© 2013, Wiley Periodicals, Inc. DOI: 10.1111/echo.12497
Echocardiography
Left Atrial Remodeling and Recurrence of Congestive Heart Failure in Patients Initially Diagnosed with Heart Failure Kazuto Yamaguchi, B.S., Hiroyuki Yoshitomi, M.D., Shimpei Ito, M.D., Saki Ito, M.D., Tomoko Adachi, M.D., Hirotomo Sato, M.D., Nobuhide Watanabe, M.D., Nobuhiro Kodani, M.D., Takashi Sugamori, M.D., Ph.D., Akihiro Endo, M.D., Ph.D., Nobuyuki Takahashi, M.D., Ph.D., and Kazuaki Tanabe, M.D., Ph.D. Division of Cardiology, Shimane University Faculty of Medicine, Izumo, Japan
Background: Left atrial volumes (LAVs) have been suggested to represent long-term exposure to elevated pressures. This study examined the recurrence of heart failure (HF) based on LAV in patients initially diagnosed with congestive HF (CHF). Methods: This study comprised 77 patients (age, 75 8 years) with well-documented, clinically defined HF, and complete two-dimensional echocardiographic examinations. The echocardiographic examinations were performed on admission and after medical treatment (90 43 days after initial examination). Patients with atrial fibrillation, flail mitral valve, or mitral valve replacement were excluded from this study. Results: The initial left ventricular ejection fraction (LVEF) was 44 17% and the indexed LAV (LAVI) was 61 22 mL/m2. After medical treatment, a decreased LAVI was observed in 38 patients and an increased LAVI (LA remodeling) was observed in 39 patients. With median follow-up periods of 454 days, compared to patients with decreased LAVI, patients with LA remodeling had a significantly higher incidence of CHF recurrence (P = 0.008). Patients with LA remodeling had a CHF-free survival rate of 36 13% vs. 81 9% (those without LA remodeling). A multivariate analysis indicated that, follow-up LV end-systolic volume (P = 0.04), LVEF (P = 0.005) and LAVI (P = 0.04) independently predicted CHF recurrence. Conclusions: Patients initially diagnosed with CHF follow divergent courses based on their LAV. LA remodeling after medical treatment can be useful for predicting CHF recurrence during follow-up. (Echocardiography 2014;31:936–940) Key words: left atrium, volume, echocardiography, heart failure During ventricular diastole, the left atrium (LA) is directly exposed to left ventricular (LV) pressures through the open mitral valve. Therefore, LA size is largely determined by the same factors that influence diastolic LV filling.1,2 Compared with Doppler assessment, LA size is a more stable indicator of LV diastolic function, reflecting both the duration and severity of diastolic dysfunction.3 LA size has also been established as a robust predictor of major adverse cardiovascular outcomes, including atrial fibrillation (AF),4,5 heart failure (HF),6,7 stroke,8–10 acute coronary events, needs for revascularization, and death.11,12 As the LV dimension is a poor indicator of LV volume, there are well-known limitations associated with the LA anteroposterior dimensions as indicators of chamber size. Two-dimensional (2D) echocardiography-derived LA volume (LAV) provides a more accurate assessment of LA size Address for correspondence and reprint requests: Kazuaki Tanabe, M.D., Ph.D., Division of Cardiology, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan. Fax: +81-853-20-2201; E-mail:[email protected]
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than that provided by M-mode LA dimensions.11 Physiologically, the atria enlarge in response to 2 broad conditions: pressure and volume overload. The relationship between increased LA size and increased filling pressures has been validated using invasive measures.1 During the medical treatment of patients initially diagnosed with congestive heart failure (CHF) and LV dysfunction (systolic or “isolated” diastolic), methods to quantify the risk of progression to cardiac events, such as CHF recurrence, would be clinically useful. The aim of this study was to determine the predictors CHF recurrence based on LAV in patients initially diagnosed with CHF. Methods: Study Population: The study population consisted of 77 patients with clinically defined CHF 13 who were admitted to Shimane University Hospital between January 2010 and December 2011. The mean age of the patients at the onset of CHF was 75 8 years; 53 patients (69%) were New York Heart
