Importance:COVID-19 can lead to long-term cardiopulmonary symptoms and is associated with coronary microvascular dysfunction (CMD). However, long-term data on CMD after severe COVID-19 are lacking. Objective:To investigate long-term left ventricular function and the presence of CMD after severe COVID-19. Design, Setting, and Participants:This case-control study was conducted among patients at a single center from the prospective Follow-Up of Patients With Severe COVID-19 (UppCov) study, with follow-up multiparametric perfusion cardiovascular magnetic resonance (CMR) at 10 months after discharge from November 2020 to February 2021. Patients previously hospitalized due to severe COVID-19 (ventilatory support, oxygen flow ≥5 L/min, or both) with or without cardiac involvement (troponin t > 14 ng/L, pulmonary artery pressure >34 mm Hg, or both) were compared with historical sex- and age-matched volunteers without symptomatic ischemic heart disease. Standard contraindications to adenosine CMR were applied. Data were analyzed between March 2023 and March 2025. Exposure:Hospitalization due to severe COVID-19. Main Measures and Outcomes:Comprehensive CMR included native T1, native T2, extracellular volume, adenosine stress and rest perfusion mapping, gadolinium enhancement, and cine imaging. Comorbidities, medications, symptoms at follow-up, and details regarding hospitalization were obtained from patient records. Results:The study included 37 patients with COVID-19 (mean age, 56 years [95% CI, 53 to 61 years]; 28 male [75.7%]) and 22 healthy volunteers (mean age, 51 years [95% CI, 45 to 57 years]; 12 male [54.4%]). Patients with COVID-19 compared with healthy patients demonstrated reduced mean stress perfusion (2.80 mL/min/g [95% CI, 2.53 to 3.07 mL/min/g] vs 3.43 mL/min/g [95% CI, 3.13 to 3.74 mL/min/g]; P = .003), impaired mean global longitudinal strain (-17% [95% CI, -18% to -16%] vs -19% [-20% to -18%]; P = .003), and impaired mean global circumferential strain (-16% [95% CI, -17% to -15%] vs -19% [-20% to -18%]; P = .001). There were no differences in stress perfusion or myocardial perfusion reserve in the COVID-19 group between patients with vs without cardiovascular risk factors or cardiac symptoms. Conclusions and Relevance:In this study, patients with COVID-19 exhibited long-term reduced stress perfusion indicating CMD, along with declined left ventricular function by global longitudinal strain and global circumferential strain. Lack of variation in stress perfusion between patients with and without cardiovascular risk factors may suggest CMD due to severe COVID-19, warranting further investigation to elucidate mechanisms and guide potential therapies.

BACKGROUND: Coronary artery calcification (CAC) has been linked to an increased risk of cardiovascular events. Its detection in asymptomatic individuals is valuable for reclassifying cardiac risk and informing management strategies. We hypothesised that an advanced electrocardiography (A-ECG) score derived from the standard 12-lead ECG predicts CAC with good diagnostic accuracy compared to computed tomography (CT). METHODS: This retrospective study included patients that had undergone a 12-lead ECG and CT CAC scoring demonstrating either the absence (n=265) or presence (n=255) of any CAC. Multivariable elastic net logistic regression was used to generate an A-ECG score validated by nested resampling. RESULTS: An A-ECG score for detecting CAC comprised of age, sex, and four ECG measures encompassing the duration of the Q wave in lead I, vectorcardiographic measures derived from the 12-lead ECG related to the spatial direction of the QRS complex (two measures) and the magnitude of the ST segment (one measure). Nested resampling estimated performance for predicting the presence of any CAC with an area under the receiver operating characteristics curve [95% confidence interval] of 0.78 [0.77-0.79], sensitivity 73 [72-75]%, specificity 66 [65-68]%, positive predictive value 70 [68-71]%, negative predictive value 71 [69-72]%, positive likelihood ratio 2.3 [2.1-2.4], and inverse negative likelihood ratio 2.6 [2.4-2.7]. CONCLUSIONS: The standard 12-lead ECG analysed by A-ECG analysis can predict the presence of CAC with good diagnostic performance. A-ECG may hold clinical utility as a low-cost and widely available initial screening test for the presence of CAC and cardiac risk prediction. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee of Northern Sydney Local Health District Human Research Ethics Committee gave ethical approval for this work I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript

