Cardiovascular Risk Factors and Disparities in Management of Embolic Stroke: A Western Sydney Perspective.

BACKGROUND: Ischaemic stroke remains one of the leading causes of death and disability worldwide. The population of Western Sydney has a unique demographic with lower socioeconomic status and a culturally and linguistically diverse population. This study aims to investigate the demographics and cardiovascular risk factors of patients in Western Sydney, focusing on the prevalence and profile of cardioembolic (CE) strokes and embolic strokes of undetermined source (ESUS). METHOD: Prospective data were collected in 463 patients with ischaemic stroke presenting to a tertiary centre in Western Sydney, who underwent predischarge transthoracic echocardiography. Patients with haemorrhagic strokes or unclear stroke diagnosis were excluded. Analysis of stroke subtype (CE, ESUS, or non-embolic) and clinical characteristics was performed based on age, gender, and prior atrial fibrillation (AF) prevalence. RESULTS: Of the 463 patients, 147 (32%) had CE strokes, and 147 (32%) had ESUS. Cardioembolic (CE) strokes were associated with older age (≥65 years) and a history of congestive cardiac failure. Older patients had higher rates of hypertension, ischaemic heart disease, AF, and congestive heart failure. History of AF was present in 67 patients (14.5%); however, only 51% received anticoagulation before admission despite a low bleeding risk. The transthoracic echocardiography characteristics of ESUS/non-embolic strokes differed from those of CE strokes; 20% of patients with ESUS had an enlarged left atrium, suggesting a subset of patients with ESUS with a left atrial myopathy. CONCLUSIONS: Patients with ischaemic stroke in Western Sydney have a high prevalence of cardiovascular risk factors which were often undertreated. Half of the patients with prior AF did not receive anticoagulation despite low bleeding risk, indicating a gap in optimal stroke prevention. There were distinct echocardiographic characteristics among stroke subtypes. Further analysis of left atrium parameters may provide greater insights into the pathogenesis and prevention of embolic strokes.

Redefining anthracycline-related subclinical cardiotoxicity: 'Absolute' and 'relative' change in longitudinal strain.

AIMS: Anthracycline chemotherapy (AC) for breast cancer can cause cancer therapy-related cardiac dysfunction (CTRCD) with resultant heart failure, traditionally defined as a reduction in left ventricular (LV) ejection fraction on echocardiography. In recent years, global longitudinal systolic strain (GLS) has been used to identify subclinical cardiac dysfunction prior to development of overt CTRCD. Recent harmonized guidelines have incorporated GLS into definitions for CTRCD to identify cardiac dysfunction and inform decisions regarding cardioprotective strategies. METHODS AND RESULTS: We evaluated subclinical dysfunction in breast cancer patients treated with AC and determined the echocardiographic and patient factors associated with significant GLS changes. One hundred fourteen HER2 negative patients treated with AC were prospectively recruited and underwent serial echocardiograms (LVEF and LVGLS) at three time points (prior to AC, 3 months, and 1 year). CTRCD was defined as an asymptomatic reduction in LVEF of 10% or symptomatic drop of 5% to LVEF <53%. Subclinical LV dysfunction was defined as a reduction of ≥10% in GLS compared with baseline, recognizing that this cut off identified an 'at risk cohort' rather than patients with established CTRCD. No participant demonstrated CTRCD by reduction in LVEF. Forty-three patients (38%) demonstrated a ≥10% relative reduction in GLS at 12 months; 20/43 (47%) had a reduced absolute GLS to <16%, and were older, had hypertension, increased LV mass, lower baseline e' velocity and GLS. GLS ≥20.5% at baseline yielded a sensitivity of 79% and specificity of 87% for a normal GLS (i.e., ≥16%) at 1 year despite a ≥10% reduction from baseline. CONCLUSIONS: We present a stepwise evaluation for subclinical LV dysfunction using both a relative reduction in GLS combined with an absolute reduction in GLS. We believe our findings may re-stratify patients with a high baseline GLS into a lower risk group despite transient relative GLS decrements ≥10%.

Left atrial shape as a marker of atrial myopathy in embolic stroke of undetermined source.

