Left Atrium Assessment by Speckle Tracking Echocardiography in Cryptogenic Stroke: Seeking Silent Atrial Fibrillation

Enfermedad auricular; Fibrilación auricular; EcocardiografíaMalaltia auricular; Fibril·lació auricular; EcocardiografiaAtrial disease; Atrial fibrillation; EchocardiographySilent atrial fibrillation (AF) may be the cause of some cryptogenic strokes (CrS). The aim of the study was to analyse atrial size and function by speckle tracking echocardiography in CrS patients to detect atrial disease. Patients admitted to the hospital due to CrS were included prospectively. Echocardiogram analysis included left atrial ejection fraction (LAEF) and atrial strain. Insertable cardiac monitor was implanted, and AF was defined as an episode of ≥1 min in the first year after stroke. Left atrial enlargement was defined as indexed volume > 34 mL/m2. Seventy-five consecutive patients were included, aged 76 ± 9 years (arterial hypertension 75%). AF was diagnosed in 49% of cases. The AF group had higher atrial volume and worse atrial function: peak atrial longitudinal strain (PALs) 19.6 ± 5.7% vs. 29.5 ± 7.2%, peak atrial contraction strain (PACs) 8.9 ± 3.9% vs. 16.5 ± 6%, LAEF 46.8 ± 11.5% vs. 60.6 ± 5.2%; p < 0.001. AF was diagnosed in 20 of 53 patients with non-enlarged atrium, and in 18 of them, atrial dysfunction was present. The multivariate logistic regression analysis demonstrated an independent association between detection of AF and atrial volume, LAEF, and strain. Cut-off values were obtained: LAEF < 55%, PALs < 21.4%, and PACs < 12.9%. In conclusion, speckle tracking echocardiography in CrS patients improves silent atrial disease diagnosis, with or without atrial enlargement.This research was funded by Instituto de Salud Carlos III-FIS (Fondo de Investigación Sanitaria, PI13/01830)

Validation of the Regicor Short Physical Activity Questionnaire for the Adult Population

OBJECTIVE: To develop and validate a short questionnaire to estimate physical activity (PA) practice and sedentary behavior for the adult population. METHODS: The short questionnaire was developed using data from a cross-sectional population-based survey (n = 6352) that included the Minnesota leisure-time PA questionnaire. Activities that explained a significant proportion of the variability of population PA practice were identified. Validation of the short questionnaire included a cross-sectional component to assess validity with respect to the data collected by accelerometers and a longitudinal component to assess reliability and sensitivity to detect changes (n = 114, aged 35 to 74 years). RESULTS: Six types of activities that accounted for 87% of population variability in PA estimated with the Minnesota questionnaire were selected. The short questionnaire estimates energy expenditure in total PA and by intensity (light, moderate, vigorous), and includes 2 questions about sedentary behavior and a question about occupational PA. The short questionnaire showed high reliability, with intraclass correlation coefficients ranging between 0.79 to 0.95. The Spearman correlation coefficients between estimated energy expenditure obtained with the questionnaire and the number of steps detected by the accelerometer were as follows: 0.36 for total PA, 0.40 for moderate intensity, and 0.26 for vigorous intensity. The questionnaire was sensitive to detect changes in moderate and vigorous PA (correlation coefficients ranging from 0.26 to 0.34). CONCLUSION: The REGICOR short questionnaire is reliable, valid, and sensitive to detect changes in moderate and vigorous PA. This questionnaire could be used in daily clinical practice and epidemiological studies

Aplicación clínica del estudio de la función auricular izquierda mediante técnicas ecocardiográficas emergentes

