appendage in fibrillation-flutter, which has an intermediate appearance on the surface electrocardiogram (ECG), has distinct characteristics that could affect thrombus formation. Methods. Sixty-one patients with atrial tachyarrhythmias underwent transesophageal echocardiographic examination of the left atrial appendage. Appendage area, peak emptying velocity and the presence of thrombus and spontaneous echo contrast were determined. The results for 14 patients with fibrillation-flutter (based on ECG fibrillatory wave characteristics) were compared with those for 30 patients with atrial fibrillation and 17 patients with atrial flutter. Results. Both fibrillation-flutter and atrial fibrillation were associated with chaotic appendage flow patterns with similarly low peak emptying velocities (18 ± 8 and 17 ± 10 cm/s, mean ± 1 SD, respectively). Atrial flutter was associated with a regular pattern of appendage contraction and a significantly higher peak emptying velocity (42 ± 18 cm/s, p < 0.0001). Mean appendage area was similar for fibrillation-flutter and fibrillation (6.3 ± 2.2 and 6.7 ± 2.1 cm2, respectively) but was significantly smaller for atrial flutter (5.3 ± 1.4 cm2, p < 0.05). The prevalence of left atrial appendage thrombus was similar for fibrillation-flutter and atrial fibrillation (40% and 29%, respctivdy), whereas no patient with atrial flutter had a thrombus (p < 0.05). Similarly, the presence of spontaneous echo contrast was higher for fibrillationflutter (50%) and atrial fibrillation (40%) than for atrial flutter (6%, p < 0.05). Conclusions. Left atrial appendage size and function in atrial fibrillation-flutter are indistinguishable from those of typical atrial fibrillation, and the frequency of thrombus and spontaneous echo contrast is similarly high. This is in contrast to atrial flutter, which is characterized by a smaller, more contractile left atrial appendage and a lower frequency of thrombus and spontaneous echo contrast.

Reduced left atrial (LA) function is associated with cardiovascular events including stroke. Silent brain infarct (SBI) is considered to be a precursor of symptomatic stroke, and has an overall prevalence ranging from 8% to 35% in the general elderly population. It is not known whether LA