Heart Failure
Left Atrial Function Predicts Heart Failure Events in Patients With Newly Diagnosed Left Ventricular Systolic Heart Failure During Short-Term Follow-Up
Angiology 2014, Vol. 65(9) 817-823 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003319713506109 ang.sagepub.com
Christina Chrysohoou, MD, PhD1, Iason Kotroyiannis, MD1, Christos-Constadinos Antoniou, MD1, Stella Brili, MD1, Sophia Vaina, MD1, George Latsios, MD1, Dimitris Tousoulis, MD1, Christos Pitsavos, MD1, and Christodoulos Stefanadis, MD1
Abstract We assessed the effect of left atrial (LA) function index, LA ejection fraction, LA kinetic energy, and maximal LA volume on 6 months clinical outcome in patients with newly diagnosed systolic heart failure (HF). During a 36-month period, 179 consecutive patients (17% female, mean age 63 + 14 years) were enrolled. During the follow-up, 46 patients had an event (32% event rate; 15 were fatal). Those with an adverse event were older, had lower creatinine clearance, advanced New York Heart Association stage, higher prevalence of ischemic HF, and lower values for right ventricle systolic wave in the tissue Doppler imaging evaluation, compared with those without an event. Multivariate analysis revealed that LA function and ischemic etiology of HF were the most significant prognostic indicators after index hospitalization. This study reveals the important role of LA function for the shortterm prognosis of patients with newly diagnosed systolic HF in sinus rhythm. Keywords left atrial function, heart failure, prognosis
Introduction Heart failure (HF) has been termed the ‘‘new epidemic of cardiovascular disease’’ for the 21st century. This is mainly attributed to improvements in the management of both patients with acute coronary syndromes and those with chronic coronary disease, which led to reduction in mortality rates and increase in the prevalence of patients surviving with chronic disease and ventricular dysfunction.1 This combined with an aging population has led to an increase in the prevalence of HF. Despite advances in diagnosis and treatment, the prognosis of HF remains unfavorable, with annual mortality exceeding 50% in selected populations.1,2 Among several factors with prognostic value for the clinical course of HF, age, left ventricular ejection fraction (LVEF), renal function, diastolic, and systolic blood pressure (BP) have been recognized as important determinants.3,4 Concerning diastolic function, left atrial (LA) contractile reserve impairment might be an early finding in the progression of HF from an abnormal relaxation to a restrictive pattern.5 Furthermore, LA remodeling due to overt or subclinical atrial volume or pressure overload could result in decreased atrial systolic function. Atrial dysfunction could lead to impaired atrial emptying, which decreases cardiac output
(CO), or it could be an early indicator of cardiac congestion or failure even when LVEF is preserved.6 Among several measurements of LA function, the American Society of Echocardiography recommended LA volume index (LAVI), the value of LA volume divided by body surface area (BSA), to measure LA size; this index has been related to cardiovascular mortality in patients after an acute coronary event.7,8 The purpose of this study was to assess the effect of LA function, as assessed by LA function index (LAFI), LA ejection fraction, LA kinetic energy (LAKE), and maximal LA volume in end systole (LAmax) on clinical outcome after a 6-month follow-up in patients with newly diagnosed systolic HF, after controlling for potential cofounders.
1
First Cardiology Clinic, School of Medicine, University of Athens, Athens, Greece
Corresponding Author: Christina Chrysohoou, First Cardiology Clinic, School of Medicine, University of Athens, 46 Paleon Polemiston St, Glyfada 166-74, Greece. Email: [email protected]
818
Angiology 65(9)
Methods Patients During a 36-month period, a total of 179 consecutive patients (17% female, mean age 63 + 14 years) hospitalized with newly diagnosed systolic HF and LVEF 120/min).10 Patients with atrial fibrillation (AF), severe valvular disease, and prosthetic valves were excluded from enrollment. New onset of acute HF, without previously known cardiac dysfunction, was diagnosed on the basis of the European Society of Cardiology criteria.11 Among the study patients, 146 (81%) were diagnosed with ischemic cardiomyopathy, and the rest (n ¼ 33, 19%) were diagnosed with dilated cardiomyopathy.
