Measures of left atrial function predict incident atrial fibrillation in STEMI patients treated with primary percutaneous coronary intervention

doi:10.1016/j.ijcard.2018.03.013

International Journal of Cardiology

Volume 263, 15 July 2018, Pages 1-6

https://doi.org/10.1016/j.ijcard.2018.03.013 Get rights and content

Highlights

•
Only measurement of maximal left atrial volume is included in current guidelines.
•
Measures of left atrial function are superior to maximal left atrial volume.
•
Measures of left atrial function predict atrial fibrillation after STEMI.

Abstract

Rationale

Atrial fibrillation (AF) is the most common arrhythmia following acute myocardial infarction (AMI). Maximal left atrial (LA) volume is the only echocardiographic atrial parameter employed clinically to assess risk of AF development.

Objective

This study sought to determine the prognostic value of left atrial functional measures such as left atrial emptying fraction (LAEF) and left atrial expansion index (LAi) in predicting incident AF in the post-STEMI setting.

Methods and results

STEMI patients treated with primary percutaneous coronary intervention (pPCI) at Gentofte Hospital, Denmark were prospectively enrolled from September 2006 to December 2008 and had an echocardiogram performed a median 2 days (interquartile-range: 1-3 days) following pPCI. LA maximal volume, LA minimal volume, LAEF and LAi were measured from echocardiograms of 373 patients using the area-length method. End point was incident AF. Median follow-up time was 5.6 years (interquartile-range: 5.0-6.1 years), 24 patients (6%) developed incident AF, and follow-up was 100%. In multivariable Cox regression, LAEF and LAi but not maximal LA volume remained independent predictors of AF. Results were similar in competing risk analysis treating all–cause mortality as a competing risk. LAEF and LAi, but not maximal LA volume, added incremental prognostic information in predicting incident AF when added to the CHARGE-AF risk score and the CHA2DS2-VASc score.

Conclusion

LAEF and LAi independently predicted incident AF following STEMI and added incremental prognostic information in addition to established predictors of AF. Maximal LA volume was not an independent predictor of incident AF after multivariable adjustment.

Introduction

Complications following acute myocardial infarctions (MI) include both atrial and ventricular arrhythmias. Of these, ventricular arrhythmias pose the greatest risk of adverse outcome. Atrial fibrillation (AF), however, is far more common than ventricular arrhythmias following MI [1]. AF is associated with several adverse outcomes such as recurrent MI, progressive heart failure, stroke and malignant ventricular arrhythmias [2,3] Furthermore, asymptomatic episodes of paroxysmal AF are suspected to be a significant contributor to the underlying pathology of cryptogenic strokes [4]. The increased morbidity associated with AF can be reduced if proper treatment is initiated early, mainly through reduction of ischemic stroke (IS) risk from anti-coagulant and anti-platelet therapy [5]. Also, effective management of AF through cardioversion and medication is possible [6]. Lastly, ablation procedures display increased success rate if performed before significant atrial fibrosis develops as a result of AF, stressing the need for early intervention [7]. This calls for effective prediction and assessment of new-onset AF risk in ST-elevated myocardial infarction (STEMI) patients to improve overall prognosis and to reduce the risk of stroke and progressive heart failure following STEMI.

Echocardiographic assessment of AF risk is based on parameters of left ventricular (LV) diastolic function such as maximal left atrial (LA) volume or E/e′. E/e′, LA diameter, maximal LA volume and its index (LAVI) have all displayed proficiency in prediction of AF [8,9]. Despite this, only minimal LA volume and left atrial emptying fraction (LAEF), neither E/e′ nor maximal LA volume, were independently associated with paroxysmal AF in patients with ischemic strokes or transient ischemic attacks [10]. Furthermore, in a prospective cohort of 2200 patients with dyspnea, left atrial expansion index (LAi) but not LAVI accurately predicted persistent AF [11]. This suggest that less commonly employed echocardiographic parameters such as LAEF and LAi may offer incremental prognostic information compared to maximal LA volume in prediction of new-onset AF. Only measurement of maximal LA volume is included in current guidelines [12]. This study seeks to determine whether adding measures of LA function such as LAEF and LAi provides incremental prognostic information compared to maximal LA volume in predicting new-onset AF in STEMI patients treated with pPCI.

