No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Role of Left Atrial Volume Index in Patients with a First-ever Acute Ischemic Stroke
Abstract
Background:
Although an enlarged left atrium has recently emerged as a marker of adverse outcomes in various diseases, its discriminatory value and prognostic role in acute ischemic stroke (AIS) are not well studied. We studied whether left atrial volume index (LAVI) predicts mortality and discriminates stroke subtypes after AIS.
Methods:
We prospectively followed 310 consecutive first-ever AIS patients aged 50 years or older who were admitted to the hospital within 24 hours of the onset of stroke symptoms. The type of AIS was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. All of the patients underwent transthoracic echocardiography within the first 24 hours. LAVI was measured with the biplane area-length method and categorized as 28 mL/m(2) or lower (normal), 28.1-32 mL/m(2), 32.1-36 mL/m(2), and >36 mL/m(2). The patients were followed for 1 year or until death, whichever came first.
Results:
The LAVI of the cardioembolic group was significantly higher than that of the noncardioembolic group (32.4 ± 4.0 versus 29.7 ± 3.4 mL/m(2), respectively; P < .001). The optimal cutoff value, sensitivity, and specificity of LAVI to distinguish cardioembolic stroke from noncardioembolic stroke were 30 mL/m(2), 81%, and 64%, respectively. Mortality in each LAVI category was 4%, 7.8%, 25.9%, and 70.9%, respectively (P = .026). Kaplan-Meier analysis showed that there was a stepwise increase in risk of mortality with each increment of LAVI category.
Conclusions:
The LAVI can distinguish cardioembolic stroke from noncardioembolic stroke and provides an independent information over clinical and other echocardiographic variables for predicting mortality in patients with first-ever AIS.
... Disturbances in LA expansion can be easily identified during routine transthoracic echocardiographic (TTE) examinations and it is also strongly associated with the development of atrial fibrillation (AF). On the other hand, LA volume increase is associated with death, atherosclerotic heart disease, myocardial infarction (MI) and stroke [6][7][8][9][10][11]. Several comorbid conditions including HT, LV diastolic and systolic dysfunction, aortic and mitral valve diseases, diabetes mellitus (DM), obesity and aging are previously demonstrated to cause increase in LA [2,3]. ...
... Previously Xu et al. showed the presence of significant association between ED and LA dilatation among hypertensive patients with target organ damage [6]. However, diabetic patients were included and patients were under antihypertensive therapy in that study. ...
Background:
Arterial hypertension is associated with cardiovascular morbidity and mortality. It was previously shown that left atrium volume increase associated with mortality and atherosclerotic heart disease. The aim of the present study was to demonstrate the value of endothelial dysfunction in predicting left atrium volume increase in newly diagnosed hypertension patients.
Methods:
This study included 96 consecutive newly diagnosed hypertensive patients. Left atrium volume and left ventricular ejection fraction were calculated. Pulse wave velocity and brachial artery flow-mediated dilation measurements were obtained from each patient.
Results:
Left Ventricle Mass Index (114 ± 29 g/m, 91 ± 17 g/m, P < 001), left ventricular septum (P < 0.001) and posterior wall thickness (P = 0.001), left ventricular end diastolic diameter (P = 0.016) were significantly higher in patients with higher left atrial volume index. FMD% was lower in patients with higher left atrial volume index those without (9.7 ± 3.5 vs. 13.31 ± 6.01, P = 0.004). Lateral wall E wave velocity was significantly lower (8.68 ± 2.8, 10.2 ± 2.8; P = 0.009), while isovolumetric relaxation time (101.9 ± 19.9 ms, 85.7 ± 15.2 ms; P < 0.001), and ejection time was longer (101.9 ± 19.9 ms, 85.7 ± 15.2 ms; P = 0.077) and Mitral E/ lateral wall E ratio (E/E relation) was significantly higher (P = 0.031) in patients with higher left atrial volume index.
Conclusion:
The rate of isovolumetric relaxation time, FMD% and E/E' ratio independently predicted left atrial volume index increase in newly diagnosed hypertension patients.
... Atrial fibrillation (AF) is the most common cardiac arrhythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity (1). Studies have found that left atrial enlargement (LAE) as a marker of atrial myopathy is associated with an increased risk of ischemic stroke and all-cause of death despite the controversy surrounding this (2,3). The association between atrial myopathy and stroke may be unrelated to AF (4,5). ...
Background
The inflammatory process underlying atrial myopathy may affect the inflammatory response activated in acute ischemic stroke (AIS).
Objectives
We aimed to assess whether left atrial enlargement (LAE) as a marker of atrial myopathy is associated with a different profile of circulating inflammatory markers in AIS patients.
Methods
HIBISCUS-STROKE is a cohort study including anterior circulation AIS patients treated with mechanical thrombectomy following MRI. Ten circulating inflammatory markers were measured at admission and 6, 24, and 48 h after admission. LAE was defined as a left atrial volume index (LAVi) ≥34 ml/m ² . A multiple logistic regression model was performed to detect an independent association between the area under the curve (AUC) of these markers and LAE.
Results
We included 143 patients. Of them, 85 (59.4%) had LAE. On univariable analysis, we found that patients with LAE had higher soluble form suppression of tumorigenicity 2 (sST2), soluble tumor necrosis factor receptor I (sTNFR1), and vascular cellular adhesion molecule-1 (VCAM-1) AUC, were older, mostly female, had a higher National Institutes of Health Stroke Scale (NIHSS) score and blood glucose level at admission, had more often hypertension, and a cardioembolic source of AIS, such as atrial fibrillation, while they were less frequently current smokers and had a lower rate of tandem occlusion than patients without LAE. On multivariable analysis, we found that among circulating inflammatory markers, only high VCAM-1 (OR: 9.13, 95% CI: 3.21–25.9) and sST2 (OR: 3.40, 95% CI: 1.68–6.86) AUC remained associated with LAE.
Conclusions
High VCAM-1 and sST2 levels within the first 48 h are associated with LAE in AIS patients.
... LAVI is also a powerful predictor of mortality in patients with acute coronary syndrome (ACS). [6][7][8][9] However, data on prognostic value of LAVI are still limited in Chinese patients with CAD. Therefore, we attempted to further examine the association between baseline LAVI and long-term outcomes after three strategies including percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and medical therapy (MT) in a large cohort of patients with three-vessel coronary disease (TVD), and to analyze the prognostic value of LAVI for this special population. ...
