Stroke Prevention in Atrial Fibrillation – The Unmet Need and Morbidity Burden

2011 ◽  
Vol 7 (3) ◽  
pp. 187 ◽  
Author(s):  
A John Camm ◽  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Left Atrial ◽  
Unmet Need ◽  
Left Ventricular ◽  
Risk Category ◽  
Intermediate Risk ◽  
Thromboembolic Complications ◽  
Thromboembolic Stroke ◽  
Age Related

Atrial fibrillation (AF) occurs in epidemic proportion and is now recognised to occur in about 2 % of the general population. Its prevalence is age-related – about 10 % of 80-year-olds have this arrhythmia with hypertension, valvular disease and heart failure being the most frequent underlying conditions. Up to 10 % of cases of AF may be idiopathic, although genetic, autonomic, inflammatory, infective and toxic causes may account for many of these. AF is associated with serious consequences of which death, sudden death, stroke, heart failure, pulmonary disease and hospitalisation are the most serious. Thromboembolic stroke occurs in about 5 % of AF patients each year, which is approximately five-fold the stroke rate in age and gender-matched patients without AF. AF-related thromboembolic stroke accounts for 15–20 % of all strokes. Risk factors for thromboembolic stroke include clinical factors (such as age, female gender, diabetes, heart failure, hypertension, renal failure and arterial disease), elevated levels of biomarkers (such as troponin, B-type natriuretic peptide, C-reactive protein and micro-albuminuria) and echocardiographic features (such as left ventricular systolic dysfunction, increased left atrial size, left atrial ‘smoke’ and thrombus). There are several clinical risk stratification schemes used to identify AF patients at high risk of thromboembolic stroke. The CHADS2 scheme is popular, but tends to group a high proportion of patients in low and intermediate risk categories. The recently introduced CHA2DS2-VASc scheme identifies truly low-risk patients and avoids placing more than a small proportion in a low or intermediate risk category where there is a guideline mandated choice between anticoagulant, antiplatelet or no therapy. This scheme, which is well validated, has been recommended by the European Society of Cardiology in anticipation of the introduction of new and safer oral anticoagulants. Although warfarin is an effective therapy for the prevention of thromboembolic complications of AF it is inadequately used because of fear of haemorrhagic complications and the difficulties associated with monitoring and maintenance of the correct level of anticoagulation. At present, as few as 20 % of patients who should be anticoagulated are effectively treated. New anticoagulant therapies, which are much easier to use, coupled with more attention to the indications for anticoagulation, should result in more effective anticoagulation and a major reduction in the thromboembolic complications associated with AF.

P1766Clinical impact of atrial fibrillation and heart failure in a cohort of patients with hypertrophic cardiomyopathy

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
I Esteve Ruiz ◽  
H Llamas Gomez ◽  
I M Esteve Ruiz ◽  
M J Romero Reyes ◽  
R Pavon Jimenez ◽  
...  
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Hypertrophic Cardiomyopathy ◽  
Left Atrial ◽  
Left Ventricular ◽  
Left Atrial Diameter ◽  
Myocardial Thickness ◽  
Worse Prognosis ◽  
Echocardiographic Findings

