Search

Background: Transthoracic echocardiography (TTE) plays a key role in the initial work‐up of myocarditis where the identification of pathologic structural and functional changes may assist in its diagnosis and management. The aim of this systematic review was to appraise the evidence for the utility of echocardiographic parameters of cardiac structure and function in the diagnosis of myocarditis in adult populations. Methods: A systematic literature search of medical databases was performed using PRISMA principles to identify all relevant studies assessing TTE parameters in adult patients with myocarditis (1995–2020; English only; PROSPERO registration CRD42021243598). Data for a range of structural and functional TTE parameters were individually extracted and those with low heterogeneity were then meta‐analyzed using a random‐effects model for effect size, and assessed through standardized mean difference (SMD). Results: Available data from six studies (with a pooled total of 269 myocarditis patients and 240 controls) revealed that myocarditis can be reliably differentiated from healthy controls using echocardiographic measures of left ventricular (LV) size and systolic function, in particular LV end‐diastolic diameter, LV ejection fraction (LVEF) and LV global longitudinal strain (LV‐GLS) (p ≤.01 for all). LV‐GLS demonstrated the highest overall effect size, followed by LVEF and LVEDD (SMD: |0.46–1.98|). Two studies also demonstrated that impairment in LV‐GLS was associated with adverse cardiovascular outcomes in this population, irrespective of LVEF. Conclusions: LV‐GLS demonstrated the greatest overall effect size and therefore ability to differentiate myocarditis populations from healthy controls. GLS was also shown to be a predictor of adverse cardiovascular outcomes, in this population. Hightlights: What is already known on this subject? Myocarditis is a disease process that is often a diagnosis of exclusion, as it frequently mimics other acute cardiac pathologies.Transthoracic echocardiography is traditionally the initial imaging modality used for noninvasive structural assessment in populations with myocarditis. What might this study add? This study demonstrates that left ventricular (LV) global longitudinal strain, LV ejection fraction and LV end‐diastolic diameter can differentiate between myocarditis patients and healthy controls.LV‐GLS demonstrated the greatest overall effect size when comparing these two populations, in comparison to the other measures. How might this impact on clinical practice? This study demonstrates that assessment of myocardial deformation indices allows for sensitive discrimination between myocarditis patients from healthy controls.Routine assessment of LV‐GLS may serve as an important diagnostic tool in the acute care setting. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a prevalent disease with associated mortality risk, mediated in large part through its associated cardiovascular risk factors. Standard modifiable cardiovascular risk factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes and smoking) are established drivers of cardiovascular disease; however, the importance of non‐traditional mediators of cardiovascular risk (NTRFs) such as chronic renal impairment, obstructive sleep apnoea and obesity is emerging. The differential impact of these risk factors on outcomes in patients with AF is not well studied. Methods: Consecutive patients admitted to our service between January 2013 and January 2018 with a primary diagnosis of non‐valvular AF were assessed. Assessment of demographic, anthropometric, risk factor profile and pharmacotherapeutics was performed. The clinical course of these patients was followed for up to five years for the composite outcome of all‐cause death and major adverse cardiovascular events. Results: Of the 1010 patients (62.29 ± 16.81 years, 51% men) included, 154 (15%) had no risk factors, 478 (47%) had only SMuRFs, 59 (6%) had only NTRFs and 319 (32%) had both SMuRFs and NTRFs. Over a mean follow‐up period of 33.18 ± 21.27 months, a total of 288 patients met the composite outcome. On Cox regression, the coexistence of SMuRFs and NTRFs was an independent predictor of the composite outcome (HR 1.40; 95%CI 1.09–1.82, p =.01). Other independent predictors included age, heart failure, CHA2DS2VASc score, persistent AF and anaemia. Conclusions: The presence of both SMuRFs and NTRFs has prognostic implications in patients with non‐valvular AF. [ABSTRACT FROM AUTHOR]

