BACKGROUND:Influenza infection has been associated with multiple cardiac complications including acute heart failure and myocardial infarction. The FluHeart study aims to uncover the potential effect of influenza infection on cardiac structure and function as assessed by echocardiography during hospitalization. METHODS:This prospective cohort study included hospitalized influenza patients of the 2021-2022 influenza season. Participants underwent echocardiography using a prespecified protocol. Participants were successfully matched 1:1:1 on age, sex, and heart failure status with controls from the general population and controls hospitalized with COVID-19. RESULTS:This interim analysis involved 108 participants (36 influenza patients, 36 general population controls, and 36 COVID-19 patients). Mean age was 72 ± 18 years and 58% were male. Median time from admission to echocardiography was 1 day (IQI: 1:1) for influenza patients. The prevalence of left ventricular (LV) dysfunction was 75%, and right ventricular (RV) dysfunction was observed in 20% of influenza patients. N-terminal pro-brain natriuretic peptide levels were elevated ≥ 300 pg/mL in 62%, and 19% exhibited myocardial injury with elevated high-sensitivity troponin I levels. RV tricuspid annular plane systolic excursion and LV early diastolic peak mitral inflow to early diastolic tissue velocity were significantly worse in influenza patients compared to general population controls. Echocardiographic measures did not significantly differ between patients hospitalized with influenza and COVID-19. CONCLUSION:In this interim analysis of the FluHeart study, both RV and LV function measures were significantly impaired in hospitalized influenza patients compared with matched general population controls. The extent of impairment resembled that observed in hospitalized COVID-19 patients.

Chronic Obstructive Pulmonary Disease (COPD) exacerbation is known for its substantial impact on morbidity and mortality among affected patients, creating a significant healthcare burden worldwide. Coagulation abnormalities have emerged as potential contributors to exacerbation pathogenesis, raising concerns about increased thrombotic events during exacerbation. The aim of this study was to explore the differences in thrombelastography (TEG) parameters and coagulation markers in COPD patients during admission with exacerbation and at a follow-up after discharge. This was a multi-center cohort study. COPD patients were enrolled within 72 h of hospitalization. The baseline assessments were Kaolin-TEG and blood samples. Statistical analysis involved using descriptive statistics; the main analysis was a paired t-test comparing coagulation parameters between exacerbation and follow-up. One hundred patients participated, 66% of whom were female, with a median age of 78.5 years and comorbidities including atrial fibrillation (18%) and essential arterial hypertension (45%), and sixty-five individuals completed a follow-up after discharge. No significant variations were observed in Kaolin-TEG or conventional coagulation markers between exacerbation and follow-up. The Activated Partial Thromboplastin Clotting Time (APTT) results were near-significant, with p = 0.08. In conclusion, TEG parameters displayed no significant alterations between exacerbation and follow-up.

Background The extent of cardiac involvement in cystic fibrosis (CF) remains to be determined. The remarkable therapeutic advancements with new highly effective cystic fibrosis transmembrane conductance regulator (CFTR) modulator treatment and subsequent increase in life expectancy substantiates further research. We aimed to explore the prevalence of cardiac alterations in people with CF (pwCF) compared to matched controls and investigate potential cardiovascular risk factors. Methods In this cross-sectional study, 104 pwCF underwent clinical and echocardiographic assessment. All participants were matched 1:1 with controls from the general population. Results Of 104 pwCF, 44 % were female, mean age was 34 years, and 93 % received CFTR modulator treatment. The prevalence of abnormal cardiac function in pwCF was 44 %, more than double the prevalence in controls. PwCF were found to have smaller left ventricular (LV) dimensions, worse LV diastolic function, and reduced right ventricle (RV) as well as LV systolic function. After multivariable adjustment, LV diastolic function as well as LV and RV systolic function remained poorer in pwCF as compared to controls. Male sex and decreasing FEV1/FVC ratio remained independently associated with abnormal cardiac function in pwCF (male sex: OR 3.94 (1.56; 9.95), p = 0.004 and FEV1/FVC ratio: OR 2.05 per 0.1 unit decrease (1.21; 3.52), p = 0.008, respectively). Conclusions Both left- and right-sided cardiac alterations were found in pwCF. After adjustments for risk factors, both RV and LV systolic measures remained altered in pwCF, compared to controls. Male sex and decreasing pulmonary function evaluated by FEV1/FVC-ratio were associated with abnormal cardiac function in pwCF.

