doi:10.1016/j.jacc.2005.09.069 published online Feb 8, 2006 ...


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

doi:10.1016/j.jacc.2005.09.069 published online Feb 8, 2006 ...

  1. 1. 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: Downloaded from by on December 6, 2010
  2. 2. ARTICLE IN PRESSJournal of the American College of Cardiology Vol. 47, No. 5, 2006© 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00Published by Elsevier Inc. doi:10.1016/j.jacc.2005.09.069Predictive Value of Normal LeftAtrial Volume in Stress EchocardiographyAhmed A. Alsaileek, MD, Martin Osranek, MD, Kaniz Fatema, PHD, Robert B. McCully, MD,Teresa S. Tsang, MD, James B. Seward, MDRochester, Minnesota OBJECTIVES Our objective was to evaluate whether normal left atrial volume index (LAVI) is a predictor of a normal stress echocardiogram and thus a predictor of low ischemic risk. BACKGROUND Left atrial enlargement is closely related to the chronicity and intensity of the burden of increased ventricular filling pressure. Typically ischemic heart disease (IHD) has a long period of subclinical dysfunction. Increased filling pressure, reflected by enlarged LAVI, is hypoth- esized to mirror the burden of subclinical and overt IHD. We hypothesized that a normal LAVI might also be useful in predicting low IHD risk. METHODS One hundred eighty randomly selected patients (mean age, 63 15 years; 53% men) underwent outpatient exercise or dobutamine stress echocardiography for known or suspected coronary artery disease. Left atrial volume index was measured retrospectively with the biplane area-length method. The stress echocardiogram was interpreted as abnormal if wall motion abnormalities (WMAs) were noted at rest and/or with stress. RESULTS Left atrial volume index was categorized as 28 ml/m2 (normal), 28.1 to 32 ml/m2, 32.1 to 36 ml/m2, and 36 ml/m2. Abnormal stress echocardiography was identified in 57 patients (31.7%). The percentage of abnormal stress echocardiograms in each LAVI category was 5.7%, 21.9%, 38.7%, and 54.7%, respectively. The negative predictive value for LAVI 28 ml/m2 was 94.3%. CONCLUSIONS Normal resting LAVI ( 28 ml/m2) was strongly predictive of a normal stress echocardio- gram. Left atrial volume index might be a simple means of identifying patients with low ischemic risk and should be further evaluated as a complement to the assessment of ischemic risk. (J Am Coll Cardiol 2006;47:1024 – 8) © 2006 by the American College of Cardiology FoundationLeft atrial volume index (LAVI) is a preferred method for stress echocardiography database to identify patients whodetermining LA size and provides incremental prognostic had undergone clinically indicated outpatient exercise orinformation beyond that afforded by clinical risk factors (1,2). dobutamine stress echocardiography between February 1,Left atrial volume index reflects the chronicity and magnitude 2004, and March 31, 2004. The entry criterion was restingof the increased left ventricular (LV) filling pressure and is two-dimensional images appropriate for blinded retrospec-closely related to general cardiovascular risk burden (3–5). tive off-line measurement of LAVI. Exclusion criteria wereIschemic heart disease (IHD) has been demonstrated to cause images inadequate for measuring LAVI, an indeterminatesubclinical diastolic dysfunction before systolic dysfunction stress result, and denial of research authorization. Of 1,000becomes evident (6 – 8). patients, we randomly selected a sample of 200 subject Multiple studies have shown the value of normal LAVI studies with a computer algorithm.for the prediction of general cardiovascular risk (9 –14) and Data acquisition. Atrial volume, with the biplane area-a normal stress test for the prediction of low ischemic risk length method, was indexed to body surface area. With(15–18). Our study specifically addressed the hypothesis off-line rest images obtained before the stress test, LAVIthat a normal resting LAVI is also predictive of a normal was measured at the end of ventricular systole just beforestress echocardiogram and a low risk of IHD. In many opening of the mitral valve (1). Left atrial volume (LAV)clinical settings, stress testing might not be available, was calculated as follows:whereas it is often possible to obtain a focused echocardio-graphic examination, which could include measurement of Area4-chamber Area2-chamberLAVI. 