Abstract Background Atrial fibrillation (AF) and heart failure (HF) are common complications in Hypertrophic Cardiomyopathy (HCM) patients, leading to a worsening of their quality of life, need of hospitalization and prognosis. Purpose To analyze clinical variables associated with the presence of AF and HF in HCM patients. Methods HCM patients followed-up in cardiological visits from 2005 to 2017 were included and a descriptive analysis of those with AF and HF was performed. Results Out of 168 patients, 28% had reported AF. They were older than those without arrhythmia (68±15 years (yrs) vs 56±20 yrs, p<0.001) and had more comorbidities such as diabetes (27.7% vs 12.4%, p=0.02) and chronic renal disease (21.3% vs 6.6%, p=0.006). Echocardiographic findings are summarized in Table 1. In our cohort, 27.4% of the patients had HF with a functional class according to the New York Heart Association criteria ≥2. They were older than those without HF (69.3±11.6 yrs vs 55.9±20.6 yrs, p<0.001) and had higher rate of cardiovascular (CV) risk factors such as hypertension (65.2% vs 44.3%, p=0.015). The presence of HF was directly associated with the presence of AF: 52.2% of the patients with HF and 18.9% of the patients without HF developed this arrhythmia (p<0.001). HF patients associated larger left atrial diameter (48±8.1 vs 41.6±7.2mm, p<0.001), myocardial thickness (21.7±3.9 vs 19.2±5.8mm, p=0.002) and higher left ventricular outflow obstruction (LVOO) (55±32 vs 34.3±31.3mmHg, p=0.021), without any differences in the left ventricular ejection fraction. HF patients had a worse prognosis (Picture 1). Multivariate analysis showed that the presence of AF (OR 2.6, CI 95% 1.1–6.3) and LVOO (OR 4.8, CI 95% 1.5–14.8) were independent risk factors of developing HF. Table 1. Echocardiographic findings AF (n=47) Non AF (n=121) p LVOO 27.7 19 0.22 Aortic regurgitation 12.8 3.3 0.02 Mitral regurgitation 27.7 12.4 0.02 Left atrial diameter (mm) 48.8±7.2 40.7±7 <0.001 Myocardial thickness (mm) 20±5.4 19±5.2 0.02 Qualitative variables are expressed as percentages (%) and quantitative variables as mean and standard deviation (M ± SD). Picture 1. Main outcomes of HF patients Conclusions AF and HF were directly associated in our cohort, especially in elderly patients with higher comorbidities, leading to a worse prognosis with a higher hospitalization rate and CV death. This emphasizes the importance of a thorough search of both complications in order to initiate early treatment and improve the prognosis of HCM patients.

scholarly journals Game changer? A sporting indication to implant a left atrial appendage closure device in a rugby player with atrial fibrillation: a case report

2020 ◽  
Vol 4 (1) ◽  
pp. 1-5
Author(s):  
Andre Briosa e Gala ◽  
Andrew Cox ◽  
Michael Pope ◽  
Timothy Betts
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Left Ventricular ◽  
Atrial Appendage ◽  
Rugby Player ◽  
Management Options ◽  
Left Atrial Appendage Occlusion ◽  
Occlusion Device

Abstract Background Caring for athletes with cardiac disease requires an approach that caters to the specific needs of the athlete. Case summary A 27-year-old professional rugby player was admitted with decompensated heart failure and atrial fibrillation (AF). Transthoracic echocardiogram showed features in keeping with a dilated cardiomyopathy with severe left ventricular (LV) systolic impairment. He made good progress on evidence-based heart failure medication and his LV systolic function returned to normal. He failed to maintain sinus rhythm with cardioversion and remained in persistent AF. He then suffered a transient ischaemic attack despite appropriate anticoagulation. At 1-year follow-up, he was asymptomatic and against medical advice continued to play competitive rugby whilst taking rivaroxaban. He subsequently underwent implantation with a percutaneous left atrial appendage occlusion device, allowing him to discontinue anticoagulation, reduce his bleeding risk and resume his career, whilst simultaneously lowering the thromboembolic risk. Discussion Counselling should include different management options aimed at minimizing the risks to athletes if they to return to competitive sports. Left atrial appendage occlusion devices are a suitable AF-related stroke prevention strategy in athletes competing in full-contact sports.

Abstract 17226: Increased Risk of Heart Failure Associated With Left Atrial Remodeling Without Known Atrial Fibrillation

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Jodi Edwards ◽  
Jiming Fang ◽  
Jeff S Healey ◽  
Kathy Yip ◽  
Lisa Mielniczuk ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Left Atrial ◽  
Left Ventricular ◽  
Administrative Databases ◽  
Risk Scores ◽  
Atrial Remodeling ◽  
Left Atrial Remodeling ◽  
Lv Dysfunction ◽  
Increased Risk