AIMS: Embolic Stroke of Undetermined Source (ESUS) results in significant morbidity. A left atrial (LA) myopathy is implicated in a proportion of these patients. We hypothesized that LA shape varies by cause of stroke (cardioembolic versus ESUS). METHODS AND RESULTS: 236 ischemic stroke, atrial fibrillation (AF) patients and controls were recruited prospectively. AF was classified as paroxysmal (PAF) or persistent AF (PersAF). Stroke patients comprised cardioembolic stroke (CE) secondary to AF and ESUS. There were 81 AF (47 PAF, 34 PersAF), 50 ESUS, 57 CE patients (subdivided into CE with PAF (CEpaf) and CE with PersAF (CEpers) and 48 controls. Echocardiographic parameters including LA volume, function, and shape/sphericity (3D LA-sphericity and 2D-derived LA-circularity, ellipticity, sphericity and eccentricity indices) were evaluated. Increased LA volume and sphericity with LA dysfunction was present in CE, AF and ESUS groups compared to controls. K-means cluster analysis demonstrated a spectrum of LA myopathy with controls at the lowest and CEpers and PersAF at the upper extremes, with ESUS, PAF and CEpaf being similar and falling between these extremes. After adjusting for age, sex and left ventricular (LV) and LA parameters, LA sphericity markers differentiated ESUS from controls (p < 0.01). CONCLUSIONS: Alterations in LA shape are present in ESUS, AF and CE patients, particularly increased spherical remodelling. The novel markers of LA sphericity proposed may identify LA myopathy in ESUS patients and potentially guide management for secondary prevention.

Left atrial mechanics evaluated by two-dimensional strain analysis: alterations in essential hypertension.

BACKGROUND: Hypertension is a cardiovascular risk factor that predisposes to cardiac structural alterations namely increased left ventricular (LV) wall thickness, reduced LV compliance and diastolic dysfunction, with consequent left atrial (LA) dilation and functional impairment. In this article, we evaluated differences in left atrial structure and function using two-dimensional speckle tracking echocardiography in patients with hypertension compared with controls. METHODS: This was a retrospective cross-sectional study of 208 hypertensive patients and 157 controls who underwent a comprehensive transthoracic echocardiogram. Patients with hypertension were stratified by the presence of left ventricular hypertrophy (LVH). RESULTS: Non-LVH hypertension patients had lower left atrial reservoir strain (LAS RES ) (34.78 ±â€Š29.78 vs. 29.78 ±â€Š6.08; P  = 0.022) and conduit strain (LAS CD ) (19.66 ±â€Š7.29 vs. 14.23 ±â€Š4.59; P  = 0.014) vs. controls despite similar left atrial volumes (LAV) . Left atrial contractile strain (LAS CT ) was not significantly different between non-LVH hypertension patients and controls (15.12 ±â€Š3.77 vs. 15.56 ±â€Š3.79; P  = 0.601). Left atrial mechanical dispersion was significantly higher in the LVH group compared with the non-LVH hypertension group (42.26 ±â€Š13.01 vs. 50.06 ±â€Š14.95; P  = 0.009). In multivariate regression analysis, LVH correlated with left atrial mechanical dispersion ( P  = 0.016). An age-hypertension interaction independently correlated with LAS CT ( P  < 0.001). CONCLUSION: Hypertension results in functional left atrial changes even before development of LV hypertrophy and structural left atrial changes with increased left atrial volume. We demonstrate both a likely hypertension-associated left atrial myopathy that prevents age-related compensatory increase in left atrial contractile function, and impact of LVH in hypertension on left atrial dyssynchrony.

Alterations in Left Atrial Strain in Breast Cancer Patients Immediately Post Anthracycline Exposure.

AIMS: With improved diagnosis and treatments, a greater percentage of breast cancer patients are achieving long-term survival. Consequently, long-term cardiotoxicity secondary to chemotherapy has become more prevalent, warranting improved cardiac surveillance. We evaluated changes in left atrial (LA) strain in breast cancer patients immediately post anthracycline (AC) therapy to assess its utility as a marker of diastolic dysfunction. METHODS: This was a prospective cohort study of 128 consecutive human epidermal growth factor receptor 2 (HER2)-negative breast cancer patients who underwent transthoracic echocardiography prior to and immediately post AC treatment. Traditional left ventricular (LV) systolic and diastolic parameters and LA volumes were evaluated; additionally, LV global longitudinal strain (LV GLS) and LA phasic strain were measured. RESULTS: All patients had normal LV ejection fraction (>53%) post AC, though LV GLS was significantly reduced. Peak E and é velocities were reduced post AC, with no change in LA volumes. LA reservoir strain (LASRES 34.8% vs 31.5%, p<0.001) and conduit strain (LASCD 17.2% vs 14.4%, p<0.001) were significantly lower post AC and correlated modestly with LV diastolic parameters. Reduction in LA strain post AC was evident even in patients with preserved LV systolic and diastolic function. More patients demonstrated alteration in diastolic function (≥15% reduction in LASRES from baseline) (32%) compared to alteration in systolic function (≥15% reduction in LV GLS) (23%). CONCLUSIONS: LA strain is a promising marker of early diastolic dysfunction. We demonstrate its potential utility in surveillance of breast cancer patients treated with AC.

