doi:10.1016/j.jacc.2005.09.069 published online Feb 8, 2006 ...
Predictive Value of Normal Left Atrial Volume in Stress EchocardiographyAhmed A. Alsaileek, Martin Osranek, Kaniz Fatema, Robert B. McCully, Teresa S. Tsang, and James B. Seward J. Am. Coll. Cardiol. published online Feb 8, 2006; doi:10.1016/j.jacc.2005.09.069 This information is current as of December 6, 2010 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://content.onlinejacc.org/cgi/content/full/j.jacc.2005.09.069v1 Downloaded from content.onlinejacc.org by on December 6, 2010
ARTICLE IN PRESSJACC Vol. 47, No. 5, 2006 Alsaileek et al. 1025March 7, 2006:1024–8 Predictive Value of Normal Left Atrial Volume LAVI measurement had not been obtained. Of the 180 Abbreviations and Acronyms remaining patients, 96 (53%) were men (mean age, 63 15 CAD coronary artery disease years; range, 27 to 89 years) and 47.8% underwent dobut- IHD ischemic heart disease amine stress echocardiography. The patients’ baseline char- LAV left atrial volume acteristics are presented in Table 1. LAVI left atrial volume index LV left ventricle/ventricular Normal LAVI. Normal LAVI (LAVI 28 ml/m2) was WMA wall motion abnormality found in 53 patients (29.4%) (mean age, 59 13 years; range, 27 to 85 years); 45% were men and 36% underwent dobutamine stress echocardiography (Table 2). The indica-WMA at rest and additional WMA with stress; and 3) new tions for stress testing in patients with normal LAVI wereWMA—no WMA at rest and new WMA with stress. chest pain and shortness of breath in 52.8%, preoperativeStatistical analysis. Results are presented as mean values assessment in 20.8%, known coronary artery disease (CAD)SD for continuous variables and as frequency percentages for in 11.3%, and other in 15%. Of 53 patients with normalcategorical variables. Group comparisons were performed with LAVI, 50 (94.3%) had completely normal stress echocar-a standard t test or chi-square test, as appropriate. Univariate diograms and 3 (5.7%) had ﬁxed WMA of a small localizedassociations of stress echocardiographic (normal/abnormal area in the inferior wall (Fig. 1). No patient with LAVI 28test), LAVI, and clinical variables were assessed with logistic ml/m2 had stress echocardiography with ischemic or mixedmodels. The effect of LAVI on stress echocardiographic WMA (positive for ischemia). Normal LAVI had 94.7%variables was also estimated with a logistic model after sensitivity, 41% speciﬁcity, 94.3% negative predictive value,adjusting for age, gender, low ejection fraction ( 0.50), and 42.9% positive predictive value for abnormal stressLV end-diastolic diameter, and LV hypertrophy. Left atrial echocardiography.volume index was used as a dichotomous variable (LAVI LAVI and stress echocardiography results. Wall motion 28 ml/m2) in all the models. Signiﬁcance was deﬁned as p was interpreted as being entirely normal (no WMA) in 123 0.05 for all analyses. Some clinically signiﬁcant variables patients (68.3%) and abnormal (any WMA) in 57 (31.7%).were forced into the model with an insigniﬁcant p value. The indications for stress echocardiography in normal andThe interobserver variability for LAV measurements was abnormal studies were chest pain and shortness of breath indetermined for 20 randomly selected studies. The LAV 43.1% versus 28.1%, preoperative assessment in 28.4%measurement was obtained by two independent observers, versus 33.3%, known CAD in 10% versus 29.8%, and otherand the interclass correlation was estimated to be 0.91 (95% in 18.5% versus 8.8%, respectively. For patients with normalconﬁdence interval, 0.82 to 0.96). wall motion, LAVI was 31.9 10.6 ml/m2 (range, 16.9 to 68.8 ml/m2), and for those with abnormal wall motion,RESULTS LAVI was 42.7 12.8 ml/m2 (range, 23.3 to 79.9 ml/m2)Of the 200 randomly selected patients, 20 (10%) were (p 0.0001) (Fig. 2). Left atrial volume index was