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Echocardiographic findings in chronic kidney disease (CKD) vary. We sought to estimate the prevalence of abnormal cardiac structure and function in patients with CKD and their association to estimated glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (UACR).We prospectively enrolled 825 outpatients with non-dialysis-dependent CKD, mean age 58± 13 yrs, and 175 matched healthy controls, mean age 60±12 yrs. Echocardiography included assessment of left ventricular (LV) hypertrophy, LV ejection fraction (LVEF), global longitudinal strain (GLS) and diastolic dysfunction according to ASE/EACVI guidelines.LV hypertrophy was found in 9% of patients vs. 1.7% of controls (p=0.005) was independently associated with UACR (p=0.002). Median LVEF was 59.4% (IQR 55.2, 62.8) in patients vs. 60.8% (57.7, 64.1) in controls (p=0.002). GLS was decreased in patients with eGFR60ml/min/1.73m² (-17.6%±3.1%) vs. patients with higher eGFR (19.0%±2.2%, p0.001), who were similar to controls. Diastolic dysfunction was detected in 55% of patients and in 34% of controls.Non-random sampling, cross-sectional analysis.We report lower prevalence of hypertrophy than previous studies, but similar measurements of systolic and diastolic function. Cardiac remodeling in CKD may be influenced by treatment modalities, demographics, comorbidities and renal pathology.

Aims A pattern of reduced basal longitudinal strain (BLS) is often observed with left ventricular (LV) hypertrophy (LVH). Whether this pattern is associated with poor outcome is unclear. We aimed to evaluate the prognostic value of regional longitudinal strain according to LV geometry. Methods and results We investigated participants in the 4th Copenhagen City Heart Study who had an echocardiogram with speckle tracking performed. Participants were stratified according to the presence of LVH (LV mass index ≥116 g/m2 for men and ≥96 g/m2 for women). The outcome was major adverse cardiovascular events (MACE) defined as a composite of myocardial infarction, heart failure, and/or cardiovascular death. The study population consisted of 1090 participants. Mean LVEF was 60% and 160 (15%) had LVH. During a median follow-up of 14.7 years, there were 137 events. Both BLS and midventricular strain, but not apical strain, became incrementally impaired in the spectrum from normal to hypertensives subjects without LVH, and to participants with hypertension and LVH. After multivariable adjustment, BLS and midventricular strain were independently associated with MACE in participants with LVH (BLS: HR 1.08, 95% CI 1.00–1.17, P = 0.041; midventricular strain: HR 1.10, 95% CI 1.00–1.21, P = 0.041) but not in participants without LVH (BLS: HR 0.96, 95% CI 0.90–1.01, P = 0.13; midventricular strain: HR 0.97, 95% CI 0.91–1.03, P = 0.36). Conclusion BLS and midventricular strain, but not apical strain, become incrementally impaired in the spectrum from normal geometry to LVH, and are independently associated with MACE in participants with LVH.

Aims Left ventricular (LV) systolic deformation is altered early in the ventricular disease process despite normal LV ejection fraction (LVEF). These alterations seem to be characterized by decreased global longitudinal strain (GLS) and augmented global circumferential strain (GCS). This study aimed to investigate the link between myocardial deformation phenotyping using longitudinal and circumferential strain and risk of incident heart failure (HF) and cardiovascular death (CD). Methods and results The study sample was based on the prospective cohort study the 5th Copenhagen City Heart Study (2011–15). All participants were examined with echocardiography following a pre-defined protocol. A total of 2874 participants were included. Mean age was 53±18 years and 60% were female. During a median follow-up of 3.5 years, a total of 73 developed HF/CD. A U-shaped relationship between GCS and HF/CD was observed. LVEF significantly modified the association between GCS and HF/CD (P for interaction Conclusions The prognostic utility of GCS is modified by LVEF. In participants with normal LVEF, higher GCS was associated with increased risk of HF/CD, while the opposite was observed in participants with abnormal LVEF. This observation adds important information to our understanding of the pathophysiological evolution of myocardial deformation in cardiac disease progression.

Cardiovascular disease is the leading cause of mortality amongst patients with chronic kidney disease (CKD). This is the first study using 3-dimensional echocardiography (3DE) to investigate associations between adverse changes of the left ventricle, and different stages of CKD. Participants were recruited from the Copenhagen CKD cohort study and the Herlev-Gentofte CKD cohort study. Patients were stratified according to GFR category (G1 + 2: eGFR ≥ 60 mL/min/1.73 m

Background The ratio of early mitral inflow velocity to early diastolic strain rate (E/e'sr) is a novel echocardiographic measure to estimate early left ventricular (LV) filling pressure. We hypothesize that E/e'sr is a predictor of outcome following coronary artery bypass grafting (CABG) and that it is superior to the conventionally used E/e'. Methods & results Consecutive patients undergoing isolated CABG at Gentofte Hospital (n = 652) were included. The mean age of the study population was 67 ± 9 years, 84% were male, mean LVEF was 50 ± 11%. Prior to surgery, all patients underwent an extensive echocardiographic examination. The outcome was all-cause mortality. During follow-up (median 3.8 years [IQR: 2.7; 4.9 years]), a total of 73 (11.2%) died. Both E/e' and E/e'sr were significant predictors in univariable models. In a multivariable model, E/e'sr remained an independent predictor of outcome (HR:1.05 [1.01–1.10], p = 0.049, per 10 cm increase) whereas E/e' did not (HR:1.05 [0.99–1.11], p = 0.053, per 1-unit increase). The relationship between E/e'sr, and the outcome was significantly modified by GLS (p for interaction = 0.043). In the multivariable model, E/e'sr was still significantly associated with the outcome in patients with high GLS (≥13.6%) (HR:1.18 [1.02–1.36], p = 0.029) but not in patients with low GLS (HR 1.04 CI95%: [0.99–1.10], p = 0.14). E/e' was not a significant predictor of all-cause mortality after multivariable adjustment in neither of the groups. E/e'sr improved net reclassification with 33% when added to EuroSCOREII. Conclusion Following CABG, preoperative E/e'sr is an independent predictor of all-cause mortality, especially in patients with preserved systolic function and superior to E/e'.

