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J Am Coll Cardiol, 2004; 44:327-334, doi:10.1016/j.jacc.2004.03.062
© 2004 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: PROGNOSTIC MARKERS IN ACUTE MI

Long-term prognostic significance of left atrial volume in acute myocardial infarction

Roy Beinart, MD*, Valentina Boyko, MSc{dagger}, Ehud Schwammenthal, MD*, Rafael Kuperstein, MD*, Alex Sagie, MD{ddagger}, Hanoch Hod, MD, FACC*, Shlomo Matetzky, MD*, Solomon Behar, MD{dagger}, Michael Eldar, MD, FACC* and Micha S. Feinberg, MD, FACC*,*

* Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
{dagger} Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, Israel
{ddagger} Cardiology Department, Rabin Medical Center, Petach Tiqvah, Israel

Manuscript received January 15, 2004; revised manuscript received March 16, 2004, accepted March 22, 2004.

* Reprint requests and correspondence: Dr. Micha S. Feinberg, Heart Institute, Sheba Medical Center, Tel Hashomer, Israel.
micha.feinberg{at}sheba.health.gov.il


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
OBJECTIVES: The aim of this study was to evaluate the significance of increased left atrial (LA) volume determined within the first 48 h of admission as a long-term predictor of outcome in patients with acute myocardial infarction (MI).

BACKGROUND: The LA volume reflects left ventricular (LV) diastolic properties. Whereas other LV Doppler diastolic characteristics are influenced by acute changes in LV function, LA volume is stable and reflects diastolic properties before MI.

METHODS: Clinical and echocardiographic parameters were prospectively collected in 395 consecutive patients with acute MI. Patients with LA volume index (LAVI) >32 ml/m2 (normal + 2 standard deviations) were compared with those with LAVI ≤32 ml/m2. Independent clinical and echocardiographic prognostic risk factors for five years' mortality were determined by the Cox proportional hazard model.

RESULTS: Left atrial volume index >32 ml/m2 was found in 63 patients (19%) who had a higher incidence of congestive heart failure on admission (24% vs. 12%, p < 0.01), a higher incidence of mitral regurgitation, increased LV dimensions, and reduced LV ejection fraction when compared with patients with LAVI ≤32 ml/m2. Their five-year mortality rate was 34.5% versus 14.2% (p < 0.001). Significant independent risk predictors of five years' mortality were age (10 years) (odds ratio [OR] 1.45; 95% confidence interval [CI]1.14 to 1.86), Killip class ≥2 on admission (OR 2.30; 95% CI 1.29 to 4.09), LAVI >32 ml/m2 (OR 2.22; 95% CI 1.25 to 3.96), diabetes (OR 1.94; 95% CI 1.15 to 3.28), and LV restrictive filling pattern (OR 1.89; 95% CI 1.09 to 3.31).

CONCLUSIONS: In patients with acute MI, increased LA volume, determined within the first 48 h of admission, is an independent predictor of five-year mortality with incremental prognostic information to clinical and echocardiographic data.

Abbreviations and Acronyms
  BSA = body surface area
  LA = left atrial
  LAVI = left atrial volume index
  LV = left ventricle
  LVEF = left ventricular ejection fraction
  MI = myocardial infarction
  MR = mitral regurgitation

Doppler indices of left ventricular (LV) diastolic function have been shown to predict cardiovascular events in a wide spectrum of individuals ranging from apparently healthy subjects to patients with end-stage dilative cardiomyopathy (1–12). In particular, a restrictive LV filling pattern has been identified as a strong predictor of morbidity and mortality in patients with acute myocardial infarction (MI) (13–19). Because the left atrium (LA) is exposed to LV filling pressures through the open mitral orifice during diastole, its size is influenced by the same factors that determine diastolic filling pressure (20,21). However, in contrast to other Doppler variables of LV diastolic function, which are affected by acute hemodynamic changes, LA volume is a more stable parameter, integrating the effects of elevated LV filling pressures from preexisting cardiovascular conditions as well as acute disease. Tsang et al. (22) have demonstrated the close association between LV diastolic function and LA volume, which provides a sensitive morphophysiologic expression of the severity of LV diastolic dysfunction and appears to be a useful index of cardiovascular risk. Møller et al. (23) have recently shown that LA enlargement implies a poor prognosis in patients with acute MI. The purpose of the present study was to assess the significance of LA volume, as a predictor of five-year all-cause mortality in a large and consecutive series of patients with acute MI, and to compare its power to that of established mortality risk predictors in this setting.