Echocardiographic Assessment in Patients Recovered from Acute COVID-19 Illness.

Coronavirus (COVID-19) infections have spread rapidly worldwide and posed an immense public health problem. COVID-19 infection can affect the cardiovascular system both acutely and in patients followed up some period after COVID-19 infection. The aim of this study was to evaluate left ventricular (LV) and right ventricular (RV) function by echocardiography in COVID-19 recovered patients (hospitalized and non-hospitalized). Forty-two patients who recovered from COVID-19 but had ongoing symptoms were included in this retrospective observational cross-sectional study. Patients were followed-up at a median time of 112 days from confirmed COVID-19 diagnosis and a comprehensive echocardiogram was performed. COVID-19 patients were age- and sex-matched to healthy controls. Traditional TTE parameters and advanced echocardiographic parameters including two-dimensional LV global longitudinal strain (GLS) and RV free wall strain (FWS) were measured. LV volumes and LV ejection fraction were similar in COVID-19 patients and controls; however, LV GLS was significantly worse in the COVID-19 group (p = 0.002). Similarly, RV volumes and traditional RV function parameters were similar, but RV FWS (p = 0.009) and RV global strain (p = 0.015) were reduced. Alterations in LV and RV strain were observed in both hospitalized and non-hospitalized patients. In the subset of COVID-19 patients without any co-morbidities (n = 30), LV GLS remained reduced compared to controls. According to multivariate analysis, COVID-19 infection was the only independent determinant of reduced LV GLS (p = 0.012), while COVID-19 infection, diastolic blood pressure, and RV fractional area change were determinants of RV FWS. In this observational study, prior COVID-19 infection demonstrated LV dysfunction in patients with persistent symptoms. Abnormal LV strain was evident in both hospitalized and non-hospitalized patients, suggesting that these changes are independent of the severity of COVID-19 infection at presentation. The use of LV GLS in COVID-19 patients could have potential clinical utility to support the indication for cardiac magnetic resonance imaging in patients with possible COVID-19 related myocarditis. Future longitudinal studies are needed to evaluate its correlation with adverse cardiovascular events.

Cardiac "hypertrophy" phenotyping: differentiating aetiologies with increased left ventricular wall thickness on echocardiography.

Aims: Differentiating phenotypes of cardiac "hypertrophy" characterised by increased wall thickness on echocardiography is essential for management and prognostication. Transthoracic echocardiography is the most commonly used screening test for this purpose. We sought to identify echocardiographic markers that distinguish infiltrative and storage disorders that present with increased left ventricular (LV) wall thickness, namely, cardiac amyloidosis (CA) and Anderson-Fabry disease (AFD), from hypertensive heart disease (HHT). Methods: Patients were retrospectively recruited from Westmead Hospital, Sydney, and Princess Alexandra Hospital, Brisbane. LV structural, systolic, and diastolic function parameters, as well as global (LVGLS) and segmental longitudinal strains, were assessed. Previously reported echocardiographic parameters including relative apical sparing ratio (RAS), LV ejection fraction-to-strain ratio (EFSR), mass-to-strain ratio (MSR) and amyloidosis index (AMYLI) score (relative wall thickness × E/e') were evaluated. Results: A total of 209 patients {120 CA [58 transthyretin amyloidosis (ATTR) and 62 light-chain (AL) amyloidosis], 31 AFD and 58 HHT patients; mean age 64.1 ± 13.7 years, 75% male} comprised the study cohort. Echocardiographic measurements differed across the three groups, The LV mass index was higher in both CA {median 126.6 [interquartile range (IQR) 106.4-157.9 g/m2]} and AFD [median 134 (IQR 108.8-152.2 g/m2)] vs. HHT [median 92.7 (IQR 79.6-102.3 g/m2), p < 0.05]. LVGLS was lowest in CA [median 12.29 (IQR 10.33-15.56%)] followed by AFD [median 16.92 (IQR 14.14-18.78%)] then HHT [median 18.56 (IQR 17.51-19.97%), p < 0.05]. Diastolic function measurements including average e' and E/e' were most impaired in CA and least impaired in AFD. Indexed left atrial volume was highest in CA. EFSR and MSR differentiated secondary (CA + AFD) from HHT [receiver operating curve-area under the curve (ROC-AUC) of 0.80 and 0.91, respectively]. RAS and AMYLI score differentiated CA from AFD (ROC-AUC of 0.79 and 0.80, respectively). A linear discriminant analysis with stepwise variable selection using linear combinations of LV mass index, average e', LVGLS and basal strain correctly classified 79% of all cases. Conclusion: Simple echocardiographic parameters differentiate between different "hypertrophic" cardiac phenotypes. These have potential utility as a screening tool to guide further confirmatory testing.