Background:
Risk assessment and treatment stratification for three-vessel coronary disease (TVD) remain challenging. This study aimed to investigate the prognostic value of left atrial volume index (LAVI) with the Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score II, and its association with the long-term prognosis after three strategies (percutaneous coronary intervention [PCI], coronary artery bypass grafting [CABG], and medical therapy [MT]) in patients with TVD.
Methods:
This study was a post hoc analysis of a large, prospective cohort of patients with TVD in China, that aimed to determine the long-term outcomes after PCI, CABG, or optimal MT alone. A total of 8943 patients with TVD were consecutively enrolled between 2004 and 2011 at Fuwai Hospital. A total of 7818 patients with available baseline LAVI data were included in the study. Baseline, procedural, and follow-up data were collected. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), which was a composite of all-cause death, myocardial infarction (MI), and stroke. Secondary endpoints included all-cause death, cardiac death, MI, revascularization, and stroke. Long-term outcomes were evaluated among LAVI quartile groups.
Results:
During a median follow-up of 6.6 years, a higher LAVI was strongly associated with increased risk of MACCE (Q3: hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.06-1.37, P = 0.005; Q4: HR 1.85, 95%CI 1.64-2.09, P <0.001), all-cause death (Q3: HR 1.41, 95% CI 1.17-1.69, P <0.001; Q4: HR 2.54, 95%CI 2.16-3.00, P <0.001), and cardiac death (Q3: HR 1.81, 95% CI 1.39-2.37, P <0.001; Q4: HR 3.47, 95%CI 2.71-4.43, P <0.001). Moreover, LAVI significantly improved discrimination and reclassification of the SYNTAX score II. Notably, there was a significant interaction between LAVI quartiles and treatment strategies for MACCE. CABG was associated with lower risk of MACCE than MT alone, regardless of LAVI quartiles. Among patients in the fourth quartile, PCI was associated with significantly increased risk of cardiac death compared with CABG (HR: 5.25, 95% CI: 1.97-14.03, P = 0.001).
Conclusions:
LAVI is a potential index for risk stratification and therapeutic decision-making in patients with three-vessel coronary disease. CABG is associated with improved long-term outcomes compared with MT alone, regardless of LAVI quartiles. When LAVI is severely elevated, PCI is associated with higher risk of cardiac death than CABG.
... Studies have found that left atrial size was associated with an increased risk of ischemic stroke and all-cause of deaths despite of controversy (3)(4)(5). Additionally, some studies have found that this association between left atrial size and stroke seems to exist independent of atrial fibrillation (AF) (6,7). Therefore, it is important to identify the association between left atrial size and stroke, which would be helpful to stratify the risk of stroke. ...
Background: The association between left atrial size and the risk of stroke has not been fully understood. We performed a meta-analysis of prospective cohort studies to determine whether left atrial enlargement (LAE) is associated with an increased risk of stroke.
Methods: We searched PubMed, EMBASE, Web of Science, and the Cochrane Library through May 2019. Prospective cohort studies were included if they reported hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) of stroke with respect to LAE. All meta-analyses were performed using a random-effects model.
Results: Six studies involving 66,007 participants and 3,549 stroke events were included. Compared with patients without LAE, those with LAE had an increased risk of stroke (adjusted HR 1.68, 95% CI 1.36–2.07). There was also a graded association with stroke relating to LAE (adjusted HR for mild LAE 1.50, 95% CI 0.98–2.28; moderate LAE 1.40, 95% CI 1.12–1.75; and severe LAE 1.59, 95% CI 1.33–1.90). Furthermore, for each increase of 1 cm in left atrial diameter, the odds of stroke were increased by 24% (adjusted HR 1.24, 95% CI 1.03–1.50).
Conclusions: Our meta-analysis demonstrated that LAE is associated with an increased and graded risk of stroke.
... Echocardiography is the most commonly used tool for the cardiovascular evaluation of these patients. Although several studies [4][5][6][7][8] adopted volumetric assessment of left atrium for correlation with or prediction of adverse cardiovascular events, only few authors [9,10] have demonstrated that left atrial (LA) enlargement 1 3 is independently associated with new neurological events and with all-cause mortality in patients with first-ever AIS. ...
Prognostic stratification of acute ischemic stroke (AIS) patients without atrial fibrillation (AF) remains a challenge. Two-dimensional speckle tracking echocardiography (2D-STE) has recently been introduced for dynamic evaluation of left atrial function. However only few data are actually available regarding the application of 2D-STE in AIS patients. The aim of our study was to assess the prognostic role of global left atrial peak strain (GLAPS), measured by 2D-STE, in AIS patients without AF history. Eighty-five AIS patients (mean age 74.1 ± 12.1 years, 49 males) with normal sinus rhythm on ECG and without AF history were enrolled in the prospective study. All patients underwent a complete echocardiographic study with 2D-STE. At 1 year follow-up, we evaluated the occurrence of a composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. GLAPS was markedly reduced in AIS patients (15.71 ± 4.70%), without any statistically significant difference between the stroke subtypes. At 1-year follow-up, 14 deaths and 17 hospital readmissions were detected in AIS subjects. On a multivariate Cox model, variables independently associated with the occurrence of the composite endpoint were the “Rankin in” Scale (HR 1.69, p = 0.001), GFR (HR 0.98, p = 0.03) and the GLAPS value (HR 0.78, p < 0.0001). A GLAPS value ≤ 15.5% predicted the composite endpoint with sensitivity of 100% and specificity of 80%. A GLAPS value ≤ 15.5% reflects a more advanced atrial cardiomyopathy and might provide a reliable and useful prognostic risk stratification of AIS patients without AF history.
Objectives
To determine the prognostic value of positive global left atrial strain (LA-GSA+), measured by two-dimensional speckle tracking echocardiography (2D-STE) in a population of acute ischemic stroke (AIS) patients without atrial fibrillation (AF), in the setting of Emergency Department (ED).
Methods
All consecutive AIS patients with sinus rhythm on ECG and without AF history entered this prospective study. All patients underwent complete blood tests and transthoracic echocardiography implemented with 2D-STE analysis of LA strain parameters within 6–12 h after symptoms onset. At 6-months follow-up, we evaluated the composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations.