Aims More than 90% of patients with left bundle branch block (LBBB) and reduced left ventricular (LV) ejection fraction have LV dyssynchrony and a high probability of response to cardiac resynchronization therapy (CRT). A subgroup of patients with non-specific intraventricular conduction delay (IVCD) have a LBBB-like LV activation pattern when studied using invasive mapping and advanced echocardiographic techniques. These patients also frequently benefit from CRT, but these patients have proven difficult to identify using electrocardiogram criteria. Cardiovascular magnetic resonance (CMR) imaging indices of dyssynchrony may identify patients with IVCD who may benefit from CRT, but their relative accuracies for identification of LV dyssynchrony remain unknown. We compared the LV dyssynchrony classification accuracy of two commonly available CMR indices in a study population of patients with severely reduced LV ejection fraction and no scar and either LBBB or QRS duration <120 ms and normal QRS axis (controls). Methods and results In LBBB (n = 44) and controls (n = 36), using CMR feature-tracking circumferential strain, dyssynchrony was quantified as the circumferential uniformity ratio estimate (CURE) and the systolic stretch index (SSI). Deidentified CMR image data were made publicly available. Both CURE and SSI quantified more severe dyssynchrony in LBBB compared with controls (P<0.001 for both). SSI more frequently discriminated LBBB and normal conduction LV activation patterns than CURE [area under the receiver-operating characteristic curve (95% confidence interval) 0.96 (0.92-1.00) for SSI vs. 0.76 (0.65-0.86) for CURE, P < 0.001]. Conclusion SSI is superior to CURE for discriminating synchronous and dyssynchronous LV activation and should be further studied in the setting of non-LBBB conduction abnormalities.

BACKGROUND: Advanced electrocardiography (AECG) has been used to improve the diagnostic performance of the ECG in a number of cardiac disease states. We hypothesised that AECG can improve the diagnostic assessment of intermediate risk chest pain by optimising an AECG score for significant coronary artery disease (CAD) by cardiovascular computed tomography (CCT). METHODS: Participants attending an outpatient rapid access chest pain clinic underwent a 12 lead ECG and CCT. Significant CAD was defined as luminal stenosis >50%. Multivariable logistic regression was performed using measures from the conventional ECG, derived vectorcardiography, and singular value decomposition measures of waveform complexity. RESULTS: Of included patients (n=171, 60% male, age 59 +/- 13 years), 37 (22%) had >50% stenosis in at least one coronary artery, with single, double, or triple vessel disease in 38%, 38%, and 24%, respectively. A four parameter AECG score to detect significant CAD had an area under the receiver operating characteristic curve [95% confidence interval] of 0.87 [0.78 - 0.94], sensitivity 89 [69 - 97]%, specificity 82 [68 - 94]%, positive predictive value 55 [43 - 78]%, negative predictive value 96 [92 - 99]%, positive likelihood ratio 4.6 [2.9 - 13.1] and inverse negative likelihood ratio 6.4 [2.9 - 27.2]. CONCLUSION: AECG can rule out significant CAD on CCT with a high negative predictive value and overall good diagnostic performance. This supports the use of AECG to screen patients in a chest pain clinic setting who would benefit from further testing or not. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded in part by a NSW Health Grant awarded to the senior author, Dr Rebecca Kozor. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the local ethics committee (Northern Sydney Local Health District Human Research Ethics Committee) and all participants provided written informed consent or a waiver of consent was obtained. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript.