Measurements A complete medical history, as well as detailed information regarding medications, was recorded for all participants. The BP was measured, and patients with average BP 140/90 mm Hg or receiving antihypertensive medication were classified as hypertensive. Participants with fasting blood glucose >7 mmol/L (125 mg/dL) or treatment with antidiabetic medication were classified as diabetic. Following clinical investigation, patients were asked to provide information regarding their age and smoking habits. Body mass index (BMI) was calculated as weight/height2 in kg/m2, while BSA was calculated, according to the following formula: BSA ¼ ðheightÞ ^0:725 ðweightÞ ^0:425 0:007184 All other clinical variables (ie, etiology of cardiomyopathy, New York Heart Association [NYHA] functional class, and medications) were registered at the time of discharge from hospital. The specific type of cardiomyopathy (ie, ischemic or dilated) was diagnosed from the medical history and coronary catheterization results. Renal function was estimated using creatinine clearance (CrCl) calculated by the Cockcroft-Gault formula.12
Echocardiographic/Doppler Examination Echocardiographic assessment was performed in all patients during the third day of their initial hospitalization, and only patients with LV systolic dysfunction (LVEF or ¼ 65 years of age with well-preserved left ventricular systolic function. Am J Cardiol. 2005;96(6):832-836. 22. Melenovsky V, Borlaug BA, Rosen B, et al. Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction. J Am Coll Cardiol.2007;49(2):198-207. 23. Blume GG, Mcleod CJ, Barnes ME, et al. Left atrial function: physiology, assessment, and clinical implications. Eur J Echocardiogr. 2011;12(6):421-430.
Chrysohoou et al 24. Phan TT, Abozguia K, Shivu GN, et al. Increased atrial contribution to left ventricular filling compensates for impaired early filling during exercise in heart failure with preserved ejection fraction. J Card Fail. 2009;15(10):890-897. 25. Chatterjee K. Pathophysiology of systolic and diastolic heart failure. Med Clin North Am. 2012;96(5):891-899. 26. Chrysohoou C, Antoniou CK, Kotrogiannis I, et al. Role of right ventricular systolic function on long-term outcome in patients with newly diagnosed systolic heart failure. Circ J. 2011;75(9):2176-2181. 27. Boron WF, Boulpaep EL. Medical Physiology Elsevier Health Sciences; 2008. 28. Ristow B, Ali S, Whooley MA, Schiller NB. Usefulness of left atrial volume index to predict heart failure hospitalization and mortality in ambulatory patients with coronary heart disease and
823
29.
30.
31.
32.
comparison to left ventricular ejection fraction (from the Heart and Soul Study). Am J Cardiol. 2008;102(1):70-76. Tekin G, Tekin YK, Erbay AR, Turhan H, Yetkin E. Serum uric acid levels are associated with atrial fibrillation in patients with ischemic heart failure. Angiology. 2013;64(4):300-303. Scrutinio D, Passantino A, Santoro D, Catanzaro R. The cardiorenal anaemia syndrome in systolic heart failure: prevalence, clinical correlates, and long-term survival. Eur J Heart Fail. 2011;13(1):61-67. Macdougall IC, Canaud B, de Francisco ALM, et al. Beyond the cardiorenal anaemia syndrome: recognizing the role of iron deficiency. Eur J Heart Fail. 2012;14(8):882-886. Nozaki J, Kitahata H, Tanaka K, Kawahito S, Oshita S. Effects of acute normovolemic hemodilution on ventriculoarterial coupling in dogs. Acta Anaesthesiol Scand. 2003;47(1):46-52.