Results
A total of 102 AIS patients (76.4 ± 10.8 yrs, 47% males) were prospectively included. LA-GSA+ was markedly reduced in AIS patients (20.8 ± 7.7%), without any statistically significant difference between the stroke subtypes. At 6-months follow-up, 7 deaths and 27 re-hospitalizations occurred. On multivariate Cox regression analysis, variables independently associated with outcome were: LA-GSA+ (per unit) (HR 0.29, 95% CI 0.19–0.39) and C-reactive protein (CRP) (per 0.1 mg/dl) (HR 1.45, 95% CI 1.15–1.75) as continuous variables; statin therapy (HR 0.45, 95%CI 0.28–0.62), and type 2 diabetes (HR 1.65, 95% CI 1.15–2.35) as categorical variables. A LA-GSA+ ≤20.0% predicted the occurrence of the above-mentioned outcome at 6-months follow-up with 94% sensitivity and 81% specificity (AUC=0.84). Interestingly, GSA+ showed a strong inverse correlation with CRP levels (r = -0.86).
Conclusions
A LA-GSA+ ≤20% reflects a more advanced atrial cardiomyopathy and might provide a rapid and reliable prognostic risk stratification of AIS patients without AF history in the setting of ED.
Background
Stroke is a major comorbidity in patients with heart failure (HF), especially in those with decreased left atrial (LA) function, and thus, identifying patients highly at risk of stroke can prevent its occurrence. We evaluated the predictive value of global longitudinal strain of LA (LAGLS) in patients with acute HF and sinus rhythm.
Methods and Results
In this retrospective study, 2461 patients (53.3% men, 69.7±14.4 years old) with sinus rhythm and LAGLS among 4312 consecutive patients with acute HF from 3 tertiary hospitals were included. HF phenotypes were defined as HF with reduced ejection fraction (EF) (left ventricular EF ≤40%), HF with midrange EF (40% <left ventricular EF <50%), and HF with preserved ejection fraction (left ventricular EF ≥50%). Primary outcome was new‐onset stroke. The mean left ventricular EF was 39.4%±15.6%. Moreover, 1388 (57.5%), 342 (14.2%), and 682 (28.3%) were classified with HF with reduced EF, HF with midrange EF, and HF with preserved EF, retrospectively. LAGLS was 17.2%±10.4%. During the follow‐up duration (mean: 30.3±25.4 months), 100 patients experienced stroke. Patients with stroke had higher LA diameter ( P =0.031) and lower LAGLS ( P =0.010) than those without stroke. In the univariate analysis, age, diabetes mellitus, LA diameter, LA volume index, and LAGLS were significant risk factors for stroke. In the multivariate analysis, each 1% decrease in LAGLS was associated with a 3.8% increased risk for stroke (hazard ratio [HR], 1.038; 95% CI, 1.013–1.065; P =0.003). When applying a LAGLS cutoff point of 14.5%, patients with LAGLS <14.5% had approximately twice the risk for stroke after adjusting other significant variables (HR, 1.940; 95% CI, 1.269–2.965; P =0.002).
Conclusions
In patients with acute HF and sinus rhythm, decreased LAGLS (<14.5%) was associated with an increased risk for stroke, with an annual incidence of 2.38%.
Background
Enlargement of left atrium (LA) is a valuable marker of cardiovascular events, and LA size is readily available while performing non-contrast cardiac computed tomography (NCCT) for preventive purposes. We aimed to evaluate the predictive value of a single LA area from NCCT in a population-based cohort.
Method
Mainly men aged 60–75 years from DANCAVAS were included. Traditional risk factors were recorded, and an NCCT scan performed at baseline. Coronary artery calcifications (CAC) score and the largest LA area were measured. LA was indexed to body surface area and categorised into four groups. Data on incident atrial fibrillation (AF), thromboembolic events, heart failure (HF) and death were obtained from Danish national registries.
Results
In total, 14,557 individuals were eligible, excluding those without LA measurement (N = 232) and with heart valve replacement (N = 197). Known AF or HF were respectively excluded from follow-up. Median follow-up time was 2.1 to 3.4 years. In total, 304 developed AF, 149 had thromboembolism, 129 developed HF and 482 died. In adjusted analysis, LA enlargement was associated with AF (HR (95% CI): large 1.99 (1.46–2.71) and very large LA 3.77 (2.31–6.14)) and HF (large 2.40 (1.50–3.85) and very large LA 6.54 (4.07–10.51)). A very large LA significantly increased mortality (HR: 2.01 (1.44–2.82)), and was associated with a two-fold increased risk of thromboembolism; however, not significantly in adjusted analysis (p = 0.09).
Conclusion
We demonstrated that determination of LA area from NCCT was an important predictor of AF, HF and death. This knowledge could inform current risk assessment beyond CAC score.
Transthoracic echocardiogram (TTE) is widely used as part of the work-up for ischemic stroke. However, the added utility of TTE in the management of small single subcortical infarcts (SSSI) has not been extensively evaluated. Therefore, we aimed to determine the frequency of high-risk and medium-risk cardioembolic sources diagnosed by TTE in SSSI patients, and whether the findings altered clinical management. We performed a retrospective analysis of a prospective cohort of patients with confirmed acute ischemic stroke enrolled in a single-center observational registry between August 2012 and July 2014. We assessed infarct topography on brain magnetic resonance imaging, blinded to final stroke subtype and treatment, to identify patients with SSSI. We defined SSSI as lesions in the corona radiata, basal ganglia, thalamus, or brainstem measuring <1.5 cm in maximal diameter. We excluded patients with atrial fibrillation and large artery stenosis >50%, and assessed the frequency of cardioembolic sources found by TTE in the remaining patients. Among 908 patients, 75 (8.3%) had SSSI, of which 4 (5.3%) had atrial fibrillation and 6 (8%) had symptomatic large artery stenosis. TTE revealed cardiac abnormalities in 46% of the remaining patients (mean age: 65.1 y, 52% female, 58% white). The most common findings were dilated left atrium (29%), patent foramen ovale (14%), and atrial septal aneurysm (7.7%). Anticoagulants were prescribed in 3 (4.6%) patients on the basis of TTE results. TTE identified potential cardioembolic sources in almost half of the patients, but altered antithrombotic management in only 5% of patients with SSSI.
Limited data are available on the relation between left atrial size and outcome among patients referred for clinically indicated echocardiograms. Our aim was to assess the association of left atrial size with all-cause mortality and ischemic stroke in a large cohort of patients referred for echocardiography.