A novel echocardiographic risk score for light-chain amyloidosis.

Aims: The prognosis of light-chain (AL) amyloidosis, a plasma cell dyscrasia, is largely determined by the presence of cardiac involvement. Conventional staging is achieved using cardiac biomarkers (high-sensitivity troponin, N-terminal pro-beta natriuretic peptide) and free light-chain difference (Mayo staging). We sought to evaluate the role of echocardiographic parameters as prognostic markers in AL amyloidosis and examine their utility compared with conventional staging. Methods and results: Seventy-five consecutive patients with AL amyloidosis reviewed at a referral amyloid clinic who underwent comprehensive echocardiographic assessment were retrospectively identified. The evaluated echocardiographic parameters included left ventricular (LV) ejection fraction, mass, diastolic function parameters, global longitudinal strain (GLS), and left atrial (LA) volume. Mortality was assessed through a review of clinical records. During a median follow-up of 51 months, 29/75 (39%) patients died. Patients who died had a larger LA volume (47 ± 12 vs. 35 ± 10 mL/m2, P < 0.001) and a higher E/e' (18 ± 10 vs. 14 ± 6, P = 0.026). Univariate clinical and echocardiographic predictors of survival included LA volume, E/e', e', LVGLS, and Mayo stage (at significance of P < 0.1). Left atrial volume and LVGLS were significant determinants of mortality when examined using clinical cut-offs, although E/e' was not. A composite echocardiographic risk score comprising LA volume and LVGLS provided similar prognostic performance to Mayo stage [area under the curve (AUC) 0.75, 95% confidence interval (CI) 0.64-0.85 vs. AUC 0.75, 95% CI 0.65-0.858, P = 0.91]. Conclusion: Left atrial volume and LVGLS were independent predictors of mortality in AL amyloidosis. A composite echocardiographic score combining LA volume and LVGLS has similar prognostic power to Mayo stage for all-cause mortality.

Longitudinal strain with speckle-tracking echocardiography predicts electroanatomic substrate for ventricular tachycardia in nonischemic cardiomyopathy patients.

Background: Longitudinal strain (LS) derived from speckle-tracking echocardiography (STE) corresponds to regions of scar in ischemic cardiomyopathy. Objective: We investigated if regional LS abnormalities correlate with scar location and scar burden, identified using high-density electroanatomic mapping (EAM) in nonischemic cardiomyopathy (NICM). Methods: Fifty NICM patients with ventricular tachycardia (VT) underwent echocardiography; multilayer (endocardial, midmyocardial, and epicardial) regional LS and global LS (GLS) were evaluated prior to EAM for detection of low-voltage scar. Patients were divided into 3 groups by EAM left ventricular scar location: (1) anteroseptal (group 1, n = 20); (2) inferolateral (group 2, n = 20); and (3) epicardial scar (group 3; n = 10). We correlated (1) location of scar to regional LS and (2) regional strain and GLS to scar percentage. Results: Regional LS abnormalities correlated with EAM scar in all groups. Segmental impaired LS and low voltage on EAM demonstrated concordance with scar in ∼75% or its border zone in 25% of segments. In groups 1 and 2, endocardial GLS showed a strong linear correlation with endocardial bipolar scar percentage (r = 0.79, 0.75 for groups 1 and 2, respectively; P < .001), whereas midmyocardial GLS correlated with unipolar scar percentage (r = 0.82, 0.78 for groups 1 and 2, respectively; P < .001). In group 3, epicardial regional LS and GLS correlated with epicardial bipolar scar percentage (r = 0.72, P < .001). Conclusion: Regional abnormalities on LS predict scar location on EAM mapping in patients with NICM. Moreover, global and regional LS correlate with scar percentage. STE could be used as a noninvasive tool for localizing and quantifying scar prior to EAM.

