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Brainin P, Biering-Sørensen SR, Møgelvang R, Søgaard P, Jensen JS, Biering-Sørensen T. Postsystolic Shortening by Speckle Tracking Echocardiography Is an Independent Predictor of Cardiovascular Events and Mortality in the General Population. J Am Heart Assoc 2018. [PMID: 29519813 PMCID: PMC5907576 DOI: 10.1161/jaha.117.008367] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Postsystolic shortening (PSS) has been proposed as a novel marker of contractile dysfunction in the myocardium. Our objective was to assess the prognostic potential of PSS on cardiovascular events and death in the general population. Methods and Results The study design consisted of a prospective cohort study of 1296 low‐risk participants from the general population, who were examined by speckle tracking echocardiography. The primary end point was the composite of heart failure, myocardial infarction, and cardiovascular death, defined as major adverse cardiovascular events (MACEs). The secondary end point was all‐cause death. The postsystolic index (PSI) was defined as follows: [(maximum strain in cardiac cycle−peak systolic strain)/(maximum strain in cardiac cycle)]×100. PSS was regarded as present if PSI >20%. During a median follow‐up of 11 years, 149 participants (12%) were diagnosed as having MACEs and 236 participants (18%) died. Increasing number of walls with PSS predicted both end points, an association that persisted after adjustment for age, sex, estimated glomerular filtration rate, global longitudinal strain, hypertension, heart rate, left ventricular ejection fraction, LV mass index, pro‐B‐type natriuretic peptide, previous ischemic heart disease, systolic blood pressure, average peak early diastolic longitudinal mitral annular velocity (e′), ratio between peak transmitral early and late diastolic inflow velocity (E/A), and left atrial volume index: MACEs (hazard ratio, 1.35; 95% confidence interval, 1.09–1.67; P=0.006 per 1 increase in walls displaying PSS) and death (hazard ratio, 1.30; 95% confidence interval, 1.08–1.57; P=0.006 per 1 increase in walls displaying PSS). The strongest predictor of end points was ≥2 walls exhibiting PSS. The PSI also predicted increased risk of the end points, and the associations remained significant in multivariable models: MACEs (per 1% increase in PSI: hazard ratio, 1.18; 95% confidence interval, 1.02–1.36; P=0.024) and death (per 1% increase in PSI: hazard ratio, 1.18; 95% confidence interval, 1.05–1.33; P=0.005). Conclusions Presence of PSS in the general population provides independent and long‐term prognostic information on the occurrence of MACEs and death.
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Affiliation(s)
- Philip Brainin
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Sofie Reumert Biering-Sørensen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark.,The Copenhagen City Heart Study, Frederiksberg Hospital University of Copenhagen, Denmark
| | - Rasmus Møgelvang
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark.,The Copenhagen City Heart Study, Frederiksberg Hospital University of Copenhagen, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital University of Aalborg, Denmark
| | - Jan Skov Jensen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark.,The Copenhagen City Heart Study, Frederiksberg Hospital University of Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark .,The Copenhagen City Heart Study, Frederiksberg Hospital University of Copenhagen, Denmark
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102
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Hagemann CE, Hoffmann S, Olsen FJ, Jørgensen PG, Fritz-Hansen T, Jensen JS, Biering-Sørensen T. Layer-specific global longitudinal strain reveals impaired cardiac function in patients with reversible ischemia. Echocardiography 2018; 35:632-642. [DOI: 10.1111/echo.13830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Christoffer E. Hagemann
- Department of Cardiology; Herlev & Gentofte Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
| | - Søren Hoffmann
- Department of Cardiology; Herlev & Gentofte Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
| | - Flemming J. Olsen
- Department of Cardiology; Herlev & Gentofte Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
| | - Peter G. Jørgensen
- Department of Cardiology; Herlev & Gentofte Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
| | - Thomas Fritz-Hansen
- Department of Cardiology; Herlev & Gentofte Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
| | - Jan S. Jensen
- Department of Cardiology; Herlev & Gentofte Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology; Herlev & Gentofte Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
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103
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Potter E, Marwick TH. Assessment of Left Ventricular Function by Echocardiography. JACC Cardiovasc Imaging 2018; 11:260-274. [DOI: 10.1016/j.jcmg.2017.11.017] [Citation(s) in RCA: 279] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 11/16/2017] [Accepted: 11/27/2017] [Indexed: 12/13/2022]
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Scharrenbroich J, Hamada S, Keszei A, Schröder J, Napp A, Almalla M, Becker M, Altiok E. Use of two-dimensional speckle tracking echocardiography to predict cardiac events: Comparison of patients with acute myocardial infarction and chronic coronary artery disease. Clin Cardiol 2018; 41:111-118. [PMID: 29359809 DOI: 10.1002/clc.22860] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/13/2017] [Accepted: 11/21/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Two-dimensional speckle strain (2D STE) echocardiography can aid in the prognosis of acute myocardial infarction (AMI) and chronic coronary artery disease (CAD). HYPOTHESIS Differences occur in the prediction of cardiac events using 2D STE in AMI vs CAD patients. METHODS In this prospective study, 94 patients with a first AMI and successful revascularization, and 137 patients with stable CAD after complete revascularization were included. In all patients, we performed echocardiography and myocardial deformation analysis for layer-specific global circumferential strain (GCS) and longitudinal strain. Receiver operating characteristic (ROC) curve analysis was used to predict the presence of a cardiac event using strain values and baseline characteristics in different regression models. RESULTS Patients were followed for 3.6 ± 0.8 years. Strain parameters in AMI and CAD patients were significantly different with respect to the occurrence of a cardiac event. Frequency of diabetes and hypertension was associated with the presence of a cardiac event in CAD patients. Furthermore, in CAD patients, ROC analysis demonstrated that the addition of endocardial GCS to baseline characteristics and ejection fraction to a regression model significantly improved the prediction of cardiac events (area under curve = 0.86, cutoff value: 20%, sensitivity: 79%, specificity: 84%). In contrast, the addition of strain parameters in AMI patients did not increase the prediction power for cardiac events. CONCLUSIONS Global strain parameters by 2D STE may be useful for the prediction of cardiac events in patients with CAD but add no supplemental information to baseline characteristic and ejection fraction in patients with AMI.