Background: Atrial fibrillation (AF) significantly increases risk for heart failure (HF) and independently increases mortality and adverse in-hospital outcomes in HF patients. Validated clinical risk scores (ARC2H) can predict HF in patients with AF, but are limited in application as AF is frequently clinically silent or undetected. However, AF may be preceded by significant preclinical remodeling (left atrial enlargement (LAE) or excessive atrial ectopy (EAE)). Whether LAE and EAE are associated with HF prior to AF is unclear. Method(s): We analyzed consecutive adults >65 years with outpatient echocardiography or Holter at 11 Ontario community cardiology clinics (2010-2017). Exclusions were history of AF, anticoagulation, pacemaker/ICD/ILR, and prosthetic valve. Using linked administrative databases, we assessed 5-year rates of HF (primary) and incident AF and death (secondary) associated with LAE and EAE and among subgroups (M vs. F; <75 vs. >75; CHADS-VASC 0-2 vs. 3-6). Competing risks cox proportional hazards estimated adjusted hazard of HF for severe LAE: >47mm (M);>52mm (F)) or increased APBs/hour (EAE: >30) or both LAE and EAE, adjusting for age, vascular comorbidities and left ventricular (LV) dysfunction. Results: In 28,261 adults (mean 73+/-6 years), direct age-adjusted survival was reduced for those with severe LAE and EAE. 5-year rates of HF were increased for severe (8.8%) vs. moderate (3.5%) and mild (1.4%) LAE and for those with excessive (3.8%) vs. normal (2.5%) ectopy. For both LAE and EAE, those >75 and with a CHADS score 3-6 showed marked increases in HF at 5 years compared to <75 (LAE: 10.6% vs. 7.9%; EAE: 4.3% vs. 1.9%) and CHADS score 0-2 (LAE:21.4% vs. 6.6%; EAE: 8.9% vs. 2.4%). Severe LAE increased hazard of HF 2-fold (HR=2.07; p<.0001), and incident AF over 3-fold (HR= 3.43; p<.0001) and EAE increased hazard of HF (HR=1.31; p<.0001) and incident AF (HR=1.13; p<.0001). Those with both LAE and EAE showed an over 3-fold increased hazard of HF (HR=3.28; p<.0014). Conclusions: Severe LAE and EAE without known AF are associated with increased risk of HF and AF after adjusting for LV dysfunction, particularly for those >75 and with high vascular burden. These data have implications for risk stratification, AF screening, and trials for HF prevention in individuals with left atrial remodeling.

1227 Risk stratification of patients with asymptomatic moderate mitral regurgitation: the prognostic value of left atrial strain

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
M Cameli ◽  
M C Pastore ◽  
F M Righini ◽  
G E Mandoli ◽  
F D"ascenzi ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Mitral Regurgitation ◽  
Risk Stratification ◽  
Left Atrial ◽  
Longitudinal Strain ◽  
Left Ventricular ◽  
Event Free Survival ◽  
Free Survival