LA Remodeling and Recurrence of Heart Failure
Association functional class III or IV. The patients had a mean LV ejection fraction (EF) of 44 17%; CHF patients with preserved left ventricular ejection fraction (LVEF) were included in this study population. Coronary artery disease was present in 44 patients (57%). Patients with AF, flail mitral valve, prosthetic mitral valves, mitral valve stenosis, or pacemaker implantation were excluded from this study. For measuring brain natriuretic peptide (BNP) concentrations, blood samplings were performed before echocardiographic studies. The plasma concentration of BNP (normal value, ≤20 pg/mL) was measured using commercially available radioimmunoassay kits. Chronic kidney disease was ascertained through laboratory evaluation, with calculation of glomerular filtration rate, with a cutoff point of or = 65 years of age (the cardiovascular health study). Am J Cardiol 2006;97:83– 89. 8. Benjamin EJ, D’Agostino RB, Belanger AJ, et al: Left atrial size and the risk of stroke and death. The Framingham heart study. Circulation 1995;92:835–841. 9. Barnes ME, Miyasaka Y, Seward JB, et al: Left atrial volume in the prediction of first ischemic stroke in an elderly cohort without atrial fibrillation. Mayo Clin Proc 2004; 79:1008–1014.
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10. Fatema K, Bailey KR, Petty GW, et al: Increased left atrial volume index: Potent biomarker for first-ever ischemic stroke. Mayo Clin Proc 2008;83:1107–1115. 11. Tsang TSM, Abhayaratna WP, Barnes ME, et al: Prediction of cardiovascular outcomes with left atrial size: Is volume superior to area or diameter? J Am Coll Cardiol 2006;47:1018–1023. 12. Tsang TSM, Barnes ME, Gersh BJ, et al: Prediction of risk for first age-related cardiovascular events in an elderly population: The incremental value of echocardiography. J Am Coll Cardiol 2003;42:1199–1205. 13. McKee PA, Castelli WP, McNamara PM, et al: The natural history of congestive heart failure: The Framingham study. N Engl J Med 1971;285:1441–1446. 14. Hunt SA, Abraham WT, Chin MH, et al: 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;119:e391–e479. 15. Daimon M, Watanabe H, Abe Y, et al: Normal values of echocardiographic parameters in relation to age in a healthy Japanese population-The JAMP study. Circ J 2008;72:1859–1866. 16. Rudski LG, Lai WW, Afilalo J, et al: Guidelines for the echocardiographic assessment of the right heart in adults: A report from the American society of echocardiography. J Am Soc Echocardiogr 2010;23:685–713. 17. Yamaguchi K, Tanabe K, Tani T, et al: Left atrial volume in normal Japanese adults. Circ J 2006;70:285–288. 18. Abhayaratna WP, Seward JB, Appleton CP, et al: Left atrial size: Physiologic determinants and clinical applications. J Am Coll Cardiol 2006;47:2357–2363. 19. Greenberg B, Chatterjee K, Parmley WW, et al: The influence of left ventricular filling pressure on atrial contribution to cardiac output. Am Hear J 1979;98:742–751. 20. Rossi A, Cicoira M, Zanolla L, et al: Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy. J Am Coll Cardiol 2002;40:1425–1430. 21. Losi M-A, Betocchi S, Barbati G, et al: Prognostic significance of left atrial volume dilatation in patients with hypertrophic cardiomyopathy. J Am Soc Echocardiogr 2009;22:76–81. 22. Møller JE, Hillis GS, Oh JK, et al: Left atrial volume. A powerful predictor of survival after acute myocardial infarction. Circulation 2003;107:2207–2212. 23. Tsang TSM, Barnes ME, Abhayaratna WP, et al: Effects of quinapril on left atrial structural remodeling and arterial stiffness. Am J Cardiol 2006;97:916–920. 24. Gerdts E, Wachtell K, Omvik P, et al: Left atrial size and risk of major cardiovascular events during antihypertensive treatment: Losartan intervention for endpoint reduction in hypertension trial. Hypertension 2007;49:311–316.