Country- and ethnicity-specific reference values for echocardiographic parameters are necessary for decision making. No prior studies have examined reference values in adults from the Amazon Basin of Brazil. We performed echocardiographic examinations in 290 healthy adults (mean age 37 ± 14 years, 40% male) from the Brazilian Amazon. Left ventricular (LV) dimensions and volumes were obtained and indexed to body surface area. We also assessed systolic (LV ejection fraction [LVEF] and global longitudinal strain [GLS]) and diastolic function. LV dimensions and volumes were larger in males compared to females, but after indexation only volumes remained larger (P

Aims Left atrial (LA) fibrosis is a hallmark of atrial cardiomyopathy, and non-invasive surrogate measures of LA fibrosis are therefore needed. We investigated the association between four-dimensional (4D) echocardiographic LA measures and LA fibrosis. Methods and results A multimodality imaging substudy was performed in a randomized clinical trial (LOOP study), recruiting elderly participants with cardiovascular risk factors. LA late gadolinium enhancement (LGE) by cardiac magnetic resonance imaging was used as a surrogate for LA fibrosis. 4D echocardiographic LA quantification was used to measure maximal and minimal LA volume (LAVmax and LAVmin, respectively), LA emptying fractions (LAEFtotal), and strain. Logistic regression was used to relate LA measures to high LA LGE (≥17 cm2). Of the 44 participants (mean age 76 years, 64% men, median LA LGE 13.1 cm2), 14 exhibited high LA LGE. These participants exhibited abnormalities in several LA functional measures but not LAVmax. In linear regressions, only increasing LAVmin, and decreasing LAEFtotal, and reservoir strain were associated with increasing LA LGE. Furthermore, increasing LAVmin was associated with a higher likelihood of high LA LGE [odds ratio (OR) = 1.19 (1.04–1.37)]. Decreasing LAEFtotal and reservoir strain were also associated with higher likelihood of LA LGE [OR = 1.18 (1.05–1.33)] and OR = 1.15 (1.02–1.30), per 1% decrease in LAEFtotal and reservoir strain, respectively]. These findings were consistent after multivariable adjustments. LAEFtotal provided the highest performance for detecting high LA LGE (area under the curve of 0.78). Conclusion LAVmin, LAEFtotal, and reservoir strain measured by 4D echocardiography are significantly associated with LA LGE. LAEFtotal provides the best performance for detecting high LA LGE.

Global longitudinal strain (GLS) has proven to be a powerful prognostic marker in various patient populations, but the prognostic value of layer-specific GLS has not yet been investigated in patients with suspected stable angina pectoris (SAP). We sought to investigate the prognostic value of layer-specific and whole wall GLS in patients with suspected SAP. From September 2008 to March 2011, 296 consecutive patients with clinically suspected SAP, normal ejection fraction, and no previous cardiac history were enrolled in a prospective cohort study. Patients underwent echocardiography including two-dimensional speckle tracking at rest, exercise stress test, and coronary angiography. The end-point was a composite of incident heart failure, acute myocardial infarction, and cardiovascular death (MACE). Out of the 285 included patients (mean age 61 years, 50% male), 24 (8%) developed MACE during a median follow-up of 3.5 years. Both endocardial [hazard ratio (HR) 1.21, 95% CI 1.08–1.35, p = 0.001], epicardial (HR 1.29, 95% CI 1.12–1.50, p = 0.001) and whole wall GLS (HR 1.25, 1.10–1.42, p = 0.001) were significantly associated with an increased risk of developing MACE during follow-up in univariable Cox regression analysis. In multivariable analysis, only epicardial (HR 1.23, 95% CI 1.00–1.51, p = 0.046) and whole wall GLS (HR 1.20, 95% CI 1.00–1.43, p = 0.049) remained significantly associated with an increased risk of MACE independent of various baseline clinical variables, left ventricular ejection fraction (LVEF), E/eʹ and Duke Score. Layer-specific and whole wall GLS were significant predictors of MACE in this cohort of patients with suspected SAP independent of various baseline clinical variables, LVEF, E/eʹ and Duke Score.