Left Atrial Function Predicts Heart Failure Events in Patients With Newly Diagnosed Left Ventricular Systolic Heart Failure During Short-Term Follow-Up
Angiology 2014, Vol. 65(9) 817-823 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003319713506109 ang.sagepub.com
Christina Chrysohoou, MD, PhD1, Iason Kotroyiannis, MD1, Christos-Constadinos Antoniou, MD1, Stella Brili, MD1, Sophia Vaina, MD1, George Latsios, MD1, Dimitris Tousoulis, MD1, Christos Pitsavos, MD1, and Christodoulos Stefanadis, MD1
Abstract We assessed the effect of left atrial (LA) function index, LA ejection fraction, LA kinetic energy, and maximal LA volume on 6 months clinical outcome in patients with newly diagnosed systolic heart failure (HF). During a 36-month period, 179 consecutive patients (17% female, mean age 63 + 14 years) were enrolled. During the follow-up, 46 patients had an event (32% event rate; 15 were fatal). Those with an adverse event were older, had lower creatinine clearance, advanced New York Heart Association stage, higher prevalence of ischemic HF, and lower values for right ventricle systolic wave in the tissue Doppler imaging evaluation, compared with those without an event. Multivariate analysis revealed that LA function and ischemic etiology of HF were the most significant prognostic indicators after index hospitalization. This study reveals the important role of LA function for the shortterm prognosis of patients with newly diagnosed systolic HF in sinus rhythm. Keywords left atrial function, heart failure, prognosis
Introduction Heart failure (HF) has been termed the ‘‘new epidemic of cardiovascular disease’’ for the 21st century. This is mainly attributed to improvements in the management of both patients with acute coronary syndromes and those with chronic coronary disease, which led to reduction in mortality rates and increase in the prevalence of patients surviving with chronic disease and ventricular dysfunction.1 This combined with an aging population has led to an increase in the prevalence of HF. Despite advances in diagnosis and treatment, the prognosis of HF remains unfavorable, with annual mortality exceeding 50% in selected populations.1,2 Among several factors with prognostic value for the clinical course of HF, age, left ventricular ejection fraction (LVEF), renal function, diastolic, and systolic blood pressure (BP) have been recognized as important determinants.3,4 Concerning diastolic function, left atrial (LA) contractile reserve impairment might be an early finding in the progression of HF from an abnormal relaxation to a restrictive pattern.5 Furthermore, LA remodeling due to overt or subclinical atrial volume or pressure overload could result in decreased atrial systolic function. Atrial dysfunction could lead to impaired atrial emptying, which decreases cardiac output
(CO), or it could be an early indicator of cardiac congestion or failure even when LVEF is preserved.6 Among several measurements of LA function, the American Society of Echocardiography recommended LA volume index (LAVI), the value of LA volume divided by body surface area (BSA), to measure LA size; this index has been related to cardiovascular mortality in patients after an acute coronary event.7,8 The purpose of this study was to assess the effect of LA function, as assessed by LA function index (LAFI), LA ejection fraction, LA kinetic energy (LAKE), and maximal LA volume in end systole (LAmax) on clinical outcome after a 6-month follow-up in patients with newly diagnosed systolic HF, after controlling for potential cofounders.
1
First Cardiology Clinic, School of Medicine, University of Athens, Athens, Greece
Corresponding Author: Christina Chrysohoou, First Cardiology Clinic, School of Medicine, University of Athens, 46 Paleon Polemiston St, Glyfada 166-74, Greece. Email: [email protected]
818
Angiology 65(9)
Methods Patients During a 36-month period, a total of 179 consecutive patients (17% female, mean age 63 + 14 years) hospitalized with newly diagnosed systolic HF and LVEF 120/min).10 Patients with atrial fibrillation (AF), severe valvular disease, and prosthetic valves were excluded from enrollment. New onset of acute HF, without previously known cardiac dysfunction, was diagnosed on the basis of the European Society of Cardiology criteria.11 Among the study patients, 146 (81%) were diagnosed with ischemic cardiomyopathy, and the rest (n ¼ 33, 19%) were diagnosed with dilated cardiomyopathy.