Left atrial diameter was measured in 52 639 patients aged 18 years or older (mean age 61.8 [standard deviation (SD) 16.3] years; 52.9% men) who underwent a first transthoracic echocardiogram for clinical reasons at our institution between April 1990 and March 2008. The outcomes were all-cause mortality and nonfatal ischemic stroke.
Based on the criteria of the American Society of Echocardiography, 50.4% of the patients had no left atrial enlargement, whereas 24.5% had mild, 13.3% had moderate and 11.7% had severe left atrial enlargement. Over a mean follow-up period of 5.5 (SD 4.1) years, 12 527 patients died, and 2314 patients had a nonfatal ischemic stroke. Cumulative 10-year survival was 73.7% among patients with normal left atrial size, 62.5% among those with mild enlargement, 54.8% among those with moderate enlargement and 45% among those with severe enlargement (p < 0.001). After adjustment in multivariable Cox proportional hazard analysis, left atrial diameter remained a predictor of all-cause mortality in both sexes (hazard ratio [HR] per 1-cm increment in left atrial size 1.17, 95% confidence interval [CI] 1.12-1.22, p < 0.001 in women, and HR 1.09, 95% CI 1.05-1.13, p < 0.001 in men) and of ischemic stroke in women (HR 1.25, 95% CI 1.14-1.37, p < 0.001).
Left atrial diameter has a graded and independent association with all-cause mortality in both sexes and with ischemic stroke in women.
The left atrial volume index (LAVI) reflects left ventricular (LV) filling pressure and has been shown to predict outcome in various cardiovascular diseases. However, its value for the prediction of mortality in patients referred for suspected heart failure (HF) is unknown.
To assess the value of LAVI for the prediction of mortality independently of clinical, electrocardiographic (ECG) and echocardiographic prognostic parameters in patients with suspected HF referred from the community.
356 (mean (SD) age 72 (13) years) patients with suspected HF referred from the community were followed up for mortality after undergoing clinical assessment, ECG and echocardiography, including Doppler, to assess LV filling.
Data were obtained for 335/356 (94%) patients (162 male, 173 female) over a mean (SD) follow-up period of 30 (10) months, during which 38 (11.3%) died. The univariate predictors for all-cause mortality were age, symptom of leg swelling, clinical signs of HF, abnormal ECG, LV ejection fraction, LAVI, LV end-systolic (LVESD) and diastolic dimension, septal wall thickness and the presence of other significant cardiac abnormalities. The only independent predictors of mortality were age (hazard ratio (HR) = 2.15, 95% CI 1.42 to 3.25, p<0.001), symptom of leg swelling (HR = 2.83, 95% CI 1.43 to 5.59, p = 0.005), LAVI (HR = 1.25, 95% CI 1.01 to 1.54, p = 0.04) and LVESD (HR = 1.32, 95% CI 1.02 to 1.70, p = 0.04).
LAVI provided independent information over clinical and other echocardiographic variables for predicting mortality in patients with suspected HF referred from the community.
Increased left atrial (LA) size has been proposed as a predictor of poor cardiovascular outcome in the elderly. In the present study, we evaluated the relationship between LA size and stroke in subjects of all ages who presented with preserved left ventricular systolic function (LVSF) and sinus rhythm (SR), and investigated the relationships between LA size and other echocardiographic parameters of diastolic function.
A total of 472 subjects were enrolled in the study (161 men, 311 women) and divided into the stroke group (n=75) and control group (n=397). A conventional echocardiographic study was then performed. Subjects with valvular heart disease, atrial fibrillation, or coronary heart disease were excluded.
The mean subject age was 65.2+/-5.1 years in the stroke group and 65.6+/-5.9 years in the control group. Mitral inflow pattern and E & A velocity showed no significant relationship with stroke (p=NS, p=NS, respectively). Left ventricular mass index and LA dimension were significantly related to stroke (p=0.003, p=0.023, respectively), and hypertension showed a marginal relationship with stroke (p=0.050). Age was not related to stroke in the present study (p=NS).
The LA dimension is significantly related to the incidence of stroke. Therefore, strategies for prevention of stroke in patients with preserved LVSF and SR should be considered in cases of LA enlargement.
We designed a 15-item neurologic examination stroke scale for use in acute stroke therapy trials. In a study of 24 stroke patients, interrater reliability for the scale was found to be high (mean kappa = 0.69), and test-retest reliability was also high (mean kappa = 0.66-0.77). Test-retest reliability did not differ significantly among a neurologist, a neurology house officer, a neurology nurse, or an emergency department nurse. The stroke scale validity was assessed by comparing the scale scores obtained prospectively on 65 acute stroke patients to the patients' infarction size as measured by computed tomography scan at 1 week and to the patients' clinical outcome as determined at 3 months. These correlations (scale-lesion size r = 0.68, scale-outcome r = 0.79) suggested acceptable examination and scale validity. Of the 15 test items, the most interrater reliable item (pupillary response) had low validity. Less reliable items such as upper or lower extremity motor function were more valid. We discuss methods for improving the reliability and validity of brief examination scales to be used in stroke therapy trials.
The objectives of this study were to determine the long-term outcome and the predictors of adverse events in patients originally diagnosed with lone atrial fibrillation (AF).
This population-based historical cohort study comprised 46 residents of Olmsted County, MN, USA, with well-documented, clinically defined lone AF and a complete two-dimensional echocardiographic examination. The original echocardiographic videotape recordings were analysed in a blinded fashion for left atrial volume (LAV) and left ventricular ejection fraction. With 1296 person-years of follow-up, the median duration of AF was 27 (first quartile=24, third quartile=33) years. Twenty-three (50%) patients developed events. Cerebral infarction occurred in seven patients, myocardial infarction in 11, and congestive heart failure in 16. In a multivariable analysis, patients with indexed LAV >or=32 mL/m(2) had a significantly worse event-free survival (adjusted HR, 4.46; 95% CI, 1.56-12.74; P=0.005). All cerebral infarctions occurred in patients with an indexed LAV >32 mL/m(2).
Patients originally diagnosed with benign lone AF follow divergent courses based on LAV. Those originally diagnosed with lone AF and normal sized atria had a benign clinical course throughout the long-term follow-up. Patients with increased LAV at diagnosis or later during the follow-up experienced adverse events.
