Myocardial Strain Analysis by 2-Dimensional Speckle Tracking Echocardiography Improves Diagnostics of Coronary Artery Stenosis in Stable Angina Pectoris

Non-invasive Global and Regional Myocardial Work Predicts High-Risk Stable Coronary Artery Disease Patients With Normal Segmental Wall Motion and Left Ventricular Function

Background: Previous studies suggested that myocardial work (MW) may identify abnormalities in the left ventricular (LV) function and establish a more sensitive index for LV dysfunction at the early stage. This study aimed to explore the value of global and regional MW parameters in predicting high-risk stable coronary artery disease (SCAD) patients with normal wall motion and preserved LV function. Patients and Methods: A total of 131 patients, who were clinically diagnosed as SCAD with normal wall motion and LV function, were finally included in this study. Global MW parameters, including global work index (GWI), global constructive work (GCW), global waste work (GWW), and global work efficiency (GWE) were measured with non-invasive LV pressure-strain loops constructed from speckle-tracking echocardiography. Regional myocardial work index (RWI) and work efficiency (RWE) were also calculated according to the perfusion territory of each major coronary artery. All patients underwent coronary angiography and were divided into the high-risk SCAD group, the non-high-risk SCAD group, and the No SCAD group according to the range and degrees of coronary arteries stenosis. Results: The global longitudinal strain (GLS), GWI and GCW were statistically different (P < 0.001) among the three groups. In the high-risk SCAD group, GLS, GWI, and GCW were significantly lower than the other two groups (P < 0.05). Receiver operating characteristic analysis demonstrated GWI and GCW could predict high-risk SCAD at a cutoff value of 1,808 mm Hg% (sensitivity, 52.6%; specificity, 87.8%; predictive positive value, 76.3%; predictive negative value, 69.9%) and 2,308 mm Hg% (sensitivity, 80.7%; specificity, 64.9%; predictive positive value, 63.3%; predictive negative value, 80.0%), respectively. Multivariate analyses showed that carotid plaque, decreased GWI, and GCW was independently related to high-risk SCAD. The cutoff values of RWI_LAD, RWI_LCX, and RWI_RCA were 2,156, 1,929, and 1,983 mm Hg% in predicting high-risk SCAD, respectively (P < 0.001). When we combined RWI in two or three perfusion regions, the diagnostic performance of SCAD was improved (P < 0.001). Conclusions: Both global and regional MW parameters have great potential in non-invasively predicting high-risk SCAD patients with normal wall motion and preserved LV function, contributing to the early identification of high-risk patients who may benefit from revascularization therapy.

Evaluating the role of left ventricle global longitudinal strain in myocardial perfusion defect assessment

Myocardial perfusion defect, assessed with single photon emission computed tomography (SPECT), is useful for patient management and risk stratification. Left ventricle Global Longitudinal Strain (LV GLS) has gained interest for observing subclinical LV dysfunction. We aimed to investigate the utility of LV GLS in evaluating myocardial perfusion defect. A retrospective study of all patients who underwent SPECT and LV GLS at Tel Aviv Sourasky medical center. Overall, 86 patients were included. LV GLS and SPECT correlated in the base and apex sections for infraction, and in the apex only for ischemia. Adjusted analysis showed a significant correlation between LV GLS of both the mid and apical section and infarction by SPECT, but no association with ischemia. No associations were found by arterial supply territory. A sub-analysis of patients without left bundle branch block (LBBB) strengthened the correlations, with a 58-70% higher chance of both fixed and reversible defects for every 1-unit decrease LV GLS in the mid and apical sections. LV GLS effectively evaluated the presence of infarction by SPECT in the mid and apical sections, particularly in patients without LBBB. Due to its high availability, LV GLS may have a role in evaluating myocardial perfusion defect.

Speckle-Tracking Echocardiography in Cardio-Oncology and Beyond

Speckle-tracking echocardiography has enabled clinicians to detect changes in myocardial function with more sensitivity than that afforded by traditional diastolic and systolic functional measurements, including left ventricular ejection fraction. Speckle-tracking echocardiography enables evaluation of myocardial strain in terms of strain (percent change in length of a myocardial segment relative to its length at baseline) and strain rate (strain per unit of time). Both measurements have potential for use in diagnosing and monitoring the cardiovascular side effects of cancer therapy. Regional and global strain measurements can independently predict outcomes not only in patients who experience cardiovascular complications of cancer and cancer therapy, but also in patients with a variety of other clinical conditions. This review and case series examine the clinical applications and overall usefulness of speckle-tracking echocardiography in cardio-oncology and, more broadly, in clinical cardiology.

[Non-invasive cardiac imaging in the work-up of coronary artery disease]

Cardiovascular imaging has experienced and is still experiencing tremendous advancements as far as hardware as well as software technology is concerned. In every day clinical routine, crucial decisions are daily being taken based on imaging findings. These decisions include changes to treatment strategies, performing further testing, recommending or adhering to preventive measures, and ultimately affect patient outcomes. Appropriate use of different imaging modalities which includes choosing the right modality, adequate performance of the imaging test as well as professional reporting is crucial for providing high quality medical care. Furthermore, a growing body of scientific evidence is currently available that show the clinical relevance of different imaging methods in the clarification of different disease constellations. This article describes various imaging modalities that are used in the work-up of CAD in everyday cardiac routine.

Role of Left Ventricular Speckle Tracking Imaging in Detection of Coronary Artery Disease in Non-Diabetic Patients

This study aimed to determine the role of global longitudinalstrain (GLS) in early diagnosis and detection of severity of coronaryartery disease (CAD) in non-diabetic patients with preservedleft ventricular ejection fraction (EF) without regionalwall motion abnormalities presented with chronic coronary syndrome,and to identify the role of territorial longitudinal strain(TLS) in detection of the affected coronary artery. We enrolled60 non-diabetic patients with suspected CAD who underwentresting echocardiography and speckle tracking imaging andsubsequently coronary angiography then results were correlatedtogether. Patients with family history of CAD (68.3%), hypertension(68.3%), smokers (43.3%), and dyslipidemia (81.6%). Allparticipants had normal left ventricular systolic function withmean EF of 64.02±6.15% and no regional wall motion abnormalitiesat rest. Patients were classified angiographically accordingto the number of the diseased vessels into: 3 vessels disease(43.3%), 1-2 vessels disease (35%), and normal coronaryangiography (21.7%) with GLS mean values of -13.69±1.94%,-15.4±1.74%, and -18.80±2.14%, respectively. There was a negativesignificant correlation between GLS values and the numberof diseased vessels (P=0.001). The values of TLS were significantlylower in myocardial regions supplied by stenotic arteries thanthose supplied by non-stenotic arteries. Mean TLS values forstenotic left anterior descending, left circumflex, and right coronaryarteries were -15.51±3.19, -13.06±2.90, -13.27±2.60 withP=0.011, 0.001, and 0.001, respectively. Speckle tracking derivedGLS is an effective non-invasive method in predicting presenceand severity of CAD and in locating the affected vessels basedon the distribution of segments affected in TLS.