Left atrial strain in cardiac surveillance of bone marrow transplant patients with prior anthracycline exposure.

BACKGROUND: Bone marrow transplantation (BMT) has significantly improved survival rates in various hematological malignancies. However, this has led to an increased prevalence of long-term cardiotoxicity, particularly in those with prior anthracycline (AC) therapy. OBJECTIVES: To evaluate changes in left atrial (LA) volume and function, including LA strain, in BMT patients with prior AC exposure and evaluate its utility as a marker of diastolic dysfunction. METHODS: This was a cross-sectional analysis of 79 BMT patients with prior AC exposure who underwent a comprehensive surveillance transthoracic echocardiogram compared to age-matched healthy volunteers. Left ventricular (LV) and LA parameters were evaluated between the 2 groups. BMT patients were stratified using traditional measures of diastolic function and additionally utilizing LA strain. RESULTS: LV systolic dysfunction with reduced LVEF (13/79) or global longitudinal strain (29/79) was present in BMT patients. There were no differences in LA volumes between the two groups. LA reservoir strain (30.1 ± 11.2% vs 34.1 ± 9.6%, p < 0.001) and LA conduit strain (13.6 ± 8.4% vs 17.0 ± 10.5%, p < 0.001) were reduced in the BMT group compared to controls. LA reservoir strain had modest correlation with mitral annular e' velocity (r = 0.468, p < 0.001). Using current diastolic function guidelines, 26/79 BMT patients had evidence of diastolic dysfunction. However, utilizing LA reservoir strain, an additional 35 patients were identified. CONCLUSIONS: LA strain can identify early diastolic dysfunction in BMT patients with prior AC treatment. With diastolic dysfunction known to precede systolic dysfunction post AC, changes in LA reservoir strain may identify more patients with cardiac dysfunction, prompting increased surveillance and treatment.

The utility of strain imaging in the cardiac surveillance of bone marrow transplant patients.

OBJECTIVE: To evaluate the utility of two-dimensional multiplanar speckle tracking strain to assess for cardiotoxicity post allogenic bone marrow transplantation (BMT) for haematological conditions. METHODS: Cross-sectional study of 120 consecutive patients post-BMT (80 pretreated with anthracyclines (BMT+AC), 40 BMT alone) recruited from a late effects haematology clinic, compared with 80 healthy controls, as part of a long-term cardiotoxicity surveillance study (mean duration from BMT to transthoracic echocardiogram 6±6 years). Left ventricular global longitudinal strain (LV GLS), global circumferential strain (LV GCS) and right ventricular free wall strain (RV FWS) were compared with traditionl parameters of function including LV ejection fraction (LVEF) and RV fractional area change. RESULTS: LV GLS (-17.7±3.0% vs -20.2±1.9%), LV GCS (-14.7±3.5% vs -20.4±2.1%) and RV FWS (-22.6±4.7% vs -28.0±3.8%) were all significantly (p=0.001) reduced in BMT+AC versus controls, while only LV GCS (-15.9±3.5% vs -20.4±2.1%) and RV FWS (-23.9±3.5% vs -28.0±3.8%) were significantly (p=0.001) reduced in BMT group versus controls. Even in patients with LVEF >53%, ~75% of patients in both BMT groups demonstrated a reduction in GCS. CONCLUSION: Multiplanar strain identifies a greater number of BMT patients with subclinical LV dysfunction rather than by GLS alone, and should be evaluated as part of post-BMT patient surveillence. Reduction in GCS is possibly due to effects of preconditioning, and is not fully explained by AC exposure.

Segmental Cardiac Radiation Dose Determines Magnitude of Regional Cardiac Dysfunction.