Abstract Background In asymptomatic moderate mitral regurgitation (MR), the criteria for risk stratification are still uncertain. Therefore, in these patients, optimal time of surgery remains controversial. Purpose Our aim was to compare left atrial (LA) strain to other echocardiographic parameters for the prediction of cardiovascular (CV) events in patients with asymptomatic moderate MR. Methods 401 patients with primary degenerative asymptomatic moderate MR was enrolled and prospectively followed for the development of CV events (i.e. atrial fibrillation, stroke/transient ischemic attack, acute heart failure, CV death). Patients with history of atrial fibrillation, myocardial infarction, heart failure, cardiac surgery or heart transplantation, severe MR, mitral valve surgery during follow-up were excluded. Results During a mean follow up of 3.4 ± 2 years, of the 326 patients eligible (mean age 65 ± 9 years), 122 patients had 149 new events. There were no significative differences in mean age and sex, clinical and therapeutic characteristics between the two groups. The event-group presented reduced global peak atrial longitudinal strain (PALS), LA emptying fraction, LV strain at baseline, and larger LA volume indexed (p &lt;0.0001). Receiver operating characteristics curves proved the greatest predictive performance for global PALS &lt; 35% (AUC 0.88). Bland-Altman analysis demonstrated good intra- and inter-observer agreement and Kaplan Meier analysis showed a graded association between PALS and event-free-survival. Conclusions Speckle tracking echocardiography could provide a useful index, global PALS, to estimate LA function in patients with asymptomatic moderate MR in order to optimize surgical timing before the development of irreversible myocardial dysfunction. Echo-data of our study population Variable No CV events (n = 204) CV events (n = 122) LV ejection fraction (%) 59 ± 9 58 ± 10 LV global longitudinal strain (%) - 18.5 ± 3.4 -17.6 ± 3.6* LA volume indexed (ml/m2) 32.5 ± 6.7 36.4 ± 7.1* LA emptying fraction (%) 68 ± 13 62 ± 15* Mitral E/A ratio 0.94 ± 0.14 0.95 ± 0.16 Mitral E/E’ ratio 11.2 ± 6.5 12.4 ± 7.1 Mitral regurgitant fraction (%) 38.9 ± 8.1 39.1 ± 9.4 End regurgitation orifice area (cm2) 0.34 ± 0.05 0.34 ± 0.06 Global PALS (%) 32.5 ± 8.5 19.7 ± 8.1* *Significative variation between groups. Cardiovascular, CV; Left atrial, LA; Left ventricular, LV; Peak atrial longitudinal strain, PALS Abstract 1227 Figure. Event-free survival according to PALS

Atrial fibrillation is not associated with altered left atrial microRNA expression profile in ischemic end-stage human heart failure

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Ruppert ◽  
B Agg ◽  
A.A Sayour ◽  
S.Z Kugler ◽  
P Perge ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Mrna Expression ◽  
Mirna Expression ◽  
Left Atrial ◽  
Interstitial Fibrosis ◽  
Left Ventricular ◽  
Funding Source ◽  
Human Heart Failure ◽  
End Stage

Abstract Introduction In patients with chronic heart failure (CHF) left ventricular dysfunction results in elevated left atrial (LA) pressure, triggering pathological atrial remodelling and atrial fibrillation (AF). Nevertheless, it has been reported that some patients with CHF remain in sinus rhythm (SR) despite of the pathological structural alterations (e.g. dilation and fibrosis) of the LA. Of particular interest, data is scarce regarding the molecular explanation for the observed variability in AF development among CHF patients. Recent studies have indicated that alterations in microRNA (miRNA) expression might contribute to the pathogenesis of AF. However, the majority of previous studies focusing on miRNA expression compared healthy LA with SR to pathologically remodelled, dilated LA with AF. Consequently, whether dysregulation of miRNA expression directly contribute to AF and not only to pathological LA remodelling has not been tested before. Purpose The present study aimed to investigate miRNA expression in comparably remodelled LA from end-stage CHF patients with permanent AF (CHF-AF) or SR (CHF-SR). Methods LA samples were collected from male, non-diabetic, ischemic end-stage CHF patients undergoing heart transplantation (n=24). Patients were carefully selected to avoid any differences in age (55±2 vs. 54±2 years, CHF-AF vs. CHF-SR, n.s.), ejection fraction ([EF]: 22.5±1.8 vs. 23.3±2.5%, CHF-AF vs. CHF-SR, n.s.) LA diameters (longitudinal LA diameter: 56±4 vs. 48±5mm.; CHF-AF vs. CHF-SR, n.s.; horizontal LA diameter: 61±2 vs. 54±3, CHF-AF vs. CHF-SR, n.s.) and NYHA stage. As a molecular marker of atrial load, the mRNA expression of atrial natriuretic peptide (ANP) was measured with qRT-PCR. The extent of left atrial fibrosis was assessed on picrosirius red stained histological sections. Global LA miRNA expression profiling (including the measurement of 800 human miRNA) was carried out using a commercially available kit. Results LA mRNA expression of ANP was comparable between the AF-CHF and the SR-CHF groups, suggesting that atrial load occurred to the same level in the two experimental groups. Furthermore, no differences could be observed in the extent of atrial collagen content between the AF-CHF and the SR-CHF groups (collagen area: 20.3±1.3% vs. 23.9±3.1%, n.s.), providing evidence that fibrotic remodelling had occurred to a similar magnitude. The high-throughput miRNA measurement revealed no differences in atrial miRNA expression between the two study groups. Conclusion The present study provides evidence for the first time that AF is not associated with different LA miRNA expression in end-stage CHF patients with comparable level of LA dilatation, ANP expression (atrial load) and interstitial fibrosis. Based on these findings, the potential of miRNA-based therapeutic interventions might be limited in AF patients with ischemic end-stage CHF. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): NVKP_16-1-2016-0017