Background: Stress echocardiography (SE) is relatively resource intensive and has a low incidence of abnormal tests for detecting coronary artery disease (CAD) in low-to-intermediate risk patients. This study aimed to derive and determine the diagnostic performance of a resting advanced electrocardiography (A-ECG) score for detecting inducible myocardial ischemia on SE in patients with low-to-intermediate risk stable chest pain. Methods: Patients were included if they presented with low-to-intermediate risk stable chest pain to the emergency department, had acute coronary syndrome ruled out by electrocardiography (ECG) and high-sensitivity troponin, and subsequently underwent outpatient SE. Patients were excluded if they had known CAD or confounders on resting ECG. A-ECG was retrospectively applied to a standard resting 12-lead ECG and a multivariable logistic regression score was derived to predict myocardial ischemia on SE. Results: Among 292 patients (51% male, age 58+/-14 years), 24 (8%) exhibited inducible myocardial ischemia on SE. A 3-parameter A-ECG score had an area under the receiver-operating characteristic curve (AUC [bootstrapped 95% confidence interval]) of 0.85 [0.75-0.93], sensitivity 92 [67-100]%, specificity 67 [64-94]%, positive predictive value 22 [20-55]%, negative predictive value 99 [96-100]%, positive likelihood ratio 2.8 [2.5-12.0] and inverse negative likelihood ratio 8.1 [2.5-18.0]. Conclusions: An A-ECG score had a good overall diagnostic performance and excellent performance for ruling out inducible myocardial ischemia on SE. This supports the use of an A-ECG score to triage and improve the selection of patients with low-intermediate risk stable chest pain that should undergo further testing with SE.

BACKGROUND:Both hospitalised (H) and non-hospitalised (NH) individuals may have different symptoms and impairments after COVID-19. We aimed to explore symptoms, mental and physical health after initial COVID-19 for both groups of individuals and the association between physical and mental impairments in relation to self-rated health status and to identify different cluster profiles. METHODS:Participants were recruited between June 2020 until December 2022 at the Karolinska University Hospital, Sweden. Data was collected at first assessment after COVID-19 and consisted of demographics, medical history, symptoms and results from physical function tests and self-reported questionnaires. RESULTS:Here we show that among 931 participants, the H-group are older (mean age 56.7 years) and predominantly male (72%), while the NH-group are younger (mean age 44.4 years) and mostly female (84%). Fatigue, dyspnoea, joint pain, paraesthesia, and chest pressure are common symptoms reported across all participants. Physical function is lower than predicted in both groups and the NH-group have higher prevalence of depression and fatigue. These impairments together with dyspnoea, number of symptoms and sick leave are also associated with reduced self-rated health. Four specific cluster profiles have been identified, and 66.4% of the participants have severe to moderate impairments. CONCLUSIONS:Regardless of the initial level of care approximately two-thirds of the participants exhibit various physical and mental impairments associated to self-rated health after COVID-19. We propose that defining specific cluster profiles is crucial for tailoring management of post-COVID sequelae. Further long-term studies are needed to understand recovery trajectories to optimise targeted interventions.