Background Subclinical left ventricular dysfunction detected by 2-dimensional global longitudinal strain post breast radiotherapy has been described in patients with breast cancer. We hypothesized that left ventricular dysfunction postradiotherapy may be site specific, based on differential segmental radiotherapy dose received. Methods and Results Transthoracic echocardiograms were performed at baseline, 6 weeks, and 12 months postradiotherapy on 61 chemotherapy-naïve women with left-sided breast cancer undergoing tangential breast radiotherapy. Radiation received within basal, mid, and apical regions for the 6 left ventricular walls was quantified from the radiotherapy treatment planning system. Anterior, anteroseptal, and anterolateral walls received the highest radiation doses, while inferolateral and inferior walls received the lowest. There was a progressive increase in the radiation dose received from basal to apical regions. At 6 weeks, the most significant percentage deterioration in strain was seen in the apical region, with greatest reductions in the anterior wall followed by the anteroseptal and anterolateral walls, with a similar pattern persisting at 12 months. There was a within-patient dose-response association between the segment-specific percentage deterioration in strain at 6 weeks and 12 months and the radiation dose received. Conclusions Radiotherapy for left-sided breast cancer causes differential segmental dysfunction, with myocardial segments that receive the highest radiation dose demonstrating greatest strain impairment. Percentage deterioration in strain observed 6 weeks postradiotherapy persisted at 12 months and demonstrated a dose-response relationship with radiotherapy dose received. Radiotherapy-induced subclinical cardiac dysfunction is of importance because it could be additive to chemotherapy-related cardiotoxicity in patients with breast cancer. Long-term outcomes in patients with asymptomatic strain reduction require further investigation.

Strain by speckle tracking echocardiography correlates with electroanatomic scar location and burden in ischaemic cardiomyopathy.

AIMS: Ventricular tachycardia (VT) in ischaemic cardiomyopathy (ICM) originates from scar, identified as low-voltage areas with invasive high-density electroanatomic mapping (EAM). Abnormal myocardial deformation on speckle tracking strain echocardiography can non-invasively identify scar. We examined if regional and global longitudinal strain (GLS) can localize and quantify low-voltage scar identified with high-density EAM. METHODS AND RESULTS: We recruited 60 patients, 40 ICM patients undergoing VT ablation and 20 patients undergoing ablation for other arrhythmias as controls. All patients underwent an echocardiogram prior to high-density left ventricular (LV) EAM. Endocardial bipolar and unipolar scar location and percentage were correlated with regional and multilayer GLS. Controls had normal GLS and normal bipolar and unipolar voltages. There was a strong correlation between endocardial and mid-myocardial longitudinal strain and endocardial bipolar scar percentage for all 17 LV segments (r = 0.76-0.87, P < 0.001) in ICM patients. Additionally, indices of myocardial contraction heterogeneity, myocardial dispersion (MD), and delta contraction duration (DCD) correlated with bipolar scar percentage. Endocardial and mid-myocardial GLS correlated with total LV bipolar scar percentage (r = 0.83; 0.82, P < 0.001 respectively), whereas epicardial GLS correlated with epicardial bipolar scar percentage (r = 0.78, P < 0.001). Endocardial GLS -9.3% or worse had 93% sensitivity and 82% specificity for predicting endocardial bipolar scar >46% of LV surface area. CONCLUSIONS: Multilayer strain analysis demonstrated good linear correlations with low-voltage scar by invasive EAM. Validation studies are needed to establish the utility of strain as a non-invasive tool for quantifying scar location and burden, thereby facilitating mapping and ablation of VT.

Changes in left atrial phasic strain and mechanical dispersion: Effects of age and gender.

PURPOSE: Left atrial (LA) function by two-dimensional (2D) strain is an emerging tool with increasing clinical utility. Age and gender are key modulators of strain parameters; however, the specific time course for LA structural and functional changes is not clearly defined. METHODS: A total of 147 healthy individuals (20-69 years) underwent transthoracic echocardiography; subjects were evaluated by age (decade) and gender. LA and left ventricular (LV) volumetric and strain measurements were performed. RESULTS: Left atrial reservoir (ƐR) and conduit strain (ƐCD) with negatively correlated with age (r =-.36; r = -.56; P < .001, respectively) being significantly lower by the 6th and 5th decades, respectively. Contractile strain (ƐCT) positively correlated with age (r = .36; P < .001), being significantly higher by the 6th decade. ƐR and ƐCD were higher in young females (20-34 years) compared to young males (P = .033 and P < .001, respectively). ƐCT was significantly higher in middle-aged adult males (35-50yrs; P = .010), though seen later in females (≥51 years; P = .005). Standard deviation of time to positive strain (SD-TPS) significantly higher by the 5th decade and correlated with age in both males (r = .44; P <.001) and females (r = .40; P = .001). CONCLUSION: We demonstrate that ƐR and ƐCD are lower with age, with differing rates between males and females. As a compensatory mechanism for decline in ƐCD, ƐCT is higher, more notably in males; comparatively, females display a more prominent decline in ƐR and ƐCD with age. Alteration in electromechanical properties occurred in both genders with SD-TPS becoming higher with age.