Objectives. The purpose of this study was to determine whether left atrial size and ejection fraction are related to left ventricular filling pressures in patients with coronary artery disease.Background. In patients with coronary artery disease, left ventricular filling pressures can be estimated by using Doppler mitral and pulmonary venous flow velocity variables. However, because these flow velocities are age dependent, additional variables that indicate elevated left ventricular filling pressures are needed to increase diagnostic accuracy.Methods. Echocardiographic left atrial and Doppler mitral and pulmonary venous flow velocity variables were correlated with left ventricular filling pressures in 70 patients undergoing cardiac catheterization.Results. Left atrial sin and volumes were larger and left atrial ejection fractions were lower in patients with elevated left ventricular filling pressures. Mean pulmonary wedge pressure was related to mitral E/A wave velocity ratio (r = 0.72), left atrial minimal volume (r = 0.70), left atrial ejection fraction (r = −0.66) and atrial filling fraction (r = −0.66). Left ventricular end-diastolic and A wave pressures were related to the difierence in pulmonary venous and mitral A wave duration (both r = 0.77). By stepwise multilinear regression analysis, the ratio of mitral E to A wave velocity was the most important determinant of pulmonary wedge (r = 0.63) and left ventricular pre-A wave (r = 0.75) pressures, whereas the difference in pulmonary venous and mitral A wave duration was the most important variable for both left ventricular A wave (r = 0.75) and left ventricular end-diastolic (r = 0.80) pressures. The sensitivity of a left atrial minimal volume >40 cm3 for identifying a mean pulmonary wedge pressure >12 mm Hg was 82%, with a specificity of 98%.Conclusions. Left atrial size, left atrial ejection fraction and the difference between mitral and pulmonary venous flow duration at atrial contraction are independent determinants of left ventricular filling pressures in patients with coronary artery disease. The additive value of left atrial size and Doppler variables in estimating filling pressures and the possibility that left atrial size may be less age dependent than other mitral and pulmonary venous flow velocity variables merit further investigation.
An enlarged left atrium is associated with increased risk for stroke. However, there are controversies regarding how left atrial size should be measured.
Echocardiography and carotid artery ultrasound were performed in 120 patients with essential hypertension (HT group) and in 64 hypertensive patients admitted with a first-ever ischemic stroke (HT-stroke group). Left atrial size was measured as antero-posterior diameter (LAD) and as left atrial volume (LAV) and indexed to body surface area (LADi/LAVi). All patients were in sinus rhythm and without mitral valve disease.
In the HT-stroke group, LAVi and LADi were significantly larger as compared with the HT group (P ≤ 0.03 for all). In bivariate correlations, larger left atrial size was associated with higher SBPs and DBPs and significant carotid artery stenosis both in HT and HT-stroke groups (all P < 0.05). In multivariate logistic regression analysis, stroke was associated significantly with larger LAVi [odds ratio (OR) 1.73, 95% confidence interval (CI) 1.06-2.65]; left ventricular mass index (OR 1.11, 95% CI 1.03-1.21); significant carotid artery stenosis (OR 1.09, 95% CI 1.03-1.24); and any carotid artery stenosis (OR 1.07, 95% CI 1.03-1.14). Analysis of receiver operating characteristic curves revealed that LAVi was the best left atrial measurement for prediction of stroke (OR 0.77, 95% CI 0.70-0.84).
In hypertensive patients, a first-ever ischemic stroke was associated with larger left atrial size, left ventricular mass index and internal carotid artery stenosis. LAVi was the left atrial measurement most closely associated with ischemic stroke.
Left atrial volume index (LAVI) is known to reflect the duration and severity of increased left atrial pressure caused by left ventricular (LV) diastolic dysfunction. However, the prognostic value of LAVI in patients with heart failure (HF) has not been fully investigated.
Transthoracic echocardiography was performed in 146 consecutive patients (78 men, 68 women; mean age 72 ± 12 y) who were hospitalized for HF. There were 45 cardiac events (32%) during a median follow-up period of 448 days. There were no significant differences in LV end-diastolic dimensions or ejection fraction between patients who did or did not have cardiac events. However, LAVI was markedly higher in patients with, than those without, cardiac events (56 ± 26 vs 44 ± 22 mL/m(2); P < .01). Kaplan-Meier analysis showed that there was a stepwise increase in risk of cardiac events with each increment of LAVI category, and LAVI >53.3 mL/m(2) correlated with the highest risk of cardiac events (log-rank test; P < .01). Multivariate Cox proportional hazard analysis showed that high LAVI was an independent predictor for cardiac events (hazard ratio 1.427; 95% confidence interval 1.024-1.934; P < .05).
LAVI may be useful for stratification of risk in patients with HF.
The maximum left atrial volume index (LAVI) has been shown to be of prognostic values, but previous studies have largely been limited to older patients with specific cardiovascular conditions. We examined the independent prognostic values of LAVI in a large unselected series of predominantly younger patients in sinus rhythm followed up for a long period. We evaluated 483 consecutive patients (mean age 47.3 years) using transthoracic echocardiography. The median LAVI was 24 ml/m(2). A primary combined end point of cardiovascular death, stroke, heart failure, myocardial infarction, and atrial fibrillation was sought. We had complete follow-up data for 97.3% of the 483 patients. During a median follow-up of 6.8 years, 86 patients (18.3%) reached the primary end point. Older age, male gender, diabetes, hypertension, hypercholesterolemia, chronic renal failure, a history of myocardial infarction or stroke, a mitral E deceleration time of </=150 ms, and LAVI of >/=24 ml/m(2) were univariate predictors of the primary end point. Event-free survival was significantly lower for patients with a LAVI of >/=24 ml/m(2). Age, a history of stroke, hypertension, chronic renal failure, and male gender were independent clinical predictors. A LAVI of >/=24 ml/m(2) was the only independent echocardiographic predictor (hazard ratio 1.72, 95% confidence interval 1.34 to 2.13, p = 0.018), with the chi-square of the Cox model increased significantly with the addition of the LAVI (p <0.001). The LAVI independently predicted an increased risk of cardiovascular death, heart failure, atrial fibrillation, stroke, or myocardial infarction during a median follow-up of 6.8 years. In conclusion, the prognostic values were incremental to the clinical risks and were valid in a younger, general patient population.
To establish the incidence and correlation of increased left atrial volume index (LAVI) in patients with first-ever ischemic stroke.