Aims: The persistence of atrial fibrillation (AF) has been associated with differential clinical outcomes, with studies showing that persistent and permanent AF results in increased morbidity and mortality when compared to the paroxysmal subtype. Given the established prognostic implications of AF subtype, we sought to discern the clinical and structural cardiac parameters associated with persistent/ permanent AF. Materials and methods: Consecutive patients admitted to our institution between January 2013 and January 2018 with a primary diagnosis of non‐valvular AF who underwent comprehensive transthoracic echocardiography were retrospectively appraised. Assessment of clinical and echocardiographic parameters was undertaken and compared according to AF subtype. Results: Of 1010 patients, 665 (mean age 66.8 ± 13.5 years, 53% men) had comprehensive transthoracic echocardiography on index admission and were included in the primary analysis. The majority of patients (n = 468; 70%) had paroxysmal AF while 197 (30%) had persistent/ permanent AF. Multivariable logistic regression analysis showed that heart failure (adjusted OR 3.135; 95% CI 2.099 to 4.682, P <.001), right atrial (RA) area ≥18 cm2 (adjusted OR 2.147; 95% CI 1.413 to 3.261, P <.001) and left atrial emptying fraction (LAEF) ≤34% (adjusted OR 2.959; 95% CI 1.991 to 4.398, P <.001) were independent predictors of persistent /permanent AF. Conclusions: The presence of heart failure, increased RA size and impaired LA function were associated with persistent/ permanent AF. These clinical and cardiac structural risk markers of AF persistence may identify a target population for early intervention to prevent adverse cardiovascular outcomes. [ABSTRACT FROM AUTHOR]

Ischaemic left ventricular (LV) dysfunction can arise from myocardial stunning, hibernation, or necrosis. Imaging modalities have become front-line methods in the assessment of viable myocardial tissue, with the aim to stratify patients into optimal treatment pathways. Initial studies, although favorable, lacked sufficient power and sample size to provide conclusive outcomes of viability assessment. Recent trials, including the STICH and HEART studies, have failed to confer prognostic benefits of revascularisation therapy over standard medical management in ischaemic cardiomyopathy. In lieu of these recent findings, assessment of myocardial viability therefore should not be the sole factor for therapy choice. Optimization of medical therapy is paramount, and physicians should feel comfortable in deferring coronary revascularisation in patients with coronary artery disease with reduced LV systolic function. Newer trials are currently underway and will hopefully provide a more complete understanding of the pathos and management of ischaemic cardiomyopathy. [ABSTRACT FROM AUTHOR]

Hypertension is a globally prevalent condition, with a heavy clinical and economic burden. It is the predominant risk factor for premature cardiovascular and cerebrovascular disease, and is associated with a variety of clinical disorders including stroke, congestive cardiac failure, ischaemic heart disease, chronic renal failure, and peripheral arterial disease. A significant subset of hypertensive patients have resistant hypertensive disease. In this group of patients, catheter-based renal artery denervation has emerged as a potential therapy, with favourable clinical efficacy and safety in early trials. Additional benefits of this therapy are also being identified and include effects on left ventricular remodeling, cardiac performance, and symptom status in congestive cardiac failure. Utility of renal denervation for the management of resistant hypertension, however, has become controversial since the release of the Symplicity HTN-3 trial, the first large-scale blinded randomised study investigating the efficacy and safety of renal artery denervation. The aim of this paper is to evaluate the history, utility, and clinical efficacy of renal artery denervation technology, including an in-depth appraisal of the current literature and principal trials. [ABSTRACT FROM AUTHOR]