0.85 Shortest lengthMETHODS Normal and abnormal LAVIs have been previously pub-Study population. Approval was obtained from the insti- lished (5,19,20). For this study, we used LAVI 28 ml/m2tutional review board of the Mayo Foundation. We used the as normal. As published previously (21,22), the stress echocardio- From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. grams were interpreted as normal if wall motion was normalDr. Osranek was supported by post-doctoral fellowships from the Austrian Science Fund both at rest and with stress. Wall motion abnormalities(Schrödinger Stipend) and the American Heart Association. Manuscript received May 23, 2005; revised manuscript received August 16, 2005, (WMAs) were divided into three groups: 1) fixed—WMAaccepted September 19, 2005. at rest, which remained unchanged with stress; 2) mixed— Downloaded from by on December 6, 2010
  3. 3. 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 by on December 6, 2010
  4. 4. 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 by on December 6, 2010
  5. 5. 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. Am Jpressures cause increased atrial wall tension and myocyte Cardiol 1999;84:829 –32.stretch, which induces atrial enlargement, myolysis, apopto- 2. Pritchett AM, Jacobsen SJ, Mahoney DW, Rodeheffer RJ, Bailey KR,sis, and fibrosis (27–30). The normal LAVI is 22 6 ml/m2 Redfield MM. Left atrial volume as an index of left atrial size: a population-based study. J Am Coll Cardiol 2003;41:1036 – 43.(upper normal, approximately 28 ml/m2) (5,19,20,26). With 3. Simek CL, Feldman MD, Haber HL, Wu CC, Jayaweera AR, Kaulnormal hemodynamics, a normal LAVI remains relatively S. Relationship between left ventricular wall thickness and left atrial size: comparison with other measures of diastolic function. J Am Socunchanged throughout life (31,32). End-systolic LAV does Echocardiogr 1995;8:37– 47.not change significantly with acute alterations in loading (33). 4. Appleton CP, Galloway JM, Gonzalez MS, Gaballa M, BasnightIn contrast to other measures of loading pressure, LAVI best MA. Estimation of left ventricular filling pressures using two- dimensional and Doppler echocardiography in adult patients withrepresents the average burden of elevated filling pressure (25). cardiac disease: additional value of analyzing left atrial size, left atrialCardiovascular risk, including acute and chronic IHD, is ejection fraction and the difference in duration of pulmonary venouspreceded by a long period of asymptomatic change in and mitral flow velocity at atrial contraction. J Am Coll Cardiol 1993;22:1972– 82.cardiovascular pathophysiology. 5. Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial A normal stress echocardiogram is a strong predictor of a volume as a morphophysiologic expression of left ventricular diastoliclow IHD risk (15–18,21,23). Echocardiographic combined dysfunction and relation to cardiovascular risk burden. Am J Cardiol 2002;90:1284 –9.with clinical findings have been shown to provide a risk 6. Apstein CS, Grossman W. Opposite initial effects of supply andmodel for assessing death after an exercise stress test (34). demand ischemia on left ventricular diastolic compliance: the ischemia- diastolic paradox. J Mol Cell Cardiol 1987;19:119 –28.Left atrial volume index was not included in that particular 7. Hirota Y. A clinical study of left ventricular relaxation. Circulationstudy. The current study suggests that LAVI in conjunction 1980;62:756 – 63.with stress testing should be examined further. 