Using our institution's epidemiological database, we defined a cohort of 432 patients (cases) who underwent transthoracic echocardiography within 60 days of first ischemic stroke between January 1, 1985, and December 31, 1994. Left atrial volume was measured with the biplane area-length method, indexed to body surface area (LAVI, expressed as mL/m(2)). The control group consisted of 416 community residents who underwent transthoracic echocardiography as participants in a stroke risk factor study. Increased LAVI was defined as 28 mL/m(2) or higher. Survival in patients was compared with expected survival among white Minnesotans and was further modeled as a function of age, sex, LAVI, and clinical risk factors.
Among the included 306 patients, 230 (75%) had increased LAVI (mean+/-SD, 49+/-21 mL/m(2)). Patients with increased LAVI were older than those with normal LAVI (mean+/-SD age, 76+/-11 vs 71+/-13 years; P=.003) and had more cardiovascular risk factors (mean+/-SD number, 1.8+/-0.07 vs 1.3+/-0.89; P<.001). Mean LAVI was higher in cases than in age- and sex-matched controls (P<.001). At 5-year follow-up, cases showed excess mortality compared with age-matched controls (P=.001). After variables were adjusted for age, sex, and clinical risk factors, LAVI was independently associated with mortality.
A useful index for prediction of adverse cardiovascular events, LAVI might also predict first ischemic stroke and subsequent mortality.
The medical literature contains conflicting reports on the association of left atrial (LA) enlargement with risk of stroke. The relation of LA size to risk of stroke and death in the general population remains largely unexplored.
Subjects 50 years of age and older from the Framingham Heart Study were studied to assess the relations between echocardiographic LA size and risk of stroke and death. During 8 years of follow-up, 64 of 1371 (4.7%) men and 73 of 1728 (4.2%) women sustained a stroke, and 296 (21.6%) men and 271 (15.7%) women died. Sex-specific Cox proportional-hazards models were adjusted for age, hypertension, diabetes, atrial fibrillation, smoking, ECG left ventricular (LV) hypertrophy, and congestive heart failure or myocardial infarction. After multivariable adjustment, for every 10-mm increase in LA size, the relative risk of stroke was 2.4 in men (95% CI, 1.6 to 3.7) and 1.4 in women (95% CI, 0.9 to 2.1); the relative risk of death was 1.3 in men (95% CI, 1.0 to 1.5) and 1.4 in women (95% CI, 1.1 to 1.7). Adjusting for ECG LV mass/height attenuated the relation of LA size to stroke and death.
After multivariable adjustment, LA enlargement remained a significant predictor of stroke in men and death in both sexes. The relation of LA enlargement to stroke and death appears to be partially mediated by LV mass.
The etiology of ischemic stroke affects prognosis, outcome, and management. Trials of therapies for patients with acute stroke should include measurements of responses as influenced by subtype of ischemic stroke. A system for categorization of subtypes of ischemic stroke mainly based on etiology has been developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST).
A classification of subtypes was prepared using clinical features and the results of ancillary diagnostic studies. "Possible" and "probable" diagnoses can be made based on the physician's certainty of diagnosis. The usefulness and interrater agreement of the classification were tested by two neurologists who had not participated in the writing of the criteria. The neurologists independently used the TOAST classification system in their bedside evaluation of 20 patients, first based only on clinical features and then after reviewing the results of diagnostic tests.
The TOAST classification denotes five subtypes of ischemic stroke: 1) large-artery atherosclerosis, 2) cardioembolism, 3) small-vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology. Using this rating system, interphysician agreement was very high. The two physicians disagreed in only one patient. They were both able to reach a specific etiologic diagnosis in 11 patients, whereas the cause of stroke was not determined in nine.
The TOAST stroke subtype classification system is easy to use and has good interobserver agreement. This system should allow investigators to report responses to treatment among important subgroups of patients with ischemic stroke. Clinical trials testing treatments for acute ischemic stroke should include similar methods to diagnose subtypes of stroke.
We postulated that in patients with essential hypertension and normal left ventricular (LV) systolic function, left atrial (LA) size correlates with LV wall thickness by better reflecting the chronicity and duration of LA hypertension than the commonly used hemodynamic and Doppler measures of LV diastolic function. Accordingly, hemodynamic, Doppler, and two-dimensional echocardiographic measurements were performed in 30 subjects with no cardiovascular abnormalities other than essential hypertension (mean systolic blood pressure of 150 +/- 29 mm Hg). The mean LV wall thickness was 0.57 +/- 0.14 cm/m2 and the mean LV ejection fraction was 0.62 +/- 0.12. Hemodynamic and Doppler measures including pulmonary capillary wedge and LV end-diastolic pressures, isovolumic LV pressure relaxation, LV chamber elastic stiffness, and E/A ratio (E and A waves on the pulsed Doppler signal of the mitral valve) correlated poorly (r = 0.01 to -0.52) with LV wall thickness. Both E/A ratio and isovolumic LV pressure relaxation correlated better (p = 0.05) with patient age than with LV wall thickness. In contrast, LA area (in the apical four-chamber view) had a good correlation (r = 0.77 for LA area in atrial diastole and r = 0.86 for LA area in atrial systole) with LV wall thickness. Multiple regression analysis revealed LA area in atrial systole to be the best correlate of LV wall thickness. We conclude that because the left atrium is a thin-walled structure, its size may increase with an increase in LA pressure. In the absence of mitral valve disease and atrial fibrillation, LA size may reflect the chronicity and duration and thus the history of LA hypertension. LA size in the apical four-chamber view may, therefore, provide a simple noninvasive assessment of the degree of LV diastolic dysfunction.
The purpose of this study was to determine whether left atrial size and ejection fraction are related to left ventricular filling pressures in patients with coronary artery disease.
In patients with coronary artery disease, left ventricular filling pressures can be estimated by using Doppler mitral and pulmonary venous flow velocity variables. However, because these flow velocities are age dependent, additional variables that indicate elevated left ventricular filling pressures are needed to increase diagnostic accuracy.
Echocardiographic left atrial and Doppler mitral and pulmonary venous flow velocity variables were correlated with left ventricular filling pressures in 70 patients undergoing cardiac catheterization.