Background: Coronavirus disease 2019 (COVID-19) can lead to long-term cardiopulmonary symptoms and is associated to coronary microvascular dysfunction (CMD). However, long-term data on CMD following severe COVID-19 are lacking. Objective: To determine long-term left ventricular (LV) function and presence of CMD after severe COVID-19, utilizing cardiovascular magnetic resonance (CMR) and stress perfusion mapping. Methods: Hospitalized COVID-19 patients underwent CMR at 10 months follow-up (1.5T Aera, Siemens Healthineers) including cine imaging, native T1 and T2, extracellular volume, and adenosine stress perfusion mapping. Clinical data were obtained from patient records. Patients were compared to volunteers without symptomatic ischemic heart disease (IHD). Results: COVID-19 patients (n=37, age 56±12 years, 76% male) and volunteers (n=22, age 51±13 years, 55% male, p=ns for both) were included. COVID-19 patients demonstrated reduced stress perfusion (2.8±0.81 vs 3.4±0.69 ml/min/g, p=0.003), impaired global longitudinal strain (GLS, -17±2 vs -19±2 %, p=0.003) and global circumferential strain (GCS, -16±3 vs -19±3 %, p=0.001). There were no differences in stress perfusion or myocardial perfusion reserve between COVID-19 patients with or without cardiovascular risk factors or cardiac symptoms. Conclusion: COVID-19 patients exhibit long-term reduced stress perfusion indicating CMD, and impaired LV function by GLS and GCS. Lack of variation in stress perfusion between patients with and without cardiovascular risk factors suggests that CMD may be a consequence of severe COVID-19, warranting further investigation to elucidate mechanisms, and guide potential therapeutic interventions. ### Competing Interest Statement Sanofi Genzyme AB has previously awarded JN minor speaker compensation for work unrelated to this study. PK receives research support (source codes) from Siemens Healthineers. Karolinska University Hospital has a research and development agreement with Siemens Healtineers. The rest of the authors declare no competing interests. ### Funding Statement Funding was provided by the Swedish Research Council, Swedish Heart and Lung Foundation, the Swedish Society of Medicine, the Stockholm County Council and Karolinska Institutet. MS has received research grants from Dysautonomia International, Swedish Research Foundation, Swedish Virology Society. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: All procedures were granted ethical approval by the Swedish Ethical Review Authority (Dnr 2021-03293, 2022-0695, 2020-02397). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data supporting the findings are available from corresponding author upon reasonable request.

Severe Covid-19 may cause a cascade of cardiovascular complications beyond viral pneumonia. The severe inflammation may affect the microcirculation which can be assessed by cardiovascular magnetic resonance (CMR) imaging using quantitative perfusion mapping and calculation of myocardial perfusion reserve (MPR). Furthermore, native T1 and T2 mapping have previously been shown to identify changes in myocardial perfusion by the change in native T1 and T2 during adenosine stress. However, the relationship between native T1, native T2, ΔT1 and ΔT2 with myocardial perfusion and MPR during long-term follow-up in severe Covid-19 is currently unknown. Therefore, patients with severe Covid-19 (n = 37, median age 57 years, 24% females) underwent 1.5 T CMR median 292 days following discharge. Quantitative myocardial perfusion (ml/min/g), and native T1 and T2 maps were acquired during adenosine stress, and rest, respectively. Both native T1 (R2 = 0.35, p < 0.001) and native T2 (R2 = 0.28, p < 0.001) correlated with myocardial perfusion. However, there was no correlation with ΔT1 or ΔT2 with MPR, respectively (p > 0.05 for both). Native T1 and native T2 correlate with myocardial perfusion during adenosine stress, reflecting the coronary circulation in patients during long-term follow-up of severe Covid-19. Neither ΔT1 nor ΔT2 can be used to assess MPR in patients with severe Covid-19.

Body surface area (BSA) is the most commonly used metric for body size indexation of echocardiographic measures, but its use in patients who are underweight or obese is questioned (body mass index (BMI) < 18.5 kg/m 2 or ≥ 30 kg/m 2 , respectively). We aim to use survival analysis to identify an optimal body size indexation metric for echocardiographic measures that would be a better predictor of survival than BSA regardless of BMI. Adult patients with no prior valve replacement were selected from the National Echocardiography Database Australia. Survival analysis was performed for echocardiographic measures both unindexed and indexed to different body size metrics, with 5-year cardiovascular mortality as the primary endpoint. Indexation of echocardiographic measures (left ventricular end-diastolic diameter [n = 230,109] and mass [n = 224,244], left atrial volume [n = 150,540], aortic sinus diameter [n = 90,805], right atrial area [n = 59,516]) by BSA had better prognostic performance vs unindexed measures (underweight: C-statistic 0.655 vs 0.647; normal weight/overweight: average C-statistic 0.666 vs 0.625; obese: C-statistic 0.627 vs 0.613). Indexation by other body size metrics (lean body mass, height, and/or weight raised to different powers) did not improve prognostic performance versus BSA by a clinically relevant magnitude (average C-statistic increase ≤ 0.02), with smaller differences in other BMI subgroups. Indexing measures of cardiac and aortic size by BSA improves prognostic performance regardless of BMI, and no other body size metric has a clinically meaningful better performance.

