Prediction of All-Cause Mortality by the Left Atrial Volume Index in Patients With Normal Left Ventricular Filling Pressure and Preserved Ejection Fraction.

OBJECTIVE: To describe the prevalence of left atrial (LA) enlargement (LAE) and its association with all-cause mortality in 10,719 patients with an early diastolic transmitral flow velocity (E) to early diastolic mitral annular velocity (e') ratio-determined normal left ventricular (LV) filling pressure and preserved LV ejection fraction (LVEF). METHODS: We evaluated 10,719 patients (deceased patients: n = 479; mean [SD] age, 65 [14] years; 60% male; surviving patients: n = 10,240; mean (SD) age, 54 (16) years; 48% male) with estimated normal LV filling pressure (E/e' ratio ≤ 8) and preserved LVEF (≥ 50%) to determine the impact of LA volume index (LAVi) on all-cause mortality during a mean (SD) follow-up of 2.2 (1.0) years. RESULTS: In the univariate analysis, with every milliliter per square meter increase in LAVi, all-cause mortality risk increased by 3% (hazard ratio [HR], 1.03; 95% CI, 1.02-1.04; P < .001). After adjusting for covariates, LAVi (as a continuous variable) was an independent predictor of all-cause mortality (HR, 1.015; 95% CI, 1.005-1.026; P = .01). When LAVi was assessed as a categorical variable with normal LAVi (≤ 28 mL/m(2)) as the reference group, moderate LAVi (34-39 mL/m(2)) and severe LAVi (≥ 40 mL/m(2)) were independent predictors of all-cause mortality (HR, 1.34; 95% CI, 1.01-1.79; P = .04; and HR, 1.65; 95% CI, 1.18-2.29; P = .003, respectively). CONCLUSION: LAE was independently associated with an increased risk of all-cause mortality in our large cohort of 10,719 patients with normal LV filling pressure and preserved LVEF.

Impact of echocardiographic left ventricular geometry on clinical prognosis.

Abnormal left ventricular (LV) geometry, including LV hypertrophy (LVH), is associated with increased risk of major cardiovascular (CV) events and all-cause mortality and may be an independent predictor of morbid CV events. Patients with LVH have increased risk of congestive heart failure, coronary heart disease, sudden cardiac death and stroke. We review the risk factors for LVH and its consequences, as well as the risk imposed by concentric remodeling (CR). We also examine evidence supporting the benefits of LVH regression, as well as evidence regarding the risk of CR progressing to LVH, as opposed to normalization of CR. We also briefly review the association of abnormal LV geometry with left atrial enlargement and the combined effects of these structural cardiac abnormalities.

Body composition and mortality in a large cohort with preserved ejection fraction: untangling the obesity paradox.

OBJECTIVE: To evaluate the effects of body composition as a function of lean mass index (LMI) and body fat (BF) on the correlation between increasing body mass index (BMI; calculated as the weight in kilograms divided by the height in meters squared) and decreasing mortality, which is known as the obesity paradox. PATIENTS AND METHODS: We retrospectively assessed 47,866 patients with preserved left ventricular ejection fraction (≥50%). We calculated BF by using the Jackson-Pollock equation and LMI using (1 - BF) × BMI. The population was divided according to the sex-adjusted BMI classification, sex-adjusted LMI classification, and sex-adjusted BF tertiles. The population was analyzed by using multivariate analysis for total mortality over a mean follow-up duration of 3.1 years by using the National Death Index, adjusting for left ventricular ejection fraction, left ventricular mass index, age, sex, and relative wall thickness. RESULTS: In the entire population, higher BMI was narrowly associated (hazard ratio [HR], 0.99; P<.001) with lower mortality. The higher LMI group was clearly protective (HR, 0.71; P<.001), whereas BF tertile was associated with lower mortality only if no adjustment was made for LMI (HR, 0.87; P<.001 without LMI; HR, 0.97; P=.23 with LMI). In the lean patients, low BMI was clearly associated with higher mortality (HR, 0.92; P<.001) and lower BF tertile was associated with lower mortality only if no adjustment was made for LMI (HR, 0.80; P<.001 without LMI; HR, 1.01; P=.83 with LMI). The underweight patients stratified by BF seemed to have an increased mortality (HR, 1.91; 95% CI, 1.56-2.34) that was independent of LMI. However, in obese patients, both BMI (HR, 1.03; P<.001) and BF (HR, 1.18; P=.003) were associated with higher mortality, even after adjusting for LMI, which remained protective (HR, 0.57; P<.001) independently of BF. CONCLUSION: Body composition could explain the inverse J shape of the mortality curve noted with increasing BMI. Body fat seems to be protective in this cohort only if no adjustment was made for LMI, although being underweight stratified by BF seems to be an independent risk factor. Lean mass index seems to remain protective in obese patients even when BMI is not.