Echocardiography
Left Atrial Remodeling and Recurrence of Congestive Heart Failure in Patients Initially Diagnosed with Heart Failure Kazuto Yamaguchi, B.S., Hiroyuki Yoshitomi, M.D., Shimpei Ito, M.D., Saki Ito, M.D., Tomoko Adachi, M.D., Hirotomo Sato, M.D., Nobuhide Watanabe, M.D., Nobuhiro Kodani, M.D., Takashi Sugamori, M.D., Ph.D., Akihiro Endo, M.D., Ph.D., Nobuyuki Takahashi, M.D., Ph.D., and Kazuaki Tanabe, M.D., Ph.D. Division of Cardiology, Shimane University Faculty of Medicine, Izumo, Japan
Background: Left atrial volumes (LAVs) have been suggested to represent long-term exposure to elevated pressures. This study examined the recurrence of heart failure (HF) based on LAV in patients initially diagnosed with congestive HF (CHF). Methods: This study comprised 77 patients (age, 75 8 years) with well-documented, clinically defined HF, and complete two-dimensional echocardiographic examinations. The echocardiographic examinations were performed on admission and after medical treatment (90 43 days after initial examination). Patients with atrial fibrillation, flail mitral valve, or mitral valve replacement were excluded from this study. Results: The initial left ventricular ejection fraction (LVEF) was 44 17% and the indexed LAV (LAVI) was 61 22 mL/m2. After medical treatment, a decreased LAVI was observed in 38 patients and an increased LAVI (LA remodeling) was observed in 39 patients. With median follow-up periods of 454 days, compared to patients with decreased LAVI, patients with LA remodeling had a significantly higher incidence of CHF recurrence (P = 0.008). Patients with LA remodeling had a CHF-free survival rate of 36 13% vs. 81 9% (those without LA remodeling). A multivariate analysis indicated that, follow-up LV end-systolic volume (P = 0.04), LVEF (P = 0.005) and LAVI (P = 0.04) independently predicted CHF recurrence. Conclusions: Patients initially diagnosed with CHF follow divergent courses based on their LAV. LA remodeling after medical treatment can be useful for predicting CHF recurrence during follow-up. (Echocardiography 2014;31:936–940) Key words: left atrium, volume, echocardiography, heart failure During ventricular diastole, the left atrium (LA) is directly exposed to left ventricular (LV) pressures through the open mitral valve. Therefore, LA size is largely determined by the same factors that influence diastolic LV filling.1,2 Compared with Doppler assessment, LA size is a more stable indicator of LV diastolic function, reflecting both the duration and severity of diastolic dysfunction.3 LA size has also been established as a robust predictor of major adverse cardiovascular outcomes, including atrial fibrillation (AF),4,5 heart failure (HF),6,7 stroke,8–10 acute coronary events, needs for revascularization, and death.11,12 As the LV dimension is a poor indicator of LV volume, there are well-known limitations associated with the LA anteroposterior dimensions as indicators of chamber size. Two-dimensional (2D) echocardiography-derived LA volume (LAV) provides a more accurate assessment of LA size Address for correspondence and reprint requests: Kazuaki Tanabe, M.D., Ph.D., Division of Cardiology, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan. Fax: +81-853-20-2201; E-mail:[email protected]
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than that provided by M-mode LA dimensions.11 Physiologically, the atria enlarge in response to 2 broad conditions: pressure and volume overload. The relationship between increased LA size and increased filling pressures has been validated using invasive measures.1 During the medical treatment of patients initially diagnosed with congestive heart failure (CHF) and LV dysfunction (systolic or “isolated” diastolic), methods to quantify the risk of progression to cardiac events, such as CHF recurrence, would be clinically useful. The aim of this study was to determine the predictors CHF recurrence based on LAV in patients initially diagnosed with CHF. Methods: Study Population: The study population consisted of 77 patients with clinically defined CHF 13 who were admitted to Shimane University Hospital between January 2010 and December 2011. The mean age of the patients at the onset of CHF was 75 8 years; 53 patients (69%) were New York Heart