largestexcluded because echocardiographic images suitable for for older patients with mixed WMA, 46.5 13.2 ml/m2.Table 1. Clinical and Echocardiographic Features of the Study Group, Categorized by Stress Echocardiography Results Myocardial Wall Motion Abnormal (n 57) Feature Normal (n 123) Ischemic (n 12) Fixed (n 19) Mixed (n 26)Age, yrs, mean SD (range) 61 15 (27–89) 63 14 (36–86) 67 12 (51–88) 72 9* (50–89)Men, % 46 50 63 80*WMSI, mean SD Resting 1.0 0.0 1.02 0.07 1.5 0.5* 1.5 0.4* At peak 1.0 0.0 1.2 0.3* 1.4 0.5* 1.7 0.5*LAVI, ml/m2, mean SD (range) 31.9 10.6 (16.9–68.8) 38.6 10.8* (29.2–61.4) 39.7 12.3* (23.3–77.3) 46.5 13.2* (30.2–80)Dobutamine echo, % 43 60 63 57LV wall thickness, mm Septal 9.5 1.3 10.4 1.1 9.6 1.7 9.9 1.3 Posterior wall 9.5 1.4 9.1 1.3 9.2 1.3 9.7 1.4LV dimensions, cm LVDD 4.6 0.4 4.8 0.6 5.2 0.6* 5.1 0.8* LVSD 3.1 0.3 3.3 1.0 4.0 0.7* 3.7 0.8*LVEF, % Resting 61.2 4.2 64.0 4.2 50.8 12.6* 50.0 13.4* At peak 74.0 5.6 71.7 7.8 61.4 14.3* 56.2 15.6**p 0.05 compared with the normal. EF ejection fraction; LAVI left atrial volume index; LV left ventricular; LVDD left ventricular end-diastolic; LVSD left ventricular end-systolic; WMSI wallmotion score index. Downloaded from content.onlinejacc.org by on December 6, 2010
ARTICLE IN PRESS1026 Alsaileek et al. JACC Vol. 47, No. 5, 2006 Predictive Value of Normal Left Atrial Volume March 7, 2006:1024–8Table 2. Clinical and Echocardiographic Features of the Study Group, Categorized by LAVI Results LAVI Categories, ml/m2 Feature <28 (n 53) 28.1–32 (n 32) 32.1–36 (n 31) >36 (n 64)Age, yrs, mean SD (range) 59 13 (27–85) 56 12 (32–80) 63 13 (35–86) 71 13* (44–89)Men, % 45 59 45 61BMI, kg/m2, mean SD 28.9 5.3 30.1 8.3 28.5 5.1 27.7 5.2WMSI, mean SD Resting 1.01 0.06 1.01 0.03 1.15 0.33 1.26 0.44* At peak 1.01 0.06 1.05 0.15 1.22 0.38 1.34 0.48*Dobutamine echo, % 36 50 39 61LV wall thickness, mm Septal 9.5 1.3 9.7 1.5 10.2 2.2 10.1 1.6 Posterior wall 9.3 1.3 9.4 1.5 9.6 1.7 9.9 1.6LV dimensions, cm LVDD 4.7 0.5 4.8 0.5 4.8 0.6 5.0 0.6* LVSD 3.0 0.4 3.2 0.8 3.9 0.8* 3.6 0.8*LVEF, % Resting 61.1 4.6 61.1 4.9 57.8 9.7 56.0 11.5* At peak 74.0 6.4 72.8 5.6 68.9 12.7 65.8 14.1**p 0.05 compared with LAVI 28 ml/m2. BMI body mass index; other abbreviations as in Table 1.Any WMA also increased in frequency relative to an the more likely the presence of abnormal wall motion (new,increase in LAVI (Fig. 1). With logistic regression (Table ﬁxed, or mixed), which is consistent with data suggesting3), LAVI was an independent predictor of normal stress the greatest risk for IHD is in the mixed WMA subgroupechocardiography even after adjusting for age, gender, (21–23).resting ejection fraction, LV hypertrophy, and LV dimen- This study was designed to address the value of normalsions (p 0.0013). LAVI as an indicator of low general cardiovascular and ischemic risk. Left atrial volume index has been shown to beDISCUSSION highly predictive of general cardiovascular risk, including hypertension, atrial ﬁbrillation, heart failure, stroke, deathThis study demonstrates that LAVI is strongly predictive of associated with dilated cardiomyopathy, and death afterstress echocardiographic results. Two observations deserve acute myocardial infarction (5,9 –14,24). Forty-seven pa-emphasis. First, a normal LAVI is strongly associated with tients (50%) with LAVI 32 ml/m2 had a normal stressa normal stress echocardiogram. Of the patients with LAVI echocardiogram. As we previously reported (5,25), increased 28 ml/m2, only three (5.7% of abnormal exams) had a LAVI is consistent with chronic elevation of ﬁlling pressureresting WMA and 100% had no stress-induced WMA. Inthree patients a ﬁxed WMA was small and localized to the and increased general cardiovascular risk.basal inferior wall. Second, the more abnormal the LAVI, A normal stress echocardiogram is highly associated with a low risk of developing IHD