Left atrial size and volumes were larger and left atrial ejection fractions were lower in patients with elevated left ventricular filling pressures. Mean pulmonary wedge pressure was related to mitral E/A wave velocity ratio (r = 0.72), left atrial minimal volume (r = 0.70), left atrial ejection fraction (r = -0.66) and atrial filling fraction (r = -0.66). Left ventricular end-diastolic and A wave pressures were related to the difference in pulmonary venous and mitral A wave duration (both r = 0.77). By stepwise multilinear regression analysis, the ratio of mitral E to A wave velocity was the most important determinant of pulmonary wedge (r = 0.63) and left ventricular pre-A wave (r = 0.75) pressures, whereas the difference in pulmonary venous and mitral A wave duration was the most important variable for both left ventricular A wave (r = 0.75) and left ventricular end-diastolic (r = 0.80) pressures. The sensitivity of a left atrial minimal volume > 40 cm3 for identifying a mean pulmonary wedge pressure > 12 mm Hg was 82%, with a specificity of 98%.
Left atrial size, left atrial ejection fraction and the difference between mitral and pulmonary venous flow duration at atrial contraction are independent determinants of left ventricular filling pressures in patients with coronary artery disease. The additive value of left atrial size and Doppler variables in estimating filling pressures and the possibility that left atrial size may be less age dependent than other mitral and pulmonary venous flow velocity variables merit further investigation.
The association between left atrial size and ischemic stroke is controversial and has been suggested to exist only in men and to be mediated by left ventricular mass. Data are available almost exclusively for white patients. The purpose of this study was to evaluate the association between left atrial size and ischemic stroke in a multiethnic population.
A population-based case-control study was conducted in 352 patients aged >39 years with first ischemic stroke and in 369 age-, gender-, and race-ethnicity-matched community controls. Left atrial diameter was measured by 2-dimensional transthoracic echocardiography and indexed by body surface area. Conditional logistic regression analysis was performed to assess the risk of stroke associated with left atrial index in the overall group and in the age, gender, and race-ethnic strata after adjustment for the presence of other stroke risk factors.
Left atrial index was associated with ischemic stroke in the overall group (adjusted OR 1.47 per 10 mm/1.7 m(2) of body surface area; 95% CI 1.03 to 2.11). The association was present in men (adjusted OR 2.81, 95% CI 1.42 to 5.57) but not in women (adjusted OR 1.08, 95% CI 0.70 to 1.66), and in patients aged <60 years (adjusted OR 3.78, 95% CI 1.36 to 10.54) but not >60 years (adjusted OR 1.23, 95% CI 0.84 to 1.81). Subgroup analyses showed the risk to be present in men across all age subgroups. In women, the lack of association between left atrial index and stroke was most strongly influenced by left ventricular hypertrophy. A trend toward an association between left atrial index and stroke was observed in whites (adjusted OR 1.81, 95% CI 0.81 to 4.09) and Hispanics (adjusted OR 1.61, 95% CI 0.98 to 2.65) but was less evident in blacks (adjusted OR 1.25, 95% CI 0.74 to 2.14).
Left atrial enlargement is associated with an increased risk of ischemic stroke after adjustment for other stroke risk factors, including left ventricular hypertrophy. The association is observed in men of all ages, whereas in women it is attenuated by other factors, especially left ventricular hypertrophy. Interracial differences in the stroke risk may exist that need further investigation.
We aimed to investigate the determinants of left atrial (LA) volume and its prognostic value in patients with dilated cardiomyopathy (DCM).
Enlargement of the LA is a marker of mortality in the general population. Patients with DCM are characterized by a wide range of LA sizes, but the clinical role of this observation has been played down.
A complete echocardiographic Doppler examination was performed in 337 patients (age 60 +/- 13 years; 84% male) with the diagnosis of DCM. Left atrial maximal volume (LA(max)) was measured at left ventricular (LV) end systole (four-chamber view; area-length method). Left ventricular end-diastolic and end-systolic volumes (LVEDV and LVESV) and ejection fraction (EF) were also measured. Mitral regurgitation (MR) was graded using a 5-point scale. Mitral E-wave (E) and A-wave (A) velocities, as well as their ratio (E/A), were measured off-line.
Determinants of LA(max) were: atrial fibrillation (r = 0.34, p < 0.0001), LVEDV (r = 0.46, p < 0.0001), EF (r = 0.40, p < 0.0001), MR (r = 0.39, p < 0.0001), and E/A ratio (r = 0.36, p < 0.0001). During follow-up (41 +/- 29 months), 77 patients died and 12 underwent heart transplantation. Univariate Cox analysis showed that LA(max) (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.007-1.013, p < 0.0001), LVESV (HR 1.003, CI 1.001-1.005, p = 0.0003), E/A ratio (HR 1.6, CI 1.3-2.005, p < 0.0001), and MR (HR 1.21, CI 1.03-1.44, p = 0.02) were related to the outcome. On bivariate Cox analysis, LA(max) predicted the prognosis independently of each determinant. Patients with a larger LA volume (LA(max)/m(2) >68.5 ml/m(2)) had a risk ratio of 3.8 compared with those with a smaller LA volume.
In patients with DCM, LA volume is associated with LV remodeling, diastolic dysfunction, and the degree of MR. The maximal volume of the LA has an independent and incremental prognostic value, compared with all its determinants.
Left ventricular (LV) diastolic dysfunction is prevalent in the community. Current assessment of diastolic function can be complex, involving Doppler evaluation of an array of hemodynamic data. The relation between left atrial (LA) volume and diastolic function, and between LA volume and cardiovascular risk and disease burden are not well known. In the present prospective study of 140 adults, mean age 58 +/- 19 years, referred for a clinically-indicated echocardiogram and in sinus rhythm, with no history of atrial arrhythmias or valvular heart disease, we determined the LA volume, LV diastolic function status, cardiovascular risk score (based on age, gender, history of systemic hypertension, diabetes mellitus, hyperlipidemia, and smoking), and cardiovascular disease burden (based on confirmed vascular disease, congestive heart failure, and transient ischemic attack or stroke). LA volume was found to correlate positively with age, body surface area, cardiovascular risk score, LV end-diastolic and end-systolic dimensions, LV mass, diastolic function grade, tissue Doppler E/E', tricuspid regurgitation velocity, and negatively with LV ejection fraction (all p <0.006). In a multivariate clinical model, LA volume indexed to body surface area (indexed LA volume) was independently associated with cardiovascular risk score (p <0.001), congestive heart failure (p = 0.014), vascular disease (p = 0.012), transient ischemic attack or stroke (p = 0.021), and history of smoking (p = 0.008). In a clinical and echocardiographic model, indexed LA volume was strongly associated with diastolic function grade (p <0.001), independent of LV ejection fraction, age, gender, and cardiovascular risk score. In patients without a history of atrial arrhythmias or valvular heart disease, LA volume expressed the severity of diastolic dysfunction and provided an index of cardiovascular risk and disease burden.