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Affiliation(s)
- Jörg Scharrenbroich
- Department of Cardiology, University Hospital Aachen, Rhenish-Westphalian Technical University, Aachen, Germany
| | - Sandra Hamada
- Department of Cardiology, University Hospital Aachen, Rhenish-Westphalian Technical University, Aachen, Germany
| | - Andras Keszei
- Department of Medical Statistics, University Hospital Aachen, Rhenish-Westphalian Technical University, Aachen, Germany
| | - Jörg Schröder
- Department of Cardiology, University Hospital Aachen, Rhenish-Westphalian Technical University, Aachen, Germany
| | - Andreas Napp
- Department of Cardiology, University Hospital Aachen, Rhenish-Westphalian Technical University, Aachen, Germany
| | - Mohammad Almalla
- Department of Cardiology, University Hospital Aachen, Rhenish-Westphalian Technical University, Aachen, Germany
| | - Michael Becker
- Department of Cardiology, University Hospital Aachen, Rhenish-Westphalian Technical University, Aachen, Germany
| | - Ertunc Altiok
- Department of Cardiology, University Hospital Aachen, Rhenish-Westphalian Technical University, Aachen, Germany
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105
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Biering-Sørensen F, Biering-Sørensen T, Liu N, Malmqvist L, Wecht JM, Krassioukov A. Alterations in cardiac autonomic control in spinal cord injury. Auton Neurosci 2018; 209:4-18. [DOI: 10.1016/j.autneu.2017.02.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 01/30/2017] [Accepted: 02/14/2017] [Indexed: 01/22/2023]
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Two-dimensional speckle-tracking global longitudinal strain in high-sensitivity troponin-negative low-risk patients with unstable angina: a “resting ischemia test”? Int J Cardiovasc Imaging 2017; 34:561-568. [DOI: 10.1007/s10554-017-1269-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/04/2017] [Indexed: 01/05/2023]
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107
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Moustafa S, Elrabat K, Swailem F, Galal A. The correlation between speckle tracking echocardiography and coronary artery disease in patients with suspected stable angina pectoris. Indian Heart J 2017; 70:379-386. [PMID: 29961454 PMCID: PMC6034017 DOI: 10.1016/j.ihj.2017.09.220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 08/30/2017] [Accepted: 09/26/2017] [Indexed: 11/18/2022] Open
Abstract
Background To examine the value of speckle tracking echocardiography to detect the presence, extent and severity of coronary artery affection in patients with suspected stable angina pectoris. Methods Two hundred candidates with suspected stable angina pectoris and normal resting conventional echocardiography were subjected to speckle tracking echocardiography and coronary angiography. Global and segmental longitudinal peak systolic strain were assessed and were correlated to the results of coronary angiography for each patient. Results There was a statistically significant difference in the mean of global longitudinal peak systolic strain between normal coronaries and different degrees of coronary artery disease (CAD) (−20.11 ± 0.8 for normal, −18.34 ± 2.52 for single vessel, −16.14 ± 2.85 for two vessels, −14.81 ± 2.12 for three vessels, −13.01 ± 2.92 for left main disease). GLPSS showed high sensitivity for the diagnosis of single vessel CAD (90%, specificity 95.1%, cutoff value: −18.44, AUC: 0.954); two vessels disease (90%, sensitivity 88.9%, cutoff value −17.35, AUC: 0.906) and for three vessels CAD (cutoff value −15.33, sensitivity 63% and specificity 72.2% AUC 0.681) segmental LPSS also showed statistical significance for localization of the affected vessel for left anterior descending, left circumflex and right coronary artery (ρ = 0.001) and inverse correlation with syntax score that was significant with high and intermediate score (ρ = 0.001) and insignificant for low syntax score (ρ value 0.05). Conclusion Two-dimensional speckle tracking echocardiography has good sensitivity and specificity to predict the presence, extent and severity of CAD.
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Affiliation(s)
- Shaimaa Moustafa
- Department of Cardiology, Benha Faculty of Medicine, Benha University, and National Heart Institute, Egypt.
| | - Khalid Elrabat
- Department of Cardiology, Benha Faculty of Medicine, Benha University, and National Heart Institute, Egypt
| | - Fathy Swailem
- Department of Cardiology, Benha Faculty of Medicine, Benha University, and National Heart Institute, Egypt
| | - Alaa Galal
- Department of Cardiology, Benha Faculty of Medicine, Benha University, and National Heart Institute, Egypt
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Eitan A, Kehat I, Mutlak D, Lichtenberg G, Amar D, Agmon Y. Longitudinal two-dimensional strain for the diagnosis of left ventricular segmental dysfunction in patients with acute myocardial infarction. Int J Cardiovasc Imaging 2017; 34:237-249. [PMID: 28825162 DOI: 10.1007/s10554-017-1231-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/08/2017] [Indexed: 12/21/2022]
Abstract
The objectives of this study were to assess whether 2-dimensional strain (2DS) can detect left ventricular (LV) segmental dysfunction and to compare the diagnostic accuracy of various 2DS parameters. Multiple segmental longitudinal 2DS parameters were measured in 54 patients with a first myocardial infarction and single vessel coronary artery disease (age: 56 ± 11 years, 74% men, LV ejection fraction: 47 ± 10%, left anterior descending artery occlusion in 63%) and 14 age-matched subjects. 2DS parameters were compared to visual assessment of segmental function by multiple observers. Using receiver-operating characteristics analysis, the area under the curve (AUC) for peak systolic strain in diagnosing segmental dysfunction (akinetic or hypokinetic LV segments) and for diagnosing akinetic segments was 0.85 (95% confidence interval 0.83-0.88) and 0.88 (0.85-0.90), respectively (all P values < 0.001). Other 2DS strain parameters had similar (peak strain, peak strain rate) or lower (post-systolic shortening, time-to-peak strain, diastolic 2DS parameters) AUC values. An absolute value of peak systolic strain <16.8% (25th percentile in normal subjects) had high sensitivity (0.89) and negative predictive values (0.88), but low specificity (0.55) and positive predictive values (0.59) for diagnosing segmental dysfunction. Similar findings were observed using a cutoff of <13.3% (absolute value of 10th percentile) for diagnosing akinetic segments. Diagnostic accuracy was significantly worse for segments in which visual segmental assessment was discordant between observers. In conclusion, 2DS can be used to diagnose segmental LV dysfunction with high sensitivity but limited specificity. The diagnostic limitation of 2DS is partially related to the visual echocardiographic definition of segmental abnormality.
