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Hemodynamic chameleons: a paired echocardiographic analysis of diastolic function in sinus Rhythm versus atrial Fibrillation
Session:
Sessão de Comunicações Orais 10 – Estratificação de risco guiada por imagem em situações cardíacas complexas
Speaker:
Luís Cotrim
Congress:
CPC 2026
Topic:
B. Imaging
Theme:
03. Imaging
Subtheme:
03.1 Echocardiography
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Luís Cotrim; Lígia Mendes
Abstract
<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">Background and Aim:</span></span></span></strong></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">Current echocardiographic guidelines are derived from patients in sinus rhythm (SR), creating uncertainty regarding their applicability in atrial fibrillation (AF). This study aimed to bridge this knowledge gap by performing a systematic, paired comparison of diastolic parameters obtained during SR versus AF episodes within the same patient cohort.</span></span></span></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">Methods:</span></span></span></strong></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">It is a retrospective, single-center, within-subject cohort study of 97 patients with persistent AF. Each participant served as their own control, having undergone transthoracic echocardiography in both SR and AF. The primary endpoint was the absolute difference in the E/e' ratio. Secondary endpoints included Left Atrial Volume index (LAVi), LV Ejection Fraction (LVEF), and tissue Doppler velocities (e'). Paired statistical tests were used to assess differences. Benjamini-Hochberg was applied to control the false discovery rate (FDR) at 5% for multiple comparisons across secondary endpoints. Additionally, exploratory multivariable linear regression was used to assess if baseline clinical characteristics (age, sex, hypertension, diabetes, dyslipidemia) predicted the magnitude of change (</span></span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">D</span></span></span><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">) in endpoints.</span></span></span></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">Results:</span></span></span></strong></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">The cohort had a mean age of 75.3 </span></span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">±</span></span></span><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">9.9 years and was predominantly male (63.9%), with a high prevalence of hypertension (77.8%).</span></span></span></span></span></p> <ul> <li style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f">Primary Endpoint:</span></span></span></strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f"> There was no statistically significant difference in the E/e' ratio between rhythms (SR: 9.33</span></span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">±</span></span></span><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f"> 3.22 vs. AF: 9.64 </span></span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">±</span></span></span> <span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f">3.32; mean difference: 0.31; p = 0.12), with a negligible effect size (Cohen's d = 0.106).</span></span></span></span></span></li> <li style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f">Secondary Endpoints:</span></span></span></strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f"> LAVi increased significantly during AF (SR: 48.75 vs. AF: 58.19 mL/m<sup>2</sup>; p < 0.001), representing a medium effect size. LVEF showed a small but significant decrease during AF (SR: 59.7% vs. AF: 57.4%; p = 0.01). Both septal and lateral e' velocities increased significantly during AF (p < 0.001 for both). Figure 1</span></span></span></span></span></li> <li style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f">Exploratory Analysis:</span></span></span></strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f"> The magnitude of rhythm-related changes </span></span></span><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">(</span></span></span><span style="font-size:10.0pt"><span style="font-family:Symbol"><span style="color:black">D</span></span></span><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">) </span></span></span><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:#1f1f1f">in hemodynamic parameters was independent of baseline clinical profiles; age, sex, and cardiovascular risk factors were not significant predictors of the observed shifts in E/e', LAVi, or tissue velocities.</span></span></span></span></span></li> </ul> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><strong><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">Conclusion:</span></span></span></strong></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Aptos,sans-serif"><span style="font-size:10.0pt"><span style="font-family:"Arial",sans-serif"><span style="color:black">In this paired analysis, the E/e' ratio showed remarkable stability across rhythm states. However, this stability challenges the validity of the parameter in AF, where elevated natriuretic peptides suggest persistently high wall stress. The study further revealed that AF drives acute LA remodeling and increases mitral annular velocities (e') — changes driven by altered loading conditions rather than intrinsic myocardial properties. Crucially, these shifts were not predicted by age or comorbidities, indicating they are obligate consequences of the rhythm itself. These findings suggest that the hemodynamic footprint of the arrhythmia itself distorts standard parameters, necessitating a departure from SR-derived guidelines.</span></span></span></span></span></p>
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