Measurements A complete medical history, as well as detailed information regarding medications, was recorded for all participants. The BP was measured, and patients with average BP 140/90 mm Hg or receiving antihypertensive medication were classified as hypertensive. Participants with fasting blood glucose >7 mmol/L (125 mg/dL) or treatment with antidiabetic medication were classified as diabetic. Following clinical investigation, patients were asked to provide information regarding their age and smoking habits. Body mass index (BMI) was calculated as weight/height2 in kg/m2, while BSA was calculated, according to the following formula: BSA ¼ ðheightÞ ^0:725 ðweightÞ ^0:425 0:007184 All other clinical variables (ie, etiology of cardiomyopathy, New York Heart Association [NYHA] functional class, and medications) were registered at the time of discharge from hospital. The specific type of cardiomyopathy (ie, ischemic or dilated) was diagnosed from the medical history and coronary catheterization results. Renal function was estimated using creatinine clearance (CrCl) calculated by the Cockcroft-Gault formula.12
Echocardiographic/Doppler Examination Echocardiographic assessment was performed in all patients during the third day of their initial hospitalization, and only patients with LV systolic dysfunction (LVEF or ¼ 65 years of age with well-preserved left ventricular systolic function. Am J Cardiol. 2005;96(6):832-836. 22. Melenovsky V, Borlaug BA, Rosen B, et al. Cardiovascular features of heart failure with preserved ejection fraction versus nonfailing hypertensive left ventricular hypertrophy in the urban Baltimore community: the role of atrial remodeling/dysfunction. J Am Coll Cardiol.2007;49(2):198-207. 23. Blume GG, Mcleod CJ, Barnes ME, et al. Left atrial function: physiology, assessment, and clinical implications. Eur J Echocardiogr. 2011;12(6):421-430.
Chrysohoou et al 24. Phan TT, Abozguia K, Shivu GN, et al. Increased atrial contribution to left ventricular filling compensates for impaired early filling during exercise in heart failure with preserved ejection fraction. J Card Fail. 2009;15(10):890-897. 25. Chatterjee K. Pathophysiology of systolic and diastolic heart failure. Med Clin North Am. 2012;96(5):891-899. 26. Chrysohoou C, Antoniou CK, Kotrogiannis I, et al. Role of right ventricular systolic function on long-term outcome in patients with newly diagnosed systolic heart failure. Circ J. 2011;75(9):2176-2181. 27. Boron WF, Boulpaep EL. Medical Physiology Elsevier Health Sciences; 2008. 28. Ristow B, Ali S, Whooley MA, Schiller NB. Usefulness of left atrial volume index to predict heart failure hospitalization and mortality in ambulatory patients with coronary heart disease and
823
29.
30.
31.
32.
comparison to left ventricular ejection fraction (from the Heart and Soul Study). Am J Cardiol. 2008;102(1):70-76. Tekin G, Tekin YK, Erbay AR, Turhan H, Yetkin E. Serum uric acid levels are associated with atrial fibrillation in patients with ischemic heart failure. Angiology. 2013;64(4):300-303. Scrutinio D, Passantino A, Santoro D, Catanzaro R. The cardiorenal anaemia syndrome in systolic heart failure: prevalence, clinical correlates, and long-term survival. Eur J Heart Fail. 2011;13(1):61-67. Macdougall IC, Canaud B, de Francisco ALM, et al. Beyond the cardiorenal anaemia syndrome: recognizing the role of iron deficiency. Eur J Heart Fail. 2012;14(8):882-886. Nozaki J, Kitahata H, Tanaka K, Kawahito S, Oshita S. Effects of acute normovolemic hemodilution on ventriculoarterial coupling in dogs. Acta Anaesthesiol Scand. 2003;47(1):46-52.