Abstract Background Cystic fibrosis (CF) is an autosomal recessive disease affecting multiple organs. Emerging evidence indicates an elevated risk of cardiovascular complications in people with CF (pwCF), with some studies implicating CF-related cardiomyopathy as an underlying mechanism. Whether screening for cardiac symptoms and N-terminal pro B-type natriuretic peptide (NT-proBNP) levels may aid in identifying cardiac impairment in pwCF remains unknown. Purpose To assess prevalence of dyspnea and chest pain in pwCF and investigate whether symptoms and NT-pro-BNP are predictive of cardiac impairment. Methods We interviewed 104 adult pwCF and 104 age- and sex-matched controls from the general population about symptoms of dyspnea and chest pain. All participants were examined with transthoracic echocardiography and NT-proBNP. Cardiac impairment was defined as left ventricular (LV) ejection fraction (LVEF) <50%, LV global longitudinal strain (GLS) < 16% or presence of diastolic dysfunction. Results Chest pain was more frequent in pwCF than in controls: (29% vs. 1%, p<0.001), although primarily characterized as atypical and non-exertional chest pain (27%). PwCF also suffered more from dyspnea than controls (89% vs. 18%, p<0.001) (Figure 1) and more pwCF had abnormal cardiac function compared to controls (44% versus 22%, p<0.001). Median NT-proBNP in pwCF was 50.0 pg/ml (40.7; 100.8) and increasing NT-proBNP level was associated with decreasing FEV1 (L) (estimate: -0.008, p<0.001). NT-proBNP level was not associated with neither dyspnea nor chest pain (p=0.60 and p=0.15, respectively). PwCF with dyspnea did not differ from those without on clinical or echocardiographic parameters. However, pwCF with chest pain had lower absolute GLS compared to pwCF without (17.4% vs.18.5%, p=0.026). Neither dyspnea nor chest pain was more frequent in pwCF with cardiac impairment versus normal cardiac function (54% vs. 39%, p=0.17 and 29% vs. 28%, p=0.91, respectively). Decreasing absolute GLS was associated with increased odds of chest pain (OR 1.25, 95% CI 1.02; 1.53, p=0.030) (Figure 2). Neither dyspnea or chest pain alone, nor in combination with NT-proBNP were able to predict abnormal cardiac function. While dyspnea and chest pain combined showed a slight improvement in sensitivity and positive predictive value for diagnosing cardiac impairment, the combination of symptoms and increased NT-proBNP did not enhance diagnostic accuracy. Conclusions In this cross-sectional study, dyspnea and atypical, non-exertional chest pain were common symptoms in adult pwCF. While abnormal cardiac function was prevalent in pwCF, neither symptoms, NT-proBNP nor a combination of these were associated with increased odds of cardiac impairment. Dyspnea and chest pain, though prevalent, are multifactorial in pwCF and do not seem to serve as sensitive markers of cardiac impairment, even when combined with NT-proBNP level.

Abstract Objectives Men with erectile dysfunction (ED) are at elevated risk of heart disease. However, data on the prevalence of abnormal cardiac structure and function in ED is scarce. We utilized echocardiography to assess cardiac characteristics in men with ED. Methods In this prospective cohort study of men with ED referred to a tertiary urology clinic, all participants underwent transthoracic echocardiography following a predefined protocol and electrocardiogram. Erectile function was graded according to the International Index of Erectile Function - Erectile Function (IIEF-EF) questionnaire. Participants with neurological disease, a medical history of pelvic surgery or trauma were excluded. Left ventricular (LV) structure was evaluated by ventricular mass index (LVMi). LV diastolic function was evaluated according to early diastolic mitral annular velocity (e'), ratio of early transmitral filling velocity to (E/e’) and left atrial volume index (LAVi). LV systolic function was evaluated by LV ejection fraction (LVEF), and global longitudinal strain (GLS). Results We included 100 patients with a median age of 61 yr (IQR 13) and median IIEF-EF was 15 (IQR 14). Comorbidities included hypertension (43%), dyslipidemia (41%), diabetes mellitus (29%), ischemic heart disease (12%), arrhythmia (12%), and heart failure (3%). Regarding cardiac structure, 25 patients had LV hypertrophy. Signs of LV diastolic dysfunction were a common observation; 21 patients had an E/e' ratio > 9, while 30 patients had reduced septal and/or lateral e' velocities with only 1 patient having left atrial dilation (LAVi > 34 ml/m2). Regarding LV systolic dysfunction, 83 patients had reduced GLS (< 16%) with 14 suffering reduced LVEF < 52%. 4 patients were referred for further evaluation, due to previously undiagnosed left bundle branch block, mitral valve regurgitation, aortic valve regurgitation, and incident heart failure, respectively. Conclusions A majority of patients with ED demonstrated impairment of cardiac structure and function assessed by measures of diastolic dysfunction and myocardial deformation. Conflicts of Interest The authors declare no conflict of interest.