Inter-vendor comparison of left atrial strain using layer specific strain analysis.

Left atrial strain (LAS) on transthoracic echocardiogram (TTE) is increasingly recognised to have clinical utility in cardiovascular disease. Differences in LAS measurements between vendors remains a barrier for clinical use. We sought to compare LAS between two commonly used software platforms; the layer-specific endocardial and mid-myocardial measurements of LAS on General Electric (GE) Echopac were compared to TomTec strain. LAS was measured in 88 individuals with no previous cardiac history and 40 paroxysmal AF (PAF) patients, in sinus rhythm at TTE. Conventionally, LAS measured using GE Echopac is mid-myocardial strain (GE-mid); additionally, endocardial (GE-endo) LAS was evaluated. Both LAS measurements by GE were compared to TomTec-Arena (v2.30.02) measurements. Reservoir (ƐR), contractile (ƐCT) and conduit (ƐCD) phasic strain were evaluated. Both GE-mid and GE-endo LAS correlated well with TomTec LAS. On Bland-Altman analysis, GE-mid LAS measurements were systematically lower than TomTec LAS (ƐR: mean difference (MD) - 6.08%, limits of agreement (LOA) - 12%, 0%, ƐCT: MD - 0.8%, LOA - 7%, 5%, ƐCD: MD - 5.2% LOA - 12%, 1%). GE-endo LAS demonstrated no systematic difference from TomTec LAS, but had wider limits of agreement (ƐR: MD 0.41%, LOA - 7%, 8%, ƐCT: MD 0.50%, LOA - 6%, 7%, ƐCD: MD - 0.08%, LOA - 7%, 7%). ƐR had the best reproducibility. Mid-myocardial LAS, routinely evaluated by GE Echopac software, systematically underestimates LAS compared to TomTec. Using GE endocardial LAS eliminated this bias, but introduced greater variation between measurements. Serial measurements of LAS should therefore be performed on the same vendor system.

Differing mechanisms of atrial fibrillation in athletes and non-athletes: alterations in atrial structure and function.

AIMS: Atrial fibrillation (AF) is more common in athletes and may be associated with adverse left atrial (LA) remodelling. We compared LA structure and function in athletes and non-athletes with and without AF. METHODS AND RESULTS: Individuals (144) were recruited from four groups (each n = 36): (i) endurance athletes with paroxysmal AF, (ii) endurance athletes without AF, (iii) non-athletes with paroxysmal AF, and (iv) non-athletic healthy controls. Detailed echocardiograms were performed. Athletes had 35% larger LA volumes and 51% larger left ventricular (LV) volumes vs. non-athletes. Non-athletes with AF had increased LA size compared with controls. LA/LV volume ratios were similar in both athlete groups and non-athlete controls, but LA volumes were differentially increased in non-athletes with AF. Diastolic function was impaired in non-athletes with AF vs. non-athletes without, while athletes with and without AF had normal diastolic function. Compared with non-AF athletes, athletes with AF had increased LA minimum volumes (22.6 ± 5.6 vs. 19.2 ± 6.7 mL/m2, P = 0.033), with reduced LA emptying fraction (0.49 ± 0.06 vs. 0.55 ± 0.12, P = 0.02), and LA expansion index (1.0 ± 0.3 vs. 1.2 ± 0.5, P = 0.03). LA reservoir and contractile strain were decreased in athletes and similar to non-athletes with AF. CONCLUSION: Functional associations differed between athletes and non-athletes with AF, suggesting different pathophysiological mechanisms. Diastolic dysfunction and reduced strain defined non-athletes with AF. Athletes had low atrial strain and those with AF had enlarged LA volumes and reduced atrial emptying, but preserved LV diastolic parameters. Thus, AF in athletes may be triggered by an atrial myopathy from exercise-induced haemodynamic stretch consequent to increased cardiac output.