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Affiliation(s)
- Amnon Eitan
- Echocardiography Laboratory and Heart Valves Clinic, Department of Cardiology, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, P. O. Box 9602, 31096, Haifa, Israel
| | - Izhak Kehat
- Echocardiography Laboratory and Heart Valves Clinic, Department of Cardiology, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, P. O. Box 9602, 31096, Haifa, Israel
| | - Diab Mutlak
- Echocardiography Laboratory and Heart Valves Clinic, Department of Cardiology, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, P. O. Box 9602, 31096, Haifa, Israel
| | - Gershom Lichtenberg
- Echocardiography Laboratory and Heart Valves Clinic, Department of Cardiology, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, P. O. Box 9602, 31096, Haifa, Israel
| | - Dina Amar
- Echocardiography Laboratory and Heart Valves Clinic, Department of Cardiology, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, P. O. Box 9602, 31096, Haifa, Israel
| | - Yoram Agmon
- Echocardiography Laboratory and Heart Valves Clinic, Department of Cardiology, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, P. O. Box 9602, 31096, Haifa, Israel.
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Solomon SD, Biering-Sørensen T. LA Strain When Ejection Fraction Is Preserved. JACC Cardiovasc Imaging 2017; 10:744-746. [DOI: 10.1016/j.jcmg.2016.09.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 09/29/2016] [Indexed: 11/27/2022]
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Roushdy A, Abou El Seoud Y, Abd Elrahman M, Wadeaa B, Eletriby A, Abd El Salam Z. The additional utility of two-dimensional strain in detection of coronary artery disease presence and localization in patients undergoing dobutamine stress echocardiogram. Echocardiography 2017; 34:1010-1019. [PMID: 28548371 DOI: 10.1111/echo.13569] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Dobutamine stress echocardiogram (DSE) is a feasible and safe exercise-independent stress modality for diagnoses of coronary artery disease (CAD), but it is subjective, and operator dependant. Two-dimensional strain at peak stress could overcome these limitations and thus increase the accuracy of DSE. METHODS AND RESULTS This was a prospective observational study in which 80 patients underwent DSE, two-dimensional strain at peak stress, and coronary angiography. Global longitudinal strains (GLS) cutoff point of -16.75 had 77.42% sensitivity and 83.33% specificity to detect significant CAD. Global circumferential strain (GCS) cutoff point of -20.75 had 93.55% sensitivity and 66.67% specificity to detect significant CAD (P=.003, areas under the curve [AUC]=0.73). The average territorial strain cutoff point for significant left anterior descending (LAD) lesion was -15.4 with 77.78% sensitivity and 82.86% specificity (P=.0001, AUC=0.78) and for non-LAD lesion was -16.9 with 82.93% sensitivity and 53.85% specificity (P=.0009, AUC=0.69). Two-dimensional strain at peak stress showed better agreement than DSE as regard number of vessels affected (K=0.579 vs 0.107), LAD lesion detection (K=0.783 vs 0.438), and non-LAD lesion detection (K=0.699 vs 0.233). Global longitudinal strain (GLS) at peak stress reduced DSE false positivity by 83%; the number of false-positive patients was reduced from 18 patients to only three patients. CONCLUSION Two-dimensional strain at peak stress had an incremental value over DSE visual assessment/ wall-motion score index (WMSI) in reducing false-positive results of DSE. Two-dimensional strain at peak stress had greater accuracy than DSE alone not only in detection of significant CAD but also in detection of number of vessels with significant lesion as well as CAD localization.
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Affiliation(s)
- Alaa Roushdy
- Cardiology Department, Ain Shams University Hospital, Cairo, Egypt
| | | | | | - Basem Wadeaa
- Cardiology Department, Ain Shams University Hospital, Cairo, Egypt
| | - Adel Eletriby
- Cardiology Department, Ain Shams University Hospital, Cairo, Egypt
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111
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Biering-Sørensen T, Biering-Sørensen SR, Olsen FJ, Sengeløv M, Jørgensen PG, Mogelvang R, Shah AM, Jensen JS. Global Longitudinal Strain by Echocardiography Predicts Long-Term Risk of Cardiovascular Morbidity and Mortality in a Low-Risk General Population: The Copenhagen City Heart Study. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005521. [PMID: 28264868 DOI: 10.1161/circimaging.116.005521] [Citation(s) in RCA: 264] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 01/20/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Global longitudinal strain (GLS) is prognostic of adverse cardiovascular outcomes in various patient populations, but the prognostic utility of GLS for long-term cardiovascular morbidity and mortality in the general population is unknown. METHODS AND RESULTS A total of 1296 participants in a general population study underwent a health examination, including echocardiography measurement of GLS. The primary end point was the composite of incident heart failure, acute myocardial infarction, or cardiovascular death. During a median follow-up of 11 years, 149 (12%) participants were diagnosed with heart failure, acute myocardial infarction, or cardiovascular death. Lower GLS was associated with a higher risk of the composite end point (hazard ratio, 1.12; 95% confidence interval, 1.08-1.17; P<0.001 per 1% decrease), an association that persisted after multivariable adjustment for age, sex, heart rate, hypertension, systolic blood pressure, left ventricular ejection fraction, left ventricular mass index, left ventricular dimension, deceleration time, left atrium dimension, E/e', and pro B-type natriuretic peptide (hazard ratio, 1.05; 95% confidence interval, 1.00-1.11; P=0.045 per 1% decrease). GLS provided incremental prognostic information beyond the Framingham Risk Score, the Systemic Coronary Evaluation risk chart, and the modified American College of Cardiology/American Heart Association Pooled Cohort Equation for the composite outcome and incident heart failure. Sex modified the relationship between GLS and outcome such that after multivariable adjustment, GLS was an independent predictor of outcomes in men but not in women (hazard ratio, 1.14; 95% confidence interval, 1.06-1.24; P=0.001, and hazard ratio, 0.99; 95% confidence interval, 0.92-1.07; P=0.81, respectively; P for interaction =0.032). CONCLUSIONS In the general population, GLS provides independent and incremental prognostic information regarding long-term risk of cardiovascular morbidity and mortality. GLS seems to be a stronger prognosticator in men than in women.