Introduction: Cardiac power (CP) integrates echocardiographic and clinical parameters of hemodynamics, but the prognostic value of CP in the general population remains to be established. Hypothesis: This study investigates the association between CP and incident heart failure (HF) and cardiovascular (CV) mortality in the general population Methods: A total of 4,022 participants without known HF from a general population cohort study was included in the study. CP was calculated by cardiac output x mean blood pressure x 0.222. CP was expressed in W/100 g of LV myocardium. The composite outcome was incident HF or CV death. Cox regression models were used to determine the association of cardiac power with the risk of the composite outcome. Cumulative incidence curves were constructed to visualize the risk of outcome throughout the follow-up period, while accounting for non-cardiovascular death as a competing event. The association was additionally explored in a restricted cubic spline model. Results: During a median follow-up of 3.5 years (IQR 2.6;4.4 years), 134 (3.3%) participants reached the composite outcome. The risk of the composite outcome was significantly increased in those with CP <0.84 W/100 g throughout the follow-up period, while accounting for non-cardiovascular death as a competing event. We found significant interaction between LVEF and CP (p interaction <0.001). When stratifying the population according to LVEF, CP had no prognostic value in LVEF >50% (p=0.74) but in individuals with LVEF < 50%, CP remained an independent prognostic marker after multivariable adjustment (HR 1.20 per 0.1 W/100 g decrease in cardiac power (95% CI: 1.04-1.37, p=0.01) (Figure 1). Conclusion: CP was associated with incident HF and CV death in the general population, however, LVEF significantly modified the relationship between CP and the composite outcome. CP was only independently associated with incident HF and cardiovascular death in participants with LVEF<50%.

Abstract Background Inflammation as an underlying cause of cardiac dysfunction has been underscored in recent years. Patients with inflammatory arthritis (IA) are at risk of being exposed to a high degree of chronic and systemic inflammation. It is therefore important to investigate whether high inflammatory burden impacts cardiac structure and function in patients with IA. Purpose To examine the impact of long-term inflammation on measures of cardiac structure and function in individuals with rheumatoid arthritis (RA) and axial Spondyloarthritis (axSpA), collectively referred to as IA, in a large cohort. Methods In a prospective cohort study, outpatients with a diagnosis of IA were included over two years during their biannual rheumatological routine appointment. In total, 1,285 participants were included. Participants were evaluated at a cardiology research center where echocardiography was performed following a pre-defined protocol. To evaluate chronic inflammation, C-reactive protein (CRP) was averaged from clinical outpatient visits registered in a rheumatological database. Uni- and multivariable linear regressions were used to examine the relationship between echocardiographic measures and log-transformed CRP. Results Among the 1,285 participants, 903 (70%) were diagnosed with RA, 358 (28%) with axSpA, and 24 (2%) with other forms of IA. Mean age was 60 ± 13 years, 64% were female. The median number of outpatient visits was 30 (Interquartile range (IQR): 18 - 48), median disease duration was 12 (IQR: 6 - 20) years, and the median outpatient CRP was 5.7 (IQR: 3.7 – 9.8) mg/L. 519 (40%) patients had hypertension (HT), 113 (9%) diabetes mellitus (DM), 76 (5.9%) ischemic heart disease (IHD) and 35 (2.5%) heart failure (HF). Mean left ventricular (LV) ejection fraction was 54.6 ± 5.7%, mean numerical global longitudinal strain (GLS) was 17.8 ± 2.4%, mean LV mass index (LVMi) was 73 ± 18 g/m2 and mean tricuspid annular plane systolic excursion (TAPSE) was 2.5 ± 0.4 cm. In univariable analyses, higher levels of CRP were significantly associated with lower GLS, p < 0.001; higher E/e’, p = 0.001; higher LVMi, p < 0.001 and lower TAPSE, p = 0.005 (Figure). The associations remained significant after adjusting for clinical characteristics including disease duration, age, sex, blood pressure, body mass index, physical activity, pack-years of smoking, cholesterol, HT, DM, heart rate, atrial fibrillation, IHD and HF (p < 0.05 for all associations). We observed no significant interactions between the IA diagnosis and inflammation across the significant echocardiographic measures. Conclusion In a large cohort of patients with IA, increasing levels of chronic inflammation determined by outpatient CRP was associated with impaired measures of cardiac structure and function and remained significant after adjusting for clinical characteristics. The prognostic and clinical implication of these findings needs to be explored in future studies.Linear regression splines

