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Keywords:

  • AVPD;
  • CAD;
  • mortality;
  • prognosis

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

Abstract. Rydberg E, Erhardt L, Brand B, Willenheimer R (Malmö University Hospital, University of Lund, Malmö, Sweden). Left atrioventricular plane displacement determined by echocardiography: a clinically useful, independent predictor of mortality in patients with stable coronary artery disease. J Intern Med 2003; 254: 479–485.

Background. Echocardiographically determined left atrioventricular plane displacement (AVPD) is strongly related to prognosis in patients with chronic heart failure and in postmyocardial infarction patients. We aimed at exploring whether AVPD, unlike ejection fraction, is related to mortality in patients with stable coronary artery disease (CAD).

Methods and results. Atrioventricular plane displacement was assessed by two dimensionally guided M-mode echocardiography in the four and two chamber views, in 333 consecutive patients with stable CAD and an abnormal coronary angiogram. Patients were followed up for an average of 41 months. AVPD was lower in patients who died (n = 30, 9.0 %) compared with survivors (9.0 ± 2.2 vs. 11.5 ± 2.1 mm, P < 0.0001). Amongst patients with prior myocardial infarction (n = 184) AVPD was 8.7 ± 2.3 mm in those who died (n = 17) and 11.2 ± 2.3 mm in the survivors (P < 0.0001). In patients without prior myocardial infarction (n = 149), AVPD was 9.4 ± 2.1 (n = 13) and 11.8 ± 1.8 mm, respectively (P < 0.0001). Age, AVPD and four other echocardiographical variables correlated significantly with prognosis in univariate logistic regression analysis. In multiple logistic regression analysis only AVPD (P < 0.0001) correlated independently with mortality.

Conclusion. Echocardiographically determined AVPDis a clinically useful, independent prognostic tool in patients with stable CAD. The presence of a documented previous myocardial infarction does not influence this observation.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

Left ventricular (LV) systolic function expressed as ejection fraction (EF) is a well-known prognostic predictor in patients with congestive heart failure [1–7]. Patients with preserved systolic function have a lower mortality risk than those with clearly reduced LVEF, but their mortality risk is increased fourfold when compared with control subjects free from congestive heart failure [8]. LVEF is therefore obviously not useful for prognostication in patients with preserved or slightly depressed LV systolic function. In patients with stable coronary artery disease (CAD), the only echocardiographical method having a prognostic value is stress echocardiography [9–16].

Left atrioventricular plane displacement (AVPD) correlates well with LVEF [17–20]. Although significantly correlated [17, 18, 20], AVPD and LVEF are quite different measurements of LV systolic function. AVPD is considered to be the result of contraction of mainly the subendocardial, longitudinal fibres and LVEF is predominantly a function of contraction of subepicardial, circumferential fibres [21, 22]. AVPD is strongly related to prognosis in patients with congestive heart failure and after a myocardial infarction [23–25].

Left AVPD seems to be more sensitive to small changes in LV function than LVEF [26], possibly strengthening the prognostic value of AVPD. The fact that LVEF only reflects systolic function might also limit its prognostic value in patients with preserved or mildly decreased LV systolic function. However, AVPD is independently related to both systolic and diastolic LV performance in patients with congestive heart failure and CAD [27, 28].

The purpose of the present study was to examine the prognostic value of left AVPD at rest in patients with stable CAD.

Patients

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

The study was performed at the Department of Cardiology at Malmö University Hospital, with a primary catchment area of 250 000 inhabitants. Patients referred for elective coronary angiography with stable CAD were consecutively included between September 1995 and January 1996, and October 1996 and March 1997. Stable CAD was defined as a history of unchanged angina for 3 months. Exclusion criteria were coronary by-pass grafting and percutaneous transluminal coronary angioplasty (PTCA), within 12 months prior to this study. Patients with atrial fibrillation were also excluded as AVPD decreases with 20–30% in these patients. Patients who had no significant stenoses were excluded from all analyses. Consecutively the remaining 333 patients (age 65 ± 11 years, 243 men) who had significant stenoses at coronary angiography were included.

Echocardiographical examination

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

Two-dimensional echocardiography and Doppler examinations were performed using a Hewlett–Packard (Andover, MA, USA) Sonos 2000, or 2500 echocardiography system and a 2.5 MHz transducer. Pulsed, continuous and colour-flow Doppler examinations were performed with the same transducers. Parasternal and apical views were obtained with the patient in a left lateral recumbent position. Measurements were acquired during silent respiration or end-expiratory apnoea.