Effects of left ventricular geometry and obesity on mortality in women with normal ejection fraction.

Left ventricular (LV) geometry is an independent predictor of cardiovascular morbidity and mortality. Although obesity is a known risk factor for cardiovascular diseases, studies have suggested a paradoxical relation between obesity and prognosis. We retrospectively assessed 26,126 female patients with normal LV ejection fraction to determine the impact of LV geometry, including normal structure, concentric remodeling, and eccentric or concentric LV hypertrophy, and obesity on mortality during an average follow-up of 1.7 years. Abnormal LV geometry occurred more commonly in obese (body mass index ≥30 kg/m(2), n = 10,465) compared with nonobese (body mass index <30 kg/m(2), n = 15,661) patients (56% vs 47%, respectively, p <0.0001). Overall mortality, however, was considerably less in obese compared with nonobese patients (5.6% vs 8.7%, respectively, p <0.0001). In both groups, progressive increases in mortality were observed from normal structure to concentric remodeling and then to eccentric and concentric LV hypertrophy (obese patients 2.9%, 6.5%, 6.7%, and 11.1%, respectively, and nonobese patients 5.3%, 10.6%, 11.4%, and 16.8%, respectively, p <0.0001 for trend). In conclusion, although an obesity paradox exists, in that obesity in women is associated with abnormal LV geometry but less mortality, our data demonstrate that abnormal LV geometric patterns are highly prevalent in both obese and nonobese female patients with normal ejection fraction and are associated with greater mortality.

Obesity paradox and the heart: which indicator of obesity best describes this complex relationship?

PURPOSE OF REVIEW: Despite the detrimental effects of obesity on coronary heart disease (CHD) and heart failure, obesity is found to be paradoxically associated with improved survival in secondary care of CHD and heart failure. This 'obesity paradox' is an area of active research, and it might be the result of an inaccurate working definition of obesity, which is traditionally defined in terms of BMI. We reviewed the recent literature on the paradox and examined different anthropomorphic measurements and their association with prognosis in cardiovascular diseases. RECENT FINDINGS: In CHD, obesity is associated with improved prognosis when defined by high BMI and body fat, independent of fat-free mass (FFM). High waist circumference seems to be associated with worse prognosis in some studies, but is associated with protection and an obesity paradox in those with poor cardiorespiratory fitness (CRF). In patients with heart failure, BMI, body fat and waist circumference, and possibly FFM, have been associated with improved survival. Despite these findings, intentional weight loss remains protective. In both CHD and heart failure, CRF seems to significantly impact the relationship between adiposity and subsequent prognosis, and an obesity paradox is only present with low CRF. SUMMARY: Body composition, including waist circumference, body fat and FFM have a role in clinical practice. Emphasis should be placed on improving CRF, regardless of weight status. Intentional weight loss, particularly while maintaining FFM, should be encouraged in obese individuals.

Relation of body fat categories by Gallagher classification and by continuous variables to mortality in patients with coronary heart disease.

