Left atrial volumetric and strain analysis by three-dimensional speckle-tracking echocardiography in noncompaction cardiomyopathy: results from the MAGYAR-path study

Introduction: Noncompaction cardiomyopathy (NCCM) is a rare congenital cardiomyopathy characterised by a distinctive 2-layered appearance of the myocardium due to hypertrabecularisation and deep intertrabecular recesses. The present study was designed to assess left atrial (LA) volumes and volumetric and strainbased functional properties by three-dimensional speckle-tracking echocardiography (3DSTE) in NCCM. Methods: The study included 12 consecutive NCCM patients. Their results were compared to 20 age-and sex-matched healthy controls. Complete two-dimensional Doppler echocardiography and 3DSTE were performed in all cases. Results: Calculated LA maximum (76.5 ± 26.8 mL vs. 45.3 ± 15.1 mL, p=0.0002) and minimum (56.9 ± 27.3 mL vs. 25.3 ± 15.2 mL, p=0.0002) volumes and LA volume before atrial contraction (67.1 ± 28.2 mL vs. 35.7 ± 16.4 mL, p=0.0004) were significantly greater in NCCM patients. Total, active, and passive LA emptying fractions proved to be smaller in NCCM. Peak global radial (-9.3 ± 7.8% vs.-16.8 ± 10.2%, p=0.05), circumferential (12.8 ± 8.4% vs. 26.2 ± 9.2%, p=0.0003), longitudinal (12.8 ± 8.2% vs. 22.5 ± 8.5%, p=0.004), and area (26.7 ± 18.5% vs. 51.6 ± 20.3%, p=0.001) strains were significantly smaller in NCCM patients as compared to matched controls. Conclusions: Significantly greater LA volumes and compromised LA functional properties could be demonstrated by 3DSTE in patients with NCCM. © 2016, Hellenic Cardiological Society. All rights reserved

Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation

Appropriate antithrombotic regimens for patients with atrial fibrillation who have an acute coronary syndrome or have undergone percutaneous coronary intervention (PCI) are unclear.In an international trial with a two-by-two factorial design, we randomly assigned patients with atrial fibrillation who had an acute coronary syndrome or had undergone PCI and were planning to take a P2Y12 inhibitor to receive apixaban or a vitamin K antagonist and to receive aspirin or matching placebo for 6 months. The primary outcome was major or clinically relevant nonmajor bleeding. Secondary outcomes included death or hospitalization and a composite of ischemic events.Enrollment included 4614 patients from 33 countries. There were no significant interactions between the two randomization factors on the primary or secondary outcomes. Major or clinically relevant nonmajor bleeding was noted in 10.5% of the patients receiving apixaban, as compared with 14.7% of those receiving a vitamin K antagonist (hazard ratio, 0.69; 95% confidence interval [CI], 0.58 to 0.81; P<0.001 for both noninferiority and superiority), and in 16.1% of the patients receiving aspirin, as compared with 9.0% of those receiving placebo (hazard ratio, 1.89; 95% CI, 1.59 to 2.24; P<0.001). Patients in the apixaban group had a lower incidence of death or hospitalization than those in the vitamin K antagonist group (23.5% vs. 27.4%; hazard ratio, 0.83; 95% CI, 0.74 to 0.93; P = 0.002) and a similar incidence of ischemic events. Patients in the aspirin group had an incidence of death or hospitalization and of ischemic events that was similar to that in the placebo group.In patients with atrial fibrillation and a recent acute coronary syndrome or PCI treated with a P2Y12 inhibitor, an antithrombotic regimen that included apixaban, without aspirin, resulted in less bleeding and fewer hospitalizations without significant differences in the incidence of ischemic events than regimens that included a vitamin K antagonist, aspirin, or both. (Funded by Bristol-Myers Squibb and Pfizer; AUGUSTUS ClinicalTrials.gov number, NCT02415400.)

Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease

Evolocumab is a monoclonal antibody that inhibits proprotein convertase subtilisin-kexin type 9 (PCSK9) and lowers low-density lipoprotein (LDL) cholesterol levels by approximately 60%. Whether it prevents cardiovascular events is uncertain.We conducted a randomized, double-blind, placebo-controlled trial involving 27,564 patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of 70 mg per deciliter (1.8 mmol per liter) or higher who were receiving statin therapy. Patients were randomly assigned to receive evolocumab (either 140 mg every 2 weeks or 420 mg monthly) or matching placebo as subcutaneous injections. The primary efficacy end point was the composite of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization. The key secondary efficacy end point was the composite of cardiovascular death, myocardial infarction, or stroke. The median duration of follow-up was 2.2 years.At 48 weeks, the least-squares mean percentage reduction in LDL cholesterol levels with evolocumab, as compared with placebo, was 59%, from a median baseline value of 92 mg per deciliter (2.4 mmol per liter) to 30 mg per deciliter (0.78 mmol per liter) (P<0.001). Relative to placebo, evolocumab treatment significantly reduced the risk of the primary end point (1344 patients [9.8%] vs. 1563 patients [11.3%]; hazard ratio, 0.85; 95% confidence interval [CI], 0.79 to 0.92; P<0.001) and the key secondary end point (816 [5.9%] vs. 1013 [7.4%]; hazard ratio, 0.80; 95% CI, 0.73 to 0.88; P<0.001). The results were consistent across key subgroups, including the subgroup of patients in the lowest quartile for baseline LDL cholesterol levels (median, 74 mg per deciliter [1.9 mmol per liter]). There was no significant difference between the study groups with regard to adverse events (including new-onset diabetes and neurocognitive events), with the exception of injection-site reactions, which were more common with evolocumab (2.1% vs. 1.6%).In our trial, inhibition of PCSK9 with evolocumab on a background of statin therapy lowered LDL cholesterol levels to a median of 30 mg per deciliter (0.78 mmol per liter) and reduced the risk of cardiovascular events. These findings show that patients with atherosclerotic cardiovascular disease benefit from lowering of LDL cholesterol levels below current targets. (Funded by Amgen; FOURIER ClinicalTrials.gov number, NCT01764633 .)

Left atrial ejection force correlates with left atrial strain and volume-based functional properties as assessed by three-dimensional speckle tracking echocardiography (from the MAGYAR-Healthy Study)

INTRODUCTION AND OBJECTIVE: Three-dimensional (3D) speckle tracking echocardiography (3DSTE) is a novel method for assessment of left atrial (LA) volumes and function without geometrical assumptions. 3DSTE allows detailed assessment of LA features including volume measurements, strain assessments and calculation of LA ejection force (LAEF). LA strain and volume-based functional parameters originate from the same 3D dataset, but assessment of LAEF requires more data including measurement of mitral annular dimensions and Doppler-derived inflow velocities. The present study was designed to find correlations between LAEF and 3DSTE-derived LA volume-based functional properties and strain parameters in healthy subjects. METHODS: The study population comprised 34 randomly selected healthy subjects (age 36.1+/-11.2 years, 15 men) in sinus rhythm, all of whom had undergone standard two-dimensional transthoracic Doppler echocardiographic study extended with 3DSTE. RESULTS: Mitral annulus diameter-based LAEF correlated with global LA peak circumferential (r=0.39, p=0.02), longitudinal (r=0.32, p=0.05) and area (r=0.43, p=0.01) strain, total atrial stroke volume (r=0.30, p=0.05) and total atrial emptying fraction (r=0.31, p=0.05) characterizing (systolic) LA reservoir function and global LA 3D strain at atrial contraction (r=-0.44, p=0.01) and active atrial emptying fraction (r=0.36, p=0.04) characterizing (diastolic) LA contraction function (booster pump phase). CONCLUSIONS: Complex LA functional assessment can be provided by 3DSTE, including calculation of LAEF and volume-based and strain functional properties, with significant correlations between these parameters

Left Atrial Volumetric and Strain Analysis by Three-Dimensional Speckle-Tracking Echocardiography in Noncompaction Cardiomyopathy: Results from the MAGYAR-Path Study

Noncompaction cardiomyopathy (NCCM) is a rare congenital cardiomyopathy characterised by a distinctive 2-layered appearance of the myocardium due to hypertrabecularisation and deep intertrabecular recesses. The present study was designed to assess left atrial (LA) volumes and volumetric and strain-based functional properties by three-dimensional speckle-tracking echocardiography (3DSTE) in NCCM. Methods: The study included 12 consecutive NCCM patients. Their results were compared to 20 age- and sex-matched healthy controls. Complete two-dimensional Doppler echocardiography and 3DSTE were performed in all cases. Results: Calculated LA maximum (76.5 ± 26.8 mL vs. 45.3 ± 15.1 mL, p=0.0002) and minimum (56.9 ± 27.3 mL vs. 25.3 ± 15.2 mL, p=0.0002) volumes and LA volume before atrial contraction (67.1 ± 28.2 mL vs. 35.7 ± 16.4 mL, p=0.0004) were significantly greater in NCCM patients. Total, active, and passive LA emptying fractions proved to be smaller in NCCM. Peak global radial (−9.3 ± 7.8% vs. −16.8 ± 10.2%, p=0.05), circumferential (12.8 ± 8.4% vs. 26.2 ± 9.2%, p=0.0003), longitudinal (12.8 ± 8.2% vs. 22.5 ± 8.5%, p=0.004), and area (26.7 ± 18.5% vs. 51.6 ± 20.3%, p=0.001) strains were significantly smaller in NCCM patients as compared to matched controls. Conclusions: Significantly greater LA volumes and compromised LA functional properties could be demonstrated by 3DSTE in patients with NCCM