8. Bonow RO, Kent KM, Rosing DR, et al. Improved left ventricular diastolic filling in patients with coronary artery disease afterStudy limitations. The study population was small and percutaneous transluminal coronary angioplasty. Circulation 1982;selected randomly from an outpatient referral cardiology 66:1159 – 67.practice. Left atrial volume index was measured retrospec- 9. Møller JE, Hillis GS, Oh JK, et al. Left atrial volume: a powerful predictor of survival after acute myocardial infarction. Circulationtively but in a blinded manner. Although a normal stress 2003;107:2207–12.echocardiogram indicates a favorable outcome, it does not 10. Beinart R, Boyko V, Schwammenthal E, et al. Long-term prognosticnecessarily exclude general cardiovascular risk. At best, significance of left atrial volume in acute myocardial infarction. J Am Coll Cardiol 2004;44:327–34.current stress testing, including nuclear, has a sensitivity and 11. Di Tullio MR, Sacco RL, Sciacca RR, Homma S. Left atrial size andspecificity of approximately 85% (35–37); however, a nor- the risk of ischemic stroke in an ethnically mixed population. Stroke 1999;30:2019 –24.mal stress test is consistently associated with a low risk for 12. Barnes ME, Miyasaka Y, Seward JB, et al. Left atrial volume in thesubsequent cardiovascular events. We found that a normal prediction of first ischemic stroke in an elderly cohort without atrialLAVI was highly predictive of a normal stress test. In fibrillation. Mayo Clin Proc 2004;79:1008 –14. 13. Tsang TS, Barnes ME, Bailey KR, et al. Left atrial volume: importantcertain clinical settings, LAVI might be useful in determin- risk marker of incident atrial fibrillation in 1655 older men anding low IHD risk. Left atrial volume index following acute women. Mayo Clin Proc 2001;76:467–75.coronary syndrome is highly predictive of death (13), but 14. Tsang TS, Barnes ME, Gersh BJ, et al. Prediction of risk for first age-related cardiovascular events in an elderly population: theLAVI during an acute event has not been prospectively incremental value of echocardiography. J Am Coll Cardiol 2003;42:performed, although LAVI is relatively insensitive to acute 1199 –205. Downloaded from by on December 6, 2010
  6. 6. ARTICLE IN PRESS1028 Alsaileek et al. JACC Vol. 47, No. 5, 2006 Predictive Value of Normal Left Atrial Volume March 7, 2006:1024–815. Elhendy A, Modesto KM, Mahoney DW, Khandheria BK, Seward 27. Boixel C, Fontaine V, Rucker-Martin C, et al. Fibrosis of the left atria JB, Pellikka PA. Prediction of mortality in patients with left ventric- during progression of heart failure is associated with increased matrix ular hypertrophy by clinical, exercise stress, and echocardiographic metalloproteinases in the rat. J Am Coll Cardiol 2003;42:336 – 44. data. J Am Coll Cardiol 2003;41:129 –35. 28. Li D, Fareh S, Leung TK, Nattel S. Promotion of atrial fibrillation by16. McCully RB, Roger VL, Ommen SR, et al. Outcomes of patients with heart failure in dogs: atrial remodeling of a different sort. Circulation reduced exercise capacity at time of exercise echocardiography. Mayo 1999;100:87–95. Clin Proc 2004;79:750 –7. 29. Boyden PA, Tilley LP, Pham TD, Liu SK, Fenoglic JJ Jr., Wit AL.17. McCully RB, Roger VL, Mahoney DW, et al. Outcome after normal Effects of left atrial enlargement on atrial transmembrane potentials exercise echocardiography and predictors of subsequent cardiac events: and structure in dogs with mitral valve fibrosis. Am J Cardiol 1982;49: follow-up of 1,325 patients. J Am Coll Cardiol 1998;31:144 –9. 