Introduction: Decreased hydraulic force has recently been identified as a mechanism contributing to left ventricular (LV) diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF). However, it is unclear if hydraulic forces are independently associated with survival. Hypothesis: Decreased diastolic hydraulic force, estimated as the atrioventricular area difference (AVAD), is associated with survival independent of conventional diastolic dysfunction measures. Methods: Patients (n=37947, median [interquartile range] 4.9 [2.9-8.0] years follow-up, 6103 events) were selected from the National Echo Database Australia based on the presence of relevant transthoracic echocardiographic measures, LV ejection fraction (LVEF) ≥ 50%, heart rate 50-100 beats/minute, the absence of moderate or severe valvular disease, pericardial disease or mitral annular calcification, and no prior cardiac surgery. AVAD was calculated as the cross-sectional area difference between the LV and left atrium (LA) using circular approximation of LV end-diastolic diameter and LA end-systolic diameter. LV diastolic dysfunction grading was performed according to 2016 guidelines. Results: In multivariable linear regression, AVAD was weakly associated with E/e’, e’, peak tricuspid regurgitation velocity, and LVEF (global adjusted R2=0.11, p<0.001), but not associated with left atrial volume index (p=0.83). In multivariable Cox regression, there was an association with survival for both AVAD (chi-square 279, hazard ratio (HR) [95% confidence interval] 1.23 [1.20-1.26], p<0.001) and diastolic dysfunction grading (chi-square 1217, HR 3.21 [3.00-3.42], p<0.001). In a separate multivariable model, there was an association with survival for both AVAD (chi-square 371, HR 1.27 [1.24-1.30], p<0.001) and E/e’ (chi-square 1020, HR 1.39 [1.36-1.42], p<0.001). Conclusions: Decreased hydraulic force, estimated as AVAD, is associated with diastolic dysfunction, and provides prognostic information beyond conventional measures used to grade diastolic dysfunction. This suggests that increased LA size relative to LV size is a potential therapeutic target in HFpEF.

This dataset has been curated and made available as part of a study by Loewenstein, et al (https://doi.org/10.1101/2022.11.11.22282225). We compared the LV dyssynchrony classification accuracy of two commonly available CMR indices in a study population of patients with severely reduced LV ejection fraction and no scar, and either LBBB or normal conduction (normal QRS duration and axis, controls).We retrospectively identified 80 patients from three centers, with LV ejection fraction <=35%, no scar by CMR late gadolinium enhancement, and either normal electrocardiographic QRS duration (<120ms) and normal frontal plane electrical axis (-30 to +90 degrees) (control, n=36), or LBBB by Strauss’ criteria (LBBB, n=44).Provided is the image data and analysis code to reproduce all aspects of the current study.Datasets with original and delineated CMR exams can be found in the provided zip archive.Please see the README.docx document provided above for more details.