Although obesity is a coronary heart disease risk factor, in cohorts of patients with coronary heart disease, an "obesity paradox" exists whereby patients with obesity have a better prognosis than do leaner patients. Obesity is generally defined by body mass index, with relatively little described regarding body fat (BF). In this study, 581 consecutive patients with coronary heart disease divided into the Gallagher BF categories of underweight (n = 12), normal (n = 189), overweight (n = 214), and obese (n = 166) were evaluated, and 3-year mortality was assessed using the National Death Index. Mortality was U shaped, being highest in the underweight group (25%, p <0.0001 vs all groups) and lowest in the overweight group (2.3%), with intermediate mortality in the normal-BF (6.4%, p = 0.02 vs overweight) and obese (3.6%) groups. In multiple regression analysis, high BF (odds ratio 0.89, 95% confidence interval 0.82 to 0.95) and higher Gallagher class (odds ratio 0.46, 95% confidence interval 0.25 to 0.84) were independent predictors of lower mortality. In conclusion, on the basis of Gallagher BF, an obesity paradox exists, with the highest mortality in the underweight and normal-BF groups and the lowest mortality in the overweight group. Lower BF as a continuous variable and by Gallagher classification as a categorical value were independent predictors of higher mortality.

Body composition and survival in stable coronary heart disease: impact of lean mass index and body fat in the "obesity paradox".

OBJECTIVES: Our goal was to determine the impact of lean mass index (LMI) and body fat (BF) on survival in patients with coronary heart disease (CHD). BACKGROUND: An inverse relationship between obesity and prognosis has been demonstrated (the "obesity paradox") in CHD, which has been explained by limitations in the use of body mass index in defining body composition. METHODS: We studied 570 consecutive patients with CHD who were referred to cardiac rehabilitation, stratified as Low (≤25% in men and ≤35% in women) and High (>25% in men and >35% in women) BF and as Low (≤18.9 kg/m2 in men and ≤15.4 kg/m2 in women) and High LMI, and followed for 3 years for survival. RESULTS: Mortality is inversely related to LMI (p<0.0001). Mortality was highest in the Low BF/Low LMI group (15%), which was significantly higher than in the other 3 groups, and lowest in the High BF/High LMI group (2.2%), which was significantly lower than in the other 3 groups. In Cox regression analysis as categoric variables, low LMI (hazard ratio [HR]: 3.1; 95% confidence interval [CI]: 1.3 to 7.1) and low BF (HR: 2.6; 95% CI: 1.1 to 6.4) predicted higher mortality, and as continuous variables, high BF (HR: 0.91; 95% CI: 0.85 to 0.97) and high LMI (HR: 0.81; 95% CI: 0.65 to 1.00) predicted lower mortality. CONCLUSIONS: In patients with stable CHD, both LMI and BF predict mortality, with mortality particularly high in those with Low LMI/Low BF and lowest in those with High LMI/High BF. Determination of optimal body composition in primary and secondary CHD prevention is needed.

Association of Left Ventricular Geometry With Left Atrial Enlargement in Patients With Preserved Ejection Fraction.

Left ventricular (LV) hypertrophy (LVH) is a known independent determinant of left atrial (LA) size; however, there is controversy regarding whether the LV geometric patterns are associated with LA enlargement (LAE), a major indicator of diastolic heart failure. The authors evaluated 47,865 patients with preserved ejection fraction to determine the relationship of LV geometry on LAE as determined by LA volume index (LAVi) 29 mL/m². Abnormal LV geometry was identified in 48% and LAE was indentified in 43% with associated higher prevalence of abnormal LV geometry(59% vs 41%, P<.0001). Both LV mass index and relative wall thickness (RWT) were independent determinants of LAE (P<.0001). LAVi and prevalence of LAE differ significantly by LV geometric patterns (P<.0001). In multivariate analysis, abnormal LV geometry patterns, especially eccentric and concentric LVH, were independently associated with LAE. In conclusion, LAE assessed as increased LAVi is strongly associated not only with LV mass index but also with RWT. Furthermore, LAE was independently associated with abnormalities in LV geometry.

Body composition and coronary heart disease mortality--an obesity or a lean paradox?