L'ictus i la insuficiència cardíaca son dues patologies amb elevada morbimortalitat. L'ictus criptogènic (ICr) es defineix como un ictus d'etiologia desconeguda després d'excloure causes potencials i pot arribar fins al 30% dels ictus isquèmics. Estudis previs han demostrat que la fibril·lació auricular (FA) silent segueix sent una possible causa de cardioembolisme i no és infrequent la seva detecció durante el seguiment dels pacients amb ICr. Actualment, la insuficiència cardíaca (IC) és una patologia prevalent, on la disfunció de l'auricula esquerra (AE) pot ser causa o conseqüència. En ambdues malalties, l'estudi funcional de l'AE mitjançant tècniques d'imatge, pot proporcionar paràmetres útils en la pràctica clínica. Per aquesta raò, l'objetiu d'aquesta tesi consistí en avaluar la funció auricular per ecocardiografía amb speckle tracking per al diagnòstic de FA en ICr i com a marcador pronòstic en IC aguda. Es van realitzar dos estudis prospectius que van incloure consecutivament a pacients ingressats per ICr en el primer estudi i per IC aguda en el segon estudi. A tots se'ls practicà un ecocardiograma que va incloure l'estudi de la mida auricular, la fracció d'ejecció auricular esquerra (FEAE) i el strain auricular per speckle tracking. Als pacients ingressats per ICr se'ls va implantar un Holter insertable previ a l'alta de l'hospital i la FA es definí com un episodi de durada ≥ 1 minut en els primers 12 mesos. Als pacientes ingressats per IC aguda es va fer un seguiment clínic a l'alta per a detectar events adversos amb la variable composta de primer reingrès per IC i/o mort cardíaca. En el primer estudi es van incloure 75 pacients consecutius amb ICr amb edat mitja de 76 ± 9 anys (56% varons) i una elevada prevalença d'hipertensió arterial (75%). Es diagnosticà FA en 37 (49%) dels casos. El volum auricular indexat (OR: 1,13; IC al 95%: 1,05-1,21; p = 0,001), la FEAE (OR: 0,80; IC al 95%: 0,72-0,89; p 34mL/m2, atrial dysfunction was associated with AF. In 20 of 53 (38%) patients with non-dilatated atrium, AF was detected and 18 of them also showed atrial dysfunction. Moreover, cut-off values were obtained to distinguish between population with and without AF: LAEF 55%, PALS 21.4% and PACS 12.9%. In the second study related to acute HF, 122 consecutive patients were included, aged 72 ± 11 years (68% men). The three HF phenotypes according to the left ventricular ejection fraction were represented and also sinus rhythm and AF were included. The group with worse atrial function had more decompensated HF than first acute HF and higher E/e' ratio. The AF group had worse atrial function than sinus rhythm. Adverse clinical events happened in 79 (64.8%) cases with a median follow-up of 3.73 years: first rehospitalizations for HF in 65 and cardiac deaths in 14 patients. The group with worse atrial function analysed by strain (reservoir phase or PALS) or LAEF was associated with more rehospitalization for HF and/or cardiac death (PALS HR 2.33; IC 95%: 1.20- 4.52; p = 0.012; LAEF HR 2.24; IC 95%: 1.14-4.38; p = 0.018). In conclusion, the atrial function study by echocardiography with speckle tracking is useful in clinical practice. Its application in CrS allows improving atrial myopathy diagnosis associated with silent AF and its quantification in acute HF is related to adverse clinical outcomes with increased risk of HF readmission and/or cardiac death

Aplicación clínica del estudio de la función auricular izquierda mediante técnicas ecocardiográficas emergentes