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Background Assessment of maximal LA volume (LAVmax) is recommended in imaging guidelines but evidence suggests additional value of functional LA measures. How extended measures of LA function associate to left ventricular filling pressure has not been fully explored. Purpose To investigate the association between functional LA measures and left ventricular end-diastolic pressure (LVEDP) Methods Patients suspected of coronary artery disease referred for angiography had simultaneous left heart catheterization performed for invasive pressure measurements. LVEDP > 12mmHg was considered elevated. LA measurements by echocardiography included: LAVmax, minimal LA volume (LAVmin), total LA emptying fraction (total LAEF), passive LA emptying fraction (passive LAEF), and active LA emptying fraction (active LAEF). Results Of 43 patients, 28 (65%) had elevated LVEDP. These patients more frequently had coronary vessel disease (VD) and impaired LA mechanics by all accounts except by LAVmax. All LA measures except LAVmax were associated with LVEDP in unadjusted linear regression analyses, however, only LA emptying fractions remained associated with LVEDP after adjusting for age and VD (2.6 (1.2-4.0) mmHg increase, p = 0.001, per 5% decrease in total LAEF; 1.4 (0.1-2.8) mmHg increase, p = 0.040, per 5% decrease in active LAEF; 1.8 (0.1-3.4) mmHg increase, p = 0.038, per 5% decrease in passive LAEF). In logistic regression, passive LAEF was significantly associated with elevated LVEDP (figure), and this was also the case after adjusting for age and VD (OR = 1.11 (1.01-1.21), p = 0.023, per 1% decrease). Similar findings were made in subgroup analyses among patients without dilated LA and patients without conventional indicators of elevated filling pressure. Conclusion Left ventricular end-diastolic pressure is significantly associated with LA functional measures but not LA volumes. Additionally, passive LAEF is associated with elevated LVEDP. Future studies examining LA function should include all components of LAEF. Abstract Figure.

The aim of this study was to evaluate layer-specific global longitudinal strain (GLS), obtained by speckle tracking, in predicting outcomes following ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). Echocardiography, including layer-specific GLS, was performed at median two days after the STEMI in a prospective study of STEMI patients treated with pPCI between September 2006 and December 2008. The outcome was the composite of heart failure hospitalization and/or cardiovascular death (HF/CVD). A total of 349 patients were included. Mean age was 62.2 ± 11.5 years, 76% were male, and mean ejection fraction (LVEF) was 46 ± 9. Seventy-seven (22%) patients developed HF/CVD during median follow-up 5.4 years. Patients with HF/CVD had lower absolute values for all GLS-layers: endocardial (GLSEndo) 11.4%vs 14.5% (p

To explore the association between E-wave propagation index (EPI) as a marker of apical washout and the risk of left ventricular thrombus (LVT) formation in patients with ST-elevation myocardial infarction (STEMI).We performed a post-hoc analysis on 364 prospectively enrolled STEMI patients from a single-center. Non-contrast transthoracic echocardiographic examinations were performed a median of 2 days (IQR:1-3 days) after PCI. The endpoint was LVT formation, identified retrospectively. Univariable and multivariable logistic regression was applied to assess the association between EPI and LVT formation. Multivariable adjustments included LVEF, LAD culprit, prior myocardial infarction, heart rate, and early myocardial relaxation velocity. Area under receiver operating characteristic curves (AUC) was used to assess the diagnostic ability.Among 364 patients, 31 (8.5%) developed LVT. The mean age was 62 years, 75% were men, and mean LVEF was 46%. Patients developing LVT had increased heart rate, lower LVEF, impaired GLS, and more frequently had prior myocardial infarction. Variables associated with low values of EPI included, among others, LVEF, LV aneurysm, and GLS. EPI and LVT formation were significantly associated in the univariable model (OR = 1.87 (1.53-2.28), p 0.001), and EPI showed an AUC of 0.90. After multivariable adjustments, EPI and LVT formation remained significantly associated (OR = 1.79 (1.42-2.27), p 0.001). Patients with an EPI 1.0 had a 23 times higher likelihood of LVT formation (OR = 23.41 (10.06-54.49), p 0.001). EPI and LVT formation are strongly associated in patients with STEMI, with low values of EPI indicating a markedly increased probability of LVT formation.

Aims Technical advancements in 2D-speckle tracking echocardiography (2DSTE) have allowed for quantification of layer-specific global longitudinal strain (GLS) and circumferential strain (GCS) of the left ventricle (LV). The aim of this study was to establish age- and sex-based reference ranges of peak systolic layer-specific GLS and GCS and to assess normal values of regional strain. Methods and results We performed 2DSTE analysis of 1997 members of the general population from the fifth round of the Copenhagen City Heart Study, who were free of cardiovascular disease and risk factors. The mean age was 46 ± 16 years (range 21–97) and 62% were female. Mean values for peak systolic whole wall GLS (GLSWW.Sys), endomycardial (GLSEndo.Sys), and epimyocardial (GLSEpi.Sys) were 19.9 ± 2.1% (prediction interval [PI]: 15.8–24.0%), 23.5 ± 2.5% (PI: 18.6–28.4%), and 17.3 ± 1.9% (PI: 13.6–21.1%), respectively. Mean peak systolic whole wall GCS (GCSWW.Sys), was 21.6 ± 3.7% (PI: 14.3–28.9%), endomyocardial (GCSEndo.Sys) was 31.9 ± 4.7% (PI: 22.7–41.1%), and epimyocardial (GCSEpi.Sys) was 14.3 ± 3.8% (PI: 6.8–21.8%). A significant discrepancy in normal strain values between males and females was observed. Men had lower mean values and lower reference limits for all strain parameters. Furthermore, GLS and GCS changed differently with age in males and females. Finally, regional LS decreased from the apical to the basal LV region in both sexes, and regional CS varied significantly by LV segment. Conclusion In this study, we reported age- and sex-based reference ranges of layer-specific GLS and GCS. These reference ranges varied significantly with sex and age.