Layer-specific and whole wall global longitudinal strain predict major adverse cardiovascular events in patients with stable angina pectoris

Global longitudinal strain (GLS) has proven to be a powerful prognostic marker in various patient populations, but the prognostic value of layer-specific GLS has not yet been investigated in patients with suspected stable angina pectoris (SAP). We sought to investigate the prognostic value of layer-specific and whole wall GLS in patients with suspected SAP. From September 2008 to March 2011, 296 consecutive patients with clinically suspected SAP, normal ejection fraction, and no previous cardiac history were enrolled in a prospective cohort study. Patients underwent echocardiography including two-dimensional speckle tracking at rest, exercise stress test, and coronary angiography. The end-point was a composite of incident heart failure, acute myocardial infarction, and cardiovascular death (MACE). Out of the 285 included patients (mean age 61 years, 50% male), 24 (8%) developed MACE during a median follow-up of 3.5 years. Both endocardial [hazard ratio (HR) 1.21, 95% CI 1.08-1.35, p = 0.001], epicardial (HR 1.29, 95% CI 1.12-1.50, p = 0.001) and whole wall GLS (HR 1.25, 1.10-1.42, p = 0.001) were significantly associated with an increased risk of developing MACE during follow-up in univariable Cox regression analysis. In multivariable analysis, only epicardial (HR 1.23, 95% CI 1.00-1.51, p = 0.046) and whole wall GLS (HR 1.20, 95% CI 1.00-1.43, p = 0.049) remained significantly associated with an increased risk of MACE independent of various baseline clinical variables, left ventricular ejection fraction (LVEF), E/e' and Duke Score. Layer-specific and whole wall GLS were significant predictors of MACE in this cohort of patients with suspected SAP independent of various baseline clinical variables, LVEF, E/e' and Duke Score.

The feasibility, reliability, and incremental value of two-dimensional speckle-tracking for the detection of significant coronary stenosis after treadmill stress echocardiography

Background

Two-dimensional speckle-tracking echocardiography (STE) may help detect coronary artery disease (CAD) when combined with dobutamine stress echocardiography. However, few studies have explored STE with exercise stress echocardiography (ESE). We aimed to evaluate the feasibility, reliability, and incremental value of STE combined with treadmill ESE compared to treadmill ESE alone to detect CAD.

Methods

We conducted a case–control study of all consecutive patients with abnormal ESE in 2018–2020 who subsequently underwent coronary angiography within a six-month interval. We 1:1 propensity score-matched these patients to those with a normal ESE. Two blinded operators generated a 17-segment bull's-eye map of longitudinal strain (LS). We utilized the mean differences between stress and baseline LS values in segments 13–17, segment 17, and segments 15–16 to create receiver operator curves for the overall examination, the left anterior descending artery (LAD), and the non-LAD territories, respectively.

Results

We excluded 61 STEs from 201 (30.3%) eligible ESEs; 47 (23.4%) because of suboptimal image quality and 14 (7.0%) because of excessive heart rate variability precluding the calculation of a bull's-eye map. After matching, a total of 102 patients were included (51 patients in each group). In the group with abnormal ESE patients (mean age 66.4 years, 39.2% female), 64.7% had significant CAD (> 70% stenosis) at coronary angiogram. In the group with normal ESE patients (mean age 65.1 years, 35.3% female), 3.9% were diagnosed with a new significant coronary stenosis within one year. The intra-class correlation for global LS was 0.87 at rest and 0.92 at stress, and 0.84 at rest, and 0.89 at stress for the apical segments. The diagnostic accuracy of combining ESE and STE was superior to visual assessment alone for the overall examination (area under the curve (AUC) = 0.89 vs. 0.84, p = 0.025), the non-LAD territory (AUC = 0.83 vs. 0.70, p = 0.006), but not the LAD territory (AUC = 0.79 vs. 0.73, p = 0.11).

Conclusions

Two-dimensional speckle-tracking combined with treadmill ESE is relatively feasible, reliable, and may provide incremental diagnostic value for the detection and localization of significant CAD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-021-00259-w.

Incremental Value of Three-dimensional Speckle-tracking Echocardiography for Evaluating Left Ventricular Systolic Function in Patients with Coronary Slow Flow

The purpose was to evaluate left ventricular (LV) systolic function in patients with coronary slow flow (CSF), and compared the incremental values of 3-dimensional (3D) speckle-tracking echocardiography (STE). Seventy-three patients with CSF and 60 control subjects were enrolled. CSF was diagnosed during coronary angiography. Two-dimensional (2D) and 3D global strain were measured using STE. Sex, mitral E, 2D GLS, and all 3D strain parameters were independent predictors of CSF. Combination of sex, mitral E, and 3D GTS had the highest area under the curve (AUC) for identifying CSF (AUC, 0.81; P < 0.001). Integrated discrimination index (IDI) improved adding 3D GTS to the combined sex and mitral E model (IDI = 0.12, P = 0.01) or 2D GLS model (IDI = 0.14, P < 0.001). LV systolic function was impaired in CSF patients. 3D GTS had an independent and incremental value for predicting CSF compared with 2D echocardiography.

Left Ventricular Twist and Untwist in Patients Undergoing Elective Percutaneous Coronary Intervention

BACKGROUND

Left ventricular (LV) twist and untwist plays important roles in physiological adaptation and development of clinically relevant cardiac diseases.

AIMS

To assess LV twist and untwist in patients undergoing elective percutaneous coronary intervention (PCI) by two-dimensional (2D) speckle tracking echocardiography (STE).

SUBJECTS AND METHODS

Fifty patients who had stable angina pectoris and/or abnormal result from noninvasive stress tests were enrolled after undergoing elective PCI. Conventional and 2D STE were performed before elective PCI and after 3 months.