L’ictus i la insuficiència cardíaca son dues patologies amb elevada morbimortalitat. L’ictus criptogènic (ICr) es defineix como un ictus d’etiologia desconeguda després d’excloure causes potencials i pot arribar fins al 30% dels ictus isquèmics. Estudis previs han demostrat que la fibril·lació auricular (FA) silent segueix sent una possible causa de cardioembolisme i no és infrequent la seva detecció durante el seguiment dels pacients amb ICr. Actualment, la insuficiència cardíaca (IC) és una patologia prevalent, on la disfunció de l’auricula esquerra (AE) pot ser causa o conseqüència. En ambdues malalties, l’estudi funcional de l’AE mitjançant tècniques d’imatge, pot proporcionar paràmetres útils en la pràctica clínica. Per aquesta raò, l’objetiu d’aquesta tesi consistí en avaluar la funció auricular per ecocardiografía amb speckle tracking per al diagnòstic de FA en ICr i com a marcador pronòstic en IC aguda. Es van realitzar dos estudis prospectius que van incloure consecutivament a pacients ingressats per ICr en el primer estudi i per IC aguda en el segon estudi. A tots se’ls practicà un ecocardiograma que va incloure l’estudi de la mida auricular, la fracció d’ejecció auricular esquerra (FEAE) i el strain auricular per speckle tracking. Als pacients ingressats per ICr se’ls va implantar un Holter insertable previ a l’alta de l’hospital i la FA es definí com un episodi de durada ≥ 1 minut en els primers 12 mesos. Als pacientes ingressats per IC aguda es va fer un seguiment clínic a l’alta per a detectar events adversos amb la variable composta de primer reingrès per IC i/o mort cardíaca. En el primer estudi es van incloure 75 pacients consecutius amb ICr amb edat mitja de 76 ± 9 anys (56% varons) i una elevada prevalença d’hipertensió arterial (75%). Es diagnosticà FA en 37 (49%) dels casos. El volum auricular indexat (OR: 1,13; IC al 95%: 1,05-1,21; p = 0,001), la FEAE (OR: 0,80; IC al 95%: 0,72-0,89; p <0,001) i el strain auricular (PALS OR: 0,80; IC al 95%: 0,71-0,84; p <0,001; PACS OR: 0,72; IC al 95%: 0,59-0,87; p = 0,001) es van associar amb la detección de FA silent després de l’ICr. A més, es van obtenir valors de punt de tall per a diferenciar la població amb i sense FA: FEAE 55%, PALS 21,4% y PACS 12,9%. En el segon estudi d’IC aguda, es van incloure 122 pacients consecutius amb edat mitja de 72 ± 11 anys (68% varons). Varen estar representats els tres fenotipos d’IC segons el valor de fracció d’ejecció del ventricle esquerre i es van incloure pacients tant en ritme sinusal com en fibril·lació auricular. El grup amb pitjor funció auricular mostrà major proporció de casos con IC descompensada respecte a IC de debut i valors superiors de relació E/e’. En una mediana de seguiment de 3,73 anys, 79 (64,8%) dels casos presentaren events clínics adversos: primer reingrès per IC en 65 i mort de causa cardíaca en 14. El grup amb pitjor funció auricular mesurada per strain (funció de reservori o PALS) o FEAE s’associà a major freqüència de reingrès per IC i/o mort de causa cardíaca (PALS HR 2,33; IC 95%: 1,20- 4,52; p = 0,012; FEAI HR 2,24; IC 95%: 1,14-4,38; p = 0,018). En conclusió, l’estudi de la funció auricular per ecocardiografia amb speckle tracking és una tècnica útil en la pràctica clínica. La seva aplicació en ICr permet millorar el diagnòstic de miopatia auricular que s’associa a FA silent i la seva quantificació en IC aguda s’associa a una evolució clínica desfavorable en forma de reingrès por IC i/o mort cardíaca.El ictus y la insuficiencia cardíaca son dos patologías con elevada morbimortalidad. El ictus criptogénico (ICr) se define como un ictus de etiología desconocida después de excluir causas potenciales y puede alcanzar hasta el 30% de los ictus isquémicos. Estudios previos han demostrado que la fibrilación auricular (FA) silente sigue siendo una posible causa de cardioembolismo y no es infrecuente su detección durante el seguimiento de los pacientes con ICr. La insuficiencia cardíaca (IC) es, actualmente, una patología prevalente, donde la disfunción de la aurícula izquierda (AI) puede ser causa o consecuencia. En ambas enfermedades, el estudio funcional de la AI mediante técnicas de imagen, puede proporcionar parámetros útiles en la práctica clínica. Por esta razón, el objetivo de esta tesis consistió en evaluar la función auricular por ecocardiografía con speckle tracking para el diagnóstico de FA en ICr y como marcador pronóstico en IC aguda. Se realizaron dos estudios prospectivos que incluyeron consecutivamente a pacientes ingresados por ICr en el primer estudio y por IC aguda en el segundo estudio. Se les practicó a todos un ecocardiograma que incluyó el estudio del tamaño auricular, la fracción de eyección auricular izquierda (FEAI) y el strain auricular por speckle tracking. A los pacientes ingresados por ICr se les implantó un Holter insertable previo al alta del hospital y la FA se definió como un episodio de duración ≥ 1 minuto en los primeros 12 meses. En los pacientes ingresados por IC aguda se llevó a cabo un seguimiento clínico al alta para detectar eventos adversos con la variable compuesta de primer