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Affiliation(s)
- Tor Biering-Sørensen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.).
| | - Sofie Reumert Biering-Sørensen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Flemming Javier Olsen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Morten Sengeløv
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Peter Godsk Jørgensen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Rasmus Mogelvang
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Amil M Shah
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Jan Skov Jensen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
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Grondin J, Waase M, Gambhir A, Bunting E, Sayseng V, Konofagou EE. Evaluation of Coronary Artery Disease Using Myocardial Elastography with Diverging Wave Imaging: Validation against Myocardial Perfusion Imaging and Coronary Angiography. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:893-902. [PMID: 28256343 PMCID: PMC5385294 DOI: 10.1016/j.ultrasmedbio.2017.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/19/2016] [Accepted: 01/04/2017] [Indexed: 05/27/2023]
Abstract
Myocardial elastography (ME) is an ultrasound-based technique that can image 2-D myocardial strains. The objectives of this study were to illustrate that 2-D myocardial strains can be imaged with diverging wave imaging and differ, on average, between normal and coronary artery disease (CAD) patients. In this study, 66 patients with symptoms of CAD were imaged with myocardial elastography before a nuclear stress test or an invasive coronary angiography. Radial cumulative strains were estimated in all patients. The end-systolic radial strain in the total cross section of the myocardium was significantly higher in normal patients (17.9 ± 8.7%) than in patients with reversible perfusion defect (6.2 ± 9.3%, p < 0.001) and patients with significant (-0.9 ± 7.4%, p < 0.001) and non-significant (3.7 ± 5.7%, p < 0.01) lesions. End-systolic radial strain in the left anterior descending, left circumflex and right coronary artery territory was found to be significantly higher in normal patients than in CAD patients. These preliminary findings indicate that end-systolic radial strain measured with ME is higher on average in healthy persons than in CAD patients and that ME has the potential to be used for non-invasive, radiation-free early detection of CAD.
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Affiliation(s)
- Julien Grondin
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Marc Waase
- Department of Medicine, Columbia University, New York, New York, USA
| | - Alok Gambhir
- Department of Medicine, Columbia University, New York, New York, USA
| | - Ethan Bunting
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Vincent Sayseng
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Elisa E Konofagou
- Department of Biomedical Engineering, Columbia University, New York, New York, USA; Department of Radiology, Columbia University, New York, New York, USA.
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Biering-Sørensen T, Knappe D, Pouleur AC, Claggett B, Wang PJ, Moss AJ, Solomon SD, Kutyifa V. Regional Longitudinal Deformation Improves Prediction of Ventricular Tachyarrhythmias in Patients With Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005096. [DOI: 10.1161/circimaging.116.005096] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 10/18/2016] [Indexed: 11/16/2022]
Abstract
Background—
Left ventricular dysfunction is a known predictor of ventricular arrhythmias. We hypothesized that measures of regional longitudinal deformation by speckle-tracking echocardiography predict ventricular tachyarrhythmias and provide incremental prognostic information over clinical and conventional echocardiographic characteristics.
Methods and Results—
We studied 1064 patients enrolled in the MADIT-CRT trial (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy) with speckle-tracking data available. Peak longitudinal strain was obtained for the septal, lateral, anterior, and inferior myocardial walls at baseline. The end point was the first event of ventricular tachycardia (VT) or fibrillation (VF). During the median follow-up of 2.9 years, 254 (24%) patients developed VT/VF. Patients with VT/VF had significantly lower left ventricular ejection fraction (28.3% versus 29.5%;
P
<0.001) and longitudinal strain in all myocardial walls compared with patients without VT/VF (anterior-strain, −7.7% versus −8.8%;
P
<0.001; lateral-strain, −7.3% versus −7.9%;
P
=0.022; inferior-strain, −8.3% versus −9.9%;
P
<0.001; septal-strain, −9.1% versus −10.0%;
P
<0.001). After multivariate adjustment, only anterior and inferior longitudinal strain remained independent predictors of VT/VF (anterior: hazard ratio, 1.08 [1.03–1.13];
P
=0.001; inferior: hazard ratio, 1.08 [1.04–1.12];
P
<0.001; per 1% absolute decrease for both). When including B-type natriuretic peptide in the model, only a decreasing myocardial function in the inferior myocardial wall predicted VT/VF (hazard ratio, 1.05 [1.00–1.11];
P
=0.039). Only strain obtained from the inferior myocardial wall provided incremental prognostic information for VT/VF over clinical and echocardiographic parameters (C statistic 0.71 versus 0.69;
P
=0.005).
Conclusions—
Assessment of regional longitudinal myocardial deformation in the inferior region provided incremental prognostic information over clinical and echocardiographic risk factors in predicting ventricular tachyarrhythmias.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00180271.
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Affiliation(s)
- Tor Biering-Sørensen
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Dorit Knappe
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Anne-Catherine Pouleur
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Brian Claggett
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Paul J. Wang
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Arthur J. Moss
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Scott D. Solomon
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Valentina Kutyifa
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
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114
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Dimitriu-Leen AC, Scholte AJHA, Katsanos S, Hoogslag GE, van Rosendael AR, van Zwet EW, Bax JJ, Delgado V. Influence of Myocardial Ischemia Extent on Left Ventricular Global Longitudinal Strain in Patients After ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2017; 119:1-6. [PMID: 27776800 DOI: 10.1016/j.amjcard.2016.08.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/25/2016] [Accepted: 08/25/2016] [Indexed: 11/28/2022]
Abstract
Two-dimensional echocardiographic left ventricular (LV) global longitudinal strain (GLS) after ST-segment elevation myocardial infarction (STEMI) is moderately correlated with infarct size and reflects the residual LV systolic function. This correlation may be influenced by the presence of myocardial ischemia. The present study investigated how myocardial ischemia modulates the correlation between LV GLS and infarct size determined with single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients with first STEMI treated with primary coronary intervention. A total of 1,128 patients (age 60 ± 11 years) who underwent SPECT MPI for the evaluation of infarct size and residual ischemia were evaluated. LV GLS was measured on transthoracic echocardiography. The time interval between echocardiography and SPECT MPI was 1 ± 1 month. A moderate correlation between echocardiographic LV GLS and infarct size on SPECT MPI was observed (r = 0.58, p <0.001). This correlation was weakened by the presence or extent of ischemia; in the group of patients without ischemia, the correlation between LV GLS and infarct size on SPECT MPI was r = 0.66 (p <0.001), whereas in patients with mild or moderate-to-severe ischemia, the correlations were r = 0.56 and 0.38, respectively (both p <0.001). Moderate-to-severe myocardial ischemia was independently associated with more impaired LV GLS after adjusting for infarct size, age, diabetes mellitus, and hypertension (β 0.60, 95% confidence interval 013 to 1.06). In conclusion, the presence of myocardial ischemia after STEMI impacts on the correlation between echocardiographic LV GLS and infarct size measured on SPECT MPI. Residual ischemia is independently associated with more impaired LV GLS.