Recently established heart failure therapies, including sodium glucose co-transporter 2 inhibitors, angiotensin-neprilysin inhibitors, and cardiac resynchronization therapy, have led to both clinical and structural improvements. Reverse remodelling describes the structural and functional responses to therapy and has been shown to correlate with patients' clinical response, acting as a biomarker for treatment success. The introduction of these new therapeutic agents in addition to advances in non-invasive cardiac imaging has led to an expansion in the evaluation and the validation of cardiac reverse remodelling. Methods including volumetric changes as well as strain and myocardial work have all been shown to be non-invasive end-points of reverse remodelling, correlating with clinical outcomes. Our review summarizes the current available evidence on reverse remodelling in heart failure by the non-invasive cardiac imaging techniques, in particular transthoracic echocardiography., (© 2023 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Subclinical changes in left ventricular (LV) function have been demonstrated in patients with acute-phase myocarditis (AM) despite normal LV ejection fraction. The impact of AM on right ventricular (RV) and left atrial (LA) function has not been well described. This study aimed to assess for subclinical chamber dysfunction by speckle tracking echocardiography and its clinical relevance in this population. Patients with a diagnosis of AM (as per the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases) admitted to our institution from 2013 to 2018 were assessed. Patients with elevated serum troponin, normal coronary assessment, and normal LV ejection fraction on transthoracic echocardiogram were included. Clinical and echocardiographic parameters were compared with healthy age-, gender- and risk-factor matched controls. Global longitudinal strain assessed through speckle tracking echocardiography was performed using vendor independent software (v4.6; TomTec Arena, Munich, Germany). The final cohort consisted of 80 patients (40 AM patients and 40 controls). No significant differences in baseline clinical characteristics were observed between groups. Of the echocardiographic parameters, AM patients had lower LV-global longitudinal strain (p <0.01), lower RV free-wall strain (p = 0.02) and lower peak LA strain (p <0.01). There were no differences in traditional echocardiographic measures of LV, RV, and LA function appreciated between groups. The presence of multichamber involvement was associated with peak Troponin levels (p <0.01). In conclusion, our study demonstrates the presence of global subclinical myocardial dysfunction in patients with AM. Additionally, the presence of multichamber involvement was significantly associated with degree of myocardial necrosis., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Obesity has been linked with alterations in hemodynamic, autonomic, and hormonal pathways in the body, leading to a spectrum of cardiovascular changes. We sought to evaluate the effects of obesity on structural and functional changes of the heart in the absence of cardiac disease and associated risk factors., Methods: We identified healthy outpatients without any cardiovascular disease or risk factors from our institution's echocardiography database (2017-2020). Patients were stratified by body mass index (BMI; normal: 18.5-25 kg/m 2 ; overweight: 25-30 kg/m 2 ; class 1 obesity: 30-35 kg/m 2 ; class 2 obesity: 35-40 kg/m 2 ; class 3 obesity: >40 kg/m 2 ). Traditional and advanced echocardiographic parameters of cardiac chamber size and function including left ventricular global longitudinal strain (LV-GLS), left atrial reservoir strain (LASr), and right ventricular free wall strain (RV-FWS) were examined. The optimal cut-off BMI for discriminating LV-GLS (>-17.5%), LASr (<23%), and RV-FWS (>-23%) impairment was calculated using ROC curves., Results: 307 patients were assessed (41.5 ± 13.3yrs; 36.5%male; LVEF 61.3 ± 4.8%). No significant differences in indexed chamber volumes or LVEF were appreciated across BMI groups (p > 0.05 for all). LV-GLS, LASr, and RV-FWS were all significant on one-way ANOVA for differences from the group mean (all p < 0.01). Jonckheere-Terpstra test confirmed a significant trend of lower absolute LV-GLS, LASr and RV-FWS values across the rising BMI groups. On ROC curve analysis, a BMI value of 29.9 kg/m 2 , 35.1 kg/m 2 , and 37.3 kg/m 2 were associated with LASr (AUC: 0.75), RV-FWS (AUC: 0.72), and LV-GLS (AUC: 0.75) impairment respectively., Conclusion: Obesity is linked with subclinical reduction of cardiac function in otherwise healthy subjects without cardiovascular risk factors, with reduction of left atrial function occurring at lower BMI, followed by the right and left ventricular function., Competing Interests: None., (© 2023 Published by Elsevier B.V.)