Left AVPD was determined in two dimensionally guided M-mode, in the four and two chamber views [23, 24, 28, 29]. The regional AVPD (mm) was the distance covered by the atrioventricular plane between the position most remote from the apex (corresponding to the onset of contraction) and the location closest to the apex (corresponding to the end of contraction, including any postejection shortening), i.e. the full extent of the displacement. AVPD was measured in the septal, lateral, posterior and anterior regions, and was calculated from an average of two heart cycles at each site in patients with regular rhythm and four in patients with irregular rhythm. The mean of the average displacement in the four regions was calculated and expressed as left AVPD.

In the laboratory, the mean inter-observer variability between two investigators examining each patient, immediately after one another, was 4.8% (AVPD difference range 0–1.2 mm) in a series of 53 consecutive patients with a mean AVPD of 7.8 mm (range 3.3–15.5 mm) [24]. The intra-observer variability of the determination of left AVPD was mean 2.0% (range 0–6%), corresponding to 0.23 mm (range 0–0.45 mm), in 39 randomly examined patients with a mean left AVPD of 11.2 mm (range 5.6–17.5 mm) [30]. The average AVPD in 15 controls [mean age 65 years, range 54–77 years, eight (53%) women] was 13.5 ± 1.1 mm and a mean AVPD <10.0 mm is considered abnormal [30].

Cardiac dimensions, left atrial diameter (LA), LV end diastolic diameter (LVEDD), LV posterior wall diameter (LVPWD), right ventricular internal diameter at end diastole (RVIDD) and interventricular septum diameter at end diastole (IVSD) were measured in the parasternal long axis view in two-dimensional mode [31]. Semi-quantitative grading of valvular regurgitation was based on colour Doppler signal area, continuous Doppler signal density and continuous Doppler pressure half-time (aortic regurgitation only) in the parasternal and apical views. The different degrees were: none (0), trace (0.5), mild (1), mild–moderate (1.5), moderate (2), moderate–severe (2.5) and severe (3).

Coronary angiography

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

Coronary angiography was performed in all patients within 30 days after echocardiography. The evaluation of the examinations was carried out by visual assessment, by physicians blinded to the results of the echocardiographical examination. Occlusions and significant stenoses, defined as ≥50% reduction of the coronary artery cross-sectional lumen area were registered. The most severe stenosis in each of the three vessel areas constituted the respective degree of stenosis. Left main coronary artery stenosis was classified as two-vessel disease. The angular artery was considered as a branch of the circumflex artery.

Electrocardiogram and assessment of myocardial infarction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

A patient was diagnosed to have had a myocardial infarction if this event had been validated at hospitalization and/or if the electrocardiogram showed specified signs of myocardial infarction. Electrocardiographical changes, suggestive of myocardial infarction, were assessed by standard clinical criteria based on the Minnesota code.

Follow-up

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

Patients were followed up with respect to mortality for an average of 41 months after the echocardiographical examination. All deaths in Malmö are registered in a central database. As all patients included were residents of Malmö, the mortality assessed from this database was reliable. The causes of death were established from information in the medical records and from the death certificates, and were divided into cardiac and noncardiac. Cardiac causes were congestive heart failure and myocardial infarction. The analysis of mortality data was performed blindly to the results of the determinations of AVPD.

Statistics

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

To test differences between two groups regarding continuous variables the unpaired t-test was applied and the Kruskal–Wallis test was used to compare more than two groups. Differences between groups with respect to nominal variables were tested by a chi-squared test. Correlations between a ‘yes or no’ dependent variable and nominal or continuous independent variables were examined with simple and multiple logistic regression analyses. In order to be selected for a multivariate model, independent variables showing significant correlation with the dependent variable in univariate analysis had to lack internal correlations with one another in univariate linear regression analysis. Any such correlation showing an R-value of at least 0.3 resulted in removal of the variable with the lowest chi-square value in univariate logistical regression analysis with the dependent variable. Data are expressed as mean ± SD and a P-value <0.05 was considered significant.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

All-cause mortality during the 41-month follow-up was 9.0% (n = 30). Left AVPD was significantly lower in the patients who died compared with those who survived: 9.0 ± 2.2 vs. 11.5 ± 2.1 mm, P < 0.0001. The relationship between the mean left AVPD and all-cause mortality by logistic regression analysis is shown in Fig. 1.

image

Figure 1. All-cause mortality risk plotted against atrioventricular plane displacement by logistic regression analysis. Dotted lines show 95% confidence interval.