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Affiliation(s)
| | - Arthur J H A Scholte
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Spyridon Katsanos
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Georgette E Hoogslag
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexander R van Rosendael
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics and Bio-informatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
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115
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Xu L, Cai Z, Xiong M, Li Y, Li G, Deng Y, Hau WK, Li S, Huang W, Qiu J. Efficacy of an early home-based cardiac rehabilitation program for patients after acute myocardial infarction: A three-dimensional speckle tracking echocardiography randomized trial. Medicine (Baltimore) 2016; 95:e5638. [PMID: 28033254 PMCID: PMC5207550 DOI: 10.1097/md.0000000000005638] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/14/2016] [Accepted: 11/21/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The effect of an early short-term home-based cardiac rehabilitation (CR) program on ventricular function in acute myocardial infarction (AMI) patients is not yet clear. The purpose of this study was to evaluate the efficacy of our CR program on the improvement of myocardial function using three-dimensional speckle tracking echocardiography (3D-STE) in AMI patients. METHODS Fifty-two AMI patients were randomly assigned to 2 groups after discharge: the rehabilitation group, which participated in an early, home-based CR program, and the control group, which received only usual care. All subjects in both groups underwent 3D-STE examinations of the left ventricle within 48 hours of percutaneous coronary intervention and again 4 weeks after discharge. Global longitudinal strain (GLS), global radial strain (GRS), global area strain (GAS), global circumferential strain (GCS), left ventricular ejection fraction (LVEF), and segmental strains were computed. The CR program was initially conducted with supervised inpatient training, followed by an unsupervised home-based training program during a 4-week follow-up. RESULTS We obtained segmental strains from 832 segments, of which 319 were defined as interventional segments, 179 as ischemic segments, and the remaining segments as normal segments. At the 4-week follow-up, when controlling for baseline values, the rehabilitation group showed significant improvements in GLS, GRS, GCS, GAS, LVEF, and in all of the segmental strains of the 3 subgroups compared with the control group (P <0.05). CONCLUSION Our study suggests that an early, home-based CR program can greatly improve the ventricular function of AMI patients in a short period of time.
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Affiliation(s)
- Lin Xu
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA
| | - Zekun Cai
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA
- The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Meihua Xiong
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA
| | - Yekuo Li
- Department of Ultrasound, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou
| | - Guoying Li
- Department of Ultrasound, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou
| | - Yu Deng
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA
| | - William Kongto Hau
- LiKaShing Faculty of Medicine, Institute of Cardiovascular Medicine and Research, University of Hong Kong, Hong Kong, China
| | - Shuo Li
- Department of Medical Imaging, Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Wenhua Huang
- School of Basic Medical Science, Southern Medical University, Guangzhou, China
| | - Jian Qiu
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA
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116
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Biering-Sørensen T, Santos M, Rivero J, McCullough SD, West E, Opotowsky AR, Waxman AB, Systrom DM, Shah AM. Left ventricular deformation at rest predicts exercise-induced elevation in pulmonary artery wedge pressure in patients with unexplained dyspnoea. Eur J Heart Fail 2016; 19:101-110. [PMID: 27878925 DOI: 10.1002/ejhf.659] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/01/2016] [Accepted: 08/15/2016] [Indexed: 11/09/2022] Open
Abstract
AIMS Impaired left ventricular (LV) deformation despite preserved LV ejection fraction (LVEF) is common and predicts outcomes in heart failure with preserved LVEF. We hypothesized that impaired LV deformation at rest is a marker of impaired cardiac systolic and diastolic reserve, and aimed to determine whether resting longitudinal (LS) and circumferential strain (CS) are associated with invasively measured haemodynamic response to exercise in patients with dyspnoea and a normal LVEF. METHODS AND RESULTS We studied 85 patients with LVEF ≥50% and free of significant valvular disease who were referred for evaluation of dyspnoea. All patients underwent rest echocardiography followed by right heart catheterization and cardiopulmonary exercise testing with concomitant invasive haemodynamic monitoring. The LS, CS and CS/LS ratio were measured by two-dimensional speckle-tracking echocardiography at rest. Lower absolute LS at rest was associated with greater increase in pulmonary arterial wedge pressure (PAWP) from rest to peak exercise (r = 0.23, P = 0.034). In contrast, higher absolute CS at rest predicted a greater increase in PAWP (r = - 0.27, P = 0.032) and greater stroke volume augmentation with exercise (r = - 0.26, P = 0.021). Higher CS/LS ratio was most predictive of elevation in PAWP with exercise (r = 0.30, P = 0.015). Of the measures of LV systolic and diastolic function assessed, the CS/LS ratio resulted in the highest area under the curve and specificity for the presence of rest- or exercise-induced pulmonary venous hypertension. CONCLUSION Left ventricular deformation at rest predicts exercise-induced rise in PAWP among patients with dyspnoea and a preserved LVEF. A pattern of rest deformation characterized by worse LS and exaggerated CS is most strongly associated with exercise-induced rise in PAWP.