OBJECTIVE: To determine the combined effects of body mass index (BMI) and body fat (BF) on prognosis in coronary heart disease (CHD) to better understand the obesity paradox. PATIENTS AND METHODS: We studied 581 patients with CHD between January 1, 2000, and July 31, 2005, who were divided into low (<25) and high BMI (≥25), as well as low (≤25% men and ≤35% women) and high BF (>25% in men and >35% in women). Four groups were analyzed by total mortality during the 3-year follow-up by National Death Index: low BF/low BMI (n=119), high BF/low BMI (n=26), low BF/high BMI (n=125), and high BF/high BMI (n=311). RESULTS: During the 3-year follow-up, mortality was highest in the low BF/low BMI group (11%), which was significantly (P<.001) higher than that in the other 3 groups (3.9%, 3.2%, and 2.6%, respectively); using the high BF/high BMI group as a reference, the low BF/low BMI group had a 4.24-fold increase in mortality (confidence interval [CI], 1.76-10.23; P=.001). In multivariate logistic regression for mortality, when entered individually, both high BMI (odds ratio [OR], 0.79; CI, 0.69-0.90) and high BF (OR, 0.89; CI, 0.82-0.95) as continuous variables were independent predictors of better survival, whereas low BMI (OR, 3.60; CI, 1.37-9.47) and low BF (OR, 3.52; CI, 1.34-9.23) as categorical variables were independent predictors of higher mortality. CONCLUSION: Although both low BF and low BMI are independent predictors of mortality in patients with CHD, only patients with combined low BF/low BMI appear to be at particularly high risk of mortality during follow-up. Studies are needed to determine optimal body composition in the secondary prevention of CHD.

Left atrial volume index predictive of mortality independent of left ventricular geometry in a large clinical cohort with preserved ejection fraction.

OBJECTIVE: To determine the effect on mortality of the left atrial volume index (LAVI) and left ventricular (LV) geometry (normal, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy). PATIENTS AND METHODS: From January 1, 2004, through December 31, 2006, we evaluated 36,561 patients with preserved ejection fraction with an average follow-up of 1.7±1.0 years. The LAVI was categorized as normal (≤28 mL/m(2)) or increased (mild, 29-33 mL/m(2); moderate, 34-39 mL/m(2); severe, ≥40 mL/m(2)). RESULTS: Progressive increases in LAVI and mortality were noted with abnormal LV geometry. Similarly, abnormal LV geometry and mortality were significantly higher in patients with increased LAVI. In patients who died vs surviving patients, the LAVI ± SD was significantly higher (33.0±14.8 vs 28.1±10.8 mL/m(2); P<.001) and abnormal LV geometry was significantly more prevalent (62% vs 44%; P<.001). Compared with those with a normal LAVI, patients with a severe LAVI had a 42% increased risk of mortality. In patients with normal LV geometry or concentric remodeling, a severe LAVI was a significant independent predictor of mortality, with an increased risk of 28% and 46%, respectively. Similarly, in patients with eccentric hypertrophy and concentric hypertrophy, the mortality risk in patients with a severe LAVI was twice that of patients with a normal LAVI. Comparison of area under the curve (0.565 [without LAVI] vs 0.596 [with LAVI]; P<.001] and predictive models with and without LAVI for mortality prediction were significant, indicating increased mortality prediction by the addition of LAVI to other independent predictors. CONCLUSION: The LAVI significantly predicts mortality risk, independent of LV geometry, and adds to the overall mortality prediction in a large cohort of patients with preserved systolic function.

Serum alanine aminotransferase and its association with metabolic syndrome in children: the bogalusa heart study.