ObjectiveTo determine the prognostic value of global longitudinal strain (GLS) after coronary artery bypass grafting (CABG).MethodsWe performed a retrospective cohort study on patients undergoing CABG between 2006 and 2011 who had an echocardiogram available for strain analysis. The patients were followed up through nationwide registries for development of all-cause mortality, cardiovascular death (CVD) and major adverse cardiovascular events (MACEs) defined as heart failure hospitalisation and/or CVD. Multivariable Cox regression was applied to adjust for the European System for Cardiac Operative Risk Evaluation II (EuroSCORE-II). Additive value was assessed by Net Reclassification Index (NRI) improvement.ResultsOf the 709 patients included, 80 died during a median follow-up of 3.8 years. Of these, 45 had CVD, and 72 patients experienced MACE. Mean age was 68 years and 85% were men. Left ventricular ejection fraction (LVEF) was 50% and GLS was −13%.GLS was an independent predictor when adjusted for the EuroSCORE-II (all-cause mortality: HR=1.07 (1.01–1.13), p=0.018; CVD: HR=1.11 (1.03–1.20), p=0.007; MACE: HR=1.12 (1.06–1.19), pLVEF modified the association between GLS and outcomes (p for interactionConclusionGLS is an independent predictor of long-term outcomes after CABG. The predictive value appears strongest among patients with preserved LVEF.

We hypothesized that adults with uncomplicated malaria have lower left ventricular contractile function compared to the general population and that this improves after antimalarial treatment. We examined uncomplicated malaria and the general population from the Western part of the Brazilian Amazon Basin. All persons underwent an echocardiographic examination and peripheral blood smears. Left ventricular function was assessed by speckle tracking analysis of global longitudinal strain (GLS). Logistic regression models were used to assess the association between malaria status (yes/no) and GLS and improvement in GLS by follow-up was assessed using a paired T-test. We enrolled 99 adults with uncomplicated malaria (mean age 40 years, 46% female) of whom 75 had Plasmodium vivax, 22 Plasmodium falciparum and two had both species [median 1595 (528 to 6585) parasites/mm

Four-dimensional (4D) echocardiography may provide more accurate estimations of left atrial (LA) volumes than 2-dimensional (2D) measures. We sought to compare the concordance of a novel 4D LA quantification software versus 2D echocardiography against cardiac magnetic resonance (CMR). This was a multimodality imaging substudy of a randomized clinical trial (the LOOP study). Elderly participants with stroke risk factors were included. A subgroup of this study population underwent transthoracic echocardiography (n = 1441) and a subset underwent CMR within two weeks (n = 73). The mean age of the echocardiographic study population was 74 years and 54% were men. The maximal LA volume (LAVmax) was 47 mL by 2D, 52 mL by 4D, and 104 mL by CMR. While 2D echocardiography showed a moderate correlation with 4D (R2 = 0.51) it yielded significantly lower values for LAVmax with a mean difference of 4.5 ± 11.9 mL, p

Background: Pressure-strain loop analyses is a noninvasive technique capable of evaluating myocardial work. Reference values are needed to benchmark these myocardial work indices for clinical practice. Methods: Healthy participants from a general population study were used to establish reference values for global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) measured by pressure-strain loop analyses. The relation to age and sex was examined. We furthermore examined the proportion of abnormal work indices according to low, intermediate, and high cardiovascular risk by the Framingham risk score. Results: The healthy sample consisted of 1827 participants (median age, 45 years; 39% men). Lower reference values were GWI, 1576 mm Hg%; GCW, 1708 mm Hg%; and GWE, 93.0% and upper reference value for GWW was 159 mm Hg%. Women exhibited significantly higher GWI, GCW, and GWW and lower GWE. Sex significantly modified the association between all indices and age ( P for interaction: 0.001 for GWI, 0.009 for GCW, 0.003 for GWW, and 0.009 for GWE). For men, only GCW increased with age, whereas the other indices did not change with age. For women, GCW increased linearly with increasing age, whereas GWI, GWW, and GWE changed in a curvilinear fashion with age such that GWI increased in younger participants, GWW increased in elderly, and GWE declined concordantly. Abnormalities in myocardial work indices became more frequent with increasing Framingham risk score category (abnormal GWI: 2% versus 4% versus 5%, P =0.001; abnormal GCW: 2% versus 3% versus 4%, P =0.006; abnormal GWW: 3% versus 6% versus 11%, P P Conclusions: Myocardial work indices differ between sexes and change with age in a sex-dependent manner. Accordingly, we established age- and sex-specific reference values from a general population sample. Abnormal work indices become more frequent with higher clinical risk. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02993172.