Optimising guideline-directed anticoagulation in atrial fibrillation remains a perennial problem despite strong evidence for improved health outcomes with guideline-directed use of anticoagulation. Efforts to improve uptake have been hampered by barriers found at the level of the physician, patient, disease, and choice of therapy. Clinician judgement is often clouded by factors such as therapeutic inertia, aversion to bleeding risk, and implicit bias. For patients, negative preconceptions of therapy, impact of therapy on day-to-day life, and the nocebo effect pose significant barriers. Both groups are affected by poor education. Utility of a single-pronged approach directed toward clinicians or patients have demonstrated variable success, with the highest impact appreciated in studies using shared-decision models. Further, there is emerging evidence for use of integrated models of care, which have shown efficacy in improving patient outcomes, as well as use of digital platforms such as mobile app-based interventions, which can be of aid to the clinician in improving patient adherence to anticoagulation, with translated improved outcomes in clinical trials. This narrative review aims to investigate the physician and health system, patient, and drug therapy and disease barriers to uptake of guideline-directed anticoagulation in the treatment of nonvalvular atrial fibrillation., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Stroke of undetermined source, commonly termed cryptogenic stroke (CS), accounts for a significant proportion of ischemic stroke etiology and have high rates of stroke recurrence. The heterogeneous etiology of CS makes decisions regarding treatment for such patients challenging. The aim of this study was to evaluate the diagnostic and prognostic value of left atrial (LA) function in the identification of cardioembolism and prediction of outcomes in patients with CS., Methods: Consecutive patients admitted to a tertiary institution with ischemic stroke or transient ischemic attack (TIA) who underwent transthoracic echocardiography were recruited, with comprehensive evaluation of LA metrics including LA strain. Ischemic strokes and TIAs were classified as noncardioembolic, cryptogenic, or cardioembolic. A total of 709 patients (mean age, 66.0 ± 15.1 years; 55% men) were recruited. Two hundred ninety-one patients had CS, 189 had noncardioembolic stroke, and 229 had cardioembolic stroke. Patients with CS were followed for 20.0 ± 13.8 months for recurrent ischemic stroke or TIA., Results: Receiver operating characteristic curves showed LA reservoir and contractile strain to be strong discriminators of cardioembolic strokes, and log-rank tests showed both measures to be significantly associated with the distribution of time to recurrent ischemic stroke or TIA in patients with CS. Multivariable hazard models showed LA reservoir and contractile strain to be independent predictors of recurrent ischemic stroke or TIA in patients with CS, in addition to estimated glomerular filtration rate and active smoking., Conclusions: LA reservoir and contractile strain were strong discriminators of cardioembolic stroke and independently predicted recurrent ischemic stroke or TIA in patients with CS. Use of LA strain may improve risk stratification and decision-making in patients with CS, with particular regard to prolonged ambulatory heart rhythm monitoring and/or empiric anticoagulation., (Copyright © 2022 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: The presence of myocardial late gadolinium enhancement (LGE) indicates myocyte necrosis, and assists with the diagnosis of acute myocarditis (AM). Cardiac magnetic resonance (CMR) measures other than LGE i.e. tissue characterization and myocardial structural and functional parameters, play an important diagnostic role in assessment for inflammation, as seen in AM. The aim of this systematic review was to appraise the evidence for the use of quantitative CMR measures to identify myocardial inflammation in order to diagnose AM in adult patients., Methods: A systematic literature search of medical databases was performed using PRISMA principles to identify relevant CMR studies on AM in adults (2005-2020; English; PROSPERO registration CRD42020180605). Data for a range of quantitative CMR measures were extracted. Continuous variables with low heterogeneity were meta-analyzed using a random-effects model for overall effect size measured as the standard mean difference (SMD)., Results: Available data from 25 studies reporting continuous quantitative 1.5-T CMR measures revealed that AM is most reliably differentiated from healthy controls using T1 mapping (SMD 1.80, p<0.01) and T2 mapping (SMD 1.63, p<0.01), respectively. All other measures examined including T2-weighted ratio, extracellular volume, early gadolinium enhancement ratio, right ventricular ejection fraction, and LV end-diastolic volume, mass, ejection fraction, longitudinal strain, circumferential strain, and radial strain also had discriminatory ability although with smaller standard mean difference values (|SMD| 0.32-0.96, p < 0.01 for all)., Conclusions: Meta-analysis shows that myocardial tissue characterization (T1 mapping>T2 mapping) followed by measures of left ventricular structure and function demonstrate diagnostic discriminatory ability in AM., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.