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
Study population.   During 1996, 451 consecutive patients with documented acute MI were admitted to the coronary care unit of the Heart Institute of Chaim Sheba Medical Center and Cardiology Department of the Rabin Medical Center. Myocardial infarction was detected by the presence of at least two of the following criteria: chest pain lasting >30 min, typical electrocardiographic changes, and elevated creatinine kinase-MB fraction. Myocardial infarction location was determined by electrocardiographic criteria (24). Twelve patients died shortly after admission, before echocardiographic assessment could be performed. In 22 patients echocardiographic assessment was not possible within 48 h of admission because of logistic limitations. In a further 22 patients LA volume could not be determined because of inadequate imaging. The remaining 395 patients constituted the study population. Patients were included in a registry accumulated during the screening period of the Argatroban in Myocardial Infarction (ARGAMI)-2 Study, a multicenter study designed to assess the safety and relative efficacy of direct antithrombin (i.e., Argatroban), compared with intravenous heparin in patients with acute MI receiving thrombolytic therapy. Argatroban exerted neither a favorable nor an adverse detectable effect on outcome. The study protocol was approved by the Sheba and Rabin Medical Center committee on human research. Relevant data on medical history, physical examination, laboratory findings, and electrocardiograms during the hospital course and 30-day follow-up were prospectively collected for all patients. The data concerning mortality five years after admission were obtained from the Israeli population Interior Ministry Registry.

Echocardiography.   All patients underwent a complete echocardiographic examination (Sonos 2500 ultrasound system with 2.5 MHz transducer, Hewlett-Packard; Andover, Massachusetts) and were recorded on videotapes. The studies were interpreted by a single experienced observer (M.S.F.) and all measurements were obtained offline by a single technician. Left ventricular volume was measured by manually tracing the LV cavity using the biplane modified Simpson's algorithm when >80% of the endocardial border could be detected in both the apical four- and two-chamber views, and by a single plane when 80% of the endocardial border could be detected only in the apical four-chamber view. Regional myocardial assessment and wall motion score index were determined by assigning a segmental score (1 = normal, 2 = hypokinetic, 3 = akinetic, 4 = dyskinetic) to each of the 16 left ventricular segments, as recommended by the American Society of Echocardiography (25). All segment scores were added and divided by the number of segments analyzed to obtain the wall motion score index. Mitral inflow was assessed with pulsed-wave Doppler echocardiography from the apical four-chamber view. The Doppler beam was aligned parallel to the direction of flow and a 1- to 2-mm sample volume was placed between the tips of mitral leaflets during diastole (26). From the mitral inflow profile, the E- and A-wave velocity, E-deceleration time, and E/A velocity ratio were measured. Pulmonary venous flow was recorded with pulsed-wave Doppler with a sample volume placed ~1 cm into the right upper pulmonary vein. The flow velocities were recorded and the ratio of systolic to diastolic forward flow (Si/Di ratio) was calculated. Mitral regurgitation (MR) was graded by color Doppler flow mapping using an algorithm that integrated jet expansion within the LA (27,28), jet eccentricity (29), and size of the proximal area (30–32). Mitral regurgitation was considered mild when regurgitant jet area occupied <20% of the LA area in the absence of a wall jet and a proximal isovelocity surface area visible without baseline shifting. Regurgitation was considered severe in all patients in whom jet area was >40% of the LA area. Jet eccentricity or a sizable proximal flow convergence radius (≥6 mm in a patient with jet area <20%, and ≥9 mm in a patient with a jet area between 20% and 40%) raised the grade of MR by 1°. The maximal LA volume was measured by the method of discs using the offline software of Sonos 2500, from the apical four-chamber view at end-systole, a method shown to be equivalent to the biplane methods (33). The LA volume index (LAVI) cutoff level of 32 ml/m2 (mean + 2 SD) was used as has been previously reported (22,23,34). Left ventricular filling patterns were determined according to the criteria of the European Study Group on Diastolic Heart Failure (35). Left ventricular restrictive filling pattern was determined in patients <50 years when E/A ratio was more than 3 and E deceleration time <140 ms, and in patients ≥50 years when E/A ratio was more than 2 and E deceleration time <140 ms. Left ventricular impaired relaxation was determiner in patients <50 years when E/A ration was <1 and E deceleration time more than 240 ms, and in patients ≥50 years when E/A ratio was <0.5 and E deceleration time more than 280 ms. Stroke distance and volume were determined by pulse Doppler at the level of the outflow tract, assuming a circular LV outflow area at the level of the insertion of the aortic valve cusps. Myocardial performance index was determined as previously reported (36). The sum of isovolumic contraction and relaxation time was obtained by subtracting ejection time (b) from the interval between two mitral inflow periods (a). Myocardial performance index then was determined as (a – b)/b. All measurements were performed by an experienced observer who was blinded to the clinical data and were averaged from three to five cardiac cycles, in beats with similar lengths (±10%).