BACKGROUND: The aim of this study was to examine the distribution of alanine aminotrasferase (ALT) and its association with metabolic syndrome variables and their clustering in apparently healthy children. METHODS: A cross-sectional study of 1,524 preadolescents (age, 4-11 years, 62% white, 51% male) and 1,060 adolescents (age, 12-18 years, 58% white, 51% male) enrolled in the Bogalusa Heart Study was performed. RESULTS: ALT levels showed a significant race (whites > blacks) difference in preadolescents and a gender (males > females) difference in adolescents. Both preadolescents and adolescents in the age, race, and gender-specific top versus bottom quartiles of ALT had significant increases in the prevalence of adverse levels (>75th percentile specific for age, race, and gender) of body mass index (BMI), systolic blood pressure, total cholesterol to high-density lipoprotein cholesterol (HDL-C) ratio (adolescents only), insulin resistance index (HOMA-IR), and clustering of all four of these metabolic syndrome variables. In multivariate analyses, BMI was the major independent predictor of ALT in both preadolescents and adolescents; other independent predictors were total cholesterol to HDL-C ratio, HOMA-IR, white race in preadolescents and male gender in adolescents. With respect to the ability of ALT to identify children with clustering of the metabolic syndrome variables, area under the receiver operating characteristic curve analysis (c-statistics) adjusted for age, race, and gender yielded a value of 0.67 for preadolescents and 0.82 for adolescents. CONCLUSION: An elevation in serum ALT within the reference range relate adversely to all of the major components of metabolic syndrome and their clustering in children and, thus, may be useful as a biomarker of the presence of metabolic syndrome and related risk in pediatric population, especially adolescents.

Obesity and left ventricular dilatation in young adulthood: the Bogalusa Heart Study.

BACKGROUND: Cardiac enlargement is an important predictor of adverse cardiovascular (CV) events. Left ventricular (LV) dilatation is a precursor both of LV dysfunction and clinical heart failure. The present study examines risk factors for LV dilatation among 832 young adults (341 male, 491 female) who participated in the Bogalusa Heart Study. HYPOTHESIS: A unique set of risk factors predicts LV dilatation among young adults. METHODS: Standard ventricular dimensions were determined by M-mode echocardiography and indexed to height using a standard method. LV dilatation was considered as the top 20th percentile of LV end-diastolic dimension indexed to height. Logistic regression models were used, stratified by race and sex, to assess the relationship of CV risk factors with quintile of LV end-diastolic dimension indexed to height. RESULTS: The mean age (standard deviation) of men and women in the population was 36.4 years (3.9 years) and 35.9 years (4.6 years), respectively. In sex-specific models adjusted for age, race, systolic and diastolic blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, and glycosylated hemoglobin, body mass index (BMI) was a significant predictor of LV dilatation in both men and women. The odds ratio (95% confidence interval) for a 1-unit change in BMI was 1.12 (1.02-1.19) in men and 1.09 (1.05-1.13) in women. Among men, triglyceride level was also significantly associated with LV dilatation (P=0.03), whereas among women there was no such association. CONCLUSIONS: Our findings indicate that obesity is the most consistent predictor of LV dilatation in both men and women, whereas triglyceride level was a significant predictor among men only.

End-stage renal disease in young black males in a black-white population: longitudinal analysis of the Bogalusa Heart Study.

BACKGROUND: Risk factors in childhood create a life-long burden important in the development of cardiovascular (CV) disease in adulthood. Many risk factors for CV disease (e.g., hypertension) also increase the risk of renal disease. However, the importance of childhood risk factors on the development of chronic kidney disease and end-stage renal disease (ESRD) is not well characterized. METHODS: The current observations include data from Bogalusa Heart Study participants who were examined multiple times as children between 1973 and 1988. RESULTS: Through 2006, fifteen study participants subsequently developed ESRD in adulthood; seven with no known overt cause. Although the Bogalusa Heart Study population is 63% white and 37% black and 51% male and 49% female, all seven ESRD cases with no known overt cause were black males (p < 0.001). Mean age-adjusted systolic and diastolic blood pressure in childhood was higher among the ESRD cases (114.5 mmHg and 70.1 mmHg, respectively) compared to black (103.0 mmHg and 62.3 mmHg, respectively) and white (mean = 103.3 mmHg and 62.3 mmHg, respectively) boys who didn't develop ESRD. The mean age-adjusted body mass index in childhood was 23.5 kg/m2 among ESRD cases and 18.6 kg/m2 and 18.9 kg/m2 among black and white boys who didn't develop ESRD, respectively. Plasma glucose in childhood was not significantly associated with ESRD. CONCLUSION: These data suggest black males have an increased risk of ESRD in young adulthood. Elevated body mass index and blood pressure in childhood may increase the risk for developing ESRD as young adults.