RESULTS

There was no significant systolic improvement in conventional echocardiography. However, there was a significant diastolic improvement after elective PCI as higher E, E/A, e` and lower E/e` (P < 0.034, <0.042, 0.015, and 0.033, respectively). In addition, there was a statistically significant improvement of STE-derived systolic parameters as regard higher global longitudinal strain, peak twist, and torsion (P value 0.009, 0.009, and < 0.001, respectively). Furthermore, there was significant improvement of STE-derived diastolic parameters as higher peak untwist, recoil, and lower time to peak untwist (P value 0.013, 0.001, and 0.004, respectively).

CONCLUSIONS

LV and untwist parameters were improved before most of conventional echocardiographic parameters in postrevascularization of stable coronary artery disease.

Myocardial strain analysis as a non-invasive screening test in the diagnosis of stable coronary artery disease

Background

Coronary artery disease (CAD) is one of the most prevalent diseases around the world; however, finding the best noninvasive, low-cost, and more easily accessible test for its screening has been a challenge for several years. Eighty-nine patients suspected of stable CAD underwent 2D-speckle-tracking echocardiography (2DSTE) at resting position and offline longitudinal myocardial strain analysis, followed by coronary angiography. The correlation of the global longitudinal strain (GLS) and territorial longitudinal strain (TLS) with significant CAD (70% and more stenosis in at least one coronary artery) was then evaluated.

Results

The statistical analysis showed a significant correlation between low GLS and significant CAD (P=0.0001). The results also showed a significant correlation between low TLS and significant CAD in the left and right coronary artery territories. The optimal cut-off point of GLS for the detection of significant CAD was −19.25, with a sensitivity of 76.5% and specificity of 76.6%.

Conclusion

This study confirmed the usefulness of 2DSTE myocardial strain analysis in diagnosis of CAD for detecting the affected coronary arteries using GLS and SLS.

Rapidly and Accurately Detecting Significant Coronary Artery Stenosis in Patients with Suspected Stable Coronary Artery Disease and Normal Segmental Wall Motion by Speckle Tracking Automated Functional Imaging

This study was performed to explore the value of a machine with built-in speckle tracking automated functional imaging (AFI) in predicting the severity of coronary artery lesions in patients with suspected stable coronary artery disease (SCAD) with normal wall motion. One hundred forty-three consecutive patients with clinically suspected SCAD with normal wall motion were included. Multiple parameters, including global longitudinal peak strain, post-systolic index (PSI) and peak strain dispersion, were automatically analyzed with AFI. Territorial longitudinal strain (TLS) and territorial PSI (TPSI) were also calculated. Receiver operating characteristic curve analyses revealed that global longitudinal peak strain and PSI were superior to other parameters in detecting left main or three-vessel SCAD. A combination of TLS and TPSI could improve diagnostic performance in identifying significant stenotic left anterior descending and right coronary arteries. In conclusion, 2-dimensional speckle tracking AFI can rapidly provide multiple parameters for detecting significant coronary artery stenosis with high accuracy in patients suspected of having SCAD with normal wall motion.

Speckle Tracking Echocardiography: Early Predictor of Diagnosis and Prognosis in Coronary Artery Disease

Echocardiography represents a first level technique for the evaluation of coronary artery disease (CAD) which supports clinicians in the diagnostic and prognostic workup of these syndromes. However, visual estimation of wall motion abnormalities sometimes fails in detecting less clear or transient myocardial ischemia and in providing accurate differential diagnosis. Speckle tracking echocardiography (STE) is a widely available noninvasive tool that could easily and quickly provide additive information over basic echocardiography, since it is able to identify subtle myocardial damage and to localize ischemic territories in accordance to the coronary lesions, obtaining a clear visualization with a "polar map" useful for differential diagnosis and management. Therefore, it has increasingly been applied in acute and chronic coronary syndromes using rest and stress echocardiography, showing good results in terms of prediction of CAD, clinical outcome, left ventricular remodeling, presence, and quantification of new/residual ischemia. The aim of this review is to illustrate the current available evidence on STE usefulness for the assessment and follow-up of CAD, discussing the main findings on bidimensional and tridimensional strain parameters and their potential application in clinical practice.

Global longitudinal strain predicts cardiovascular events after coronary artery bypass grafting

OBJECTIVE

To determine the prognostic value of global longitudinal strain (GLS) after coronary artery bypass grafting (CABG).

METHODS

We performed a retrospective cohort study on patients undergoing CABG between 2006 and 2011 who had an echocardiogram available for strain analysis. The patients were followed up through nationwide registries for development of all-cause mortality, cardiovascular death (CVD) and major adverse cardiovascular events (MACEs) defined as heart failure hospitalisation and/or CVD. Multivariable Cox regression was applied to adjust for the European System for Cardiac Operative Risk Evaluation II (EuroSCORE-II). Additive value was assessed by Net Reclassification Index (NRI) improvement.

RESULTS

Of the 709 patients included, 80 died during a median follow-up of 3.8 years. Of these, 45 had CVD, and 72 patients experienced MACE. Mean age was 68 years and 85% were men. Left ventricular ejection fraction (LVEF) was 50% and GLS was -13%.GLS was an independent predictor when adjusted for the EuroSCORE-II (all-cause mortality: HR=1.07 (1.01-1.13), p=0.018; CVD: HR=1.11 (1.03-1.20), p=0.007; MACE: HR=1.12 (1.06-1.19), p<0.001, per 1% absolute decrease). GLS significantly improved the NRI score by 0.30 when added to the EuroSCORE-II for predicting MACE, but not significantly for the other endpoints.LVEF modified the association between GLS and outcomes (p for interaction<0.05 for CVD and MACE). GLS remained an independent predictor of outcomes in patients with preserved LVEF (LVEF≥50%) and improved the NRI score when added to the EuroSCORE-II for predicting CVD and MACE, but not all-cause mortality in these patients.

CONCLUSION

GLS is an independent predictor of long-term outcomes after CABG. The predictive value appears strongest among patients with preserved LVEF.

Asymptomatic Left Ventricular Dysfunction: Is There a Role for Screening in General Population?

Stage A and B heart failure (HF) include asymptomatic patients without and with structural cardiac disorder, respectively. Asymptomatic left ventricular (LV) dysfunction represents an early stage of HF that should be recognized to prevent overt HF development. Echocardiography plays a pivotal role in assessment of cardiac structure and function and represents the ideal imaging technique for screening in the general population, thanks to its availability, feasibility, and low cost. Traditional echocardiography, with LV systolic and diastolic function and cardiac remodeling assessment, is usually performed. Development of new technologies may offer additional information and insights in detection of early LV dysfunction.