Abstract Background Global longitudinal strain is a well-established prognosticator of heart failure (HF) in the general population. The prognostic values of regional left ventricular (LV) longitudinal strain of the basal, mid and apical regions remain unexplored in the general population. Purpose The purpose of this study was to investigate the relationship between regional LV strain and incident HF in the general population. Methods This prospective cohort study included randomly selected citizens from a major metropolitan area. All participants were examined with echocardiography. The outcome was incident HF. Participants were excluded if regional LV strain was not assessable in all 3 LV regions or if they had atrial fibrillation or HF at baseline. A multivariable Cox regression model adjusted for sex, age, smoking status, heart rate, systolic blood pressure, history of ischemic heart disease, hypertension, diabetes, LV mass index, LV ejection fraction and E/e’ was used. Results A total of 3,952 individuals were included. Mean age was 56±18 years and 43% were male. Mean basal, mid, and apical LV strain was 16.4±2.6%, 19.5±2.6 and 22.8±3.6% respectively. Median follow-up was 5.4 years (IQR: 4.4; 6.3) and 99 developed HF. In multivariable Cox regressions models, only decreasing LV basal strain was associated with future HF (HR = 1.18, 95%CI (1.06; 1.32), P = 0.003, per 1% decrease) (Figure 1). Additionally, LV basal strain provided incremental prognostic information regarding future HF to the Atherosclerosis Risk in Communities HF risk score (continuous net reclassification index = 0.468, 95% CI (0.155; 0.687)). Conclusion In individuals from the general population, basal LV strain entailed incremental prognostic information regarding the risk of incident HF.Basal strain and incident HF

Abstract Background Aortic stenosis (AS) and aortic valve sclerosis (AVS) as assessed by Doppler echocardiography have been associated with adverse clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, further clarification of the role of AV and AVS in the HFrEF population is warranted. Methods A total of 873 patients with stable HFrEF were included in this retrospective cohort study. At referral, the patients had a left ventricular ejection fraction (LVEF) of 45% or lower Baseline clinical and echocardiographic data were retrieved from the heart failure outpatient clinic's database, and the patients were followed through a nationwide register for the outcome of all-cause mortality. The presence of AS and AVS was assessed using Doppler-derived pressure gradients of the aortic valve (AV) from the echocardiogram. Cox-regression models were used to determine the association between AV peak gradient and mortality. Multivariable models were adjusted for demographic, clinical, and echocardiographic parameters (age, sex, diabetes (DM), ischemic heart disease (IHD), BMI, heart rate, mean arterial pressure, total cholesterol and atrial fibrillation (AF), LVEF, left atrial volume index (LAVi), left ventricular mass index (LVMi), E/e’). Results Seventy-four percent of patients were male, and mean age was 66.8 ± 11.4 years. In total, 13% had DM, 57% had IHD, 38% had NYHA III-IV, 8% had implantable cardiac device (including pacemaker, ICD, and CRT), and 15.9% had AF. Mean LVEF was 27.3 ± 9.4% with a mean LVMi of 120.2 g/m2 ± 38.2. Mean AV peak velocity was 1.4 m/s ± 0.5 and median AV peak gradient was 6.3 mmHg (IQR 4.7; 8.9). During a median follow-up of 3.3 years (IQR 1.9 – 4.7 years), 143 patients (16.4 %) reached the outcome. In univariable analysis, AV peak gradient was associated with all-cause mortality (HR 1.23 per 10 mmHg increase, 95% CI 1.05-1.44, p = 0.012). LVEF modified the prognostic value of AV peak gradient (p = 0.026 for interaction). After stratifying the population by the median value of LVEF (cut-off = 28%), AV peak gradient remained prognostic only in patients with LVEF above the median (HR 1.58 per 10 mmHg increase, 95% CI 1.30-1.91, p < 0.001), whereas AV peak gradient was not significantly associated with mortality amongst the patients with LVEF below the median level (HR 1.03 per 10 mmHg increase, 95% CI 0.83-1.37, p = 0.827). After multivariable adjustment, AV peak gradient remained an independent predictor of the outcome in patients in the higher median of LVEF (HR 1.32 per 10 mmHg increase, 95% CI 1.02-1.70, p = 0.035) (Figure 1). Conclusion Presence of AS and AVS (derived by AV peak gradient Doppler echocardiography) is an independent predictor of all-cause mortality amongst HFrEF patients. However, presence of AS and AVS only entails prognostic information amongst the HFrEF patients without severely reduced LVEF.Incidence rates of all-cause mortality

