In severe rheumatic mitral stenosis with sinus rhythm, left atrial appendage (LAA) dysfunction increases thromboembolic risk, yet clinical guidelines provide no recommendations, and its assessment via transesophageal echocardiography is not feasible for routine or repeated use. This study assessed whether left atrial (LA) strain imaging could noninvasively predict LAA contractile dysfunction.
We prospectively enrolled 138 patients with severe rheumatic MS in sinus rhythm who underwent transthoracic and transesophageal echocardiography. LAA inactivity was defined as LAA emptying velocity <25 cm/s. LA reservoir (LASr), conduit, and contractile strain were quantified using speckle-tracking echocardiography. Multivariable logistic regression and receiver-operating characteristic (ROC) analyses were performed to evaluate predictors of LAA inactivity. LAA inactivity was observed in 108 patients (78.2%), and LAA thrombus was detected in 8 patients (5.8%)—all in sinus rhythm. In multivariate analysis, LASr was the strongest independent predictor of LAA inactivity (OR 0.61 per 1% increase; 95% CI: 0.50–0.75; p < 0.0001). LASr yielded an AUC of 0.950 (95% CI: 0.911-0.989), with a threshold of ≤22.95% showing a sensitivity of 93.5%, and specificity of 90% for predicting LAA inactivity. Impaired LA strain identified patients with elevated fibrinogen, D-dimer, and the presence of LAA thrombus.
LA strain imaging provides a robust noninvasive predictor of LAA dysfunction in severe rheumatic MS patients in sinus rhythm. These findings support the potential clinical utility of LA strain in improving risk stratification and guiding anticoagulation decisions in this under-recognized high-risk population.
J. Yusuf, Gaurav Sharma, Ankit Bansal et al.· European Heart Journal Open· 0 citations
The optimal duration of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) continues to evolve, but current recommendations derived largely from Western data may not reflect the clinical profile of Indian patients, underscoring the need for region-specific guidance.
To develop consensus-based, India-specific recommendations on DAPT duration in ACS by integrating global evidence with real-world clinical considerations.
A modified Delphi process was conducted among experienced interventional cardiologists across India. Participants reviewed evidence summaries and anonymously rated ten statements on prolonged, shortened, and risk-stratified DAPT strategies. Consensus was defined as ≥75% agreement.
All 34 cardiologists completed the survey (100% response). Consensus (≥≥70%) was achieved for all statements. Strong agreement supported prolonged DAPT in high-thrombotic-risk ACS (97.1%) and balancing ischemic and bleeding risks (94.1%). Agreement with the ESC 6-month DAPT recommendation for stable DES percutaneous coronary intervention (PCI) was lower (61.8%), reflecting preference for extended therapy in Indian practice. While short DAPT reduced bleeding (85.3%), most experts acknowledged higher MI risk in ACS, consistent with SMART-DATE and STOPDAPT-2 ACS (79.4%). Prolonged DAPT (≥≥12 months) in complex PCI received strong support (97%), with universal agreement that it reduces MACE and cardiothrombotic events (100%). Key factors favoring extended therapy included smoking and prior MI/stent thrombosis (97% each), as well as procedural complexity. Routine PPI cotherapy was endorsed by 79.4%.
The GOLD-DAPT consensus offers practical, risk-adapted recommendations for Indian ACS patients, supporting individualized rather than fixed-duration DAPT and emphasizing the need for India-specific prospective data to guide future national policy.
Nagaraj Desai, G. Shetty, Naveen Chandra et al.· Heart India· 0 citations