Statistical analysis.   SAS software was used for statistical analysis. All continuous variables are presented as mean ± SD. Comparison of clinical and echocardiographic characteristics was performed by chi-square analysis for categorical variables and by Student t test for echocardiography and other continuous variables. A p value <0.05 was considered significant. Multivariate analysis to determine whether LAVI >32 ml/m2 is an independent risk predictor for five-year all-cause mortality was performed by the Cox proportional-hazards model (Release 6.11, SAS Institute, Cary, North Carolina). Significant univariate predictors and other known risk predictors were entered in the model: age, gender, Killip class ≥2, primary reperfusion, diabetes, systemic hypertension, paroxysmal atrial fibrillation, previous MI, left ventricular ejection fraction (LVEF), moderate and severe MR, LAVI > 32 ml/m2, restrictive LV filling pattern, LV end-systolic volume index and body surface area (BSA). A stepwise selection method was used with the significance level of 0.10 for entering and 0.05 for remaining an explanatory variable. Unadjusted survival curves were produced using the Kaplan-Meier method. The log-rank test was used to compare survival curves. Adjusted survival curves were constructed using variables entered into the Cox model set to their mean values in the total population.


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
Baseline characteristics of the study population (Table 1). A total of 395 patients (84 women), mean age 62 ± 12 years, constituted the study population. Left atrial volume index was >32 ml/m2 in 63 (19%). Compared with patients with LAVI ≤32 ml/m2, these patients were older, had a greater prevalence of female gender, history of smoking, and cerebrovascular attack or transient ischemic attack. They presented more frequently with heart failure (Killip score ≥2) on admission. There was no difference in the prevalence of hypertension, diabetes mellitus, hyperlipidemia, history of MI and revascularization, percutaneous coronary intervention, or coronary artery bypass grafting.


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  		Table 1 Clinical Characteristics

 
In-hospital course (Table 1).   Congestive heart failure was a more frequent complication in patients with LAVI >32 ml/m2 (14/63 [22.2%] vs. 37/332 [11.1%], p = 0.016). There was no difference in the prevalence of arrhythmias including atrial fibrillation (4/63 [6.3%] vs. 22/332 [6.6%], p = 0.94) and ventricular tachycardia or ventricular fibrillation (13/63 [20.6%] vs. 51/332 [15.4%], p = 0.30), or in the incidence of cardiogenic shock (4/63 [6.3%] vs.10/332 [3.0%], p = 0.19) during hospitalization and in MI type (Q-wave vs. non–Q-wave MI) in the two groups.

Patients with LAVI ≤32 ml/m2 were treated less with intra-aortic balloon pump (4.3% vs. 11.7%, p = 0.022). No significant differences in the treatment with thrombolysis (46.4% vs. 43.9%, p = 0.72), percutaneous coronary intervention (43.3% vs. 31.7%, p = 0.09) or coronary artery bypass grafting (6.5% vs. 8.3%, p = 0.60) was noted, as well as no difference in the in-hospital revascularization rate (48.5% vs. 36.5%, p = 0.08). At hospital discharge, there was no difference in the use of aspirin (97.2% vs. 86.7%, p = 0.06), angiotensin-converting enzyme inhibitors (46.1% vs. 51.7%, p = 0.43), nitrates (83.0% vs. 73.3%, p = 0.08), antiarrhythmic agents (32.5% vs. 28.3%, p = 0.52), or lipid-lowering drugs (10.5% vs. 11.7%, p = 0.79). However, patients with LAVI ≤32 ml/m2 were more often receiving beta-adrenergic blocking agents (72.4% vs. 48.3%), p < 0.001).