Background Left anterior fascicular block (LAFB) has been associated with increased mortality, but the underlying causes are unknown.Objectives To determine whether LAFB is associated with increased left ventricular (LV) scar burden and reduced LV ejection fraction (LVEF).Methods LAFB patients (n=51) and matched control patients (n=600) were retrospectively enrolled. Both groups had been referred for cardiovascular magnetic resonance imaging (CMR) and electrocardiography (ECG). They were compared regarding size and location of LV scar, LVEF, and a dysfunction index describing the difference between measured LVEF and expected LVEF based on scar size.Results Patients with LAFB had on average a larger LV scar (median [interquartile range] 0.7 [0.0-6.6] vs 0.0 [0.0-1.5] % LV mass, p<0.001). LAFB was associated with a higher prevalence of any scar (59% vs 33%, p<0.001). The groups had similar prevalence of ischemic scar (29% vs 23%, p=0.40) but LAFB patients a higher prevalence of non-ischemic scar (29% vs 10%, p=0.001) most frequently located in the basal and mid inferoseptal segments and the anterior and lateral apical LV segments. LVEF was lower in LAFB than in controls (58 [43-60] vs 60 [55-60] %, p=0.02). There was no difference in dysfunction index (24.0 [17.8-25.5] vs 24.0 [19.0-27.8] %-points of LVEF, p=0.32).Conclusions In a matched cohort, LAFB was associated with a small decrease in LVEF that was proportionate to the increased LV scar burden, which was more commonly of non-ischemic etiology and not infarction, and not more commonly located near the expected course of the left anterior fascicle.### Competing Interest StatementDr. Ugander has a development agreement for CMR between Karolinska University Hospital and Siemens Healthineers. Dr. Atwater is an advisory board member at Medtronic, Biotronik, Biosense Webster and Abbott and a consultant at Abbott. The remaining authors have no relationships to declare.### Funding StatementThis study did not receive any external funding.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:IRB of Duke University, Durham, North Carolina, USA, gave ethical approval for this work.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesData produced in the present study may be available upon reasonable request to the authors if permissible.* LAFB : Left anterior fascicular block LV : Left ventricle ECG : Electrocardiography CMR : Cardiovascular magnetic resonance imaging LGE : Late gadolinium enhancement LVEF : Left ventricular ejection fraction LBBB : Left bundle branch block RBBB : Right bundle branch block HF : Heart failure

This dataset has been curated and made available as part of a study by Loewenstein, et al (https://doi.org/10.1101/2022.11.11.22282225). The aim of the study was to evaluate the diagnostic performance of mechanical dyssynchrony indices in a study population of patients with severely reduced ejection fraction and no LV myocardial scar assessed by cardiovascular magnetic resonance (CMR), and either left bundle branch block (LBBB) or normal QRS duration.We retrospectively identified 80 patients from three centers, with LV ejection fraction <=35%, no scar by CMR late gadolinium enhancement, and either normal electrocardiographic QRS duration (<120ms) and normal frontal plane electrical axis (-30 to +90 degrees) (control, n=36), or LBBB by Strauss’ criteria (LBBB, n=44).Provided is the image data and analysis code to reproduce all aspects of the current study.Datasets with original and delineated CMR exams can be found in the provided zip archive.Please see the README.docx document provided above for more details.

Introduction: Advanced electrocardiography (A-ECG) has been used to improve the diagnostic performance of the ECG in a number of cardiac disease states. We hypothesised that A-ECG can improve the diagnostic assessment of intermediate risk chest pain by optimising an A-ECG score for significant coronary artery disease (CAD) by cardiovascular computed tomography (CCT).

Introduction: Follow-up of Covid-19 patients is crucial to guide health interventions and planning for patients with post-acute Covid-19 syndrome (PACS). Material: In an ongoing systematic assessment, we compared two cohorts of Covid-19 patients. Hospitalised patients (HP) (n=189) with Covid-19 pneumonia and respiratory insufficiency/failure were followed-up for a median of 98 days after discharge, and compared to 67 non-hospitalised patients (nonHP) with long-term symptoms of Covid-19 and referred by primary care physicians. Results: HP were admitted for a median of 22 days, with 76% in ICU care. HP (72% male) had a median age of 57 years (range 18-81), and a median body mass index (BMI) of 30. nonHP (19% male) had a median age of 45 years (range 21-68), and a median BMI of 24.5. nonHP achieved lower percent of reference in a 6-minute walking test compared to HP (82% vs 91%, p=0.024). Self-assessed activity per the Frändin-Grimsby Scale in HP group had a median of 4 before Covid-19 and 3 at follow-up, compared to 5 and 2 in nonHP group. Dynamic spirometry values as percent of reference were lower in HP compared to nonHP (FVC 72 vs 88, p < 0.001; FEV1 73 vs 90, p<0.001; PEF and FVC/FEV1 did not differ between groups). Maximum inspiratory pressure (MIP) as percent of reference was noticeably lower (62%) in HP vs nonHP (88%), p<0.001. Conclusions: Albeit both younger and not overweight, non-hospitalised patients underperformed in MIP, 6-minute walking test and self-assessed physical activity compared to patients with severe Covid-19 pneumonia upon early follow-up.

