Umeå universitets logga

Introduction: Non-invasive assessment of coronary artery disease (CAD) in patients with hypertensive heart disease is still a major clinical challenge. The aim of this meta-analysis was to evaluate the diagnostic accuracy of different non-invasive techniques in detecting significant (> 50%) CAD in hypertensive patients.

Material and methods: We systematically searched selected electronic databases from inception until February 27(th) 2024. The main clinical endpoint was the diagnostic accuracy of non-invasive investigations including exercise electrocardiography test (EET), stress echocardiography (SE) and myocardial perfusion imaging (MPI). Random effects summary receiver operating characteristic analysis was performed.

Results: Twenty-five papers with a total of 3812 patients with systemic hypertension and suspected or known significant CAD were finally included in the meta-analysis. The diagnostic accuracy of SE was the highest compared to the two other investigations (85%, 72%, 53%, p < 0.05 for all). SE had higher sensitivity 85% (83-87%) and specificity 81% (79-83%) compared to MPI (sensitivity 81% (77-83%), specificity 64% (59-68%)) and EET (sensitivity: 53% (50-65%) and specificity 51% (47-54%)). All three tested investigations had higher accuracy in patients with multivessel disease compared to those with single-vessel disease (p < 0.05 for all). The diagnostic accuracy of SE and MPI was not significantly impacted by left ventricular hypertrophy (p > 0.05 for both) compared to EET, which was lower in patients with hypertrophy compared to those without (41% vs. 58%, p = 0.03). These results were consistent irrespective of the stress echo modality, physical, exercise or pharmacological (p > 0.05).

Conclusions: This meta-analysis reveals the powerful diagnostic value of stress echocardiography in detecting significant coronary artery disease in hypertension patients.

Catheter ablation (CA) has become a validated technique for treating patients with symptomatic or paroxysmal atrial fibrillation (AF), as recommended by the latest 2024 European society of cardiology (ESC) guidelines, class II level A. The procedure is also recommended for patients with persistent AF without major risk factors for AF recurrence, as an alternative to antiarrhythmic medications class I or III. However, CA carries the risk of AF recurrence in 30–35% of patients, sometimes after the procedure. Multiple factors impact the onset, maintenance, and recurrence of AF after CA, including clinical, biohumoral, echocardiographic, genetic, and lifestyle factors. Beyond traditional predictors, emerging factors such as obstructive sleep apnea syndrome, chronic renal failure, chronic lung disease, physical activity patterns, gut microbiota composition, and epicardial fat thickness significantly influence outcomes. Therefore, optimizing patient’s selection for CA is an important strategy to minimize the risk of AF recurrence. Many echocardiographic parameters emerged as predictors of AF recurrence post-CA, but none stood out as a potential single factor. These factors include traditional markers such as left atrial size by 2D echocardiography, LV ejection fraction, LV diastolic function parameters as well as myocardial deformation addressed by the recently developed speckle tracking analysis. Additionally, the duration and type of AF represent fundamental risk factors, with longstanding persistent AF showing significantly higher recurrence rates compared to paroxysmal forms. Novel biomarkers including MR-proANP, caspase-8, hsa-miR-206, and neurotrophin-3 show promise in enhancing risk prediction capabilities. The aim of this review is to explore the most relevant echocardiographic parameters, including myocardial deformation, that could accurately predict recurrence of AF after CA, while also examining the role of emerging clinical and biochemical predictors in comprehensive patient selection strategies.

BACKGROUND AND AIM: Cardiovascular disease progresses after menopause. Conventional risk factors, particularly diabetes, for atherosclerosis are well-established predictors of phenotypic arterial disease. The aim of this study is to assess the predictors of subclinical atherosclerosis in asymptomatic non-diabetic postmenopausal women.

METHODS: This prospective study included 117 consecutive postmenopausal women (mean age 59 ± 7 years) referred from the outpatient Rheumatology Clinic of the University Clinical Centre of Kosovo, recruited between September 2021 and December 2022. Clinical, biochemical, carotid ultrasound and coronary CT angiography data were analysed. Subclinical atherosclerosis was diagnosed when plaque and/or carotid intima-media thickness >1.00 mm were present.

