E LeAP STUDY ECHOCARDIOGRAPHIC LEFT ATRIAL PRESSURE: COMPARATIVE REVIEW IN PATIENTS WITH SINUS RHYTHM AND ATRIAL FIBRILLATION

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1 E LeAP STUDY ECHOCARDIOGRAPHIC LEFT ATRIAL PRESSURE: COMPARATIVE REVIEW IN PATIENTS WITH SINUS RHYTHM AND ATRIAL FIBRILLATION Moghniuddin Mohammed, M.B.B.S. Mentor: Dr. Harry McCrea, M.D. Dr. Yuji Saito, M.D, Ph.D.

2 OVERVIEW Epidemiology of atrial fibrillation Left atrial pressure ELeAP Study

3 STUDY OBJECTIVES Estimate prevalence of high left atrial pressure in patients with atrial fibrillation non invasively using Echocardiographic parameters.

4 ATRIAL FIBRILLATION EPIDEMIC A CONDITION THAT EFFECTS A DISPROPORTIONATELY LARGE NUMBER OF INDIVIDUALS IN A POPULATION.EXCESSIVELY PREVALENT

5 Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death File CDC WONDER. Series 20 No. 2J, 2007.

6 EPIDEMIOLOGY Treatment of atrial fibrillation represents a significant health care burden. Overall, hospitalizations increased by 23% from 2000 to 2010 (a relative increase of 14.4% after accounting for population growth) 3 Cost of hospitalization increased significantly from $6,410 in 2001 to $8,439 in 2010 (relative increase, 24.0%; P <0.001). 3. Trends of Hospitalization for Atrial Fibrillation in the United States, 2000 Through 2010: Implications for Healthcare Planning Circulation, 2014

7 EPIDEMIOLOGY Health Wealth Kills!!! NOT BENIGN!!!!!!

8 UNDERSTANDING AFIB Who it strikes How it operates

9 ATRIAL FIBRILLATION RISK FACTORS: Age HTN DM Structural heart disease Obesity OSA

10 ATRIAL FIBRILLATION Possible patho physiologic mechanism: Increased left atrial pressure and myocyte stretch. This results in: Cellular hypertrophy Interstitial fibrosis and cellular necrosis Left atrial dilatation

11 LEFT ATRIAL PRESSURE PCWP Left ventricular filling pressure Left ventricular End Diastolic Pressure 2D-ECHO

12 LEFT ATRIAL PRESSURE = E e

13 E Left ventricle relaxation + LAP

14 e Excellent marker of left ventricular relaxation.

15 E/e Left ventricle relaxation + LAP Left ventricle relaxation

16 E/e One of the most reproducible echocardiographic parameter. Preferred prognostic parameter in many cardiac conditions.

17 LAP Measurement Qualitative Normal High Different parameters in Atrial fibrillation vs Sinus rhythm.

18 LAP Measurement

19 LAP in Sinus Rhythm

20 LAP in Atrial Fibrillation Challenges: Beat to beat variation of the Doppler derived indices may affect the calculation of E/e. Doppler value may change as left ventricular filling pressure changes. Loss of organized atrial activity.

21 LAP in Atrial Fibrillation Evidence 1: E/e >= 11 predicts LVFP >= 15 Sensitivity of 75% and specificity of 93%

22 LAP in Atrial Fibrillation Evidence 2: E/e >= 16 predicts PCWP >15 Sensitivity of 91% and specificity of 85%

23 LAP in Atrial Fibrillation Evidence 3: E/e >= 16 predicts LVEDP >15

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25 STUDY DESIGN Case Control Retrospective Analysis Catholic Health System and Cardiology group of WNY Institutional Review Board Approval No conflicts of interest or financial disclosures

26 STUDY DESIGN INCLUSION CRITERIA: Adult patients who had undergone 2D echocardiogram study in Catholic Health System and Cardiology group of WNY.

27 STUDY DESIGN EXCLUSION CRITERIA: Systolic heart failure(ef<45%) Mitral stenosis Moderate and severe mitral regurgitation Diagnosis of pulmonary hypertension Sinus tachycardia(hr>100) Rapid Atrial Fibrillation(HR>100) Inadequate Echo parameters

28 STUDY DESIGN: STUDY FLOW DIAGRAM NSR 946 Echos screened Afib 1092 Echos screened Exclusion criteria applied Controls N=163 Cases N = 209

29 DISTRIBUTION OF AFIB GROUP

30 STATISTICAL METHODS IBM Statistical Package for Social Sciences (SPSS) software V.22 Continuous data expressed as Mean Categorical Number (%) Analyze Group Differences: Continuous Variables: ANOVA, unpaired t test Categorical Variables: χ² tests

31 DEMOGRAPHIC CHARACTERISTICS Variable SR (N=163) AF (N=209) p value Age <0.001 Male <0.001 Caucasian <0.001 BMI

32 DEMOGRAPHIC CHARACTERISTICS Variable SR (N=163) AF (N=209) p value Age <0.001 Male(%) <0.001 Caucasian(%) <0.001 BMI

33 CLINICAL CHARACTERISTICS Variable SR (N=163) AF (N=209) p value HTN <0.001 IDDM NIDDM CAD OSA COPD Tobacco CHF DL <0.001

34 CLINICAL CHARACTERISTICS Variable SR (N=163) AF (N=209) p value HTN <0.001 IDDM NIDDM CAD OSA COPD Tobacco CHF DL <0.001

35 RESULTS:ECHO PARAMETERS Variable SR AF p value High LAP (%) <0.001 E/e <0.001 E <0.001 Lateral e <0.001 Septal e <0.001 LAVI <0.001 LVMI

36 RESULTS:ECHO PARAMETERS Variable SR AF p value High LAP (%) <0.001 E/e <0.001 E <0.001 Lateral e <0.001 Septal e <0.001 LAVI <0.001 LVMI

37 RESULTS:ECHO PARAMETERS Variable SR AF p value High LAP (%) <0.001 E/e <0.001 E <0.001 Lateral e <0.001 Septal e <0.001 LAVI <0.001 LVMI

38 RESULTS:ECHO PARAMETERS Variable SR AF p value High LAP (%) <0.001 E/e <0.001 E <0.001 Lateral e <0.001 Septal e <0.001 LAVI <0.001 LVMI

39 RESULTS:ECHO PARAMETERS Variable SR AF p value High LAP (%) <0.001 E/e <0.001 E <0.001 Lateral e <0.001 Septal e <0.001 LAVI <0.001 LVMI

40 RESULTS:ECHO PARAMETERS

41 CONCLUSIONS Mean LAP is higher in atrial fibrillation compared to sinus rhythm.

42 LIMITATIONS Small sample size Criteria for determining LAP in PAF Retrospective study unclear if high LAP is a cause or effect of atrial fibrillation Cannot be applied to valvular Afib

43 AREAS OF FUTURE RESEARCH Assess criteria for measuring LAP in patients with paroxysmal atrial fibrillation. Assess relation of high LAP with rate control strategy.

44 TAKE HOME MESSAGE!!!! E/e LAP E/e >=16 indicates high LAP in permanent atrial fibrillation.

45 ACKNOWLEDGEMENTS DR. ABDUL JAWWAD SAMDANI DR. KHALID QAZI DR. HENRI WOODMAN IRB STAFF STAFF AT SOCH AND CARDIOLOGY GROUP OF WNY(WHERLE OFFICE)

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