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Mortality caused by congestive heart failure or myocardial infarction was 6.6% (n = 22) and that by noncardiac causes 2.4% (n = 8). Left AVPD was significantly lower in patients who died of cardiac causes compared with those who died of noncardiac causes; 8.3 ± 2.1 vs. 11.0 ± 0.8 mm, P = 0.0011 (Fig. 2). It was also significantly lower in the patients who died of a cardiac event compared with those who survived; 8.3 ± 2.1 vs. 11.5 ± 2.1, P < 0.0001 (Fig. 2). However, left AVPD did not differ significantly between those who died of noncardiac causes and the survivors; 11.0 ± 0.8 vs. 11.5 ± 2.1 mm (Fig 2). The same relationships were evident when patients were grouped according to one-, two- and three-vessel disease (Tables 1 and 2). The relationship between AVPD and cardiac mortality by logistic regression analysis is shown in Fig. 3. No patient with AVPD >12.5 mm (n = 97) died.

image

Figure 2. Atrioventricular plane displacement plotted in a box plot grouped into those who died by cardiac event, those who died by noncardiac cause and survivors.

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Table 1.  Left atrioventricular plane displacement in patients with one-, two- and three-vessel disease divided into survivors and patients who died of a cardiac event
 Survivors (n = 303)Nonsurvivors (n = 22)P
One-vessel disease (n = 53)12.1 ± 2.1 (n = 52)8.0 (n = 1) 
Two-vessel disease (n = 86)11.7 ± 2.1 (n = 82)8.1 ± 1.1 (n = 4)0.0016
Three-vessel disease (n = 186)11.2 ± 2.1 (n = 169)8.3 ± 2.3 (n = 17)<0.0001
Table 2.  Left atrioventricular plane displacement in patients with one-, two- and three-vessel disease, divided into survivors and patients who died of noncardiac causes
 Survivors (n = 303)Nonsurvivors (n = 8)P
One-vessel disease (n = 52)12.1 ± 2.1 (n = 52) 
Two-vessel disease (n = 87)11.7 ± 2.1 (n = 82)11.0 ± 0.5 (n = 5)0.51
Three-vessel disease (n = 172)11.2 ± 2.1 (n = 169)11.0 ± 1.3 (n = 3)0.85
image

Figure 3. Cardiac mortality risk plotted against atrioventricular plane displacement by logistic regression analysis. Dotted lines show 95% confidence interval.

Download figure to PowerPoint

Amongst patients with prior myocardial infarction (n = 184), left AVPD was 8.7 ± 2.3 in those who died (n = 17) and 11.2 ± 2.3 in the survivors (P < 0.0001). In patients without prior myocardial infarction (n = 149), left AVPD was 9.4 ± 2.1 (n = 13) and 11.8 ± 1.8, respectively (P < 0.0001).

Amongst patients with prior myocardial infarction (n = 184), left AVPD was significantly (P = 0.001) lower in those who died of a cardiac event (n = 11) compared with those who died of noncardiac causes (n = 6), as well when compared with the survivors (P < 0.0001) (Table 3). There was no difference between those who died of noncardiac causes and the survivors (P = 0.69) (Table 3). In patients without prior myocardial infarction, the same relationship was observed: patients who died of a cardiac event (n = 11) versus those who died of noncardiac causes (n = 2, P = 0.13); patients who died of a cardiac event versus survivors (n = 136, P < 0.0001); patients who died of noncardiac causes versus survivors (P = 0.80) (Table 3).

Table 3.  Left atrioventricular plane displacement in patients with and without a history of myocardial infarction, divided into survivors and nonsurvivors by cause of death
 Prior myocardial infarction (n = 184)No prior myocardial infarction (n = 149)P
Dead of a cardiac event (n = 22)7.5 ± 1.9 (n = 11)9.0 ± 2.0 (n = 11)0.08
Dead of a noncardiac event (n = 8)10.8 ± 0.9 (n = 6)11.5 ± 0.0 (n = 2)0.34
Survivors (n = 303)11.2 ± 2.3 (n = 167)11.8 ± 1.8 (n = 136)0.01

Age, LA, LVEDD, LVPWD, degree of mitral regurgitation and left AVPD correlated with prognosis in univariate logistic regression analysis (Table 4). Variables that showed a P-value of 0.05 or higher were: gender (P = 0.19), body surface (P = 0.93), peak early to atrial transmitral flow velocity (P = 0.13), RVIDD (P = 0.32), IVSD (P = 0.32), number of atherosclerotic vessels (P = 0.94) and LVEF (P = 0.06). Variables showing a P-value <0.05 in univariate logistic regression analysis were tested for inclusion in a multivariate logistic regression analysis. Because of internal correlations, LVEDD, LA and mitral regurgitation were not entered into the multivariate model. In the multiple analysis only left AVPD (P < 0.0001) correlated independently with mortality.

Table 4.  Variables correlating significantly with mortality in univariate logistic regression analysis
 POR95% lower95% upper
  1. LA, left atrial diameter at end diastole; LVEDD, left ventricular internal diameter at end diastole; LVPWD, left ventricular posterior wall diameter at end diastole; AVPD, atrioventricular plane displacement.