Left Ventricular Longitudinal Global Strain to Predict Severe Coronary Disease in Patients with Precordial Pain Suggestive of Non-ST-Segment Elevation Acute Coronary Syndrome

Background:

Diagnosing non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is not always straightforward. Left ventricular global longitudinal strain (LVGLS) is an echocardiographic method capable of detecting subclinical regional and global ventricular contractile dysfunction due to myocardial ischemia. The objectives of this study were to evaluate the efficacy of LVGLS in diagnosing severe coronary disease in patients with chest pain suggestive of NSTE-ACS and to assess the relationships between LVGLS reduction and ultrasensitive troponin T (UsTnT) elevation, electrocardiographic changes suggestive of ischemia, and the number of vessels with severe obstructions.

Methods:

This prospective, observational study evaluated hospitalized patients with chest pain of presumed coronary etiology. All patients underwent electrocardiography (ECG), UsTnT measurement, Doppler echocardiography, LVGLS measurement, and coronary angiography Coronary angiogram (CA) within 48 h of hospitalization.

Results:

A total of 75 patients with a mean age of 58 ± 17 years were included, of whom 84% (63 patients) were men. An LVGLS value of <-16.5, as determined by the Youden index proved to be useful for the detection of severe coronary obstructions (lesions >70%). The sensitivity, specificity, and positive and negative predictive values were 96%, 88%, 92%, and 92%, respectively. The number of coronary arteries involved had a direct relationship with the degree of LVGLS reduction (P < 0.001). Elevated UsTnT levels occurred more frequently in patients with reduced LVGLS than in those with normal LVGLS (83% vs. 17%, P < 0.0001). Abnormal strain was not associated with electrocardiographic changes suggestive of ischemia.

Conclusions:

LVGLS measurement in patients with presumed NSTE-ACS is efficient in predicting the presence of severe coronary disease. The number of coronary arteries involved has a direct relationship with the degree of LVGLS reduction. Abnormal strain is associated with UsTnT elevations but not with electrocardiographic changes suggestive of ischemia.

Detection of cardiac allograft vasculopathy by multi-layer left ventricular longitudinal strain in heart transplant recipients

Cardiac allograft vasculopathy (CAV) is an obliterative and diffuse type of coronaropathy that develops in the transplanted human heart, representing a major cause of graft failure and mortality. Nowadays the gold standard for the diagnosis of CAV is coronary angiography (CA). Non-invasive CAV detection, especially in the early stages of the disease, is still challenging. Our study aimed to investigate the role of speckle tracking echocardiography (STE), in particular three-layer STE, in predicting CAV at early stages, and if other traditional echocardiographic, clinical or biochemical parameters could relate to CAV. The study population was composed of a total of 33 heart transplanted patients, divided accordingly to the presence or absence of CAV (12 CAV+ , 22 CAV-). All subjects underwent a complete transthoracic echocardiographic examination on the same day of the CA, and all conventional parameters of myocardial function were obtained, including strain values assessed by STE. Strain values were significantly reduced in presence of CAV, at each myocardial layer but in particular the endocardial-epicardial gradient (- 4.15 ± 1.6 vs - 1.7 ± 0.4% < .0001) that was also highly predictive of CAV (AUC at ROC curve 0.97). Among diastolic parameters, the E wave deceleration time (DT) and the mean E/e' ratio were strongly positively associated with CAV. In our population, left ventricular global longitudinal strain (GLS), layer-specific GLS and the endocardial-epicardial LS gradient, E wave DT and E/e' ratio were the best independent non-invasive predictors of CAV.

Diagnostic Accuracy of Global Longitudinal Strain for Detecting Significant Coronary Artery Disease in Diabetic Patients without Regional Wall Motion Abnormality

AIMS

Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this prospective study was to assess the diagnostic accuracy of global longitudinal strain (GLS) and regional longitudinal strain (RLS) parameters at rest in comparison to stress echocardiography findings for detecting significant coronary artery disease (CAD) in patients with diabetes mellitus (DM).

METHODS

We prospectively studied echocardiographic characteristics at rest with Speckle tracking echocardiography (2D STE) measures; then stress echocardiography and coronary angiography data in 34 diabetic patients without regional wall motion abnormality (RWMA) at rest. Patients were grouped according to coronary angiography and stress echocardiography results into two groups CAD (+) vs control group CAD (-).

RESULTS

GLS at rest was lower in the CAD (+) group ((-14.2 % ± 3.1 vs -17.8 % ± 3.1 in the control group CAD (-), P=0.004). GLS at rest had the highest area under the ROC curve (AUC) (AUC 0.78, sensitivity 61%, specificity 91%,P=0.009) with the cut-off of -14.5% which is equal to predictive power of wall motion scoring index (WMSI) at peak stress to detect significant CAD (AUC=0.76 (95% CI 0.58-0.94, P= 0.016) with the cut-off value of 1.21).

CONCLUSIONS

Global longitudinal strain at rest by STE showed excellent specificity (>90%) and good sensitivity (60%) for the diagnosis of severe CAD among the diabetic population with unknown CAD. This is the first study showing that GLS at rest with cutoff value at -14.5% had good and equal diagnostic accuracy as WMSI at peak stress to detect significant CAD among the diabetic population.

Prognostic value of ratio of transmitral early filling velocity to early diastolic strain rate in patients with Type 2 diabetes

AIMS

The ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) has recently emerged as a novel measure of left ventricular filling pressure. E/e'sr has in previous studies demonstrated to have good prognostic value in various patient populations. The aim of this study is to investigate the prognostic value of E/e'sr in a large cohort of patients with Type 2 diabetes in relation to cardiovascular morbidity and mortality.

METHODS AND RESULTS

In this prospective study, 848 Type 2 diabetic patients (mean age 63.6 ± 10.3 years, 64.7% male) underwent comprehensive echocardiographic examination including 2D speckle tracking in which E/e'sr along with novel and conventional echocardiographic variables were obtained. During follow-up (median: 4.8 years, interquartile range: 4.0-5.3), 122 (14.1%) met the composite outcome of cardiovascular disease, hospitalization, and mortality. Both E/e'sr and E/e' were significantly associated with the outcome [E/e'sr: hazard ratio (HR) 1.07, 95% confidence interval (CI): 1.05-1.10; P < 0.001, per 0.10 m increase] and (E/e': HR 1.07, 95% CI: 1.05-1.10; P = 0.001, per 1 unit increase). E/e'sr remained an independent predictor after multivariable adjustment for demographical, clinical, and echocardiographic parameters (HR 1.06, 95% CI: 1.01-1.12; P = 0.032, per 10 cm increase). The same was true for E/e' (HR 1.09, 95% CI: 1.04-1.14; P < 0.001, per 1 unit increase). Additionally, E/e'sr provided incremental prognostic information beyond the UK 'Prospective Diabetes Study risk engine' 0.72 (0.68-0.77) vs. 0.74 (0.70-79), P = 0.040.