IntroductionElevated levels of soluble urokinase-type plasminogen activating receptor (suPAR) and high-sensitivity C-Reactive Protein (hs-CRP) have in previous studies been associated with increased mortality in selected cardiac surgery populations1 2. Aim of this study was to explore the relationship between suPAR and hsCRP-values and mortality in 30 days and during 1st year from surgery in patients admitted for elective cardiac surgery. Further, to assess whether a combined risk model of EuroSCORE II, suPAR and/or hs-CRP would improve the prognostic accuracy compared to EuroSCORE II alone.MethodsAdult patients admitted for elective on-pump cardiac surgery, from August 2012 to June 2018, were included (n=931). Biobank blood samples were analysed for suPAR and hs-CRP levels. Biomarkers and clinical data were explored in relation to quartiles of the two biomarkers. Kaplan-Meier and Cox proportional hazard analysis were used to explore any association between preoperative suPAR and hs-CRP-values and all-cause mortality up to 1-year after surgery. Thirty-day mortality was predicted from suPAR, hsCRP and EuroSCORE II by logistic regression and compared using area under the ROC curve and Brier scores.ResultsA doubling of suPAR and hsCRP corresponded to a hazard ratio (HR) for all-cause mortality of 2.27 (95% CI 1.65-3.11, p<0.001) and 1.26 (95% CI 1.08-1.49, p<0.005), respectively. Kaplan-Meier curves revealed a marked difference in all-cause mortality among individual quartiles of suPAR (Figure 1), with a 1-year mortality of 13.3% in patient with suPAR above the third quartile compared to 2.8% below the first quartile. A similar trend was observed for hs-CRP, with a 1-year mortality of 10.3% in patients above the third quartile and 3.7% for patients below the first quartile. Both biomarkers alone or in combination with EuroSCORE II demonstrated a discriminative ability (AUC) between 66.3-79.8. However, inclusion of biomarkers did not increase the prognostic accuracy (lower Brier scores) compared to EuroSCORE II alone.DiscussionIn conclusion, elevated levels of the proinflammatory biomarkers, suPAR and hs-CRP, can be used as preoperative risk assessment for all-cause mortality in a population of all-comers to elective on-pump cardiac surgery. However, combination of either or both biomarkers to EuroSCORE II did not improve the prognostic accuracy compared to EuroSCORE II alone. In future studies, preoperative assessment of proinflammatory biomarkers may be used to establish personalised rehabilitation programs and follow-up on high-risk patients.