BACKGROUND Studies suggest cardiac time intervals to be associated with cardiac ischemia. A novel method to assess cardiac time intervals by tissue Doppler echocardiography has been proposed. Cardiac time intervals can assess the myocardial performance index (MPI), which quantifies the proportion of time spent contributing effective myocardial work. We hypothesized that MPI associates with coronary artery lesions detected by cardiac computed tomography (CT) in patients suspected of coronary artery disease (CAD). METHODS We investigated patients referred for cardiac CT under suspicion of CAD who had an echocardiogram performed. Curved m-mode tissue Doppler imaging was used to measure cardiac time intervals and MPI. The outcome was coronary artery lesions, defined as a calcium score > 400 and/or coronary artery stenosis (>70% luminal narrowing). Logistic regression was applied with multivariable models including: (a) SCORE chart risk factors and (b) SCORE chart risk factors, body mass index, dyslipidemia, familial history of CAD, diabetes mellitus, LVEF, and left ventricular mass index. RESULTS Of 404 patients, 41 (10%) had a coronary artery lesion. Overall, 42% were male, mean age was 58 years, and LVEF was 58%. Patients with coronary artery lesions exhibited higher MPI than those without (0.52 vs. 0.44, P

This study aimed to clarify the diagnostic and prognostic potential of strain rate in patients with suspected stable angina pectoris (SAP). Strain rate by 2-dimensional speckle tracking echocardiography (2DSTE) has been suggested to be able to diagnose coronary artery disease (CAD) and predict cardiovascular events in various patient groups. Prospectively enrolled patients (n = 296) with suspected SAP, no previous cardiac disease, and normal left ventricular ejection fraction were examined by 2DSTE, exercise ECG, and coronary angiography. Obstructive CAD was defined as stenosis ≥ 70% in ≥ 1 coronary artery on coronary angiography (n = 107). Major adverse cardiac events (MACE) included myocardial infarction, heart failure, atrial fibrillation, and stroke. In multivariable analysis adjusted for baseline data, conventional echocardiography, and Duke score, early diastolic strain rate (SRe) was independently associated with significant CAD with a 1.35 increased risk of having CAD per 0.1 decrease in SRe (OR = 1.35, 95% CI 1.03-1.76, P = 0.027). Peak velocity of early diastolic filling (E)/SRe was not associated with significant CAD (OR = 1.14, 95% CI 0.81-1.62, P = 0.445). MACE occurred in 34 patients (12%) during follow-up (median 3.5 years) and both SRe (HR 1.26, 95% CI (1.07-1.49), P = 0.006) and E/SRe (HR 1.24, 95% CI (1.04-1.47), P = 0.017) were independent predictors after multivariable adjustment. In patients with suspected SAP, SRe by 2DSTE was independently associated with presence of CAD. In addition, SRe and E/SRe provided independent and incremental prognostic value for predicting future MACE.

Many echocardiographic measures have been proposed as potential predictors of outcome following ST-elevation myocardial infarction (STEMI). We hypothesized that combining multiple echocardiographic measures in a risk model provides more prognostic information than individual echocardiographic measures. We prospectively included 373 STEMI patients which constituted our derivation cohort. We also identified 298 STEMI patients from a clinical registry that constituted our validation cohort. Echocardiogram was performed at a median of 2 days after infarction. The echocardiogram consisted of conventional and advanced measures. The end point was a composite of heart failure and/or cardiovascular death. During a median follow-up of 5.4 years, we observed 80 events in our derivation cohort. A stepwise backward Cox regression including all echocardiographic parameters identified global longitudinal strain, wall motion score index (WMSI), E/e', and E/global strain rate e (E/GLSRe) as significant predictors of outcome. A Classification and Regression Tree analysis outlined a risk model with WMSI, GLSRe, and E/e' as key echocardiographic parameters. Patients with WMSI ≥ 2.22 were at high risk, patients with WMSI2.22, GLSRe0.82s

The ratio of transmitral early filling velocity to early diastolic strain rate (E/eʹsr) has recently emerged as a novel and accurate non-invasive measure of left ventricular (LV) filling pressure. This systematic review and meta-analysis aimed to give an overview of the possible clinical implications of E/eʹsr. We conducted a systematic review and meta-analysis of all studies involving E/eʹsr. Of 598 identified studies, 16 met our inclusion criteria. Studies involving E/eʹsr either investigated its prognostic value (n = 9) or its correlation with invasively measured LV filling pressure (n = 7). The pooled meta-analysis showed a significant correlation between E/eʹsr and pulmonary capillary wedge pressure (PCWP) measured invasively across the studies assessing this relationship (Cohen’s d = 3.90 95% CI [2.38–6.39], p

Background: Height-based indexations for the evaluation of left atrial (LA) volumes have been proposed as an alternative method to account for body stature when body composition is abnormal. The aim of this study was to derive reference values for these indexation methods and to examine their association with atrial fibrillation (AF). Methods: A healthy population was randomly split into derivation and validation cohorts (n = 493 each). The derivation cohort was used to derive reference values for iso- and allometric height-indexed LA volumes. Echocardiography included measurement of maximal LA volume (LAVmax) and minimal LA volume (LAVmin). Associations between these measures and AF were investigated in the validation cohort. Cox proportional-hazards regression was performed, adjusting for CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology Atrial Fibrillation) risk score. Results: From 986 healthy subjects, allometric height-indexed exponents were determined to 1.72 and 1.56 for LAVmax and LAVmin, respectively. Upper reference values were determined to be LAVmax > 22.1 mL/m1.72 and LAVmin > 12.7 mL/m1.56. In the validation cohort, 41 patients (8%) developed AF during follow-up (median, 14.7 years). In unadjusted analyses, both isometric and allometric indexed LAVmax were associated with AF (hazard ratio, 1.07 [95% CI, 1.03-1.11; P 1.72 increase, respectively) with equal C statistics of 0.63. Height-indexed LAVmin was also associated with AF, with higher C statistics than for LAVmax. All findings were consistent after multivariable adjustment. LAVmax > 22.1 mL/m1.72 posed an increased risk for AF (hazard ratio, 4.65; 95% CI, 1.83-11.86), but LAVmin > 12.7 mL/m1.56 carried a higher risk (hazard ratio, 6.33; 95% CI, 2.66-15.07). Conclusions: Both isometric and allometric height-indexed LA volumes are associated with AF in the general population. LAVmin is more strongly associated with AF than LAVmax regardless of indexation.