Section snippets

Population

The data and study population has been previously described [13]. STEMI patients undergoing pPCI were prospectively enrolled from September 2006 to December 2008 at Gentofte University Hospital, Denmark. All patients had an echocardiographic examination performed a median of 2 days after pPCI. STEMI diagnosis criteria were: 1) chest pain for longer than 30 min but <12 h and either >2 mm of ST elevation in 2 contiguous precordial leads, >1 mm of ST elevation in 2 contiguous limb leads or a newly

End-point and follow-up

Of the 373 patients admitted with STEMI and treated with pPCI, 24 (6%) developed new-onset AF. Median follow-up time was 5.6 years (interquartile-range: 5.0–6.1 years). Follow-up was 100%. Median time from pPCI treatment to echocardiographic examination was 2 days (interquartile-range: 1-3 days).

Baseline findings

The population was stratified into tertiles of LAEF (Table 1). Female gender and lower grades of TIMI flow were associated with decreasing LAEF. With regards to biomarkers, higher peak TnI and CRP

Discussion

Several predictors of incident AF were found in this study. After multivariable analysis adjusting for age, sex, diabetes, GLS, E/e′ and peak troponin I level, LAEF and LAi remained independent predictors of incident AF. In the final multivariable model, minimal LA volume did not retain significance. Maximal LA volume was not even a significant univariable predictor of incident AF. Furthermore, only LAEF and LAi significantly improved risk stratification for AF when added to easily obtainable

Conclusion

The following is the supplementary data related to this article.

. Competing risk analysis treating death from all causes as a competing outcome and atrial fibrillation as a primary outcome in Cox regressions.

Acknowledgements

None.

Sources of funding

None. Daniel Modin was not supported by any fund or grant while preparing this manuscript.

Disclosures

The authors report nothing to disclose and no conflicts of interest.

References (27)

B. Olshansky
Are transthoracic echocardiographic parameters associated with atrial fibrillation recurrence or stroke? Results from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study
J. Am. Coll. Cardiol.
(Jun. 2005)
K.G. Skaarup
Diagnosing paroxysmal atrial fibrillation in patients with ischemic strokes and transient ischemic attacks using echocardiographic measurements of left atrium function
Am. J. Cardiol.
(Jan. 2016)
T. Biering-Sørensen et al.
Doppler tissue imaging is an independent predictor of outcome in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention
J. Am. Soc. Echocardiogr.
(2014)
E.M. Antman et al.
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction)
J. Am. Coll. Cardiol.
(2004)
W. Saliba et al.
Usefulness of CHADS2 and CHA2DS2-VASc scores in the prediction of new-onset atrial fibrillation: a population-based study
Am. J. Med.
(Aug. 2016)
T.S. Tsang
Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women
Mayo Clin. Proc.
(May 2001)
T.S.M. Tsang et al.
Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden
Am. J. Cardiol.
(Dec. 2002)
C.L. Simek et al.
Relationship between left ventricular wall thickness and left atrial size: comparison with other measures of diastolic function
J. Am. Soc. Echocardiogr.
(Feb. 1995)
K. Posina
Relationship of phasic left atrial volume and emptying function to left ventricular filling pressure: a cardiovascular magnetic resonance study
J. Cardiovasc. Magn. Reson.
(2013)
T. Biering-Sorensen
LA emptying fraction improves diagnosis of paroxysmal AF after cryptogenic ischemic stroke: results from the SURPRISE study
J. Am. Coll. Cardiol. Img.
(Sep. 2014)

P.E. Bloch Thomsen et al.

Long-term recording of cardiac arrhythmias with an implantable cardiac monitor in patients with reduced ejection fraction after acute myocardial infarction: the Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction (CARISMA) study

Circulation

(2010)

C. Jons et al.

Treating cardiac arrhythmias detected with an implantable cardiac monitor in patients after an acute myocardial infarction

Curr. Treat. Options Cardiovasc. Med.

(2012)

J. Schmitt et al.

Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications

Eur. Heart J.

(2009)

Cited by (18)