within two to three years (15–18,21,23). The current study shows a strong relationFigure 1. The percentage of patients with a normal and abnormal stressechocardiogram with normal or abnormal (ischemic, ﬁxed, or mixed) wall Figure 2. Mean SD left atrial volume index (LAVI) according tomotion for each category of left atrial volume index (LAVI). None of the different wall motion abnormality (WMA) results. Left atrial volume indexpatients with LAVI 28 ml/m2 had a positive stress echocardiogram (i.e., is signiﬁcantly different between normal and any WMA (new, ﬁxed, ornew wall motion abnormality), but three had a ﬁxed wall motion abnor- mixed). An atrial volume 28 ml/m2 is associated with escalating cardio-mality localized to the inferior wall. vascular risk, including risk of ischemic heart disease. Downloaded from content.onlinejacc.org by on December 6, 2010
ARTICLE IN PRESSJACC Vol. 47, No. 5, 2006 Alsaileek et al. 1027March 7, 2006:1024–8 Predictive Value of Normal Left Atrial VolumeTable 3. Logistic Regression Showing the Effect of Normal changes in loading, which would accompany an acuteLAVI ( 28 ml/m2) on Normal Stress Echocardiography After ischemic event (33).Adjusting for Age, Gender, Low Resting EF ( 0.50), LVH, Conclusions. Patients with a normal stress echocardio-and LVDD gram are at low risk for the development of a coronary event Variable Odds Ratio 95% CI p Value within two years. A normal LAVI ( 28 ml/m2) stronglyAge 0.969 0.940–0.999 0.0438 predicted a normal stress echocardiogram. The magnitudeGender, male 0.441 0.190–1.025 0.0570 of increased LAVI is closely related to the magnitude ofLVDD, mm 0.495 0.193–1.275 0.1452 IHD detected. Left atrial volume index is also known toLow resting EF ( 0.50) 0.024 0.002–0.247 0.0017LVH 0.398 0.159–0.992 0.0481 predict low general cardiovascular risk. Left atrial volumeLAVI 28 ml/m2 8.632 2.325–32.043 0.0013 index should be assessed further for its complementary roleCI conﬁdence interval; LVH left ventricular hypertrophy; other abbreviations as in stress testing as a means of enhancing prediction ofin Table 1. cardiovascular risk.between a normal LAVI and a normal stress echocardio- Reprint requests and correspondence: Dr. James B. Seward,gram. Thus, if validated, a normal resting LAVI could be Division of Cardiovascular Diseases, Mayo Clinic, 200 First Streetused as a predictor of low ischemic risk as well as general SW, Rochester, Minnesota 55905.cardiovascular risk. The chronicity and burden of decreased myocardial REFERENCEScompliance and increased ﬁlling pressure are thus reﬂectedin the magnitude of increased LAVI (5,26). Elevated ﬁlling 1. Lester SJ, Ryan EW, Schiller NB, Foster E. Best method in clinical practice and in research studies to determine left atrial size. 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Predictive Value of Normal Left Atrial Volume in Stress EchocardiographyAhmed A. Alsaileek, Martin Osranek, Kaniz Fatema, Robert B. McCully, Teresa S. Tsang, and James B. Seward J. Am. Coll. Cardiol. published online Feb 8, 2006; doi:10.1016/j.jacc.2005.09.069 This information is current as of December 6, 2010Updated Information including high-resolution figures, can be found at:& Services http://content.onlinejacc.org/cgi/content/full/j.jacc.2005.09.06 9v1References This article cites 37 articles, 24 of which you can access for free at: http://content.onlinejacc.org/cgi/content/full/j.jacc.2005.09.06 9v1#BIBLCitations This article has been cited by 4 HighWire-hosted articles: http://content.onlinejacc.org/cgi/content/full/j.jacc.2005.09.06 9v1#otherarticlesRights & Permissions Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://content.onlinejacc.org/misc/permissions.dtlReprints Information about ordering reprints can be found online: http://content.onlinejacc.org/misc/reprints.dtl Downloaded from content.onlinejacc.org by on December 6, 2010