CONCLUSION

In patients with Type 2 diabetes, E/e'sr provides independent and incremental prognostic information regarding cardiovascular morbidity and mortality.

Evaluation of left ventricular systolic function in patients with different types of ischemic heart disease by two-dimensional speckle tracking imaging

BACKGROUND

The purpose of this study was to evaluate left ventricular systolic function in patients with different types of ischemic heart disease using two-dimensional speckle tracking imaging (2D-STI).

METHODS

We retrospectively studied patients who were admitted to Peking University Third Hospital from January 2011 to December 2017 due to chest tightness and chest pain. Two hundred forty-two patients were divided into control group, CMD group and obstructive CAD group. The main coronary artery stenosis was confirmed by coronary angiography or coronary computed tomography and coronary flow reserve (CFR) in patients was measured by transthoracic Doppler echocardiography. Left ventricular strain and strain rate (SR) measured by 2D-STI. Cardiac structure and function were measured by conventional echocardiography.

RESULTS

Conventional echocardiography showed that there was no significant difference in cardiac structure and function among the three groups (P > 0.05). Moreover, the longitudinal strain (LS) of each ventricular wall in CMD group was notably lower than that in control group (P < 0.01). In addition, global longitudinal SR and longitudinal SR in CMD group and obstructive CAD group were obviously lower than those in control group (P < 0.01). GLS, endocardial LS and epicardial LS were negatively correlated with CFR (P < 0.01).

CONCLUSIONS

Early left ventricular systolic dysfunction was found in patients with CMD and patients with obstructive CAD, with similar degree. CFR is an independent influencing factor of GLS. GLS and stratified LS have certain diagnostic value for CMD.

2- and 3-Dimensional Myocardial Strain in Cardiac Health and Disease

Advances in speckle-tracking echocardiography allowed the rise of deformation imaging as a feasible, robust, and valuable tool for clinical routine. The global or segmental measurement of strain can objectively quantify myocardial deformation and can characterize myocardial function in a novel way. However, the proper interpretation of deformation measurements requires understanding of cardiac mechanics and the influence of loading conditions, ventricular geometry, conduction delays, and myocardial tissue characteristics on the measured values. The purpose of this manuscript is to review the basic concepts of deformation imaging, briefly describe imaging modalities for strain assessment, and discuss in depth the underlying physical and pathophysiological mechanisms which lead to the respective findings in a specific disease.

Impact of the left anterior descending artery wrapping around the left ventricular apex on cardiac mechanics in patients with normal coronary angiography

Background

We examined the impact of left anterior descending (LAD) wrapping on left ventricular (LV) mechanics in patients with normal coronary angiography. Seventy-one patients with evidence of normal coronary angiography (LAD wrapping: n = 52, 73%) and LAD non-wrapping (n = 19, 27%) were included in the study. Using 2D-strain imaging, we measured LV longitudinal and circumferential (circ) strain (ε_sys), systolic strain rate (SR_sys), early (SR_e) and atrial (SR_a) diastolic SR, LV electromechanical dyssynchrony (TTP-SD), and LV twist and torsion in study groups.

Results

No significant difference in age, gender, body surface area (BSA), or ejection fraction (EF%) between groups. LAD-wrapping group showed higher deceleration time (DT) (P < 0.0001), global longitudinal ε_sys % (P < 0.02), circ SR_a at the basal segments (P < .02), circ SR_sys and SR_e, and SR_a (P < 0.0001) at the apical segments and apical rotation compared with the non-wrapped group. LV twist was correlated negatively with LV electromechanical dyssynchrony (r = .25, P < 0.03) and positively with longitudinal ε_sys (r = .47, P < .0001), circ ε_sys% (r = .55, P < .0001), circ SR_sys (r = .23, P < .05), and circ SR_e (r = .55, P < .0001). Using multivariate regression analysis, DT: OR 0.932, CI 0.877–0.991, and P < 0.02 and circ at atrial diastole (SR_a): OR 0.000, CI .000–.271, and P < 0.03 were independent predictors of LAD wrapping around LV apex.

Conclusion

Wrapped LAD is associated with better myocardial relaxation and rotational mechanics in patients with normal coronary angiography. This could explain the worse prognosis in such population when LAD occlusion acutely emerges.

Deterioration of longitudinal, circumferential, and radial myocardial strains during acute coronary flow reduction: which direction of strain should be analyzed for early detection?

Longitudinal myocardial strain is considered to deteriorate in the early ischemic stage compared to circumferential and radial strains because the subendocardial inner oblique fibers are generally directed along the longitudinal axis. However, it is unclear whether the decrease in longitudinal strain precedes a decrease in circumferential and radial strains during acute coronary flow reduction. The left anterior descending artery was gradually narrowed in 13 open-chest dogs. Whole-wall and subendocardial longitudinal, circumferential, and radial strains were analyzed at baseline and during flow reduction. Peak systolic and end-systolic strains, the postsystolic strain index (PSI), and the early systolic strain index (ESI) were measured in the risk area; the decreasing rate in each parameter and the diagnostic accuracy to detect flow reduction were evaluated. Absolute values of peak systolic and end-systolic strains gradually decreased with flow reduction. The decreasing rate and diagnostic accuracy of longitudinal systolic strain were not significantly different from those in other strains, although the diagnostic accuracy of radial systolic strain tended to be lower. PSI and ESI gradually increased with flow reduction. In these parameters, a lower diagnostic accuracy with respect to radial strain was not demonstrated. During acute coronary flow reduction, the decrease in longitudinal systolic strain did not precede that in circumferential systolic strain; however, the decrease in radial systolic strain may be smaller than that of other systolic strains. In contrast, there appeared to be no differences in the PSI and ESI values among the three strains.

Correlation between global longitudinal strain and SYNTAX score in coronary artery disease evaluation

BACKGROUND

Speckle tracking echocardiography may allow the evaluation of myocardial systolic and diastolic dynamics across different physiologic and pathologic conditions beyond traditional echocardiographic techniques. The use of STE longitudinal strain in identification and risk stratification of CAD has good reproducibility and accuracy. The study aims to detect the relationship between SYNTAX score and global longitudinal peak systolic strain (GLPSS) in patients undergoing coronary angiography, with no history of myocardial infarction.