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Affiliation(s)
- Tor Biering-Sørensen
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.,Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Mário Santos
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal
| | - Jose Rivero
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Shane D McCullough
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Erin West
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Alexander R Opotowsky
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.,Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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117
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Ejlersen JA, Poulsen SH, Mortensen J, May O. Diagnostic value of layer-specific global longitudinal strain during adenosine stress in patients suspected of coronary artery disease. Int J Cardiovasc Imaging 2016; 33:473-480. [PMID: 27878406 DOI: 10.1007/s10554-016-1022-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 11/12/2016] [Indexed: 12/12/2022]
Abstract
Speckle tracking global longitudinal strain (GLS) from dobutamine stress echocardiography (SE) predicts coronary artery disease (CAD). The diagnostic value of GLS from vasodilator SE and the additional value of layer-specific speckle tracking analysis are unclear. We explored the usefulness of layer-specific GLS and non-layer-specific strain (automated functional imaging, AFI) from adenosine SE. The included 132 patients (67% male, 62.6 (9.0) years), of which 46 (35%) had CAD defined as ≥1 stenosis ≥70% (≥50% in the left main), underwent adenosine SE and invasive coronary angiography. Resting AFI and layer-specific GLS were similar in patients with or without CAD (p > 0.05). The stress-rest difference (Δvalue = stress-value - rest-value) in patients with CAD was less pronounced compared to patients without proved CAD (Δendocardial GLS: -1.2 (3.5)% vs. -5.0 (3.2)%; Δmidventricular GLS: -0.95 (3.0)% vs. -4.2 (2.7)%; Δepicardial GLS: -0.7 (2.5)% vs. -3.4 (2.3)%; ΔAFI: -0.8 (2.9)% vs. -3.6 (3.1)%, p < 0.00001 for all comparisons). The diagnostic value of the three layer-specific GLS values and AFI were statistically similar (p = 0.19). The four Δvalues provided independent predictive value to the risk assessment given by gender, age, wall motion and ΔEF (p = 0.002, AFI and p < 0.0001, layer-specific GLS). The accuracies were acceptable (71-80%) with modest sensitivities (54-65%) and high specificities (80-91%). The deformation response to vasodilator infusion was associated with the presence of CAD. Endocardial, midventricular and epicardial GLS and AFI from adenosine SE had similar diagnostic values. The specificities were high, but the modest sensitivities are a limitation to the clinical application.
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Affiliation(s)
- June A Ejlersen
- Cardiovascular Research Unit, Herning, Denmark.
- Department of Nuclear Medicine, Regional Hospital Herning, Gl. Landevej 61, 7400, Herning, Denmark.
| | - Steen H Poulsen
- Department of Cardiology, Skejby University Hospital, Aarhus, Denmark
| | - Jesper Mortensen
- Department of Nuclear Medicine, Regional Hospital Herning, Gl. Landevej 61, 7400, Herning, Denmark
| | - Ole May
- Cardiovascular Research Unit, Herning, Denmark
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118
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Cai Z, Dai J, Wu D, Qiu J, Ma J, Li G, Zhu W, Lei H, Huang W, Zhang H, Xu L. The value of 3-dimensional longitudinal strain in the evaluation of complex coronary lesions in non-ST-segment elevation acute coronary syndrome patient. Medicine (Baltimore) 2016; 95:e4667. [PMID: 27684797 PMCID: PMC5265890 DOI: 10.1097/md.0000000000004667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 07/18/2016] [Accepted: 08/02/2016] [Indexed: 02/04/2023] Open
Abstract
The aim of this study is to investigate the value of 3-dimensional global peak longitudinal strain (GPLS) derived from the 3-dimensional speckle-tracking echocardiography (3D-STE) in the diagnosis of the complex non-ST-segment elevation acute coronary syndromes (NSTE-ACS) by comparing GPLS to the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score.A total of 59 inpatients with NSTE-ACS in our hospital between October 2014 and January 2015 were enrolled into our study. All these subjects underwent the coronary angiography (CAG) and 3D-STE examination. The results of CAG were used to calculate the SYNTAX scores in each subject. The GPLS was assessed with speckle-tracking analysis using the dedicated software developed by GE Healthcare (Horten, Norway).We grouped all subjects according to the SYNTAX scores. A total of 23 patients (39%) were grouped as complex NSTE-ACS in our experiment. In our analysis, the values of GPLS significantly decreased from low SYNTAX scores to intermediate or high SYNTAX scores (-14.0 ± 2.7% and -9.5 ± 2.8%, respectively, P < 0.001). Multivariate regression analysis showed that GPLS and diabetes mellitus were independent predictors for complex NSTE-ACS. The area under the receiver operator characteristic curve (AUC) for GPLS to evaluate patients with complex NSTE-ACS was 0.882 (95% confidence interval [CI], 0.797-0.967, P < 0.001) with an optimal cutoff value of -11.76% (sensitivity 82.6% and specificity 83.3%). The evaluative value of the adjusted AUC for evaluating patients with complex NSTE-ACS improved after inclusion of GPLS (C statistics, 0.827-0.948, P < 0.001).The value of GPLS is significantly associated with the complexity of coronary artery lesions, according to SYNTAX score. Therefore, our study indicates that GPLS could be reproducible and efficient to evaluate the complex coronary artery disease in NSTE-ACS patients.
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Affiliation(s)
- Zekun Cai
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou
- The Second Affiliated Hospital of Shantou University Medical College, Shantou
| | - Jianwei Dai
- The Second Affiliated Hospital of Shantou University Medical College, Shantou
| | - Dan Wu
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Shenzhen
| | - Jian Qiu
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou
| | - Jun Ma
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou
| | - Guoying Li
- Department of Ultrasound, Guangzhou General Hospital of Guangzhou Military Region, PLA
| | - Wei Zhu
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou
| | - Hongqiang Lei
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou
| | | | - Heye Zhang
- Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Shenzhen
- Correspondence: Lin Xu, Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou 510010, China (e-mail: ); Heye Zhang, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Shenzhen 518055, Guangdong, China (e-mail: )
| | - Lin Xu
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou
- Correspondence: Lin Xu, Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Region, PLA, Guangzhou 510010, China (e-mail: ); Heye Zhang, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Shenzhen 518055, Guangdong, China (e-mail: )
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119
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Bakhoum SW, Taha HS, Abdelmonem YY, Fahim MA. Value of resting myocardial deformation assessment by two dimensional speckle tracking echocardiography to predict the presence, extent and localization of coronary artery affection in patients with suspected stable coronary artery disease. Egypt Heart J 2016. [DOI: 10.1016/j.ehj.2016.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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120
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Radwan H, Hussein E. Value of global longitudinal strain by two dimensional speckle tracking echocardiography in predicting coronary artery disease severity. Egypt Heart J 2016; 69:95-101. [PMID: 29622962 PMCID: PMC5839366 DOI: 10.1016/j.ehj.2016.08.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/16/2016] [Accepted: 08/06/2016] [Indexed: 11/30/2022] Open
Abstract
Background Significant coronary artery stenosis might cause persistently impaired longitudinal left ventricle (LV) function at rest. LV global longitudinal strain (LVGLS) can be accurately assessed by 2D speckle-tracking strain echocardiography(2D-STE). Objective We aimed to evaluate the diagnostic accuracy of LV global longitudinal strain obtained by 2D-STE in prediction of severity of CAD. Methods Eighty patients with suspected stable angina pectoris were included. They underwent transthoracic echocardiography (TTE) to measure LV ejection fraction, 2-D-STE to measure GLS and coronary angiography (CA). The patients were divided into two groups: group 1 (58 patients) with significant (>70%) CAD, and group 2 (22 patients) with non-significant (<70%) CAD. Images were obtained in the apical long-axis, four-chamber, and two chamber views. Regional longitudinal systolic strain was measured in 17 myocardial segments and averaged to provide global longitudinal strain (LVGLS). Results There was significant decrease in GLS in group 1 compared to group 2 (−11.86 ± 2.89% versus −18.65 ± 0.79%, P < 0.000). The optimal cutoff value of GLS for prediction of significant CAD was −15.6% [AUC 0.88, 95% CI 0.78–0.96 p < 0.000]. The sensitivity, specificity and accuracy of GLS for detecting significant CAD were 93.1%, 81.8%,and 90% respectively.There was a significant positive correlation between GLS and EF (r = 0.33; p = 0.036).There was incremental significant decrease in GLS with increasing number of coronary vessels involved. Conclusion Measurement of global longitudinal strain using 2D speckle tracking echocardiography is sensitive and accurate tool in the prediction of severe CAD.