RESULTS: Women who had subclinical atherosclerosis had higher erythrocyte sedimentation (p = 0.022), higher total cholesterol (p = 0.013), higher CAC score (p = 0.017), and higher prevalence of CAC > 100 HU and CAC > 400 HU (p = 0.017 and p = 0.034, respectively) compared to those without subclinical atherosclerosis. Women who had mild coronary calcification (CAC score ≥10 HU) were older (p = 0.005), in longer menopause (p = 0.005), had thicker CIMT (p = 0.008) with higher prevalence (p = 0.03) compared to those with CAC score <10 HU. Women with moderate coronary calcification (CAC score ≥100 HU) had higher triglycerides, worse CIMT (p = 0.005) with higher prevalence (p = 0.039) compared to those with CAC score <100 HU. In multivariate analysis [odds ratio 95% confidence interval], age [1.101 (1.032-1.174), p = 0.037] and cholesterol [2.020 (1.225-3.331), p = 0.006] independently predicted the presence of subclinical atherosclerosis.

CONCLUSIONS: In addition to the impact of age, hypercholesterolaemia is an important predictor of subclinical atherosclerosis in non-diabetic postmenopausal women.

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, and it is associated with increased stroke and dementia risk. While the established paradigm attributes these complications to blood stasis within the atria and subsequent thrombus formation with cerebral embolization, recent evidence suggests that atrial myopathy (AM) may play a key role. AM is characterized by structural and functional abnormalities of the atria, and can occur with or without AF. Moving beyond classifications based solely on episode duration, the 4S-AF characterization has offered a more comprehensive approach, incorporating patient’s stroke risk, symptom severity, AF burden, and substrate assessment (including AM) for tailored treatment decisions. The “ABC” pathway emphasizes anticoagulation, symptom control, and cardiovascular risk modification and emerging evidence suggests broader benefits of early rhythm control strategies, potentially reducing stroke and dementia risk and improving clinical outcomes. However, a better integration of AM assessment into the current framework holds promise for further personalizing AF management and optimizing patient outcomes. This review explores the emerging concept of AM and its potential role as a risk factor for stroke and dementia and in AF patients’ management strategies, highlighting the limitations of current risk stratification methods, like the CHA2DS2-VASc score. Echocardiography, particularly left atrial (LA) strain analysis, has shown to be a promising non-invasive tool for AM evaluation and recent studies suggest that LA strain analysis may be a more sensitive risk stratifier for thromboembolic events than AF itself, with some studies showing a stronger association between LA strain and thromboembolic events compared to traditional risk factors. Integrating it into routine clinical practice could improve patient management and targeted therapies for AF and potentially other thromboembolic events. Future studies are needed to explore the efficacy and safety of anticoagulation in AM patients with and without AF and to refine the diagnostic criteria for AM.

Aims: Echocardiography plays an important role in suspecting the presence of transthyretin cardiomyopathy (ATTR-CM) in patients with heart failure, based on parameters proposed as ‘red flags’ for the diagnosis of ATTR-CM. We aimed to validate those measurements in a group of patients with ATTR-CM including ATTRv and ATTRwt.