reingreso por IC y/o muerte cardíaca. En el primer estudio se incluyeron 75 pacientes consecutivos con ICr con edad media de 76 ± 9 años (56% varones) y con una elevada prevalencia de hipertensión arterial (75%). Se diagnosticó FA en 37 (49%) de los casos. El volumen auricular indexado (OR: 1,13; IC al 95%: 1,05-1,21; p = 0,001), la FEAI (OR: 0,80; IC al 95%: 0,72-0,89; p <0,001) y el strain auricular (PALS OR: 0,80; IC al 95%: 0,71-0,84; p <0,001; PACS OR: 0,72; IC al 95%: 0,59-0,87; p = 0,001) se asociaron a la detección de FA silente después de ICr. Además, se obtuvieron valores de punto de corte para diferenciar la población con y sin FA: FEAI 55%, PALS 21,4% y PACS 12,9%. En el segundo estudio de IC aguda, se incluyeron 122 pacientes consecutivos con edad media de 72 ± 11 años (68% varones). Estuvieron reflejados los tres fenotipos de IC según el valor de fracción de eyección del ventrículo izquierdo y se incluyeron pacientes tanto en ritmo sinusal como en fibrilación auricular. El grupo con peor función auricular mostró mayor proporción de casos con IC descompensada respecto a IC de debut y valores superiores de relación E/e’. Con una mediana de seguimiento de 3,73 años, 79 (64,8%) de los casos presentaron eventos clínicos adversos: primer reingreso por IC en 65 y muerte de causa cardíaca en 14. El grupo con peor función auricular medida por strain (función de reservorio o PALS) o FEAI se asoció con mayor frecuencia de reingreso por IC y/o muerte de causa cardíaca (PALS HR 2,33; IC 95%: 1,20- 4,52; p = 0,012; FEAI HR 2,24; IC 95%: 1,14-4,38; p = 0,018). En conclusión, el estudio de la función auricular por ecocardiografía con speckle tracking es una técnica útil en la práctica clínica. Su aplicación en ICr permite mejorar el diagnóstico de miopatía auricular que se asocia a FA silente y su cuantificación en IC aguda se asocia a una evolución clínica desfavorable en forma de reingreso por IC y/o muerte cardíaca.Stroke and heart failure are diseases linked to high morbidity and mortality. Cryptogenic stroke (CrS) is defined as a stroke of unknown cause after ruling out several aetiologies. CrS may represent up to 30% of ischaemic strokes. Previous studies have shown silent atrial fibrillation (AF) can be a plausible cause of cardioembolism and is not infrequent after a CrS. Currently, heart failure (HF) is prevalent and left atrial (LA) dysfunction can be both a cause and consequence. It would be interesting to study LA function by imaging techniques in both scenarios in clinical practice. For this reason, the aim of this thesis was to analyse atrial function by echocardiography with speckle tracking in order to diagnose AF in CrS and as a prognostic marker in acute HF. Two prospective studies were conducted and consecutive patients, with CrS in the first study and acute HF in the second, were included. An echocardiogram was performed that included atrial size analysis, left atrial ejection fraction (LAEF) and auricular strain by speckle tracking. In patients admitted for CrS, insertable cardiac monitor was implanted and AF was defined as an episode lasting ≥ 1 minute in the first twelve months. In acute HF patients, clinical follow-up was performed to detect adverse outcomes including first rehospitalization for HF and/or cardiac death. In the first study, seventy-five consecutive patients with CrS were included, aged 76 ± 9 years old (56% men) and with a high prevalence of arterial hypertension (75%). AF was diagnosed in 37 (49%) cases. Indexed left atrial volume (OR: 1.13; IC 95%: 1.05-1.21; p= 0.001), LAEF (OR: 0.80; IC 95%: 0.72-0.89; p 34mL/m2, atrial dysfunction was associated with AF. In 20 of 53 (38%) patients with non-dilatated atrium, AF was detected and 18 of them also showed atrial dysfunction. Moreover, cut-off values were obtained to distinguish between population with and without AF: LAEF 55%, PALS 21.4% and PACS 12.9%. In the second study related to acute HF, 122 consecutive patients were included, aged 72 ± 11 years (68% men). The three HF phenotypes according to the left ventricular ejection fraction were represented and also sinus rhythm and AF were included. The group with worse atrial function had more decompensated HF than first acute HF and higher E/e’ ratio. The AF group had worse atrial function than sinus rhythm. Adverse clinical events happened in 79 (64.8%) cases with a median follow-up of 3.73 years: first rehospitalizations for HF in 65 and cardiac deaths in 14 patients. The group with worse atrial function analysed by strain (reservoir phase or PALS) or LAEF was associated with more rehospitalization for HF and/or cardiac death (PALS HR 2.33; IC 95%: 1.20- 4.52; p = 0.012; LAEF HR 2.24; IC 95%: 1.14-4.38; p = 0.018). In conclusion, the atrial function study by echocardiography with speckle tracking is useful in clinical practice. Its application in CrS allows improving atrial myopathy diagnosis associated with silent AF and its quantification in acute HF is related to adverse clinical outcomes with increased risk of HF readmission and/or cardiac death.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin

Importance of Tricuspid Regurgitation Velocity Threshold in Risk Assessment of Pulmonary Hypertension-Long-Term Outcome of Patients Submitted to Aortic Valve Replacement

Background: The upper physiological threshold for tricuspid regurgitation velocity (TRV) of 2.8 m/s proposed by the Pulmonary Hypertension (PH) guidelines had been questioned. The aim of this study was to evaluate the prognostic significance of preoperative PH in patients with aortic stenosis, long-term after valve replacement, using two different TRV thresholds (2.55 and 2.8 m/s). Methods: Four hundred and forty four patients were included (mean age 73 ± 9 years; 55% male), with a median follow-up of 5.8 years (98% completed). Patients were divided into three PH probability groups according to guidelines (low, intermediate and high) for both thresholds (TRV ≤ 2.8 m/s and TRV ≤ 2.55 m/s), using right atrial area>18 cm 2 and right ventricle/left ventricle ratio>1 as additional echocardiographic variables. Results: In patients with measurable TRV (n = 304), the low group mortality rate was 25% and 30%, respectively for 2.55 and 2.8 m/s TRV thresholds. The intermediate group with TRV > 2.55 m/s was an independent mortality risk factor (HR 2.04; 95% CI: 1.91 to 3.48, p = 0.01), in contrast to the intermediate group with TRV>2.8 m/s (HR 1.44; 95% CI: 0.89 to 2.32, p = 0.14). Both high probability groups were associated with an increased mortality risk, as compared to their respective low groups. When including all patients (with measurable and non-measurable TRV), both intermediate groups remained independently associated with an increased mortality risk: HR 1.62 (95% CI 1.11 to 2.35 p = 0.01) for the new cut-off point; and HR 1.43 (95% CI: 0.96 to 2.13, p = 0.07) for guidelines threshold. Conclusion: A TRV threshold of 2.55 m/s, together with right cavities measures, allowed a better risk assessment of patients with PH secondary to severe aortic stenosis, with or without tricuspid regurgitation

Importance of tricuspid regurgitation velocity threshold in risk assessment of pulmonary hypertension-long-term outcome of patients submitted to aortic valve replacement