  2. The 95% confidence interval for lower and upper limits are given.

  3. The ORs refer to the increased mortality risk per unit of increased age (1 year), increased LA (1 mm/m2), increased LVEDD (1 mm/m2), increased LVPWD (1 mm/m2), increased degree of mitral regurgitation (1 unit) and decreased AVPD (1 mm).

Age<0.011.051.011.10
LA<0.00011.331.161.53
LVEDD<0.00011.221.111.34
LVPWD0.0041.891.222.92
Degree of mitral regurgitation<0.00013.101.755.49
Left AVPD<0.00011.641.371.98

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

Left ventricular EF at rest is related to prognosis in patients with clearly impaired LV systolic function [4–7]. However, estimating prognosis by echocardiography in patients with stable CAD is difficult, as no echocardiographical method at rest has showed any prognostic value. Only stress echocardiography was useful for prognostication in these patients [9–16]. In the present study, most of the patients were expected to have relatively well preserved LV systolic function. Indeed, the mean AVPD of all the patients was 11.3 ± 2.2 mm, corresponding roughly to an LVEF of 57 ± 12% [19]. As AVPD is sensitive to small changes in LV function and related to both systolic and diastolic LV function [26–28], it was hypothesized that AVPD at rest would differ enough between the patients, to have a prognostic value. Another reason for using AVPD is that, as most CAD patients are elderly, it is often difficult to obtain an image quality sufficient for LVEF, whereas AVPD is useful even when the image quality is poor [24]. Furthermore, AVPD is highly reproducible, and the mean AVPD is of value in assessing the prognosis in patients with heart failure [23, 24] and in postmyocardial infarction patients [25].

Despite the relatively good prognosis in the patient population, the present study showed that mortality in patients with stable CAD and an abnormal coronary angiogram was strongly related to mean left AVPD, independent of prior myocardial infarction, number of atherosclerotic coronary artery vessels and all other variables.

The high discriminative value of AVPD with regard to mortality is clearly shown by the logistic regression analyses (Figs 1 and 3). This is further underscored by the box plots (Fig. 2), indicating very little overlap with regard to AVPD, between patients who died of a cardiac cause and others. Furthermore, patients with AVPD <10 mm had a cardiac mortality of 21.2%, whereas no patients with AVPD >12.5 mm died. Left AVPD was especially, closely related to cardiac mortality, whereas patients who died of noncardiac causes showed an AVPD similar to that amongst the survivors.

Probably, the reason that AVPD is so sensitive to prognosis in these patients is that, as opposed to LVEF, left AVPD seems to be a marker of left ventricular dysfunction even in patients with mild CAD [27]. In patients with CAD, LV dysfunction may depend on several factors such as myocardial infarction, chronic ischaemia causing development of fibrosis, recurrent episodes of myocardial ischaemia causing myocardial stunning and continuously reduced myocardial blood flow leading to hibernating myocardium [32–35]. Probably, AVPD is related to all these factors. The subendocardial region is more prone to develop ischaemia and hibernation than the subepicardium and as AVPD reflects the functional status of subendocardial fibres, it is more likely to be decreased already by mild CAD, which may not be the case for LVEF. This may also be a possible explanation as to why AVPD was useful for prognostication in patients without prior myocardial infarction. Thus, AVPD may be decreased in patients with ischaemic, stunned or hibernating myocardium and who have not had a clinical infarction. Such patients may have a worse prognosis than those with a less affected myocardium.

In simple logistic regression analysis, not only left AVPD but also age, LA, LVEDD, LVPWD and degree of mitral regurgitation showed significant correlations with mortality. Thus, several variables commonly related to mortality were included in the analyses. Nevertheless, in multivariate analysis, left AVPD was the only variable independently correlated with mortality (P < 0.0001). This clearly indicates a high prognostic value of AVPD in patients with stable CAD.

Study limitations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

Medication was not taken into consideration, as this was not recorded as part of the investigation. However, it is believed that this does not change the fact that AVPD is a strong prognostic marker in these patients.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References

Left AVPD is a powerful clinical tool for assessment of mortality risk in patients with stable CAD, independent of a history of myocardial infarction, degree of CAD and all other variables tested in the present study. As AVPD is highly reproducible, and easily and readily assessed in all patients, it has an advantage compared with other prognostic methods. AVPD is recommend as a prognostic tool in patients with stable CAD.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Patients
  6. Echocardiographical examination
  7. Coronary angiography
  8. Electrocardiogram and assessment of myocardial infarction
  9. Follow-up
  10. Statistics
  11. Results
  12. Discussion
  13. Study limitations
  14. Conclusion
  15. Conflict of interest statement
  16. References
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