Introduction: Body surface area (BSA) is the most widely accepted metric for body size indexation of cardiac measures to improve diagnosis, but its use in obesity is questioned. Furthermore, big data analyses comparing indexation metrics are limited. Hypothesis: All-cause mortality can be used to identify an optimal indexation metric for transthoracic echocardiographic (TTE) measures that will be a better predictor of survival than BSA regardless of obesity (body mass index [BMI] ≥30kg/m2). Methods: Patients (n=11621) with no prior cardiac surgery, with all TTE measures of interest available, were selected from the National Echo Database Australia. Cox regression survival analysis for all-cause mortality (Wald chi-square) was analyzed for TTE measures both unindexed and indexed to different indexation metrics. Results: For both non-obese (n=7684, median BMI 25 kg/m2, age 65 years, 42% female, 4.2 years follow-up, 1586 deaths) and obese patients (n=3937, BMI 34 kg/m2, age 63 years, 42% female, 4.5 years follow-up, 607 deaths), indexation of cardiac sizes (atrial areas, left ventricular mass and diameter, and aortic sinus diameter) to BSA had better prognostic performance (higher chi-square) vs unindexed measures. Indexing by height^2.7 performed worse than BSA. Cardiac output had the best prognostic performance when indexed by weight^3 vs all other metrics (>3-fold higher chi-square). Stroke volume performed better unindexed than when indexed for body size. Conclusions: When using all-cause mortality as the arbiter of appropriateness among both non-obese and obese patients, indexation by BSA improved prognostic performance, cardiac output performed best when indexed by weight^3, and stroke volume performed best unindexed.

BACKGROUND: Body size indexation is a foundation of the diagnostic interpretation of cardiac size measures used in imaging assessment of cardiovascular health. Body surface area (BSA) is the most commonly used metric for body size indexation of echocardiographic measures, but its use in patients who are underweight or obese is questioned (body mass index (BMI) <18.5 kg/m2 or [≥]30 kg/m2, respectively). We hypothesized that mortality can be used to identify an optimal body size indexation metric for echocardiographic measures that would be a better predictor of survival than BSA regardless of BMI. METHODS: In this big data, cohort study, adult patients with no prior valve replacement were selected from the National Echo Database Australia. Survival analysis was performed for echocardiographic measures both unindexed and indexed to different body size metrics, with 5-year cardiovascular mortality as the primary endpoint. FINDINGS: Indexation of echocardiographic measures (left ventricular diameter [n=337,481] and mass [n=330,959], left atrial area [n=136,989], aortic sinus diameter [n=125,130], right atrial area [n=81,699], right ventricular diameter [n=3,575], right ventricular outflow tract diameter [n=2,841]) by BSA had better prognostic performance vs unindexed measures (healthy/overweight: C-statistic 0.656 vs 0.618, average change in Akaike Information Criteria ({Delta}AIC) 800; underweight: C-statistic 0.669 vs 0.654, {Delta}AIC 15; obese: C-statistic 0.630 vs 0.612, {Delta}AIC 113). Indexation by other body size metrics (lean body mass or height and/or weight raised to various powers) did not improve prognostic performance versus BSA by a clinically relevant magnitude (average C-statistic increase [≤]0.01), with smaller differences in higher BMI subgroups. Similar results were obtained using sex-disaggregated analysis, for indexation of other aortic or cardiac dimension or volume measures, and for all-cause mortality. INTERPRETATION: Indexing measures of cardiac and aortic size by BSA improves prognostic performance regardless of BMI, and no other body size metric has a clinically meaningful better performance. FUNDING: This research was supported in part by grants (PI Ugander) from New South Wales Health, Heart Research Australia, and the University of Sydney.