Echocardiographic characteristics.   The relationship between LAVI and other echocardiographic parameters is shown in Table 2. Left atrial volume index >32 ml/m2 was associated with moderate or severe MR (8/63, 12.7% vs. 12/332, 3.6%; and 2/63, 3.2%, vs. 3/332, 0.9%; respectively, p < 0.001), higher LV end-systolic volume (84 ± 44 vs. 67 ± 26, p = 0.005), and lower LVEF (41.9 ± 10.6% vs. 45.3 ± 9.2%, p = 0.01). Neither the LV filling pattern nor the E/A ratio were significantly different between the groups with LAVI ≤32 ml/BSA and LAVI >32 ml/BSA.


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  		Table 2 Echocardiographic Characteristics

 
Predictors of outcome.   During a follow-up period of 5 years, mortality rate was significantly higher in patients with LAVI >32 ml/m2, (34.5% vs. 14.2%, p < 0.001). This difference was particularly significant after the first year of the acute MI (Table 3). There was no significant difference between the two groups in mortality rate during the first 30 days.


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  		Table 3 Follow-Up

 
Univariate predictors of mortality.   Univariate variables associated with five-year all-cause mortality, their odds ratios, and their 95% confidence intervals are shown in Table 4. Univariate variables significantly associated with five-year mortality included age, female gender, Killip class ≥2 on admission, diabetes mellitus, systemic hypertension, previous MI, paroxysmal atrial fibrillation, LVEF, LV filling pattern, moderate and severe MR, LAVI >32 ml/m2, LV end-systolic volume index, and E deceleration of <140. A trend for lower mortality was noted in patients treated with primary reperfusion (p = 0.070).


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  		Table 4 Univariate Predictors of 5-Year Mortality*

 
Independent predictors of mortality.   All significant univariate variables were entered into the Cox model except for wall motion score index, because it is highly associated with LVEF, and E deceleration of <140 ms, because it is highly associated with restrictive pattern. Independent predictors of all-cause five-year mortality, their hazard ratios, and 95% confidence intervals are shown in Table 5 and Figure 1. These include age, Killip class ≥2 on admission, diabetes mellitus, LV restrictive filling pattern, and LAVI >32 ml/m2. Left atrial volume index >32 ml/m2 had a hazard ratio of 2.22 (95% confidence interval 1.25 to 3.96, p = 0.006). Left ventricular ejection fraction, LV end-systolic volume index, and moderate and severe MR did not prove to be significant predictors of all-cause mortality when LAVI was included in this model. A separate analysis using the same model was performed on the 313 patients with first MI and revealed that age, diabetes, LVEF, and LAVI >32 ml/m2 were significant independent predictors of five-year all-cause mortality (Table 6, Fig. 2).


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  		Table 5 Significant Independent Predictors of Five Years' Mortality

 


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  		Figure 1 Independent five-year mortality risk predictors of all patients; hazard ratio (95% confidence interval [CI]). LV = left ventricular; LAVI = left atrial volume index.

 

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  		Table 6 Significant Independent Predictors of Five Years' Mortality, in Patients With a First MI

 


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  		Figure 2 Independent five-year mortality risk predictors of patients with first myocardial infarction only; hazard ratio (95% confidence interval [CI]). LAVI = left atrial volume index; LVEF = left ventricular ejection fraction.

 
Kaplan-Meier survival curves for patients with LAVI ≤32 ml/m2 and those with LAVI >32 ml/m2 are shown in Figure 3 and adjusted survival curves in Figure 4.



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  		Figure 3 Kaplan-Meier survival curves of patients with left atrial (LA) volume index ≥32 ml/m2 and for patients with LA volume index >32 ml/m2. The log-rank test was used to compare survival curves. p = 0.0001.

 


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  		Figure 4 Adjusted survival curves of patients with left atrial (LA) volume index ≥32 ml/m2 and with LA volume index >32 ml/m2 were constructed using variables entered into the Cox model: age, gender, Killip class ≥2, primary reperfusion, diabetes, systemic hypertension, paroxysmal atrial fibrillation, previous myocardial infarction, left ventricular ejection fraction, moderate and severe mitral regurgitation, and restrictive left ventricular filling pattern. p = 0.02.