Methods and results: We tested a number of echocardiographic red flags in 118 patients with confirmed diagnosis of ATTR-CM. These variables were validated against healthy controls and patients with heart failure with left ventricular hypertrophy (LVH) but not ATTR-CM. The red flag measures outside the proposed cut-off values were also revalidated. In ATTR-CM, all conventional echocardiographic parameters were significantly abnormal compared with controls. Comparing ATTR-CM and LVH, LV wall thickness, LV diameter, E velocity, and relative apical sparing (RELAPS) were all different. Eighty-three per cent of ATTR-CM patients had RELAPS > 1.0, 73% had relative wall thickness (RWT) > 0.6, 72% had LVEF > 50%, 24% had global longitudinal strain (GLS) > −13%, 33% had LVEF/GLS > 4, and 54% had increased left atrial volume index (>34 mL/m2). Forty per cent of ATTR-CM patients had stroke volume index < 30 mL/m2 and 52% had cardiac index < 2.5 L/min/m2. RELAPS, LVEF, and RWT, in order of accuracy, were the three best measures for the presence ATTR-CM in the patient cohort, who all had thick myocardium. The concomitant presence of the three disturbances was found in only 50% but the combination of RELAPS > 1.0 and RWT > 0.6 was found in 72% of the patient cohort.

Conclusion: Increased relative apical sparing proved the most accurate independent marker of the presence of ATTR-CM followed by normal LV ejection fraction and then increased relative wall thickness. The other proposed red flags for diagnosing ATTR-CM did not feature as reliable disease predictors.

Doppler echocardiography is the corner-stone of non-invasive investigation of patients with a clinical diagnosis of heart failure. It provides an accurate and quantitative assessment of cardiac structure and function. Furthermore, spectral Doppler measurement is an invaluable technique for estimating intracardiac pressures with their crucial value in the optimum management of heart failure patients, irrespective of ejection fraction. Speckle tracking echocardiography stretches the unique application of echocardiography to analyze the myocardial deformation function which has proved very accurate in detecting ischemia, dyssynchrony, subclinical dysfunction and also in estimating pulmonary capillary wedge pressures. The role of longitudinal myocardial left atrial deformation dynamics has recently emerged as a valuable tool for assessing left ventricular diastolic dysfunction in patients with cardiac diseases regardless of their ejection fraction. Finally, the extent of myocardial deformation has been shown to correlate with the severity of myocardial fibrosis, a common finding in patients with heart failure.

Advanced heart failure (AdvHF) can only be treated definitively by heart transplantation (HTx), yet problems such right ventricle dysfunction (RVD), rejection, cardiac allograft vasculopathy (CAV), and primary graft dysfunction (PGD) are linked to a poor prognosis. As a result, numerous biomarkers have been investigated in an effort to identify and prevent certain diseases sooner. We looked at both established biomarkers, such as NT-proBNP, hs-troponins, and pro-inflammatory cytokines, and newer ones, such as extracellular vesicles (EVs), donor specific antibodies (DSA), gene expression profile (GEP), donor-derived cell free DNA (dd-cfDNA), microRNA (miRNA), and soluble suppression of tumorigenicity 2 (sST2). These biomarkers are typically linked to complications from HTX. We also highlight the relationships between each biomarker and one or more problems, as well as their applicability in routine clinical practice.

Risk stratification of cardiovascular death and treatment strategies in patients with heart failure (HF), the optimal timing for valve replacement, and the selection of patients for implantable cardioverter defibrillators are based on an echocardiographic calculation of left ventricular ejection fraction (LVEF) in most guidelines. As a marker of systolic function, LVEF has important limitations being affected by loading conditions and cavity geometry, as well as image quality, thus impacting inter- and intra-observer measurement variability. LVEF is a product of shortening of the three components of myocardial fibres: longitudinal, circumferential, and oblique. It is therefore a marker of global ejection performance based on cavity volume changes, rather than directly reflecting myocardial contractile function, hence may be normal even when myofibril's systolic function is impaired. Sub-endocardial longitudinal fibers are the most sensitive layers to ischemia, so when dysfunctional, the circumferential fibers may compensate for it and maintain the overall LVEF. Likewise, in patients with HF, LVEF is used to stratify subgroups, an approach that has prognostic implications but without a direct relationship. HF is a dynamic disease that may worsen or improve over time according to the underlying pathology. Such dynamicity impacts LVEF and its use to guide treatment. The same applies to changes in LVEF following interventional procedures. In this review, we analyze the clinical, pathophysiological, and technical limitations of LVEF across a wide range of cardiovascular pathologies.