Clinical impact of left ventricular hypertrophy and implications for regression.

Left ventricular hypertrophy (LVH) is an independent risk factor and predictor of cardiovascular (CV) events and all-cause mortality. Patients with LVH are at increased risk for stroke, congestive heart failure, coronary heart disease, and sudden cardiac death. Left ventricular hypertrophy represents both a manifestation of the effects of hypertension and other CV risk factors over time as well as an intrinsic condition causing pathologic changes in the CV structure and function. We review the risk factors for LVH and its consequences, concentric remodeling, and its prognostic significance, clinical benefits and supporting evidence for LVH regression, and its implications for management. We conclude our review summarizing the various pharmacological and nonpharmacological therapeutic options approved for the treatment of hypertension and LVH regression and the supporting clinical trial data for these therapeutic strategies.

The obesity paradox, weight loss, and coronary disease.

PURPOSE: Because obesity is a cardiovascular risk factor but is associated with a more favorable prognosis among cohorts of cardiac patients, we assessed this "obesity paradox" in overweight and obese patients with coronary heart disease enrolled in a cardiac rehabilitation and exercise training (CRET) program, making this assessment in patients classified as overweight/obese using both traditional body mass index (BMI) and percent body fat assessments. Additionally, we assessed the efficacy and safety of purposeful weight loss in overweight and obese coronary patients. PATIENTS AND METHODS: We retrospectively studied 529 consecutive CRET patients following major coronary events before and after CRET, and compared baseline and post program data in 393 overweight and obese patients (body mass index [BMI] > or =25 kg/m(2)) divided by median weight change (median=-1.5%; mean +2% vs -5%, respectively). In addition, we assessed 3-year total mortality in various baseline BMI categories as well as compared mortality in those with high baseline percent fat (>25% in men and >35% in women) versus those with low baseline fat. RESULTS: Following CRET, the overweight and obese with greater weight loss had improvements in BMI (-5%; P <.0001), percent fat (-8%; P <.0001), peak oxygen consumption (+16%; P <.0001), low-density lipoprotein cholesterol (-5%; P <.02), high-density lipoprotein cholesterol (+10%; P <.0001), triglycerides (-17%; P <.0001), C-reactive protein (-40%; P <.0001), and fasting glucose (-4%; P=.02), as well as marked improvements in behavioral factors and quality-of-life scores. Those with lower weight loss had no significant improvements in percent fat, low-density lipoprotein cholesterol, triglycerides, C-reactive protein, and fasting glucose. During 3-year follow-up, overall mortality trended only slightly lower in those with baseline overweightness/obesity who had more weight loss (3.1% vs 5.1%; P=.30). However, total mortality was considerably lower in the baseline overweight/obese (BMI > or =25 kg/m(2)) than in 136 CRET patients with baseline BMI <25 kg/m(2) (4.1% vs 13.2%; P <.001), as well as in those with high baseline fat compared with those with low fat (3.8% vs 10.6%; P <.01). CONCLUSIONS: Purposeful weight loss with CRET in overweight/obese coronary patients is associated with only a nonsignificant trend for lower mortality but is characterized by marked improvements in obesity indices, exercise capacity, plasma lipids, and inflammation, as well as behavioral factors and quality of life. Although an "obesity paradox" exists using either baseline BMI or baseline percent fat criteria, these results support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.

Influence of the metabolic syndrome versus the sum of its individual components on left ventricular geometry in young adults (from the Bogalusa Heart Study).