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Key Words
- 2-D speckle tracking echocardiography
- 2-DSTE, speckle-tracking strain echocardiography
- AVC, aortic valve closure
- BMI, body mass index
- BSA, body surface area
- CA, coronary angiography
- CAD
- CAD, coronary artery disease
- Coronary angiography
- DM, diabetes mellitus
- DVD, double vessel disease
- EDV, end diastolic volume
- EF, ejection fraction
- ESV, end systolic volume
- Global strain
- HTN, hypertension
- LAD, left anterior descending
- LCX, left circumflex
- LV, left ventricle
- RCA, right coronary artery
- SVD, single vessel disease
- TTE, transthoracic echocardiography, TVD, triple vessel disease
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Affiliation(s)
- Hanan Radwan
- Department of Cardiovascular, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ekhlas Hussein
- Department of Cardiovascular, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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121
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Liu C, Li J, Ren M, Wang ZZ, Li ZY, Gao F, Tian JW. Multilayer longitudinal strain at rest may help to predict significant stenosis of the left anterior descending coronary artery in patients with suspected non-ST-elevation acute coronary syndrome. Int J Cardiovasc Imaging 2016; 32:1675-1685. [PMID: 27522670 DOI: 10.1007/s10554-016-0959-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 08/08/2016] [Indexed: 12/21/2022]
Abstract
Two-dimensional speckle tracking echocardiography (2D-STE) multilayer analysis of myocardial deformation is a non-invasive method that enables discrimination of transmural differences owing to myocardial ischemia or necrosis. We wished to ascertain if multilayer longitudinal strains at rest are associated with significant (≥70 %) stenosis of the left anterior descending coronary artery (LAD) in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS). Our cohort comprised 113 consecutive patients with suspected NSTE-ACS and preserved ejection fraction (EF). Using coronary angiography, we diagnosed 63 patients with significant stenosis of the LAD and 50 patients without significant coronary artery disease. Echocardiography was done ≤48 h before angiography. Multilayer longitudinal strains were assessed from the endocardium, mid-myocardium and epicardium by 2D-STE. Regional longitudinal strain in LAD territory (RLSLAD) was calculated as the mean peak systolic longitudinal strain of segments subtended by the LAD for all myocardial layers. Significant differences were observed in all strain parameters between the two groups. RLSLAD and global longitudinal strain in the endocardium showed higher accuracy than that in the mid-myocardium and epicardium, wall motion score index (WMSI), WMSI in LAD territory, and EF for detection of significant LAD stenosis (all P < 0.05), with areas under the receiver operating characteristic curve of 0.87 and 0.91, respectively. An endocardial RLSLAD cutoff of -23.52 % showed optimal sensitivity and specificity (88.9/80.0 %). In patients with suspected NSTE-ACS, multilayer longitudinal strain analysis at rest might enable prediction of significant LAD stenosis, and could help to identify patients requiring reperfusion.
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Affiliation(s)
- Chong Liu
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, No. 148, Baojian Road, Nangang District, Harbin, 150086, China
| | - Jing Li
- Department of Ultrasound, First Hospital of Qiqihar City, No. 30, Gongyuan Road, Longsha District, Qiqihar, 161005, China
| | - Min Ren
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, No. 148, Baojian Road, Nangang District, Harbin, 150086, China
| | - Zhen-Zhen Wang
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, No. 148, Baojian Road, Nangang District, Harbin, 150086, China
| | - Zi-Yao Li
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, No. 148, Baojian Road, Nangang District, Harbin, 150086, China
| | - Fei Gao
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, No. 148, Baojian Road, Nangang District, Harbin, 150086, China
| | - Jia-Wei Tian
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, No. 148, Baojian Road, Nangang District, Harbin, 150086, China.