1896 –908.18. Sawada SG, Ryan T, Conley MJ, Corya BC, Feigenbaum H, 30. Rücker-Martin C, Pecker F, Godreau D, Hatem SN. Dedifferentia- Armstrong WF. Prognostic value of a normal exercise echocardio- gram. Am Heart J 1990;120:49 –55. tion of atrial myocytes during atrial fibrillation: role of fibroblast19. Wang Y, Gutman JM, Heilbron D, Wahr D, Schiller NB. Atrial proliferation in vitro. Cardiovasc Res 2002;55:38 –52. volume in a normal adult population by two-dimensional echocardi- 31. Thomas L, Levett K, Boyd A, Leung DY, Schiller NB, Ross DL. ography. Chest 1984;86:595– 601. Compensatory changes in atrial volumes with normal aging: is atrial20. Gutman J, Wang YS, Wahr D, Schiller NB. Normal left atrial enlargement inevitable? J Am Coll Cardiol 2002;40:1630 –5. function determined by 2-dimensional echocardiography. Am J Car- 32. Munagala VK, Jacobsen SJ, Mahoney DW, Rodeheffer RJ, Bailey KR, diol 1983;51:336 – 40. Redfield MM. Association of newer diastolic function parameters with21. Krivokapich J, Child JS, Walter DO, Garfinkel A. Prognostic value of age in healthy subjects: a population-based study. J Am Soc Echocar- dobutamine stress echocardiography in predicting cardiac events in diogr 2003;16:1049 –56. patients with known or suspected coronary artery disease. J Am Coll 33. Barberato SH, Mantilla DE, Misocami MA, et al. Effect of preload Cardiol 1999;33:708 –16. reduction by hemodialysis on left atrial volume and echocardiographic22. Chuah SC, Pellikka PA, Roger VL, McCully RB, Seward JB. Role of Doppler parameters in patients with end-stage renal disease. Am J dobutamine stress echocardiography in predicting outcome in 860 Cardiol 2004;94:1208 –10. patients with known or suspected coronary artery disease. Circulation 34. Elhendy A, Mahoney DW, McCully RB, Seward JB, Burger KN, 1998;97:1474 – 80. Pellikka PA. Use of a scoring model combining clinical, exercise test,23. Marcovitz PA, Shayna V, Horn RA, Hepner A, Armstrong WF. and echocardiographic data to predict mortality in patients with Value of dobutamine stress echocardiography in determining the known or suspected coronary artery disease. Am J Cardiol 2004;93: prognosis of patients with known or suspected coronary artery disease. 1223– 8. Am J Cardiol 1996;78:404 – 8. 35. Geleijnse ML, Fioretti PM, Roelandt JR. Methodology, feasibility,24. Sabharwal N, Cemin R, Rajan K, Hickman M, Lahiri A, Senior R. safety and diagnostic accuracy of dobutamine stress echocardiography. Usefulness of left atrial volume as a predictor of mortality in patients with ischemic cardiomyopathy. Am J Cardiol 2004;94:760 –3. J Am Coll Cardiol 1997;30:595– 606.25. Redfield MM, Jacobsen SJ, Burnett JC Jr., Mahoney DW, Bailey KR, 36. Taillefer R, DePuey EG, Udelson JE, Beller GA, Latour Y, Reeves F. Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction Comparative diagnostic accuracy of Tl-201 and Tc-99m sestamibi in the community: appreciating the scope of the heart failure epidemic. SPECT imaging (perfusion and ECG-gated SPECT) in detecting JAMA 2003;289:194 –202. coronary artery disease in women. J Am Coll Cardiol 1997;29:69 –77.26. Douglas PS. The left atrium: a biomarker of chronic diastolic dysfunc- 37. Geleijnse ML, Elhendy A, Fioretti PM, Roelandt JR. Dobutamine tion and cardiovascular disease risk. J Am Coll Cardiol 2003;42: stress myocardial perfusion imaging. J Am Coll Cardiol 2000;36: 1206 –7. 2017–27. Downloaded from by on December 6, 2010
  7. 7. 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 9v1References This article cites 37 articles, 24 of which you can access for free at: 9v1#BIBLCitations This article has been cited by 4 HighWire-hosted articles: 9v1#otherarticlesRights & Permissions Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Information about ordering reprints can be found online: Downloaded from by on December 6, 2010