Predictive value of left atrial strain in relation to atrial fibrillation following acute myocardial infarction
2022, International Journal of Cardiology
Citation Excerpt :
Over the past decade more attention has been paid to the left atrium (LA). Estimates of AF risk have previously been based on the structure of the LA with echocardiographic measurements such as LA volume indexed to body surface area (LAVI) which has been shown to be a useful predictor of AF [3]. Newer echocardiographic parameters with focus on LA function have been introduced.
Atrial fibrillation (AF) is the most common arrythmia following ST-segment elevation myocardial infarction (STEMI) and can lead to stroke and other heart-related diseases. This study aimed to determine the prognostic value of left atrial (LA) strain, obtained by speckle tracking echocardiography (STE), in predicting incident AF outcomes following STEMI treated with primary percutaneous coronary intervention (pPCI).
This prospective study comprised of 392 STEMI patients treated with pPCI. The patients had an echocardiography performed at a median of two days after their STEMI. Along with conventional measures, LA strain was obtained by speckle tracking from two apical projections. The outcome was new-onset atrial fibrillation. LA reservoir, contractile and conduit strain were measurable from echocardiograms of 303 included patients. At a median follow-up time of 5.6 years (IQR: 5.0–6.1 years), 18 patients (6,3%) developed incident AF. Mean age was 62.0 years ±11.5 and follow-up was 100%. Significantly lower LA strain values were observed in patients who experienced AF during follow-up as compared to patients who didn't. Both reservoir, contractile and conduit strain were significant univariable predictors. In the multivariable model, only LA reservoir strain remained a significant independent predictor of AF.
Left atrial reservoir strain obtained by two-dimensional speckle tracking echocardiography is an independent predictor of incident AF following STEMI.
Left Atrial Structure and Function Predictors of New-Onset Atrial Fibrillation in Patients with Chagas Disease
2020, Journal of the American Society of Echocardiography
Citation Excerpt :
In patients undergoing pacemaker implantation, LA volume and LASct were associated with incident AF independent of age, sex, systolic blood pressure, and LV size and function.21 In patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, total LA emptying fraction and minimum LA volume, but not maximum LA volume, were independent predictors of incident AF and added incremental prognostic information to the CHARGE-AF risk score and CHA2DS2-VASc score.22 LA reservoir function measured by LA ε analysis is also a predictor of AF recurrence after catheter ablation.23
Atrial fibrillation (AF) carries ominous consequences in patients with Chagas disease. The aim of this study was to determine whether left atrial (LA) volume and function assessed using three-dimensional echocardiographic (3DE) imaging and two-dimensional speckle-tracking echocardiographic deformation analysis of strain (ε) could predict new-onset AF in patients with Chagas disease.
A total of 392 adult patients with chronic Chagas disease (59% women; mean age, 53 ± 11 years) who underwent echocardiography were consecutively enrolled in this prospective longitudinal study. Echocardiographic evaluation included two-dimensional (2D) Doppler echocardiography, with evaluation of left ventricular systolic and diastolic function, LA size, and LA and left ventricular function on 3DE and ε analyses. Multivariate Cox proportional-hazards regression analysis models adjusting for age, sex, hypertension, presence of a pacemaker, and 2D Doppler echocardiographic parameters were used to test if the variables of interest had independent prognostic value for AF prediction.
Patients with Chagas disease were followed for 5.6 ± 2.7 years. Among these, 139 (35.5%) had the indeterminate form, 224 (57.1%) had the cardiac form, five (1.3%) had the digestive form, and 24 (6.1%) had the cardiodigestive form. The study end point of AF occurred in 45 patients. Total LA emptying fraction (hazard ratio, 0.93; 95% CI, 0.89–0.98; P = .002), passive LA emptying fraction (HR, 0.95; 95% CI, 0.91–0.99; P = .02), and peak negative global LA ε (HR, 1.22; 95% CI, 1.05–1.41; P = .01) were predictors of new-onset AF independent of clinical and 2D Doppler echocardiographic parameters.
LA function assessed on 3DE and ε analyses predicts new-onset AF in patients with Chagas disease independent of clinical and 2D Doppler echocardiographic indexes.
Morroniside enhances angiogenesis and improves cardiac function following acute myocardial infarction in rats
2020, European Journal of Pharmacology
Citation Excerpt :
Acute myocardial infarction (AMI) has become one of the leading causes of death in westernized countries and is becoming increasingly more prevalent in the developing world (Pek et al., 2018; Teo and Dokainish, 2017). Despite numerous therapeutic strategies, such as thrombolysis, percutaneous coronary intervention, and surgical bypass grafting (Bangalore et al., 2015; Liu et al., 2015; Modin et al., 2018), a large proportion of patients with AMI show inadequate myocardial perfusion because of poor distal vessels or unacceptable procedural risks. A promising approach consisting of stimulating angiogenesis/arteriogenesis after AMI may help to improve cardiac perfusion and function (van der Laan et al., 2009).