Aims The prognostic value of myocardial performance index (MPI) has not yet been assessed in patients with atrial fibrillation (AF). The aim of this study was to evaluate the prognostic value of MPI by tissue Doppler imaging (TDI) M-mode in AF patients. Methods and results Echocardiograms from 210 patients with AF during examination were analysed offline. Patients with known heart failure (HF) were excluded. Time intervals were measured using an M-mode line through the mitral valve leaflets to provide a colour diagram of the mitral leaflet movement so all time intervals could be measured from one cardiac cycle. MPI was calculated as the sum of isovolumic relaxation time and isovolumic contraction time divided by the ejection time [(IVRT+IVCT)/ET]. During a median follow-up of 2.4 years, 84 patients (40%) reached the combined endpoint of major adverse cardiovascular events (MACE), being all-cause mortality, HF, myocardial infarction, or stroke. Increasing MPI was significantly associated with an increased risk of MACE, and the risk increased with 20% per 0.1 increase in MPI [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.10-1.32; P < 0.001]. Increasing MPI was also significantly associated with a lower left ventricular ejection fraction (LVEF) (P < 0.001). Nevertheless, MPI remained an independent predictor even after adjustment for age, sex, diabetes mellitus, left atrial volume, and LVEF (HR 1.12, 95% CI 1.01-1.25; P = 0.038). Conclusion Increasing MPI was significantly associated with increased risk of MACE and remained an independent predictor after multivariabte adjustment. This demonstrates that the MPI obtained by TDI M-mode might be useful in assessing cardiac function in AF patients with ongoing arrhythmia during examination.

Background: Echocarcliographic assessment of systolic and diastolic function during atrial fibrillation (AF) is challenging. This study evaluates he prognostic value of strain in patients with AF and suggests a novel approach on how to Lake into account the varying heart cycle lengths in AF. Methods: Echocardiograms from 204 patients with AF during examination were analyzed offline. Patients with known heart failure (HF) were excluded. Peak global longitudinal strain (GLS) was averaged from 18 myocardial segments. To adjust for the varying heart cycle lengths, we indexed GLS with the square Fool of the RR-interval, (GLS/root(RR)). The composite endpoint included incident HF, stroke, myocardial infarction and all-cause mortality. Results: During a median follow-up of 2.4 years, 82 patients (40%) reached the composite endpoint. Decreasing GLS [(RR) was significantly associated with the composite endpoint, and the risk of reaching the endpoint increased significantly per 1%/sec(1/2) decrease in strain (HR 1.13, 95% CI 1.07-120, p < 0.001). GLS/root(RR) remained an independent predictor even after adjustment for various risk factors and conventional echocardiography (LVEF and E/e') (HR 1.10, 95% Cl: 1.02-1.19, p = 0.017). In contrast, GLS did not remain a significant predictor after adjusting for the same variables (p = 0.07), neither did LVEF (p = 0.11). Conclusion: Decreasing GLS/root(RR) was significantly associated with increased risk of an adverse outcome and remained an independent predictor after multivariable adjustment. Indexing GLS with the square root of the RR-interval can counteract the variable cycle length in Al patients and GLS/root(RR) offers a more convincing risk-stratification assessment in AF patients compared with GLS. (C) 2018 Elsevier B.V. All rights reserved.

It is often difficult to provide an exact echocardiographic measure of left ventricular systolic function in patients with atrial fibrillation, partly because of the varying cycle length affecting pre and afterload and partly because of the increased heart rate often accompanying this arrhythmia. We sought to elucidate two points: whether it would be possible to correct for the cyclic variance in systolic output, and if global longitudinal strain is preferable to the left ventricular ejection fraction at evaluating systolic function during atrial fibrillation.

Aims: This study evaluates the prognostic value of strain in patients with atrial fibrillation (AF) and suggests a novel approach on how to take into account the varying heart cycle lengths in AF. Methods: Echocardiograms from 204 patients with AF during examination were analyzed. Peak global longitudinal strain (GLS) was averaged from the apical 4-chamber, 2-chamber and long axis view. To adjust for the varying heart cycle lengths, we indexed the strain measurements with the square root of the RR-interval, (GLS/√(RR)). The combined end-point included incident heart failure, stroke, myocardial infarction and all-cause mortality. Results: During a median follow-up of 2.4 years, 82 patients (40%) reached the combined endpoint. Significant predictors at baseline included age (p<0.001) and diabetes mellitus (p=0.014). Decreasing GLS/√(RR) was significantly associated with the combined endpoint, and the risk of reaching the endpoint increased significantly per 1%/sec1/2 decrease in strain (HR 1.13, 95% CI 1.07-1.20, p<0.001), especially in the patients with the lowest values of GLS/√(RR)(Figure 1). GLS/√(RR) remained an independent predictor even after adjustment for various risk factors, LVEF and E/e’ (HR 1.10, 95% CI: 1.02-1.19, p=0.017). In contrast, GLS did not remain a significant predictor after adjusting for the same variables (p=0.07), neither did LVEF (p=0.11). Besides being associated with an adverse outcome, decreasing values of GLS/√(RR) was associated with lower LVEF, larger LV mass and larger LV dimension (p<0.001 for all). Conclusion: Decreasing GLS/√(RR) was significantly associated with increased risk of reaching the combined endpoint and remained an independent predictor after multivariable adjustment. Indexing the strain values with the square root of the RR-interval (GLS/√(RR)) can counteract the variable cycle length in AF patients and GLS/√(RR) offers a more convincing risk-stratification assessment in AF patients compared to GLS.