Background: Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, with significant clinical and economic burdens, largely driven by adverse cardiovascular outcomes and AF-related hospitalization. Left atrial (LA) parameters have been shown to have prognostic value in cardiovascular disease states. We sought to evaluate the prognostic value of measures of LA size and function, as measured through LA volume index and LA emptying fraction (LAEF), respectively, for AF rehospitalization and long-term adverse outcomes in patients with nonvalvular AF following index hospitalization., Methods: In this retrospective study, 594 consecutive patients (mean age, 67.8 ± 13.6 years, 53% men) admitted to a tertiary referral center with nonvalvular AF were assessed. Patients who underwent transthoracic echocardiography during their index admission and had complete follow-up data were included and followed for a mean period of 33.18 ± 21.27 months for the primary outcome of AF rehospitalization. The secondary outcome was a composite of all-cause death and major adverse cardiovascular events., Results: The primary outcome occurred in 250 (42%) patients, and the secondary outcome occurred in 219 (37%) patients. On multivariable regression analysis, LAEF had an independent association with AF rehospitalization (hazard ratio [HR] = 0.967; 95% CI, 0.953-0.982; P < .01), and time-dependent receiver operating characteristic curves demonstrated LAEF to have strong diagnostic accuracy in predicting early and intermediate AF rehospitalization. Both LA volume index (HR = 1.014; 95% CI, 1.003-1.026; P = .01) and LAEF (HR = 0.982; 95% CI, 0.970-0.993; P < .01) were associated with all-cause death and major adverse cardiovascular events., Conclusions: Adverse LA remodeling, as reflected through LA enlargement and reduced LA mechanical function, is associated with AF rehospitalization and long-term adverse cardiovascular outcomes in hospitalized patients with nonvalvular AF., (Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Left atrial (LA) enlargement predicts adverse cardiovascular events in patients with chronic kidney disease (CKD). The aim of our study was to evaluate the value of LA reservoir strain, a novel measure of LA function, as a prognostic marker for adverse renal outcomes. A total of 280 patients (65.8 ± 12.2years, 63% male) with stable Stage 3 and 4 CKD without prior cardiac history were evaluated with transthoracic echocardiography and prospectively followed for up to 5 years. The primary end point was progressive renal failure, which was the composite of death from renal cause, end-stage renal failure and/or doubling of serum creatinine. Over a mean follow up of 3.9 ± 2.7years, 56 patients reached the composite endpoint. By log rank test, older age, lower baseline eGFR, anemia, diabetes mellitus, higher urinary albumin/creatinine ratio, number of antihypertensive medications, higher indexed left ventricular mass, larger LA volumes, and impaired LA reservoir strain were significant predictors of the composite outcome (p <0.01 for all). Multi-variable Cox regression analysis found LA reservoir strain, eGFR, number of antihypertensive medications and urinary albumin/creatinine ratio were independent predictors for progressive renal failure (p <0.01 for all). Impaired LA reservoir strain was associated with a 2.5-fold higher risk of the composite outcome (HR 2.51, 95% CI 1.19 to 5.30, p = 0.02) and was the only echocardiographic parameter that predicted progressive renal failure independent of established clinical risk factors for end-stage renal failure. Its utility requires validation in high risk CKD patients with cardiac disease., Competing Interests: Disclosures The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice with an epidemiological coupling appreciated with advancing age, cardiometabolic risk factors, and structural heart disease. This has resulted in a significant public health burden over the years, evident through increasing rates of hospitalization and AF-related clinical encounters. The resultant gap in health care outcomes is largely twinned with suboptimal rates of anticoagulation prescription and adherence, deficits in symptom identification and management, and insufficient comorbid cardiovascular risk factor investigation and modification. In view of these shortfalls in care, the establishment of integrated chronic care models serves as a road map to best clinical practice. The expansion of integrated chronic care programs, which include multidisciplinary team care, nurse-led AF clinics, and use of telemedicine, are expected to improve AF-related outcomes in the coming years. This review will delve into current gaps in AF care and the role of integrated chronic care models in bridging fragmentations in its management.