Angiogenesis is critical for re-establishing blood supply to the ischemic myocardium after acute myocardial infarction (AMI). This study aimed to investigate the effects of morroniside on angiogenesis after AMI and explored associated proangiogenic mechanisms. A rat model of AMI was established by ligation of the left anterior descending coronary artery followed by administration of three doses of morroniside. Immunofluorescence staining was performed to identify newly generated endothelial cells and arterioles. The protein expression levels associated with angiogenesis were examined by western blots. Echocardiography was used to examine cardiac function. Our data revealed that morroniside promoted angiogenesis and improved cardiac function in rats with AMI. The proangiogenic effect of morroniside might be mediated by the VEGFA/VEGF receptor 2 signaling pathway.
Left Atrial Function Determined by Echocardiography Predicts Incident Heart Failure in Patients With STEMI treated by Primary Percutaneous Coronary Intervention
2020, Journal of Cardiac Failure
Citation Excerpt :
Parameters of left atrial function measured by echocardiography, such as the left atrial emptying fraction (LAEF), the minimal left atrial volume index (MinLAVI) and the left atrial expansion index (LAi), have been shown to correlate more strongly to LV filling pressure as compared to LAVI.10 Furthermore, our group has previously shown that parameters of LA function may be superior to LAVI for predicting atrial fibrillation both in patients with ST-elevated myocardial infarction (STEMI) and in individuals in the general population.11,12 Thus, it is possible that parameters of left atrial function may be superior to LAVI as markers of cardiac function in the short-term period following AMI.
To assess the comparative effectiveness of left atrial (LA) functional parameters (left atrial emptying fraction (LAEF), left atrial expansion index (LAi) and minimal left atrial volume index (MinLAVI)) with that of LA volume index (LAVI) in predicting heart failure (HF) and death following ST-elevated myocardial infarction (STEMI).
HF is common following STEMI. Enlarged LA volume as determined by echocardiography predicts adverse outcome following STEMI. However, whether echocardiographic parameters of LA function, such as LAEF, LAi and MinLAVI, are superior to LAVI for predicting prognosis following STEMI is unknown.
A total of 369 patients with STEMI but without atrial fibrillation or HF who were treated with primary percutaneous coronary intervention were prospectively enrolled in the period between September 2006 and December 2008. Patients underwent echocardiography shortly after STEMI. The maximal and minimal LA volumes were measured using the biplane area-length method. LAVI, MinLAVI (minimal LA volume indexed to body surface area), LAEF ((maximal LA volume–minimal LA volume)/maximal LA volume), and LAi ((maximal LA volume–minimal LA volume)/minimal LA volume) were calculated. The endpoint was a composite consisting of HF or death from any cause. During a median follow-up of 66 months (interquartile range: 50–73 months), 112 patients reached the endpoint (68 HFs, 44 deaths). Following adjustment for clinical, biochemical and echocardiographic variables, only LAEF remained an independent predictor of the composite outcome, whereas LAVI did not (LAEF: HR 1.25, P = 0.043, per 1 SD decrease) (LAVI: HR 1.01, P = 0.91, per 1 SD increase).
In patients with STEMI who were treated with primary percutaneous coronary intervention, LAEF, as measured by echocardiography shortly after infarction, was superior to LAVI in predicting incident HF and death.
Is there still a place for new echocardiographic parameters in risk stratification after acute myocardial infarction?
2018, Revista Portuguesa de Cardiologia
Left atrial functional measurements’ utility in predicting long-term risk of atrial fibrillation after isolated CABG
2023, Echocardiography

View all citing articles on Scopus

View full text

Measures of left atrial function predict incident atrial fibrillation in STEMI patients treated with primary percutaneous coronary intervention

Highlights

Abstract

Rationale

Objective

Methods and results

Conclusion

Introduction

Section snippets

Population

End-point and follow-up

Baseline findings

Discussion

Conclusion

Acknowledgements

Sources of funding

Disclosures

J. Am. Coll. Cardiol.

Am. J. Cardiol.

J. Am. Soc. Echocardiogr.

J. Am. Coll. Cardiol.

Am. J. Med.

Mayo Clin. Proc.

Am. J. Cardiol.

J. Am. Soc. Echocardiogr.

J. Cardiovasc. Magn. Reson.

J. Am. Coll. Cardiol. Img.

Long-term recording of cardiac arrhythmias with an implantable cardiac monitor in patients with reduced ejection fraction after acute myocardial infarction: the Cardiac Arrhythmias and Risk Stratification After Acute Myocardial Infarction (CARISMA) study

Circulation

Treating cardiac arrhythmias detected with an implantable cardiac monitor in patients after an acute myocardial infarction

Curr. Treat. Options Cardiovasc. Med.

Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications

Eur. Heart J.