AIMS: This study investigated left atrial (LA) parameters as measured on transthoracic echocardiography as predictors of incident heart failure (HF) in a community cohort.METHODS AND RESULTS: In a large general population study (n = 2221), participants underwent a health examination with echocardiography. The maximum and minimum LA volumes indexed to body surface area (LAVImax and LAVImin) were measured and the LA emptying fraction (LAEF) and LA expansion index (LAEI) were calculated. Among 1951 participants without atrial fibrillation or significant valve disease, the mean age was 59 ± 16 years and 58% were women. At baseline, 1% (n = 16) had a left ventricular ejection fraction of CONCLUSION: In the general population, LAVImin is an independent predictor of incident HF. LAVImax, currently the only LA measure in a routine echocardiographic examination, was not an independent predictor of incident HF.

Background: Global longitudinal strain (GLS) is a sensitive marker of myocardial dysfunction and atrial reservoir function. We sought to evaluate its value for predicting atrial fibrillation (AF) in the general population. Methods: Participants from the Copenhagen City Heart Study examined with echocardiography, including speckle tracking analyses, were included. The endpoint was AF obtained through national registries. Proportional hazards Cox regression was applied, including multivariable adjustments made for CHADS2 and CHARGE-AF risk factors. Abnormal GLS was defined as >—18%. Results: The data from 1,309 participants were analyzed. Of those, 153 (12%) developed AF during a median follow-up time of 15.9 years. The follow-up was 100%. The mean age was 57 years, 38% had hypertension, and GLS was − 18%. In unadjusted analysis, GLS was a univariable predictor of outcome (1.08 (1.04–1.13), p < 0.001, per 1% absolute decrease), but did not remain an independent predictor after adjusting for neither CHADS2 nor CHARGE-AF risk factors. However, hypertension modified the relationship between GLS and AF (p for interaction = 0.010), such that GLS only predicted AF in subjects without hypertension. In participants without hypertension, GLS remained an independent predictor of AF after adjusting for CHADS2 and CHARGE-AF (HR = 1.11 (1.03–1.20) and HR = 1.09 (1.01–1.19), respectively). In these participants, an abnormal GLS was associated with a more than twofold increased risk of AF (HR = 2.16 (1.26–3.72). The incidence rate was 3.17 and 6.81 per 1000 person-years for normal vs. abnormal GLS, respectively. Conclusion: Global longitudinal strain predicts AF in individuals without hypertension from the general population, independently of common risk scores. Graphical abstract: [Figure not available: see fulltext.]

Background Recent improvements in speckle tracking echocardiography have made sectionalized quantification of layer-specific global longitudinal strain (GLS) possible. Prior studies have reported prognostic value of GLS in several cardiac diseases, however, the use of layer-specific strain has not been investigated in patients undergoing coronary artery bypass grafting (CABG). Purpose To determine the prognostic value of layer-specific GLS for predicting all-cause mortality after CABG. Methods In this retrospective cohort study, consecutive patients undergoing isolated CABG between 2006 and 2011 were included. The patients were followed through nation-wide registries for the endpoint of all-cause mortality. Multivariable Cox regression models adjusted for clinical and echocardiographic baseline characteristics were used to assess the association between layer-specific GLS and all-cause mortality. Cumulative survival was stratified by clinical age and gender-dependent cut-off values for the layer-specific GLS, which was obtained from a large healthy population study. Results Of 641 patients included (mean age 67 years, 84% male), 70 (10.9%) died during follow-up (median 3.8 years [IQR: 2.7; 4.9 years]). Patients who died during follow-up were significantly older (71 years vs. 67 years, P = Conclusion Layer-specific GLS is an independent prognosticator of all-cause mortality after CABG. In multivariable models, GLSepi provided significant prognostic value after adjusting for echocardiographic parameters and EuroScore II. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Research grant from Herlev & Gentofte University Hospital's internal research funds. Figure 1. Kaplan-Meier survival estimatesFigure 2. Incidence rate of all-cause mortality

Postsystolic shortening (PSS) by speckle-tracking echocardiography (STE) is a marker of myocardial ischemia and may improve diagnostic strategy. We sought to evaluate if PSS is associated with the coronary artery calcium score (CACS) and stenosis by computed tomography angiography (CTA) in patients with suspected stable angina pectoris (SAP). We retrospectively studied 437 SAP patients (age 58 ± 11 years, 41% male) who underwent STE, evaluation of CACS and assessment of significant stenosis (≥ 50%) by CTA. The postsystolic index (PSI) was defined as follows: 100x([peak negative strain cardiac cycle − peak negative strain systole])/peak negative strain cardiac cycle. A wall had PSS if any segment within the wall had a PSI ≥ 20%. We defined categories for walls with PSS: 0, 1, 2 and ≥ 3, and CACS: 0, 1–100, 101–400 and > 400. Each additional wall with PSS was associated with a 43% relative increase in CACS (95%CI +9% to +87%, P = 0.010), while each 1% absolute increase in the PSI was associated with a 9% relative increase in CACS (95%CI +1% to +18%, P = 0.031). Walls with PSS (OR 1.81 per 1 wall increase, 95%CI 1.27–2.59, P = 0.001) and the PSI (OR 1.12 per 1% increase, 95%CI 1.04–1.21, P = 0.004) were associated with the occurrence of CACS > 400. Additionally, walls with PSS (OR 1.53 per 1 wall increase, 95%CI 1.21–1.93, P