Background: Patients with chronic kidney disease (CKD) are at increased risk of adverse cardiovascular events, which is underestimated by traditional risk stratification algorithms. We sought to determine clinical and echocardiographic predictors of adverse outcomes in CKD patients., Methods: Two hundred forty-three prospectively recruited stage 3/4 CKD patients (male, 63%; mean age, 59.2 ± 14.4 years) without previous cardiac disease made up the study cohort. All participants underwent a transthoracic echocardiogram, with left ventricular (LV) and left atrial (LA) strain analysis. Participants were followed for 3.9 ± 2.7 years for the primary end point of cardiovascular death and major adverse cardiovascular event (MACE). The secondary end point was the composite of all-cause death and MACE., Results: Fifty-four patients met the primary end point, and 65 the secondary end point. On log-rank tests, older age, diabetes mellitus, anemia, greater LV mass, reduced LV global longitudinal strain, larger indexed LA volume, higher E/e' ratio, and reduced LA reservoir strain (LASr; P < .01 for all) were independent predictors of cardiovascular death and MACE. On multivariable regression analysis of univariate predictors, LASr (P < .01) was the only independent predictor for the primary end point as well as for the secondary end point. Receiver operating characteristic curve analysis showed LASr was a stronger predictor of adverse events (area under the curve [AUC] = 0.84) compared to the Framingham (AUC = 0.58) and Atherosclerotic Cardiovascular Disease (AUC = 0.59) risk scores., Conclusions: LASr is an independent predictor of cardiovascular death and MACE in CKD patients, superior to clinical risk scores, LV parameters, and LA volume., (Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: Left atrial (LA) deformation during the reservoir phase (LASr) has demonstrated strong prognostic value in different clinical settings. Although determinants of left atrial reservoir strain including left atrial relaxation, left atrial compliance, and left ventricular longitudinal systolic function are fairly well defined, there is incomplete information regarding the effect of left atrial volume on this relationship which is the focus of our study., Method: Consecutive patients without prior cardiac disease referred for transthoracic echocardiography were prospectively recruited. All participants underwent clinical assessment, transthoracic echocardiography (TTE), and screening exercise stress test. Only patients with normal left ventricular ejection fraction (LVEF) without left ventricular hypertrophy (LVH) or myocardial ischemia on stress testing were included., Results: A total of 260 patients (57% male, mean age 59 ± 14 years) were included. 70% had hypertension, 33% had diabetes mellitus, and 31% had both HTN and DM. On multivariate analysis, age, e', LAVI, and LV GLS (P < .01 for all) showed an independent association with LASr. Of interest, at lower tertiles of LAVI, a linear decrease in LASr was observed parallel to worsening LV GLS, whilst at higher tertiles of LAVI, the reduction in LASr was non-linear implying that LA enlargement, consequent to LA remodeling, had an incremental effect on LASr., Conclusion: Age, e', LV GLS, and LAVI were independently associated with LASr. LA remodeling reflected by larger LAVI had an incremental negative association with LASr independent of LV GLS., (© 2020 Wiley Periodicals LLC.)