Left atrial fibrosis predicts left ventricular ejection fraction response after atrial fibrillation ablation in heart failure patients: the Fibrosis-HF Study

EP Europace ◽  
2020 ◽  
Vol 22 (12) ◽  
pp. 1812-1821
Author(s):  
Bettina Kirstein ◽  
Sebastian Neudeck ◽  
Thomas Gaspar ◽  
Judith Piorkowski ◽  
Simon Wechselberger ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ejection Fraction ◽  
Left Atrial ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Atrial Fibrosis ◽  
Ventricular Ejection Fraction ◽  
Af Ablation ◽  
Left Atrial Fibrosis

Abstract Aims Atrial fibrillation (AF) and heart failure (HF) often coexist. Catheter ablation has been reported to restore left ventricular (LV) function but patients benefit differently. This study investigated the correlation between left atrial (LA) fibrosis extent and LV ejection fraction (LVEF) recovery after AF ablation. Methods and results In this study, 103 patients [64 years, 69% men, 79% persistent AF, LVEF 33% interquartile range (IQR) (25–38)] undergoing first time AF ablation were investigated. Identification of LA fibrosis and selection of ablation strategy were based on sinus rhythm voltage mapping. Continuous rhythm monitoring was used to assess ablation success. Improvement in post-ablation LVEF was measured as primary study endpoint. An absolute increase in post-ablation LVEF ≥10% was defined as ‘Super Response’. Left atrial fibrosis was present in 38% of patients. After ablation LVEF increased by absolute 15% (IQR 6–25) (P &lt; 0.001). Left ventricular ejection fraction improvement was higher in patients without LA fibrosis [15% (IQR 10–25) vs. 10% (IQR 0–20), P &lt; 0.001]. An inverse correlation between LVEF improvement and the extent of LA fibrosis was found (R2 = 0.931). In multivariate analysis, the presence of LA fibrosis was the only independent predictor for failing LVEF improvement [odds ratio 7.2 (95% confidence interval 2.2–23.4), P &lt; 0.001]. Echocardiographic ‘Super Response’ was observed in 55/64 (86%) patients without and 21/39 (54%) patients with LA fibrosis, respectively (P &lt; 0.001). Conclusion Presence and extent of LA fibrosis predict LVEF response in HF patients undergoing AF ablation. The assessment of LA fibrosis may impact prognostic stratification and clinical management in HF patients with AF.

Abstract 15065: Impact of Ablation Strategy on Left Ventricular Function Following Catheter Ablation in Patients With Long-standing Persistent Atrial Fibrillation and Heart Failure: Results From a Single-center Study

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sanghamitra Mohanty ◽  
CHINTAN G TRIVEDI ◽  
Faiz Baqai ◽  
Domenico G Della Rocca ◽  
Carola Gianni ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Left Atrial ◽  
Persistent Atrial Fibrillation ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Group 2 ◽  
Group 1