AIM:Tissue Doppler Imaging (TDI) detects early signs of left ventricular dysfunction. The prognostic potential of TDI in patients with atrial fibrillation (AF) has, however, not yet been clarified. This study evaluates the prognostic value of TDI in patients with atrial fibrillation.METHODS AND RESULTS:In total, echocardiograms from 313 patients with AF during examination were analyzed offline. Longitudinal systolic velocity (s'), early diastolic velocity (e') and longitudinal displacement (LD) were measured by color TDI. During a median follow-up of 891 days, 64 patients (20%) died. TDI was significantly associated with all-cause mortality, and the risk of dying increased significantly per 1 cm/s decrease in s' (HR of 1.31, 95% CI 1.05-1.63; p=0.018) and e' (HR of 1.17, 95% CI 1.01-1.35; p=0.038) respectively, even after adjustment for age, gender, heart rate, aortic stenosis, DM and LVEF quartiles. LD also proved to be a significant predictor of outcome after multivariate adjustment (HR 1.23; 95% CI 1.05-1.44; p=0.012). The population was stratified according to high or low s' and e'. Patients with low s' and e' had more than three times the risk of mortality compared to the patients with high s' and e' (HR 3.64; 95% CI 1.83-7.26; p<0.001) and remained in significantly higher risk after adjustment for various risk factors.CONCLUSIONS:Both systolic and diastolic performance, as assessed by TDI, are strong predictors of mortality in patients with atrial fibrillation, and especially the combination of systolic and diastolic dysfunction is a significant prognostic marker.

Aims: Tissue Doppler Imaging (TDI) detects early signs of left ventricular dysfunction; however the prognostic significance of TDI in patients with atrial fibrillation is yet unknown. This study evaluates the prognostic value of TDI in patients with atrial fibrillation. Method and results: In total, echocardiograms from 313 patients with atrial fibrillation during examination were retrieved and analyzed offline. Longitudinal systolic velocity (S'), early diastolic velocity (E') and longitudinal displacement (LD) were measured by colour TDI at six mitral-annular-sites and averaged to provide global estimates. Endpoint was death. The study showed that per 1 cm/s decrease in S' or E', the risk of dying increased by more than 40% (HR 1.42; 95% CI 1.18-1.72; p<0.001) and 30% (HR 1.34; 95% CI 1.18-1.52; p<0.001), respectively. After adjustment for age, gender, heart rate, aortic stenosis, diabetes mellitus (DM) and ejection fraction (EF) in a multivariate Cox model, both global S' and E' remained significantly associated with mortality with a HR of 1.31 (95% CI 1.05-1.63; p=0.018) for S' and a HR of 1.17 (95% CI 1.01-1.35; p=0.038) for E'. Stratified into groups, patients with both low S' and E' had more than three times the risk of reaching the endpoint compared to the group with high S' and E' (HR 3.64; 95% CI 1.83-7.26; p<0.001). This group remained in significantly higher risk after adjustment for age, gender, heart rate, aortic stenosis, DM and EF. Longitudinal displacement also proved to be a significant predictor of outcome, showing an increased risk of 23% (HR 1.23; 95% CI 1.05-1.44; p=0.012) after adjustment for age, gender, heart rate, aortic stenosis, DM and EF. Conclusion: Both the systolic velocity, early diastolic velocity and longitudinal displacement are strong predictors of mortality in patients with atrial fibrillation. Further more, a pattern of low systolic and diastolic performance assessed by TDI is a significant marker of prognosis for patients with atrial fibrillation.