Aims: The ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) has recently emerged as a novel measure of left ventricular (LV) filling pressure. This new measure has demonstrated to have prognostic value superior to E/e’. This study aimed to investigate the prognostic value of E/e'sr in a large cohort of patients with heart failure with reduced ejection fraction (HFrEF) in relation to all-cause mortality. Methods: We retrospectively studied 897 HFrEF (mean age 66 ± 12 years, 73% male, 59% ischemic cardiomyopathy) patients who underwent speckle tracking echocardiography where E/e'sr along with novel and conventional echocardiographic parameters were obtained. The primary endpoint was defined as all-cause mortality. Results: During follow-up (median: 40 months IQR: 22-57), 137 (15.3%) patients died. Both E/e'sr and E/e’ were significantly associated with mortality (E/e'sr: HR 1.03 95%CI [1.02-1.04], p

Paroxysmal atrial fibrillation (PAF) may be the cause of a substantial part of cryptogenic strokes (CS). Echocardiography could assist risk stratification for PAF to select patients in need of prolonged rhythm monitoring. We aimed to assess the value of left atrial (LA) strain and a revised diastolic dysfunction (DDF) model with LA strain for predicting PAF. This was a prospective study of 56 CS patients who had a cardiac monitor implanted for 3 year monitoring for PAF, and an echocardiogram performed prior to monitoring. Conventional echocardiography, global longitudinal strain (GLS) and LA strain were performed. LA speckle tracking provided the LA reservoir strain (LAs). Patients were stratified into high versus low LAs by ROC curves (28.2%), and this cut-off was used to refine DDF grading. During follow-up of median 20 months, 13 (23%) patients were diagnosed with PAF. No conventional echocardiographic parameters differed between patients who developed PAF and those without PAF. However, LAs was significantly impaired in PAF patients (LAs: 30 vs. 27% for non-PAF and PAF, p = 0.046). Low LAs significantly predicted PAF independent of LA volume and GLS [OR 5.88 (1.30; 26.55), p = 0.021]. Revised DDF grading significantly predicted PAF, even when adjusted for the CHADS2 risk-score (OR 1.88 [1.01;3.50], per increase in DDF grade, p for trend = 0.047), which was not the case for conventional DDF grading. In conclusion, LAs associates with PAF independent of GLS and LA size, and may be used to improve the performance of DDF grading for identifying PAF in CS patients.

Objectives This study sought to investigate whether left atrial (LA) functional measures predict atrial fibrillation (AF) in the general population. Background Increasing evidence suggests LA functional measures are predictors of AF in several patient groups. Methods In a community-based cohort study, approximately 2,000 individuals underwent a transthoracic echocardiogram. Conventional echocardiographic measures and extended LA measures, including the minimal and maximal LA volumes (LAVmin and LAVmax, respectively) and left atrial emptying fraction (LAEF), were performed. The endpoint was incident AF, and participants with known AF were excluded, which left 1,951 for inclusion. Results Over 11.0 years of follow-up, 184 (9.4%) developed AF. Those who developed AF had significantly larger LA volumes and lower LAEF than participants free of AF. These LA measures were univariable predictors of AF (LAVmax hazard ratio [HR]: 1.10 [95% confidence interval (CI): 1.08 to 1.12] per 1-ml increase, p Conclusions LA functional measures predict AF in the general population and provide prognostic information incremental to clinical risk scores. In individuals without hypertension and nondilated LA, these measures indicate an increased risk of AF.

The ratio of early mitral inflow velocity (E) to early diastolic strain rate (E/e'sr) is a significant predictor of cardiac outcomes in various patient populations. This study aims to evaluate the predictive value of E/e'sr for heart failure, acute myocardial infarction, and death due to cardiovascular disease following acute coronary syndrome (ACS). In total, 432 ACS patients underwent echocardiography following percutaneous coronary intervention. The end point was the composite of heart failure, acute myocardial infarction, and death due to cardiovascular disease. Median follow-up was 4.4 (interquartile range 0.2 to 6.3) years. During the follow-up period, 199 (46.1%) met the composite outcome. Mean value of E/e'sr in patients was 0.70 ± 0.37 m. In univariable Cox regression, E/e'sr was a predictor of the composite outcome (hazard ratio [HR] 1.05 95% confidence interval [CI] 1.03 to 1.07, p0.001, per 0.10 m increase). After multivariable adjustment for demographic and clinical parameters, E/e'sr remained an independent predictor (HR 1.03; 95% CI 1.01 to 1.06; p = 0.013, per 0.10 m increase). Global longitudinal strain (GLS) modified the relation between E/e'sr and outcome (p value for interaction = 0.011). In ACS patients with a relatively preserved systolic function assessed by GLS (GLS ≥ 13.2%), E/e'sr showed to be a significant predictor (HR 1.20; 95% CI 1.06 to 1.36; p = 0.005, per 0.10 m increase). In contrast, E/e'sr was not a significant predictor in ACS patients with impaired systolic function (GLS13.2%; HR 1.02; 95% CI 0.99 to 1.04; p = 0.28). In conclusion, E/e'sr provides important prognostic information regarding cardiovascular morbidity and mortality in ACS patients. However, E/e'sr was not an independent predictor over that of echocardiographic parameters. Furthermore, E/e'sr is a stronger prognosticator in patients with relatively preserved systolic function as opposed to patients with impaired systolic function.