Objectives: This study sought to assess the relationship between E/e' and exercise capacity in patients with chronic kidney disease (CKD) and evaluate its prognostic role., Background: Patients with CKD have diastolic dysfunction, reduced physical fitness, and elevated risk of cardiovascular disease., Methods: Patients with stage 3 and 4 CKD without previous cardiac disease underwent resting and exercise stress echocardiograms with assessment of exercise E/e'. Patients were compared to age-, sex-, and risk factor-matched control individuals and were followed annually for 5 years for cardiovascular death and major adverse cardiovascular event(s) (MACE). Exercise capacity was assessed as metabolic equivalents (METs), with reduced exercise capacity defined as METs of ≤7. Raised exercise E/e' was defined as >13., Results: A total of 156 patients with CKD (age 62.8 ± 10.6 years; male: 62%) were compared to 156 matched control individuals. Patients with CKD were more likely to be anemic (p < 0.01) and had increased left ventricular mass (p < 0.01), larger left atrial volumes (p < 0.01), and higher resting (p < 0.01) and exercise E/e' (p < 0.01). Patients with CKD achieved lower exercise METs (p < 0.01), and more patients with CKD had METs of ≤7 (p < 0.01). Receiver-operating characteristic curves showed exercise E/e' (area under the curve [AUC]: 0.89; 95% CI: 0.84 to 0.95; p < 0.01) as the strongest predictor of reduced exercise capacity in patients with CKD. Over a follow-up period of 41.4 months, a raised exercise E/e' of >13 was an independent predictor of cardiovascular death and MACE on unadjusted and adjusted hazard models., Conclusion: E/e' is a strong predictor of exercise capacity and METs achieved by patients with CKD. Exercise capacity was reduced in patients with CKD, presumably consequent to diastolic dysfunction. Elevated exercise E/e' in patients with CKD is an independent predictor of cardiovascular death and MACE., Competing Interests: Author Disclosures Dr. Kadappu is supported by an National Health and Medical Research Council Scholarship (GNT1018215). Dr. Gan is supported by a University of New South Wales University Postgraduate Award (UNSW3080080). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Strokes in the young and middle-aged are associated with a disproportionately large economic and social impact in addition to their clinical effects. Standard Modifiable Cardiovascular Risk Factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes mellitus and smoking) are key drivers of cardiovascular disease including strokes, however recent temporal trends in the younger stroke population have not been well characterised. We aimed to evaluate recent trends of SMuRFs in a cohort of younger patients with ischaemic stroke., Methods: Consecutive patients aged <65 years with clinical and/or radiological diagnosis of ischaemic stroke or transient ischaemic attack in a tertiary referral centre (2013-2017) were retrospectively appraised. The demographic and clinical comorbidities of these patients were assessed including their SMuRF profile. The prevalence over time and clinical associations of patients with no SMuRFs were studied and compared to patients with SMuRFs., Results: Of 487 patients (53.49 ± 9.13 yrs., 60% men) analysed, 23% did not have SMuRFs. The proportion of "non-SMuRF" patients increased over time (p < 0.01) and this trend was not influenced by age (p = 0.48) or gender (p = 0.68). The presence of SMuRFs was not associated with in-hospital outcomes, however patients without SMuRFs were significantly less likely to be discharged on blood pressure (p < 0.01) and lipid-lowering therapies (p = 0.03)., Conclusions: The proportion of younger stroke patients without SMuRFs is substantial and has increased over time. Our findings highlight the need for further research to better understand the mechanisms underlying stroke development in this population and whether less risk factor treatment in this population could impact longer term outcomes., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Atrial fibrillation (AF)-related hospitalization has risen over the last 2 decades and is the most influential determinant of total disease-related expenditure. In this review article, we describe several identified drivers of hospitalization from several registries and large-scale clinical trials, including key cardiovascular and non-traditional risk factors. We also discuss available assessment tools for discerning overall risk of hospitalization, including AF symptom scores, thrombosis and bleeding disposition, and non-invasive cardiac structural assessment. Finally, we highlight the different treatment paradigms that have been proven to reduce AF burden, progression, and hospitalization in the literature., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Cardiac amyloidosis (CA) is a unique disease entity involving an infiltrative process, typically resulting in a restrictive cardiomyopathy with diastolic heart failure that ultimately progresses to systolic heart failure. The two most common subtypes are light-chain and transthyretin amyloidosis. Early diagnosis of this disease entity, especially light-chain CA subtype, is crucial, as it portends a poorer prognosis. This review focuses on the clinical utility of the various imaging modalities in the diagnosis and differentiation of CA subtypes. This review also aims to highlight the key advances in each of the imaging modalities in the diagnosis and prognostication of CA., (Copyright © 2020 Khanna, Wen, Bhat, Chen, Gan, Pathan and Tan.)