Background: Ablation strategy for long-standing persistent atrial fibrillation (LSPAF) is highly variable with diverse outcomes. Objective: We evaluated the change in left ventricular ejection fraction (LVEF) with different ablation approaches in LSPAF patients with heart failure (HF). Methods: Consecutive LSPAF patients with HF (LVEF <40%) undergoing their first catheter ablation at our center were included in the analysis. Based on the ablation strategy determined by the operators, patients were classified into two groups; group 1: received standard ablation (PV isolation+ isolation of left atrial posterior wall and superior vena cava) and group 2: standard ablation plus isolation of coronary sinus (CS) and left atrial appendage (LAA). High-dose isoproterenol challenge (20-30 μg for 10-15 min) was utilized to reveal LAA and CS triggers; electrical isolation was the procedural endpoint for LAA and CS ablation. If PVs were electrically silent due to presence of severe scar, LAA and CS were empirically isolated even in the absence of detectable triggers. LVEF was measured by transesophageal echocardiogram (TEE) performed at baseline and 6 months post-ablation. Patients were monitored for arrhythmia-recurrence off-antiarrhythmic drugs (AAD) as per our standard protocol. Results: Group 1 included 52 patients and group 2 had 106. Baseline characteristics were comparable across groups (age: 66.2 ± 7.3 and 64.4 ± 9.4; male: 41 (78.8%) and 87 (82.1%); BMI: 32.3 ± 6.8 and 30.4 ± 6.4 in group 1 and 2). Mean baseline LVEF (%) was 36.2±5.5 and 35.1±8.3 in group 1 and 2 respectively (p=NS). At the 6-month TEE, mean LVEF was significantly higher than the baseline value in group 2 (47.7±11 vs 35.1±8.3, p<0.001), whereas in group 1, although there was a positive trend, the change was statistically non-significant (39.4±10 vs. 36.2±5.5, p=0.36). A total of 7 (13.5%) patients from group 1 and 89 (84%) from group 2 were arrhythmia-free off-AAD at 1.5 year of follow-up (p<0.001). Conclusion: In our study population, ablation strategy including LAA and CS isolation along with the standard ablation resulted in significant improvement in the LVEF as well as higher rate of arrhythmia-free survival.

scholarly journals Left Atrioventricular Coupling Index as a Prognostic Marker of Cardiovascular Events: The MESA Study

Hypertension ◽  
2021 ◽  
Author(s):  
Theo Pezel ◽  
Bharath Ambale Venkatesh ◽  
Henrique Doria De Vasconcellos ◽  
Yoko Kato ◽  
Mahsima Shabani ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Cardiovascular Disease ◽  
Coronary Heart Disease ◽  
Heart Disease ◽  
Left Atrial ◽  
Cardiovascular Events ◽  
Left Ventricular ◽  
Hazard Ratio ◽  
Coronary Heart Disease Death

Both left atrial and left ventricular functional parameters influence the prognosis of patients with cardiovascular diseases. This study aimed to investigate the prognostic value of a novel left atrioventricular coupling index (LACI) in a population without history of cardiovascular diseases at baseline. Participants of the Multi-Ethnic Study of Atherosclerosis who underwent a baseline cardiovascular magnetic resonance study were analyzed. LACI was defined by the ratio of the left atrial end-diastolic volume divided by the left ventricular end-diastolic volume. Cox proportional hazard models were used to evaluate the association between LACI and atrial fibrillation, heart failure, coronary heart disease death, and hard cardiovascular disease defined by myocardial infarction, resuscitated cardiac arrest, fatal and nonfatal stroke, or coronary heart disease death. Among the 4124 participants (61.5±10.1 years, 47.4% men), 1074 cardiovascular events were observed (mean follow-up, 13.0±3.2 years). Greater LACI was independently associated with atrial fibrillation (hazard ratio, 1.86 [95% CI, 1.69–2.04]), heart failure (hazard ratio, 1.50 [95% CI, 1.38–1.62]), hard cardiovascular disease (1.23 [95% CI, 1.13–1.34]), and coronary heart disease death (hazard ratio, 1.29 [95% CI, 1.15–1.45]; all P <0.0001). After adjustment for traditional cardiovascular risk factors, LACI showed significant improvement in model discrimination and reclassification compared with currently used standard models to predict outcomes. LACI is a strong predictor for the incidence of heart failure, atrial fibrillation, hard cardiovascular disease, and coronary heart disease death. LACI has incremental prognostic value to predict cardiovascular events over traditional risk factors and better discrimination and reclassification power compared with individual left atrial or left ventricular parameters.

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