Background:
The incidence of stroke is predicted to rise because of the rapidly ageing population. However, over the past two decades, findings of randomised trials have identified several interventions that are effective in prevention of stroke. Reliable data on time-trends in stroke incidence, major risk factors, and use of preventive treatments in an ageing population are required to ascertain whether implementation of preventive strategies can offset the predicted rise in stroke incidence. We aimed to obtain these data.
Methods:
We ascertained changes in incidence of transient ischaemic attack and stroke, risk factors, and premorbid use of preventive treatments from 1981-84 (Oxford Community Stroke Project; OCSP) to 2002-04 (Oxford Vascular Study; OXVASC).
Findings:
Of 476 patients with transient ischaemic attacks or strokes in OXVASC, 262 strokes and 93 transient ischaemic attacks were incident events. Despite more complete case-ascertainment than in OCSP, age-adjusted and sex-adjusted incidence of first-ever stroke fell by 29% (relative incidence 0.71, 95% CI 0.61-0.83, p=0.0002). Incidence declined by more than 50% for primary intracerebral haemorrhage (0.47, 0.27-0.83, p=0.01) but was unchanged for subarachnoid haemorrhage (0.83, 0.44-1.57, p=0.57). Thus, although 28% more incident strokes (366 vs 286) were expected in OXVASC due to demographic change alone (33% increase in those aged 75 or older), the observed number fell (262 vs 286). Major reductions were recorded in mortality rates for incident stroke (0.63, 0.44-0.90, p=0.02) and in incidence of disabling or fatal stroke (0.60, 0.50-0.73, p<0.0001), but no change was seen in case-fatality due to incident stroke (17.2% vs 17.8%; age and sex adjusted relative risk 0.85, 95% CI 0.57-1.28, p=0.45). Comparison of premorbid risk factors revealed substantial reductions in the proportion of smokers, mean total cholesterol, and mean systolic and diastolic blood pressures and major increases in premorbid treatment with antiplatelet, lipid-lowering, and blood pressure lowering drugs (all p<0.0001).
Interpretation:
The age-specific incidence of major stroke in Oxfordshire has fallen by 40% over the past 20 years in association with increased use of preventive treatments and major reductions in premorbid risk factors.
To determine the clinical importance of left atrial (LA) volume in the prediction of first ischemic stroke.
This retrospective cohort study included randomly selected residents of Olmsted County, Minnesota, aged 65 years or older, who had undergone transthoracic echocardiography at least once at the Mayo Clinic in Rochester, Minn, between January 1, 1990, and December 31, 1998, were in sinus rhythm, and had no history of stroke, transient ischemic attack, atrial fibrillation, or valvular heart disease. Patients were monitored through medical records for first ischemic stroke or death.
Of 1554 residents (59% women) aged 75+/-7 years, 92 (6%) had experienced at least 1 ischemic stroke over 4.3+/-2.7 years (incident stroke rate, 1.4 per 100 person-years). Left atrial volume of 32 mL/m2 or greater (hazard ratio [HR], 1.63; confidence interval [CI], 1.08-2.46) was independent of age (HR, 1.04; CI, 1.02-1.07), diabetes (HR, 1.91; CI, 1.07-3.41), myocardial infarction (HR, 1.64; CI, 1.01-2.64), and hyperlipidemia (HR, 1.55; CI, 1.01-2.37) for the prediction of first ischemic stroke. When quartiles of LA dimension were plotted against quartiles of indexed LA volume, a stepwise increase in risk with each quartile increment was evident only for indexed LA volume. Also, an LA volume of 32 mL/m2 or greater was associated with an increased mortality risk (HR, 1.30; CI, 1.09-1.56), independent of age, sex, and stroke status.
In our elderly cohort with no prior atrial fibrillation, LA volume was independently predictive of first ischemic stroke, incremental to age, diabetes, myocardial infarction, and hyperlipidemia. It was also an independent predictor of death.
Left atrial (LA) volume is a load-independent marker of left ventricular diastolic function. To determine the value of LA volume to predict mortality in patients with ischemic cardiomyopathy, clinical and echocardiographic variables, including Doppler parameters, were evaluated in 109 patients with ischemic cardiomyopathy. LA volume was the only independent predictor of mortality (hazard ratio 1.03, 95% confidence interval 1.001 to 1.057, p = 0.03).
The purpose of this study was to evaluate the associations of transthoracic echocardiographic parameters with recurrent atrial fibrillation (AF) and/or stroke.
The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, an evaluation of elderly patients with AF at risk for stroke, provided an opportunity to evaluate the implications of echocardiographic parameters in patients with AF.
Transthoracic echocardiographic measures of mitral regurgitation (MR), left atrial (LA) diameter, and left ventricular (LV) function were evaluated in the AFFIRM rate- and rhythm-control patients who had sinus rhythm resume and had these data available. Risk for recurrent AF or stroke was evaluated with respect to transthoracic echocardiographic measures.
Of 2,474 patients studied, 457 had > or =2(+)/4(+) MR, and 726 had a LA diameter >4.5 cm. The LV ejection fraction was abnormal in 543 patients. The cumulative probabilities of at least one AF recurrence/stroke were 46%/1% after 1 year and 84%/5% by the end of the trial (> 5 years), respectively. Multivariate analysis showed that randomization to the rhythm-control arm (hazard ratio [HR] = 0.64; p < 0.0001) and a qualifying episode of AF being the first known episode (HR = 0.70; p < 0.0001) were associated with decreased risk. Duration of qualifying AF episode >48 h (HR = 1.55; p < 0.0001) and LA diameter (p = 0.008) were associated with an increased risk of recurrent AF. Recurrent AF was more likely with larger LA diameters (HR = 1.21, 1.16, and 1.32 for mild, moderate, and severe enlargement, respectively). No transthoracic echocardiographic measures were associated with risk of stroke.
In the AFFIRM study, large transthoracic echocardiographic LA diameters were associated with recurrent AF, but no measured echocardiographic parameter was associated with stroke.
The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease)
WHO MONICA Project Investigators. The World Health
Organization MONICA Project (monitoring trends and
determinants in cardiovascular disease). J Clin Epidemiol
1988;41:105-114.