RESULTS

The study included 70 symptomatic patients suspected to have chronic coronary syndrome aging 20-80 years (excluding those with significant structural heart disease). All patients underwent clinical evaluation, surface ECG, laboratory assessment, transthoracic echocardiographic (TTE), color TDI tracings, two-dimensional speckle tracking, and conventional coronary angiography with SYNTAX score calculation. Patients were divided into 3 groups based on the results of the coronary angiogram: normal CAD on angiogram (n = 10, control group), low SS (n = 25, SS < 22), and high SS (n = 35, SS ≥ 22). The mean age was 55 ± 9.6 years; 54% were males; two third of patients were hypertensive; 52% were diabetic; high percentage of high syntax score were noticed among males, diabetic patients, and smokers; and also low mean of GLS was noticed among diabetic patients and smokers. There was a statistically significant positive correlation between syntax score and each of LVEDD and LVESD and, on the other hand, statistically significant negative correlation between syntax score and each of E/A, GLS, AP2LS, AP3LS, and AP4LS was noticed. Peak GLS cutoff value of 17.8 and 16.5 showed 84% and 93% sensitivity and 70% and 91% specificity to detect high and low syntax score, respectively.

CONCLUSION

2D longitudinal strain analysis has incremental diagnostic value over visual assessment during echocardiography in predicting significant coronary artery disease; GLS may offer a potential sensitive tool to detect significant CAD.

Early diastolic strain rate by two-dimensional speckle tracking echocardiography is a predictor of coronary artery disease and cardiovascular events in stable angina pectoris

This study aimed to clarify the diagnostic and prognostic potential of strain rate in patients with suspected stable angina pectoris (SAP). Strain rate by 2-dimensional speckle tracking echocardiography (2DSTE) has been suggested to be able to diagnose coronary artery disease (CAD) and predict cardiovascular events in various patient groups. Prospectively enrolled patients (n = 296) with suspected SAP, no previous cardiac disease, and normal left ventricular ejection fraction were examined by 2DSTE, exercise ECG, and coronary angiography. Obstructive CAD was defined as stenosis ≥ 70% in ≥ 1 coronary artery on coronary angiography (n = 107). Major adverse cardiac events (MACE) included myocardial infarction, heart failure, atrial fibrillation, and stroke. In multivariable analysis adjusted for baseline data, conventional echocardiography, and Duke score, early diastolic strain rate (SRe) was independently associated with significant CAD with a 1.35 increased risk of having CAD per 0.1 decrease in SRe (OR = 1.35, 95% CI 1.03-1.76, P = 0.027). Peak velocity of early diastolic filling (E)/SRe was not associated with significant CAD (OR = 1.14, 95% CI 0.81-1.62, P  = 0.445). MACE occurred in 34 patients (12%) during follow-up (median 3.5 years) and both SRe (HR 1.26, 95% CI (1.07-1.49), P = 0.006) and E/SRe (HR 1.24, 95% CI (1.04-1.47), P = 0.017) were independent predictors after multivariable adjustment. In patients with suspected SAP, SRe by 2DSTE was independently associated with presence of CAD. In addition, SRe and E/SRe provided independent and incremental prognostic value for predicting future MACE.

Towards standardization of echocardiography for the evaluation of left ventricular function in adult rodents: a position paper of the ESC Working Group on Myocardial Function

Echocardiography is a reliable and reproducible method to assess non-invasively cardiac function in clinical and experimental research. Significant progress in the development of echocardiographic equipment and transducers has led to the successful translation of this methodology from humans to rodents, allowing for the scoring of disease severity and progression, testing of new drugs, and monitoring cardiac function in genetically modified or pharmacologically treated animals. However, as yet, there is no standardization in the procedure to acquire echocardiographic measurements in small animals. This position paper focuses on the appropriate acquisition and analysis of echocardiographic parameters in adult mice and rats, and provides reference values, representative images, and videos for the accurate and reproducible quantification of left ventricular function in healthy and pathological conditions.

Global longitudinal strain is a more reproducible measure of left ventricular function than ejection fraction regardless of echocardiographic training

Background

Left ventricular ejection fraction (LVEF) is an established method for evaluation of left ventricular (LV) systolic function. Global longitudinal strain (GLS) by speckle tracking echocardiography seems to be an important additive method for evaluation of LV function with improved reproducibility compared with LVEF. Our aim was to compare reproducibility of GLS and LVEF between an expert and trainee both as echocardiographic examiner and analyst.

Methods

Forty-seven patients with recent Acute Coronary Syndrome (ACS) underwent echocardiographic examination by both an expert echocardiographer and a trainee. Both echocardiographers, blinded for clinical data and each other’s findings, performed image analysis for evaluation of intra- and inter- observer variability. GLS was measured using speckle tracking echocardiography. LVEF was calculated by Simpson’s biplane method.

Results

The trainee measured a GLS of − 19.4% (±3.5%) and expert − 18.7% (±3.2%) with an Intra class correlation coefficient (ICC) of 0.89 (0.74–0.95). LVEF by trainee was 50.3% (±8.2%) and by expert 53.6% (±8.6%), ICC coefficient was 0.63 (0.32–0.80). For GLS the systematic difference was 0.21% (− 4.58–2.64) vs. 4.08% (− 20.78–12.62) for LVEF.

Conclusion

GLS is a more reproducible method for evaluation of LV function than LVEF regardless of echocardiographic training.

Cardiac function assessed by myocardial deformation in adult polycystic kidney disease patients

Background

Patients with autosomal dominant polycystic kidney disease (ADPKD) have an increased risk of cardiovascular morbidity and mortality. Impaired left ventricular (LV) global longitudinal strain (GLS) can be a sign of subclinical cardiac dysfunction even in patients with otherwise preserved ejection fraction (EF). Transmitral early filling velocity to early diastolic strain rate (E/SRe) is a novel measure of LV filling pressure, which is often affected early in cardiac disease.

Methods

A total of 110 ADPKD patients not on dialysis were included in this prospective study. All patients underwent an extensive echocardiographic examination including two-dimensional speckle tracking. GLS and strain rates were measured. The distribution of GLS and E/SRe was determined and patient characteristics were compared by median levels of GLS (− 17.8%) and E/SRe (91.4 cm). Twenty healthy participants were included as control group.