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
This prospective study confirms the observation that LAVI obtained early within the first 48 h of admission is a powerful independent predictor of survival after acute MI. Moreover, new findings include the fact that LAVI becomes a significant independent predictor of mortality within the first year following acute MI and is even more powerful for predicting five-year survival, and that LA volume obtained early upon admission is a more powerful independent long-term mortality predictor than LV volume and the presence of MR.

Left ventricular diastolic dysfunction is a well-established marker for risk stratification of patients with acute MI (13–19). However, most of the diastolic parameters that were previously assessed were affected by acute hemodynamic changes. In contrast, LA volume is influenced by LV filling pressure before acute MI and has been shown to be a sensitive expression of the severity of prior diastolic dysfunction (37). Left atrial volume is increased by a number of pathologic processes leading to diastolic LV dysfunction, such as systemic hypertension and diabetes mellitus. It also reflects LV diastolic dysfunction secondary to LV systolic dysfunction due to previous LV insults, the long-term presence of MR and its severity, and the presence of atrial fibrillation. As a common pathway reflecting all these processes that decrease "cardiac reserve" in patients with acute MI, it becomes a powerful predictor of long-term outcome.

Møller et al. (23) showed for the first time the importance of LA volume as a predictor of post-MI survival. They studied 314 patients retrospectively and showed that LAVI of 32 ml/m2 (normal + 2 standard deviations) was a powerful independent predictor of all-cause mortality during a mean follow-up period of 15 months.

The present study reconfirmed these findings prospectively and extended them further. The 395 consecutive patients with documented acute MI in our study were followed for 5 years and, despite the fact that they were significantly younger (mean age of 62 years vs. 70 years), appeared to have had a lower mortality rate, and smaller mean LA volume, their LAVI maintained its significant predictive power. Left atrial volume was estimated in our study from a single plane (apical four-chamber view), technically simpler than the biplane method used before, while maintaining its diagnostic power as previously assumed (33).

Interestingly, the multivariate analysis showed that other known powerful predictive variables such as LVEF, LV end-systolic volume index, and significant MR, lost their independent significance when LAVI was included in the statistical model. In patients with a first MI, Killip class on admission did not prove to be an independent predictor of five-year mortality, whereas LVEF did. Left atrial volume index maintained its significance in the subgroup of patients with a first acute MI.

Limitations.   The study shows the significance of LAVI obtained from echocardiographic studies performed early within the first 48 h of admission of patients with acute MI. At this early stage LV dysfunction may still be reversible and may not reflect the full remodeling process after the infarction. Therefore, these findings may not apply to studies performed at a later stage. The LA is a complicated three-dimensional structure and the geometric algorithm used only estimates its volume. Three-dimensional imaging may be a more accurate method of defining LA volume and function. Since 1996, the percentage of patients undergoing primary percutaneous coronary intervention rather than thrombolysis has increased in our institutions, as has the use of angiotensin-converting enzyme inhibitors and lipid-lowering drugs. Although these trends may have reduced the overall cardiovascular mortality, they are unlikely to affect the prognostic value of LA volume.

Conclusions.   Our study confirms the conclusions of a previous study (23) that increased LA volume is an independent risk predictor of all-cause mortality of patients with acute MI. Furthermore, it shows the long-term (five-year) survival prognostic significance of LA volume obtained early on admission over LV dimensions and significant MR with an incremental value to other clinical risk predictors.


   Acknowledgments
 
The authors are indebted to the Israel Society for the Prevention of Heart Attacks for the logistic support and commitment for data management and analysis.


