Heart Institute (InCor) - University of Sao Paulo Medical School, Sao Paulo, Brazil

1. Variables No events (n = 925) Events (n = 56) Univariate Multivariate Left atrial diameter (mm) 3.8±0.6 4.2±0.7* Variables RR (95% CI) p Value RR (95% CI) p Value Age (years) Left atrial volume (mL) 53.5±18.2 68.3±25.9* 1.01 (0.99 – 1.04) 0.2475 NS Male sex 2.11 (1.18 – 3.78) 0.0114 LADI (mm/m2) 2.17±0.36 2.36±0.39* Hyperlipidemia 0.83 (0.49 – 1.41) 0.4946 Hypertension 1.84 (0.93 – 3.66) 0.0795 LAVI (mL/m2) 30.25±10.71 38.42±15.93* Diabetes mellitus 1.86 (1.09 – 3.18) 0.0235 NS LVEF (%) 58.7±12.9 47.9±16.9* Previous CABG 1.29 (0.63 – 2.64) 0.4837 Previous PCI 0.89 (0.42 – 1.87) 0.7502 Dobutamine dose (µg/Kg/min) 33±7 32±7 Previous MI 1.72 (1.01 – 2.95) 0.0497 NS Atropine dose (mg) 1.0±0.6 0.9±0.6 AI Therapy 0.87 (0.49 – 1.51) 0.6104 ACE inhibitors 1.27 (0.75 – 2.17) 0.3662 Statins 0.81 (0.45 – 1.44) 0.4739 Aspirin 0.91 (0.53 – 1.54) 0.7134 LVEF (%) 0.96 (0.94 – 0.97) 0.0001 0.98 (0.95 – 1.00) 0.0348 LA Diameter (mm) 2.45 (1.72 – 3.50) 0.0001 NS LADI (mm/m2) 3.36 (1.78 – 6.32) 0.0002 NS LA volume (mL) 1.02 (1.01 – 1.03) 0.0001 NS LAVI (mL/m2) 1.03 (1.02 – 1.05) 0.0001 1.04 (1.02 – 1.05) 0.0001 Abnormal DSE 4.09 (2.35 – 7.11) 0.0001 2.70 (1.28 – 5.69) 0.0093 Incremental Prognostic Value of Left Atrial Volume over Dobutamine Stress Echocardiography Results in Patients with Known or Suspected Coronary Artery Disease Jeane M. Tsutsui, Paulo M. M. Dourado, Abdou Elhendy, Sandra N. R. S. Falcão, Antônio C. P. Chagas, Protásio L. da Luz, José A. F. Ramires, Wilson Mathias Jr. Heart Institute (InCor) - University of Sao Paulo Medical School, Sao Paulo, Brazil INTRODUCTION RESULTS METHODS Table 2. Predictors of death or nonfatal myocardial infarction • We studied 1219 consecutive patients from our institutional databank who were referred for DSE because of known or suspected CAD. • Exclusion criteria were: age less than 18 years, nondiagnostic DSE due to chronotropic incompetence or intolerable side effects, treatment with pacemaker implantation, hypertrophic cardiomyopathy, severe valvular disease, and resting two-dimensional images not appropriate for retrospective off-line measurements of left atrial size. • Parameters of left atrial size were left atrial antero-posterior diameter, left atrial volume, left atrial diameter indexed by body surface area (LADI), and left atrial volume indexed by body surface area to obtain LAVI. • LAVI was defined as normal when it was ≤28 mL/m2, mildly abnormal when it was 29-33 mL/m2, moderately abnormal when it was 34-39 mL/m2, and severely abnormal when it was ≥40 mL/m2 . • All patients underwent DSE with early injection of atropine protocol. • Statistical Analysis were performed as appropriated. A p value <0.05 was considered significant. • Echodopplercardiographic characteristics in the total population are described in Table 1. • By univariate analysis, predictors of death or nonfatal myocardial infarction were male sex (p=0.0114), Diabetes Melitus (p=0.0235), Previous MI (p=0.0497), LA Diameter (p=0.0001), LADI (p= 0.0002) and LA volume(p=0.0001) and by multivariate analysis were LVEF (p=0.0348), LAVI (p=0.001) and abnormal DSE (p=0.0093) (Table 2). Dobutamine stress echocardiography (DSE) is a widely used technique for diagnosis and prognostic evaluation of patients with known or suspected coronary artery disease (CAD). Manifestations of myocardial ischemia includes diastolic dysfunction, which may result in chronic pressure burden to left atrium. Left atrial volume indexed (LAVI) has been reported as a predictor of cardiovascular events. The long-term prognostic value of left atrial volume measurements in patients who underwent DSE is unknown. Table 1. Echocardiographic characteristics of patients with and without future events OBJECTIVE To determine the incremental value of LAVI over dobutamine stress echocardiography (DSE) for predicting the outcome of patients with known or suspected coronary artery disease (CAD). CONCLUSIONS LAVI provides incremental prognostic information over DSE in patients with known or suspected CAD for predicting death and nonfatal myocardial infarction. Among patients with normal DSE, those with larger LAVI had worse outcome and among patients with abnormal DSE LAVI was still predictive. Abnormal DSE 293 (32%) 37 (66%)* Inducible ischemia 149 (16%) 28 (50%)* Figure 2. Kaplan-Meier curves of patients with LAVI. The differences between LAVI ≤28 mL/m2 and 29-33 mL/m2 versus LAVI 34-39 mL/m2 and ≥40 mL/m2 curves are statistically significant (p = 0.001). Figure 1. Classification of left atrial size according LAVI (solid bars) and LADI (open bars), with p<0.001. Data are mean±SD and number (%) of patients. *p<0.05 by log-rank test.