Supplemental Digital Content is available in the text. Background: Patients with severe mental illness (SMI) including schizophrenia, bipolar disorder, and severe depression have earlier onset of cardiovascular risk factors, predisposing to worse future heart failure (HF) compared with the general population. We investigated associations between the presence/absence of SMI and long-term HF outcomes. Methods: We identified patients with HF with and without SMI in the Duke University Health System from 2002 to 2017. Using multivariable Cox regression, we examined the primary outcome of all-cause mortality. Secondary outcomes included rates of implantable cardioverter defibrillator use, cardiac resynchronization therapy, left ventricular assist device implantation, and heart transplantation. Results: We included 20 906 patients with HF (SMI, n=898; non-SMI, n=20 008). Patients with SMI presented clinically 7 years earlier than those without SMI. We observed an interaction between SMI and sex on all-cause mortality (P=0.002). Excess mortality was observed among men with SMI compared with men without SMI (hazard ratio, 1.36 [95% CI, 1.17–1.59]). No association was observed among women with and without SMI (hazard ratio, 0.97 [95% CI, 0.84–1.12]). Rates of implantable cardioverter defibrillator use, cardiac resynchronization therapy, left ventricular assist device implantation, and heart transplantation were similar between patients with and without SMI (6.1% versus 7.9%, P=0.095). Patients with SMI receiving these procedures for HF experienced poorer prognosis than those without SMI (hazard ratio, 2.12 [95% CI, 1.08–4.15]). Conclusions: SMI was associated with adverse HF outcome among men and not women. Despite equal access to procedures for HF between patients with and without SMI, those with SMI experienced excess postprocedural mortality. Our data highlight concurrent sex- and mental health-related disparities in HF prognosis, suggesting that patients with SMI, especially men, merit closer follow-up.

Background: Longitudinal left atrial (LA) strain has emerged as an attractive indicator of increased left ventricular (LV) filling pressures and poor prognosis.However, it is unclear how LA strain relates to other conventional geometric measures of the LA and LV, and to what extent each of these contribute to LA strain.Purpose: To better understand the geometric basis of LA strain measurement by addressing the hypothesis that LA strain is associated with many conventional geometric measures of LA and LV volume and function.Methods: Patients (n = 48) referred clinically for cardiovascular magnetic resonance (CMR) (1.5T or 3T MAGNETOM Aera or Skyra, Siemens Healthcare, Erlangen, Germany) were retrospectively included based on a desired even distribution of LV ejection fraction (range 12-72%) and the absence of functionally distinct myocardial disease (e.g.amyloidosis, hypertrophic cardiomyopathy).Cine images were used for all measures using commercially available software (Segment, Medviso, Lund, Sweden).LA area and length at both ventricular end diastole and end systole, were measured in the two chamber long-axis view.LV end-diastolic volume, LV stroke volume, LV ejection fraction, LV mass, LV global longitudinal strain (GLS), mitral annular plane systolic excursion (MAPSE), and LV length in end diastole were measured using established clinical methods.Body surface area was estimated based on height and weight.Associations were evaluated using univariate and multivariate linear regression.Results: LA strain was associated by univariate analysis with all evaluated measures (R2 = 0.08-0.60,p < 0.05 for all) with the exception of LV stroke volume and body surface area.In multivariable analysis, only MAPSE, LV length and LA end-diastolic area were significant contributors to explaining LA strain (global adjusted R2 = 0.76, p < 0.001, see Table ). Conclusion:LA strain is a composite measure that is closely related to both LV and LA geometry and function.It is possible to derive an excellently accurate estimate of LA strain, using only simple measures of the LV and LA commonly accessible in CMR post processing analysis.