a c statistic of 0.82 (95% CI, 0.80-0.84), the CHADS2 index was the most accurate predictor of stroke. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3-1.7) for each 1-point increase in the CHADS2 score: 1.9 (95% CI, 1.2-3.0) for a score of 0; 2.8 (95% CI, 2.0-3.8) for 1; 4.0 (95% CI, 3.1-5.1) for 2; 5.9 (95% CI, 4.6-7.3) for 3; 8.5 (95% CI, 6.3-11.1) for 4; 12.5 (95% CI, 8.2-17.5) for 5; and 18.2 (95% CI, 10.5-27.4) for 6. Conclusion The 2 existing classification schemes and especially a new stroke risk index, CHADS2, can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.

Validation of clinical classification schemes for predicting stroke: results from the national registry of atrial fibrillation☆

Atrial fibrillation (AF) is an arrhythmia that can occur as the result of numerous different pathophysiological processes in the atria. Some aspects of the morphological and electrophysiological al...

Pathophysiological Mechanisms of Atrial Fibrillation: A Translational Appraisal

While management of atrial fibrillation (AF) patients is improved by guideline-conform application of anticoagulant therapy, rate control, rhythm control, and therapy of accompanying heart disease, the morbidity and mortality associated with AF remain unacceptably high. This paper describes the proceedings of the 3rd Atrial Fibrillation NETwork (AFNET)/European Heart Rhythm Association (EHRA) consensus conference that convened over 60 scientists and representatives from industry to jointly discuss emerging therapeutic and diagnostic improvements to achieve better management of AF patients. The paper covers four chapters: (i) risk factors and risk markers for AF; (ii) pathophysiological classification of AF; (iii) relevance of monitored AF duration for AF-related outcomes; and (iv) perspectives and needs for implementing better antithrombotic therapy. Relevant published literature for each section is covered, and suggestions for the improvement of management in each area are put forward. Combined, the propositions formulate a perspective to implement comprehensive management in AF.

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Comprehensive risk reduction in patients with atrial fibrillation: emerging diagnostic and therapeutic options-a report from the 3rd Atrial Fibrillation Competence NETwork/European Heart Rhythm Association consensus conference

This article describes the pathophysiology of left atrial mechanical function and discusses both conventional and new echocardiographic parameters used to evaluate left atrial function. The evidence regarding the clinical usefulness of left atrial function assessment is also presented.

Atrial function, in a close interdependence with left ventricular (LV) function, plays a key role in maintaining an optimal cardiac performance. The left atrium (LA) modulates LV filling through its reservoir, conduit, and booster pump function, whereas LV function influences LA function throughout the cardiac cycle. The LA can act to increase LA pressure (in significant atrial disease) and can react to increased LV filling pressure (in significant ventricular disease). LA remodelling is related to LV remodellingw1 and LA function has a central role in maintaining optimal cardiac output despite impaired LV relaxation and reduced LV compliance.1 Understanding how each component of LA function is influenced by LV performance, and how each LA phasic function contributes to maintain an optimal stroke volume in normal and diseased hearts, is important for interpreting data derived from quantification of LA function.

During LV systole and isovolumic relaxation, the LA functions as a reservoir, receiving blood from the pulmonary veins and storing energy in the form of pressure. This atrial function is modulated by LV contraction, through the descent of the LV base during systole, by right ventricular systolic pressure transmitted through the pulmonary circulation, and by LA properties (ie, relaxation and chamber stiffness).w2 During early …

https://heart.bmj.com/content/heartjnl/97/23/1982.full.pdf

Left atrial function: pathophysiology, echocardiographic assessment, and clinical applications