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

  1. Kuperstein R, Feinberg MS, Rosenblat S, Beker B, Eldar M, Schwammenthal E. Prevalence, etiology, and outcome of patients with restrictive left ventricular filling and relatively preserved systolic function. Am J Cardiol. 2003;91:1517–1519[CrossRef][Medline]
  2. Clements IP, Brown ML, Zinsmeister AR, Gibbons RJ. Influence of left ventricular diastolic filling on symptoms and survival in patients with decreased left ventricular systolic function. Am J Cardiol. 1991;67:1245–1250[CrossRef][Medline]
  3. Rihal CS, Nishimura RA, Hatle LK, Bailey KR, Tajik AJ. Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy. Relation to symptoms and prognosis. Circulation. 1994;90:2772–2779[Abstract/Free Full Text]
  4. Shen WF, Tribouilloy C, Rey JL, et al. Prognostic significance of Doppler-derived left ventricular diastolic filling variables in dilated cardiomyopathy. Am Heart J. 1992;124:1524–1533[CrossRef][Medline]
  5. Werner GS, Schaefer C, Dirks R, Figulla HR, Kreuzer H. Prognostic value of Doppler echocardiographic assessment of left ventricular filling in idiopathic dilated cardiomyopathy. Am J Cardiol. 1994;73:792–798[CrossRef][Medline]
  6. Xie GY, Berk MR, Smith MD, Gurley JC, DeMaria AN. Prognostic value of Doppler transmitral flow patterns in patients with congestive heart failure. J Am Coll Cardiol. 1994;24:132–139[Abstract]
  7. Tsang TS, Gersh BJ, Appleton CP, et al. Left ventricular diastolic dysfunction as a predictor of the first diagnosed nonvalvular atrial fibrillation in 840 elderly men and women. J Am Coll Cardiol. 2002;40:1636–1644[Abstract/Free Full Text]
  8. Aurigemma GP, Gottdiener JS, Shemanski L, Gardin J, Kitzman D. Predictive value of systolic and diastolic function for incident congestive heart failure in the elderly: The cardiovascular health study. J Am Coll Cardiol. 2001;37:1042–1048[Abstract/Free Full Text]
  9. Bella JN, Palmieri V, Roman MJ, et al. Mitral ratio of peak early to late diastolic filling velocity as a predictor of mortality in middle-aged and elderly adults: The strong heart study. Circulation. 2002;105:1928–1933[Abstract/Free Full Text]
  10. Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: Appreciating the scope of the heart failure epidemic. JAMA. 2003;289:194–202[Abstract/Free Full Text]
  11. Giannuzzi P, Temporelli PL, Bosimini E, et al. Independent and incremental prognostic value of Doppler-derived mitral deceleration time of early filling in both symptomatic and asymptomatic patients with left ventricular dysfunction. J Am Coll Cardiol. 1996;28:383–390[Abstract]
  12. Dini FL, Michelassi C, Micheli G, Rovai D. Prognostic value of pulmonary venous flow Doppler signal in left ventricular dysfunction: Contribution of the difference in duration of pulmonary venous and mitral flow at atrial contraction. J Am Coll Cardiol. 2000;36:1295–1302[Abstract/Free Full Text]
  13. Pozzoli M, Capomolla S, Sanarico M, Pinna G, Cobelli F, Tavazzi L. Doppler evaluations of left ventricular diastolic filling and pulmonary wedge pressure provide similar prognostic information in patients with systolic dysfunction after myocardial infarction. Am Heart J. 1995;129:716–725[CrossRef][Medline]
  14. Nijland F, Kamp O, Karreman AJ, van Eenige MJ, Visser CA. Prognostic implications of restrictive left ventricular filling in acute myocardial infarction: A serial doppler echocardiographic study. J Am Coll Cardiol. 1997;30:1618–1624[Abstract]
  15. Sakata K, Kashiro S, Hirata S, Yanagisawa A, Ishikawa K. Prognostic value of Doppler transmitral flow velocity patterns in acute myocardial infarction. Am J Cardiol. 1997;79:1165–1169[CrossRef][Medline]
  16. Moller JE, Sondergaard E, Poulsen SH, Egstrup K. Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: A serial color M-mode doppler echocardiographic study. J Am Coll Cardiol. 2000;36:1841–1846[Abstract/Free Full Text]
  17. Cerisano G, Bolognese L, Buonamici P, et al. Prognostic implications of restrictive left ventricular filling in reperfused anterior acute myocardial infarction. J Am Coll Cardiol. 2001;37:793–799[Abstract/Free Full Text]