LA Remodeling and Recurrence of Heart Failure
Association functional class III or IV. The patients had a mean LV ejection fraction (EF) of 44 17%; CHF patients with preserved left ventricular ejection fraction (LVEF) were included in this study population. Coronary artery disease was present in 44 patients (57%). Patients with AF, flail mitral valve, prosthetic mitral valves, mitral valve stenosis, or pacemaker implantation were excluded from this study. For measuring brain natriuretic peptide (BNP) concentrations, blood samplings were performed before echocardiographic studies. The plasma concentration of BNP (normal value, ≤20 pg/mL) was measured using commercially available radioimmunoassay kits. Chronic kidney disease was ascertained through laboratory evaluation, with calculation of glomerular filtration rate, with a cutoff point of or = 65 years of age (the cardiovascular health study). Am J Cardiol 2006;97:83– 89. 8. Benjamin EJ, D’Agostino RB, Belanger AJ, et al: Left atrial size and the risk of stroke and death. The Framingham heart study. Circulation 1995;92:835–841. 9. Barnes ME, Miyasaka Y, Seward JB, et al: Left atrial volume in the prediction of first ischemic stroke in an elderly cohort without atrial fibrillation. Mayo Clin Proc 2004; 79:1008–1014.
940
10. Fatema K, Bailey KR, Petty GW, et al: Increased left atrial volume index: Potent biomarker for first-ever ischemic stroke. Mayo Clin Proc 2008;83:1107–1115. 11. Tsang TSM, Abhayaratna WP, Barnes ME, et al: Prediction of cardiovascular outcomes with left atrial size: Is volume superior to area or diameter? J Am Coll Cardiol 2006;47:1018–1023. 12. Tsang TSM, Barnes ME, Gersh BJ, et al: Prediction of risk for first age-related cardiovascular events in an elderly population: The incremental value of echocardiography. J Am Coll Cardiol 2003;42:1199–1205. 13. McKee PA, Castelli WP, McNamara PM, et al: The natural history of congestive heart failure: The Framingham study. N Engl J Med 1971;285:1441–1446. 14. Hunt SA, Abraham WT, Chin MH, et al: 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;119:e391–e479. 15. Daimon M, Watanabe H, Abe Y, et al: Normal values of echocardiographic parameters in relation to age in a healthy Japanese population-The JAMP study. Circ J 2008;72:1859–1866. 16. Rudski LG, Lai WW, Afilalo J, et al: Guidelines for the echocardiographic assessment of the right heart in adults: A report from the American society of echocardiography. J Am Soc Echocardiogr 2010;23:685–713. 17. Yamaguchi K, Tanabe K, Tani T, et al: Left atrial volume in normal Japanese adults. Circ J 2006;70:285–288. 18. Abhayaratna WP, Seward JB, Appleton CP, et al: Left atrial size: Physiologic determinants and clinical applications. J Am Coll Cardiol 2006;47:2357–2363. 19. Greenberg B, Chatterjee K, Parmley WW, et al: The influence of left ventricular filling pressure on atrial contribution to cardiac output. Am Hear J 1979;98:742–751. 20. Rossi A, Cicoira M, Zanolla L, et al: Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy. J Am Coll Cardiol 2002;40:1425–1430. 21. Losi M-A, Betocchi S, Barbati G, et al: Prognostic significance of left atrial volume dilatation in patients with hypertrophic cardiomyopathy. J Am Soc Echocardiogr 2009;22:76–81. 22. Møller JE, Hillis GS, Oh JK, et al: Left atrial volume. A powerful predictor of survival after acute myocardial infarction. Circulation 2003;107:2207–2212. 23. Tsang TSM, Barnes ME, Abhayaratna WP, et al: Effects of quinapril on left atrial structural remodeling and arterial stiffness. Am J Cardiol 2006;97:916–920. 24. Gerdts E, Wachtell K, Omvik P, et al: Left atrial size and risk of major cardiovascular events during antihypertensive treatment: Losartan intervention for endpoint reduction in hypertension trial. Hypertension 2007;49:311–316.