Results

There was a significantly worse GLS in the ADPKD patients (mean: − 17.8 ± 2.5%) compared to the healthy controls (mean: − 21.9 ± 1.9%), p < 0.001. The same was true for E/SRe (mean: 10.0 ± 0.3 cm) compared to the control group (mean: 6.5 ± 0.3 cm), p < 0.001. In simple logistic regression, male gender (OR: 4.74 [2.10–10.71], p < 0.001), fasting glucose (odds ratio (OR) 1.05 [1.01–1.10], p = 0.024), htTKV (OR: 1.07 [1.01–1.13], p = 0.013), HDL cholesterol (OR: 0.97 [0.94, 0.996], p = 0.025), triglycerides (OR: 1.01 [1.00–1.02], p = 0.039), hemoglobin (OR: 1.50 [1.11–2.04], p = 0.009), and β-blocker use (OR: 1.07 [1.01, 1.13], p = 0.013) were all associated with higher GLS. After multivariate logistic regression with backward model selection, only male gender (OR: 5.78 [2.27–14.71], p < 0.001) and β-blocker use (OR: 14.00 [1.60, 122.51], p = 0.017) remained significant. In simple logistic regression models, BMI (OR: 1.11 [1.02–1.20], p = 0.015), systolic blood pressure (OR: 1.03 [1.00–1.06], p = 0.027) and β-blocker use (OR: 17.12 [2.15–136.20], p = 0.007) were associated with higher E/SRe - a novel measure of left ventricular filling pressure. After backward elimination, only β-blocker use (OR: 17.22 [2.16, 137.14], p = 0.007) remained significant.

Conclusion

Higher GLS and E/SRe are common in ADPKD patients, even in patients with preserved eGFR and normal left ventricular EF. GLS and E/SRe may aid in cardiovascular risk stratification in patients with ADPKD as they represent early markers of cardiac dysfunction.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1500-1) contains supplementary material, which is available to authorized users.

Two-dimensional Echocardiographic Assessment of Myocardial Strain: Important Echocardiographic Parameter Readily Useful in Clinical Field

Echocardiography is the first and is the most-available imaging modality for many cardiovascular diseases, and echocardiographic parameters can give much important information for diagnosis, treatment, and prognostic evaluations. Left ventricular ejection fraction (LVEF) is the most commonly used echocardiographic parameter for left ventricular (LV) systolic function. Although LVEF is used routinely in daily practice, it is calculated from volumetric change without representing true myocardial properties. Recently, strain echocardiography has been used to objectively measure myocardial deformation. Myocardial strain can give accurate information about intrinsic myocardial function, and it can be used to detect early-stage cardiovascular diseases, monitor myocardial changes with specific therapies, differentiate cardiomyopathies, and predict the prognosis of several cardiovascular diseases. Although strain echocardiography has been applied to measure the right ventricle and left atrium, in addition to analyzing the LV, many cardiologists who are not imaging specialists are unaware of its clinical use and importance. Therefore, this review describes the measurement and clinical utility of 2-dimensional strain analysis in various cardiovascular diseases.

Improvement of left ventricular function after percutaneous coronary intervention in patients with stable coronary artery disease and preserved ejection fraction: Impact of diabetes mellitus

Background

Many patients with stable coronary artery disease (CAD) have no visual segmental wall motion abnormalities and a left ventricular (LV) ejection fraction (LVEF) ≥ 50% at rest despite significant coronary artery stenosis. Here, the aim was to determine the impact of percutaneous coronary intervention (PCI) on LV function assessed by enhanced echocardiography in patients with stable CAD with or without diabetes mellitus type 2 and a preserved LVEF.

Methods

Sixty-six consecutive patients with CAD and LVEF ≥ 50%, admitted to the hospital for planned coronary angiography, were prospectively assessed. PCI was performed for coronary artery stenosis > 70%. CAD extent was assessed using SYNTAX and EXTENT scores. To assess LV function, LVEF, global longitudinal strain (GLS), and LV peak systolic myocardial velocity (S′) were measured and Tei index was calculated before and 3 months after PCI.

Results

Before PCI, LVEF, GLS, and Tei index were significantly worse in diabetic patients. LV functional indices improved significantly after PCI in all patients (p < 0.001). Multivariate linear regression analyses were performed to evaluate the impact of selected factors on LV function after PCI expressed as changes (Δ) of LVEF, GLS, S′, and Tei index. LV function improvement expressed as ΔGLS was associated only with SYNTAX score. Higher SYNTAX scores were related to greater GLS improvement (β = 0.003, 95% confidence interval: 0.0004–0.005; p = 0.02).

Conclusions

Percutaneous coronary intervention significantly improved LV function in diabetic and non-diabetic CAD patients with preserved LVEF. Enhanced echocardiography allowed an assessment of subtle changes in LV function.

Left Ventricular Torsion in Hypertension and Hypertensive Heart Failure ― 3-Dimensional Speckle Tracking Echocardiography Assessment ―

Background: Left ventricular (LV) torsion by contraction of inner and outer oblique muscles contributes to EF. Outer muscle plays a predominant role in torsion. We evaluated the impact of LV remodeling by hypertension (HTN) on torsion using 3-dimensional speckle tracking echocardiography (3D-STE).

Methods and Results: LV strain, strain rate during systole (SR-S) and torsion at endocardium, mid-wall and epicardium were assessed on 3D-STE in 53 controls and 186 HTN patients. Torsion was defined as the difference between apical and basal rotation divided by long axis length. LVEF and strain, SR-S and torsion in all 3 layers in HTN without LV hypertrophy (LVH) were similar to those in controls. LV longitudinal strain at endocardium in HTN with LVH decreased, whereas LVEF was similar to that in controls and, which was associated with increased torsion at epicardium. Reduced LVEF in hypertensive HF was associated with reduced strain, SR-S and torsion in all layers and with LV dilation. On multivariate analysis, epicardial torsion was an independent determinant of LVEF. At epicardial torsion cut-off 0.41, the sensitivity and specificity for the identification of HFrEF were 88% and 68%.

Conclusions: Torsion on 3D-STE may represent a compensatory mechanism to maintain LVEF despite reduced endocardial function, suggesting that the deterioration of torsion caused by insult to outer muscle and dilation may lead to HFrEF.