Twenty-five percent of ischemic strokes (IS) are cryptogenic, but it is estimated that paroxysmal atrial fibrillation (PAF) is the underlying cause in up to a third of cases. We aimed to investigate the predictive value of speckle tracking of the left atrium (LA) in diagnosing PAF in IS patients. We retrospectively studied 186 IS patients with a clinical echocardiographic examination during sinus rhythm. Outcome was PAF defined by at least one reported episode of AF following their IS. Conventional echocardiographic measures were performed. Global longitudinal strain (GLS), LA reservoir-(es), conduit-(ee), contraction-strain (ea) and LA dyssynchrony (standard deviation of time-to-peak es; LA SD-T2P) were obtained by left ventricular and LA speckle tracking. Of 186 patients, 28 (15%) were diagnosed with PAF. PAF-patients did not differ from non-PAF patients with regards to GLS nor SD-TPS, but atrial strain measures were significantly impaired at baseline (es 27 vs. 35%, ee 12 vs. 16%, ea 15 vs. 18%, p

Heart failure (HF) has evolved in an epidemic manner and constitutes a major public health issue. Currently, several prognostic markers and treatment options exist to guide treatment of HF with reduced ejection fraction, but echocardiographic deformation imaging suggests novel pathophysiologic aspects that could help optimize treatment further. Even though no formal treatment options currently exist for patients with HF with preserved ejection fraction, some HF medication does seem to attenuate strain measures. Speckle tracking has furthermore helped characterize this condition and to confer prognostic information. Thus, strain imaging could facilitate novel trials, and thereby hopefully introduce treatment opportunities.

Highlights • Early systolic lengthening (ESL) is a paradoxical lengthening of myocardial fibers. • Speckle tracking echocardiography is a common imaging tool for assessment of ESL. • ESL was a predictor of cardiovascular and all-cause death in CABG patients. • Specifically, the prognostic value of ESL was enhanced in women undergoing CABG., Background Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, has been linked to loss of myocardial viability and contractile dysfunction. We assessed the long-term prognostic potential of ESL in coronary artery bypass graft (CABG) patients. Methods We retrospectively included patients (n = 709; mean age 68 years; 85% men) who underwent speckle tracking echocardiography (median 15 days) prior to CABG. Endpoints were cardiovascular death (CVD) and all-cause mortality. We assessed amplitude of ESL (%), defined as peak positive strain, and duration of ESL (ms), determined as time from Q-wave on the ECG to peak positive strain. We applied Cox models adjusted for clinical risk assessed as EuroSCORE II. Results During median follow-up of 3.8 years [IQR 2.7–4.9 years], 45 (6%) experienced CVD and 80 (11%) died. In survival analyses adjusted for EuroSCORE II, each 1% increase in amplitude of ESL was associated with CVD (HR 1.35 [95%CI 1.09–1.68], P = 0.006) and all-cause mortality (HR 1.29 [95%CI 1.08–1.54], P = 0.004). Similar findings applied to duration of ESL (per 10ms increase) and CVD (HR 1.12 [95%CI 1.02–1.23], P = 0.016) and all-cause mortality (HR 1.09 [95%CI 1.01––1.17], P = 0.031). The prognostic value of ESL amplitude was modified by sex (P interaction

Aims Assessing left atrial (LA) size and function is an important part of the echocardiographic examination. We sought to assess how LA size and function develop over time, and which clinical characteristics promote atrial remodelling. Methods and results We examined longitudinal changes of the LA between two visits in the Copenhagen City Heart Study (n = 1065). The median time between the examinations was 10.4 years. LA measurements included: maximal LA volume (LAVmax), minimal LA volume (LAVmin), and LA emptying fraction (LAEF). Clinical and echocardiographic accelerators were determined from linear regression. The value of LA remodelling for predicting incident atrial fibrillation (AF) and heart failure (HF) was examined by Cox proportional hazards regressions. During follow-up, LAVmax and LAVmin significantly increased by 8.3 and 3.5 mL/m2, respectively. LAEF did not change. Age and AF were the most impactful clinical accelerators of LA remodelling with standardized beta-coefficients of 0.17 and 0.28 for changes in LAVmax, and 0.18 and 0.38 for changes in LAVmin, respectively. Left ventricular (LV) systolic function, diameter, and mass were also significant accelerators of LA remodelling. Changes in both LAVmax and LAVmin were significantly associated with incident AF [n = 46, ΔLAVmax: HR = 1.06 (1.03–1.09), P Conclusion Both maximal and minimal LA volume increase over time. Clinical accelerators included age and AF. LV structure and systolic function also accelerate LA remodelling. LA remodelling poses an increased risk of clinical outcomes.