Atrial Fibrillation and Diabetes Mellitus: JACC Review Topic of the Week

Background: The total atrial conduction time (TACT) is an independent predictor of atrial fibrillation (AF). A new transthoracic echocardiographic tool to determine TACT by tissue Doppler imaging (PA-TDI (the time from the initiation of the P wave on the ECG (lead II) to the A′ wave on the lateral left atrial tissue Doppler tracing)) has been developed recently. Objective: To test the hypothesis that measurement of PA-TDI enables prediction of new-onset AF. Methods: 249 Patients without a history of AF were studied. All patients underwent an echocardiogram and the PA-TDI interval was measured. Patient characteristics and rhythm at follow-up were recorded. Results: During a mean (SD) follow-up of 680 (290) days, 15 patients (6%) developed new-onset AF. These patients had a longer PA-TDI interval than patients who remained in sinus rhythm (172 (25) ms vs 150 (20) ms, p = 0.001). Furthermore, the patients developing AF were older, more often had a history of heart failure or chronic obstructive pulmonary disease, more often used α blockers, had enlarged left atria and more frequently mitral incompetence on the echocardiogram. After adjusting for potential confounders, Cox regression showed that PA-TDI was independently associated with new-onset AF (OR = 1.375; 95% CI 1.037 to 1.823; p = 0.027). The 2-year incidence of AF was 33% in patients with a PA-TDI interval >190 ms versus 0% in patients with a PA-TDI interval Conclusions: A prolonged PA-TDI interval may predict the development of new-onset AF. This measure may be used to identify patients at risk in future strategies to prevent the development or complications of AF.

https://heart.bmj.com/content/heartjnl/95/10/835.full.pdf

Atrial Tissue Doppler Imaging For Prediction Of New-Onset Atrial Fibrillation

Background Currently, the total atrial activation time, as indicated by the P-wave duration using signal-averaged (SA) electrocardiogram (ECG) (SA-ECG), is the most powerful predictor of atrial fibrillation. However, because of practical limitations, this technique is not used in clinical routine. In this study we evaluated several alternative techniques to measure the total atrial activation time, including a new parameter that uses atrial Doppler tissue imaging (DTI). Methods For 30 patients who were in sinus rhythm and underwent a transthoracic echocardiogram, we determined the P-wave duration on surface ECG and SA-ECG, and the interval from the onset of the P wave (lead II) until the onset of the echocardiographic flow Doppler A wave over the mitral valve. In addition, using pulsed wave DTI in the 4-chamber view, we measured the interval of time from initiation of the ECG P wave (lead II) until the peak of the local lateral left atrial (LA) DTI signal. Correlation between the SA-ECG, surface ECG, and echocardiographic parameters were evaluated by Spearman correlation tests. Results All parameters that were used to estimate total atrial activation time showed a significant correlation with the SA-ECG P-wave duration. Although the interval of time from initiation of the ECG P wave until the peak of the local lateral LA DTI signal was significantly longer than the SA-ECG P-wave duration (151.12 ± 19.4 vs 128.4 ± 15.8 milliseconds, respectively, P R = 0.91, P P Conclusion LA DTI is an easy, fast, and reliable method to estimate the total atrial electrical activation time, and may be useful in the identification of those prone to develop atrial fibrillation.

Atrial activation time determined by transthoracic Doppler tissue imaging can be used as an estimate of the total duration of atrial electrical activation.

Objective We sought to investigate the echocardiographic prevalence of abdominal aortic aneurysm (AAA) in an unselected group of patients referred for regular transthoracic echocardiography (TTE). Methods Prospectively, during a 3-month period, a limited ultrasound examination of the infrarenal aorta was performed. AAA was defined as a diameter of 30 mm or more. Results The abdominal aorta could be visualized in 742 patients. The prevalence of AAA was 4.6%. AAA prevalence increased with age, especially in men. In 34 patients AAA was unknown and aortic diameters exceeded 50 mm in 4 patients. Two underwent elective but urgent operation. Patients with AAA were older and had an increased ascending aorta diameter, larger left ventricular dimensions, higher left ventricular mass index, and lower ejection fraction. Conclusion AAA is prevalent in patients referred for regular TTE. Routine rapid screening of the abdominal aorta during TTE is beneficial and should, therefore, be part of a standard TTE examination for patients older then 50 years.

Andrea Palmans

Papers

Atrial Tissue Doppler Imaging For Prediction Of New-Onset Atrial Fibrillation

Atrial activation time determined by transthoracic Doppler tissue imaging can be used as an estimate of the total duration of atrial electrical activation.

Abdominal aortic aneurysm screening during transthoracic echocardiography in an unselected population