•TS and AMI are separate cardiac conditions with similar clinical presentations.•TS have a higher LVSI than AMI, indicating a more spherical left ventricle.•LVSI may be utilised acutely to assist differentiation of acute phase TS and AMI., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 The Authors. Published by Elsevier B.V.)

Background: Stroke is one of the leading causes of morbidity and mortality with a significant percentage classified as cryptogenic. Left atrial (LA) remodelling, a substrate for atrial fibrillation (AF) and stroke development, may play a role in identification of the aetiology of cryptogenic stroke. We aimed to examine LA function to gain mechanistic insights into the pathophysiology of cryptogenic stroke in young patients otherwise at low risk for cardiovascular disease., Methods: Patients aged <60 years without traditional cardiovascular risk factors and who were diagnosed with ischaemic cryptogenic stroke or TIA were evaluated and compared to healthy controls and patients with paroxysmal AF with a CHA 2 DS 2 -VA score of 0. Conventional and novel left ventricular (LV) and LA echocardiographic parameters between the three groups were assessed., Results: Each group consisted of thirty patients. There were no significant differences in LV parameters (LVEF, LV endoGLS) between groups. LA strain in stroke patients was significantly lower compared to the controls (median 33%; interquartile range (IQ) [32/39] vs 31 [27/34]; p = 0.008). LA strain was significantly lower in AF patients compared to stroke patients (median 21% [19/22] vs 31% [27/34]; p < 0.0001)., Conclusion: A stepwise reduction in measures of LA function was appreciated between controls, young stroke and paroxysmal AF groups. This may indicate dynamic LA remodelling occurring in the young stroke population and suggest a shared causal mechanism for stroke development in this group. LA strain may further refine the risk for cardioembolic stroke., (© 2019 The Authors.)

The left atrium has an important role in modulating left ventricular filling and is an important biomarker of cardiovascular disease and adverse cardiovascular outcomes. While previously left atrial (LA) size was utilised, the role of LA function as a biomarker is increasingly being evaluated, both independently and also in combination with LA size. Strain analysis has been utilised for evaluation of LA function and can be measured throughout the cardiac cycle, thereby enabling the evaluation of LA reservoir, conduit and contractile function. Strain evaluates myocardial deformation while strain rate examines the rate of change in strain. This review will focus on the various types of strain analysis for evaluation of LA function, alterations in LA strain in physiological and pathologic states that alter LA function and finally evaluate its utility as a prognostic marker., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: The left atrial appendage (LAA) is a vestigial structure located in the postero-lateral aspect of the left atrium. Aneurysmal enlargement of the LAA is pathological and can predispose to adverse events, including myocardial infarction, atrial fibrillation and systemic thromboembolism. The condition is rare and usually isolated, occurring in the absence of other cardiac defects. In this cardiac vignette, we describe a case of giant left atrial appendage in a middle aged female presenting with chest pain and explore the natural history, different investigative modalities as well as issues in clinical management of this condition., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)