Current preventive cardiology guidelines strongly recommend identification of metabolic syndrome (MS), a constellation of cardiovascular risk factors, in clinical practice. These MS risk factors, individually or in a cluster, adversely alter left ventricular (LV) geometry. However, it is still unclear whether MS predicts risk, above and beyond its individual risk factors, for abnormal LV geometry. This aspect was examined in 830 asymptomatic patients (mean age 37 years, 69% whites, 41% men) as a part of the Bogalusa Heart Study. Patients with MS (as defined by the National Cholesterol Education Program Adult Treatment Panel III) showed adverse levels of echocardiographic parameters compared with patients without MS. With respect to MS components, patients with eccentric hypertrophy (EH) or concentric hypertrophy (CH) showed higher values of MS risk factors compared with patients with normal geometric pattern but no differences were noted between patients with normal and concentric remodeling. Of note, patients with concentric remodeling versus EH showed significantly higher systolic and diastolic blood pressure and fasting glucose levels. A model including only MS strongly predicted risk of EH (odds ratio [OR] 4.16, p <0.0001) and CH (OR 13.6, p <0.0001) compared with normal LV geometry. In a model including only individual MS risk factors, obesity (EH vs normal OR 14.4, p <0.0001), high blood pressure (CH vs normal OR 19.38, p <0.0001), and high fasting glucose levels (CH vs normal OR 4.02, p = 0.001) were significant predictors of abnormal LV geometry. However, the likelihood ratio test and comparisons of C-statistics for models including only individual MS risk factors versus models also including the MS variable were not significant. In conclusion, MS and its individual risk factors were strongly associated with LV geometry. However, MS did not predict risk of abnormal LV geometry independent of its individual components.

Disparate effects of obesity and left ventricular geometry on mortality in 8088 elderly patients with preserved systolic function.

BACKGROUND: Although left ventricular (LV) geometry has predicted cardiovascular (CV) prognosis, including in elderly cohorts, the role of obesity on CV prognosis has been more controversial. OBJECTIVE: To assess the independent effects of obesity and LV geometry on all-cause mortality in a large cohort of elderly patients with preserved LV systolic function. PATIENTS AND METHODS: We retrospectively assessed 8088 elderly patients (> 70 years) with an LV ejection fraction (LVEF) > or = 50% who were referred for echocardiography at a large primary, secondary, and tertiary health care system in New Orleans. We specifically assessed clinical and echocardiographic features to determine the impact of body mass index (BMI) and LV geometric patterns, including concentric remodeling (CR) and LV hypertrophy (LVH) on all-cause mortality during an average 3.1-year follow-up. RESULTS: Although abnormal LV geometry (P < 0.01) and LVH (P < 0.001) progressively increased with more obesity, total mortality was strongly and inversely (P < 0.0001) related with BMI. However, in each BMI subgroup, mortality progressively increased with abnormal LV geometry from normal, CR, eccentric LVH, and concentric LVH (P < 0.001 for all trends). In a multivariate analysis, abnormal LV geometry, including increased relative wall thickness (Chi-square 16; P < 0.0001) and LV mass index (Chi-square 12; P < 0.0001), and lower BMI (Chi-square 33; P < 0.0001) were independent predictors of mortality. CONCLUSION: Although an obesity paradox exists, in that obesity is associated with abnormal LV geometry but lower mortality, our data demonstrate that LV geometric abnormalities are prevalent in elderly patients with preserved systolic function and are associated with progressive increases in mortality.

Clinical implications of left atrial enlargement: a review.

Echocardiographically determined left atrial (LA) size has been shown to be a significant predictor of cardiovascular (CV) outcomes. We review the physiology and echocardiographic assessment of LA size and functions and describe the pathophysiologic determinants and clinical implications of LA enlargement. However, despite strong evidence, standardized LA size assessment and generalized applicability of its clinical implications to patient care have yet to be determined. Nevertheless, current findings suggest that echocardiographically determined LA size may become an important clinical risk identifier in preclinical CV disease and should be assessed as a part of routine comprehensive echocardiographic evaluation.