Background: the upper physiological threshold for tricuspid regurgitation velocity (TRV) of 2.8 m/s proposed by the Pulmonary Hypertension (PH) guidelines had been questioned. The aim of this study was to evaluate the prognostic significance of preoperative PH in patients with aortic stenosis, long-term after valve replacement, using two different TRV thresholds (2.55 and 2.8 m/s). Methods: four hundred and forty four patients were included (mean age 73 ± 9 years; 55% male), with a median follow-up of 5.8 years (98% completed). Patients were divided into three PH probability groups according to guidelines (low, intermediate and high) for both thresholds (TRV ≤ 2.8 m/s and TRV ≤ 2.55 m/s), using right atrial area>18 cm2 and right ventricle/left ventricle ratio>1 as additional echocardiographic variables. Results: in patients with measurable TRV (n = 304), the low group mortality rate was 25% and 30%, respectively for 2.55 and 2.8 m/s TRV thresholds. The intermediate group with TRV > 2.55 m/s was an independent mortality risk factor (HR 2.04; 95% CI: 1.91 to 3.48, p = 0.01), in contrast to the intermediate group with TRV>2.8 m/s (HR 1.44; 95% CI: 0.89 to 2.32, p = 0.14). Both high probability groups were associated with an increased mortality risk, as compared to their respective low groups. When including all patients (with measurable and non-measurable TRV), both intermediate groups remained independently associated with an increased mortality risk: HR 1.62 (95% CI 1.11 to 2.35 p = 0.01) for the new cut-off point; and HR 1.43 (95% CI: 0.96 to 2.13, p = 0.07) for guidelines threshold. Conclusion: A TRV threshold of 2.55 m/s, together with right cavities measures, allowed a better risk assessment of patients with PH secondary to severe aortic stenosis, with or without tricuspid regurgitation

Data_File

Data file in R forma

Data from: Validation of the Regicor short physical activity questionnaire for the adult population

Objective: To develop and validate a short questionnaire to estimate physical activity (PA) practice and sedentary behavior for the adult population. Methods: The short questionnaire was developed using data from a cross-sectional population-based survey (n=6352) that included the Minnesota leisure-time PA questionnaire. Activities that explained a significant proportion of the variability of population PA practice were identified. Validation of the short questionnaire included a cross-sectional component to assess validity with respect to the data collected by accelerometers and a longitudinal component to assess reliability and sensitivity to detect changes (n=114, aged 35 to 74 years). Results: Six types of activities that accounted for 87% of population variability in PA estimated with the Minnesota questionnaire were selected. The short questionnaire estimates energy expenditure in total PA and by intensity (light, moderate, vigorous), and includes 2 questions about sedentary behavior and a question about occupational PA. The short questionnaire showed high reliability, with intraclass correlation coefficients ranging between 0.79 to 0.95. The Spearman correlation coefficients between estimated energy expenditure obtained with the questionnaire and the number of steps detected by the accelerometer were as follows: 0.36 for total PA, 0.40 for moderate intensity, and 0.26 for vigorous intensity. The questionnaire was sensitive to detect changes in moderate and vigorous PA (correlation coefficients ranging from 0.26 to 0.34). Conclusion: The REGICOR short questionnaire is reliable, valid, and sensitive to detect changes in moderate and vigorous PA. This questionnaire could be used in daily clinical practice and epidemiological studies

Left Atrium Assessment by Speckle Tracking Echocardiography in Cryptogenic Stroke : Seeking Silent Atrial Fibrillation

Silent atrial fibrillation (AF) may be the cause of some cryptogenic strokes (CrS). The aim of the study was to analyse atrial size and function by speckle tracking echocardiography in CrS patients to detect atrial disease. Patients admitted to the hospital due to CrS were included prospectively. Echocardiogram analysis included left atrial ejection fraction (LAEF) and atrial strain. Insertable cardiac monitor was implanted, and AF was defined as an episode of ≥1 min in the first year after stroke. Left atrial enlargement was defined as indexed volume > 34 mL/m 2. Seventy-five consecutive patients were included, aged 76 ± 9 years (arterial hypertension 75%). AF was diagnosed in 49% of cases. The AF group had higher atrial volume and worse atrial function: peak atrial longitudinal strain (PALs) 19.6 ± 5.7% vs. 29.5 ± 7.2%, peak atrial contraction strain (PACs) 8.9 ± 3.9% vs. 16.5 ± 6%, LAEF 46.8 ± 11.5% vs. 60.6 ± 5.2%; p < 0.001. AF was diagnosed in 20 of 53 patients with non-enlarged atrium, and in 18 of them, atrial dysfunction was present. The multivariate logistic regression analysis demonstrated an independent association between detection of AF and atrial volume, LAEF, and strain. Cut-off values were obtained: LAEF < 55%, PALs < 21.4%, and PACs < 12.9%. In conclusion, speckle tracking echocardiography in CrS patients improves silent atrial disease diagnosis, with or without atrial enlargement