2-D speckle-tracking assessment of left and right ventricular function in rheumatoid arthritis patients with and without disease activity

Objectives

Disease activity has been considered as independent cardiovascular risk factor in rheumatoid arthritis (RA) patients. We aimed to evaluate the effect of RA disease activity on left ventricular (LV) and right ventricular (RV) functions by speckle tracking echocardiography (STE).

Methods

120 patients with RA without evidence of cardiovascular disease and 40 healthy control subjects were included. Disease activity was evaluated according to Simplified Disease Activity Index (SDAI) score and Disease Activity Score 28 (DAS28). LV and RV functions were assessed using conventional echocardiography and global longitudinal strain (GLS) technique measured by STE.

Results

81 patients had active disease while 39 patients were in remission. The LV and RV GLS value for active RA patients was reduced compared to RA patients in remission and control group (p = <0.001). There was a significant correlation between RA disease activity scores level and LV GLS value, increasing levels of disease activity was associated with worse LV GLS (r = −0.802, p value = <0.001) and r = −0.824, p value = <0.001) for SDAI and DAS28 scores respectively. Also, there were significant correlations between RA disease activity scores level and RV GLS value as the disease activity level increases the RV GLS value become worse (r = −0.682, p value = <0.001) and r = −0.731, p value = <0.001) for SDAI and DAS28 scores respectively Receiver operating characteristic (ROC) curve analysis showed that SDAI score and DAS28 were predictive for reduced LV GLS with a cut off value of >7 and >2.8 respectively with sensitivity of 77.6%, specificity of 85.0% and area under ROC curve = 90.4 for SDAI score and with sensitivity of 89.7%, specificity of 71.7% and area under ROC curve = 89.4 for DAS28 score. Also, SDAI score and DAS28 were predictive for reduced RV GLS with a cut off value of >11 and >3 respectively with sensitivity of 73.1%, specificity of 93.5% and area under ROC curve = 91.6 for SDAI score and with sensitivity of 84.6%, specificity of 80.4% and area under ROC curve = 90.8 for DAS28 score.

Conclusion

Disease activity in patients with rheumatoid arthritis is associated with lower left and right ventricular function. Disease activity scores can predict subclinical left and right ventricular dysfunction.

Layer-specific strain analysis in patients with suspected stable angina pectoris and apparently normal left ventricular wall motion

BACKGROUND

Non-invasive imaging tests are widely used in the evaluation of stable angina pectoris (SAP). Despite these tests, non-significant coronary lesions are not a rare finding in patients undergoing elective coronary angiography (CAG). Two-dimensional (2D) speckle tracking global longitudinal strain (GLS) imaging is a more sensitive and accurate technique for measuring LV function than conventional 2D methods. Layer-specific strain analysis is a relatively new method that provides endocardial and epicardial myocardial layer assessment. The aim of the present study was to evaluate longitudinal layer-specific strain (LSS) imaging in patients with suspected SAP.

METHODS

Patients who underwent CAG for SAP were retrospectively screened. A total of 79 patients with no history of heart disease and wall motion abnormalities were included in the study. Forty-three patients with coronary lesions > 70% constituted the coronary artery disease (CAD) group and 36 patients without significant CAD constituted the control group. Layer-specific GLS transmural, endocardium, and epicardium values (GLS-trans, GLS-endo, and GLS-epi, respectively) were compared between the groups.

RESULTS

Patients in the CAD group had significantly lower GLS values in all layers (GLS-trans: -18.2 + 2.4% vs -22.2 + 2.2% p < .001; GLS-endo: -20.8 + 2.8% vs -25.3 + 2.6%, p < .001; GLS-epi: 15.9 + 2.4% vs -19.5 + 1.9%, p < .001). Multivariate adjustment demonstrated GLS-trans as the only independent predictor of CAD [OR:0.472, CI (0.326-0.684), p < .001]. Additionally, the GLS values were all lower in myocardial perfusion scintigraphy (MPS) true-positive patients compared with MPS false-positive patients (GLS-trans: -17.7 ± 2.4 vs. -21.9 ± 2.4%, p < .001; GLS-endo: -20.2 ± 2.9% vs -24.9 ± 2.9%, P < .001; GLS-epi: 15.4 ± 2.6% vs. -19.2 ± 1.8%, P < .001).

CONCLUSION

Resting layer-specific strain as assessed by 2D speckle tracking analysis demonstrated that GLS values were reduced in all layers of myocardium with SAP and with no wall motion abnormalities. LSS analysis can improve the identification of patients with significant CAD but further prospective larger scale studies are needed to put forth the incremental value of LSS analysis over transmural GLS.

Ascending Aortic Strain Analysis Using 2-Dimensional Speckle Tracking Echocardiography Improves the Diagnostics for Coronary Artery Stenosis in Patients With Suspected Stable Angina Pectoris

Background

Arterial stiffening and atherosclerosis tend to coexist. Strain imaging, using a 2‐dimensional speckle tracking (2D‐ST) method, has been used for arterial stiffness assessment and early identification of atherosclerosis. We investigated whether the ascending aortic strain assessed by 2D‐ST echocardiography at rest can predict the presence of coronary artery disease (CAD).

Methods and Results

Two hundred seventy‐one consecutive patients with suspected stable angina pectoris sequentially underwent exercise treadmill testing, 2‐dimensional echocardiography, M‐mode echocardiography, 2D‐ST echocardiography, and coronary angiography. Circumferential ascending aortic strain (CAAS) and radial ascending aortic strain were assessed by 2D‐ST echocardiography. Ninety‐two patients with coronary lumen area stenosis ≥70% were categorized as having significant CAD. Global CAAS was significantly lower in patients with significant CAD (7.41±2.30% versus 11.54±4.03%; P<0.001) and remained an independent predictor of significant CAD (odds ratio, 0.64 [0.54–0.75]; P<0.001) after multivariate regression. Based on the receiver operating characteristic curve for diagnosing significant CAD, the optimal cut‐off value of global CAAS was ≤9.22% (sensitivity, 86%; specificity, 70%; area under curve=0.82; P<0.001). Global CAAS decreased with increasing severity of CAD and was significantly associated with 3‐vessel disease (odds ratio, 0.58 [0.42–0.79]; P<0.001). Diagnostics for significant CAD were remarkably better for global CAAS combined with exercise treadmill testing than for exercise treadmill testing alone (area under curve=0.88 versus 0.78; P<0.001).

Conclusions

Global CAAS assessed by 2D‐ST echocardiography at rest was able to predict the presence of significant CAD and identify multivessel disease. In addition, global CAAS combined with exercise treadmill testing remarkably improved the diagnostics for significant CAD.