  18. Poulsen SH, Jensen SE, Gotzsche O, Egstrup K. Evaluation and prognostic significance of left ventricular diastolic function assessed by Doppler echocardiography in the early phase of a first acute myocardial infarction. Eur Heart J. 1997;18:1882–1889[Abstract/Free Full Text]
  19. Poulsen SH, Jensen SE, Moller JE, Egstrup K. Prognostic value of left ventricular diastolic function and association with heart rate variability after a first acute myocardial infarction. Heart. 2001;86:376–380[Abstract/Free Full Text]
  20. Appleton CP, Galloway JM, Gonzalez MS, Gaballa M, Basnight MA. Estimation of left ventricular filling pressures using two-dimensional and Doppler echocardiography in adult patients with cardiac disease. Additional value of analyzing left atrial size, left atrial ejection fraction and the difference in duration of pulmonary venous and mitral flow velocity at atrial contraction. J Am Coll Cardiol. 1993;22:1972–1982[Abstract]
  21. Basnight MA, Gonzalez MS, Kershenovich SC, Appleton CP. Pulmonary venous flow velocity: Relation to hemodynamics, mitral flow velocity and left atrial volume, and ejection fraction. J Am Soc Echocardiogr. 1991;4:547–558[Medline]
  22. Tsang TS, Barnes ME, Gersh BJ, et al. Prediction of risk for first age-related cardiovascular events in an elderly population: The incremental value of echocardiography. J Am Coll Cardiol. 2003;42:1199–1205[Abstract/Free Full Text]
  23. Moller JE, Hillis GS, Oh JK, et al. Left atrial volume: A powerful predictor of survival after acute myocardial infarction. Circulation. 2003;107:2207–2212[Abstract/Free Full Text]
  24. Prineas RJ, Cow RS, Blackburn H. The Minnesota Code manual of Electrocardiographic Findings. In: John Wright, PSG Inc., eds. Standards and Procedures for Measurement and Classification. MA: Littelton, 1982
  25. Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr. 1989;2:358–367[Medline]
  26. Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA. Recommendations for quantification of Doppler echocardiography: A report from the doppler quantification task force of the nomenclature and standards committee of the american society of echocardiography. J Am Soc Echocardiogr. 2002;15:167–184[CrossRef][Medline]
  27. Helmcke F, Nanda NC, Hsiung MC, et al. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation. 1987;75:175–183[Abstract/Free Full Text]
  28. Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol. 1999;83:897–902[CrossRef][Medline]
  29. Chen CG, Thomas JD, Anconina J, et al. Impact of impinging wall jet on color Doppler quantification of mitral regurgitation. Circulation. 1991;84:712–720[Abstract/Free Full Text]
  30. Bargiggia GS, Tronconi L, Sahn DJ, et al. A new method for quantitation of mitral regurgitation based on color flow Doppler imaging of flow convergence proximal to regurgitant orifice. Circulation. 1991;84:1481–1489[Abstract/Free Full Text]
  31. Feinberg MS, Schwammenthal E, Shlizerman L, et al. Prognostic significance of mild mitral regurgitation by color Doppler echocardiography in acute myocardial infarction. Am J Cardiol. 2000;86:903–907[CrossRef][Medline]
  32. Rossi A, Dujardin KS, Bailey KR, Seward JB, Enriquez-Sarano M. Rapid estimation of regurgitant volume by the proximal isovelocity surface area method in mitral regurgitation: Can continuous-wave doppler echocardiography be omitted? J Am Soc Echocardiogr. 1998;11:138–148[CrossRef][Medline]
  33. Lester SJ, Ryan EW, Schiller NB, Foster E. Best method in clinical practice and in research studies to determine left atrial size. Am J Cardiol. 1999;84:829–832[CrossRef][Medline]
  34. Wang Y, Gutman JM, Heilborn D, et al. Atrial volume in a normal adult population by two-dimensional echocardiography. Chest. 1984;86:595–601[Abstract/Free Full Text]
  35. How to diagnose diastolic heart failure. European Study Group on Diastolic Heart Failure. Eur Heart J 1998;19;990–1003.
  36. Schwammenthal E, Adler Y, Amichai K, et al. Prognostic value of global myocardial performance indices in acute myocardial infarction: Comparison to measures of systolic and diastolic left ventricular function. Chest. 2003;124:1645–1651[Abstract/Free Full Text]
  37. Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB. Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. Am J Cardiol. 2002;90:1284–1289[CrossRef][Medline]



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