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122
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Zehir R, Karabay CY, Kocabay G, Erdem MR, Balaban M, Kirma C. Role of 2D Strain in the Early Identification of Cardiac Dysfunction and in the Risk Stratification of Arteriogenic Erectile Dysfunction Patients. J Sex Med 2016; 13:1227-32. [DOI: 10.1016/j.jsxm.2016.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 05/09/2016] [Accepted: 05/13/2016] [Indexed: 10/21/2022]
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123
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Park JH, Woo JS, Ju S, Jung SW, Lee I, Kim JB, Kim SJ, Kim W, Kim WS, Kim KS. Layer-specific analysis of dobutamine stress echocardiography for the evaluation of coronary artery disease. Medicine (Baltimore) 2016; 95:e4549. [PMID: 27512879 PMCID: PMC4985334 DOI: 10.1097/md.0000000000004549] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Although dobutamine stress echocardiography (DSE) is a well-defined tool for the diagnosis of coronary artery disease (CAD), false-negative and false-positive results still occur. This study investigated the diagnostic role of layer-specific analysis using 2-dimensional speckle-tracking echocardiography (STE) during DSE.A total of 121 patients who underwent DSE and showed normal wall motion and ejection fraction during baseline echocardiography were enrolled. All patients underwent coronary angiography after DSE within 2 weeks. The patients were divided into the following 4 groups according to DSE results and CAD status: negative DSE with no significant CAD (n = 73), positive DSE with significant CAD (n = 16), negative DSE with significant CAD (n = 17), and positive DSE with no significant CAD (n = 15). Layer-specific global longitudinal strain (GLS) was assessed in the endocardium, mid-myocardium, and epicardium by STE techniques.Patients with significant CAD were older, more male and showed higher glucose level compared to patients without CAD. But coronary risk factors and previous medications were not different between patients with and without CAD. There were no significant differences in whole myocardium or layer-specific GLS found in the baseline echocardiography. During recovery echocardiography, endocardial GLS was significantly different between patients with and without CAD, regardless of the DSE results. A receiver-operating characteristic curve analysis showed that endocardial GLS (>-16%) was superior for identifying significant CAD during the DSE recovery stage. Diagnostic accuracy was improved by applying the results of endocardial GLS compared with visual estimation of DSE.The assessment of layer-specific strain by STE during DSE was feasible, and the evaluation of poststress endocardial function is a more sensitive tool for the detection of CAD.
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Affiliation(s)
- Jae Hun Park
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Jong Shin Woo
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Shin Ju
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Su Woong Jung
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Insoo Lee
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
- Department of Laboratory Medicine, College of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Jin Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Soo Joong Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Weon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Woo-Shik Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Kwon Sam Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
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124
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Ejlersen JA, Poulsen SH, Mortensen J, May O. A comparison of the diagnostic value of 2D strain stress echocardiography, myocardial perfusion scintigraphy, and Duke treadmill score in patients suspected of coronary artery disease. Echocardiography 2016; 33:1523-1531. [DOI: 10.1111/echo.13297] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- June A. Ejlersen
- Cardiovascular Research Unit; Regional Hospital Herning; Herning Denmark
- Department of Nuclear Medicine; Regional Hospital Herning; Herning Denmark
| | - Steen H. Poulsen
- Department of Cardiology; Skejby University Hospital; Aarhus Denmark
| | - Jesper Mortensen
- Department of Nuclear Medicine; Regional Hospital Herning; Herning Denmark
| | - Ole May
- Cardiovascular Research Unit; Regional Hospital Herning; Herning Denmark
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125
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Biering-Sørensen T, Jensen JS, Pedersen SH, Galatius S, Fritz-Hansen T, Bech J, Olsen FJ, Mogelvang R. Regional Longitudinal Myocardial Deformation Provides Incremental Prognostic Information in Patients with ST-Segment Elevation Myocardial Infarction. PLoS One 2016; 11:e0158280. [PMID: 27348525 PMCID: PMC4922592 DOI: 10.1371/journal.pone.0158280] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/13/2016] [Indexed: 11/19/2022] Open
Abstract
Background Global longitudinal systolic strain (GLS) has recently been demonstrated to be a superior prognosticator to conventional echocardiographic measures in patients after myocardial infarction (MI). The aim of this study was to evaluate the prognostic value of regional longitudinal myocardial deformation in comparison to GLS, conventional echocardiography and clinical information. Method In total 391 patients were admitted with ST-Segment elevation myocardial infarction (STEMI), treated with primary percutaneous coronary intervention and subsequently examined by echocardiography. All patients were examined by tissue Doppler imaging (TDI) and two-dimensional strain echocardiography (2DSE). Results During a median-follow-up of 5.3 (IQR 2.5–6.1) years the primary endpoint (death, heart failure or a new MI) was reached by 145 (38.9%) patients. After adjustment for significant confounders (including conventional echocardiographic parameters) and culprit lesion, reduced longitudinal performance in the anterior septal and inferior myocardial regions (but not GLS) remained independent predictors of the combined outcome. Furthermore, inferior myocardial longitudinal deformation provided incremental prognostic information to clinical and conventional echocardiographic information (Harrell's c-statistics: 0.63 vs. 0.67, p = 0.032). In addition, impaired longitudinal deformation outside the culprit lesion perfusion region was significantly associated with an adverse outcome (p<0.05 for all deformation parameters). Conclusion Regional longitudinal myocardial deformation measures, regardless if determined by TDI or 2DSE, are superior prognosticators to GLS. In addition, impaired longitudinal deformation in the inferior myocardial segment provides prognostic information over and above clinical and conventional echocardiographic risk factors. Furthermore, impaired longitudinal deformation outside the culprit lesion perfusion region seems to be a paramount marker of adverse outcome.
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Affiliation(s)
- Tor Biering-Sørensen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
| | - Jan Skov Jensen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sune H. Pedersen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Søren Galatius
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Fritz-Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jan Bech
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Rasmus Mogelvang
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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Midtbø H, Semb AG, Matre K, Kvien TK, Gerdts E. Disease activity is associated with reduced left ventricular systolic myocardial function in patients with rheumatoid arthritis. Ann Rheum Dis 2016; 76:371-376. [PMID: 27269296 DOI: 10.1136/annrheumdis-2016-209223] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 04/14/2016] [Accepted: 05/17/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Disease activity has emerged as a new, independent risk factor for cardiovascular disease in patients with rheumatoid arthritis (RA). We tested if disease activity in RA was associated with lower left ventricular (LV) systolic function independent of traditional cardiovascular risk factors. METHODS Echocardiographic assessment was performed in 78 patients with RA having low, moderate or high disease activity (Simplified Disease Activity Index (SDAI) >3.3), 41 patients in remission (SDAI ≤3.3) and 46 controls, all without known cardiac disease. LV systolic function was assessed by biplane Simpson ejection fraction, stress-corrected midwall shortening (scMWS) and global longitudinal strain (GLS). RESULTS Patients with active RA had higher prevalence of hypertension and diabetes compared with patients in remission and controls (both p<0.05). LV ejection fraction (endocardial function) was normal in all three groups, while mean scMWS and GLS (myocardial function) were reduced in patients with RA with active disease compared with patients with RA in remission (95±18% vs 105±17% and -18.9±3.1% vs -20.6±3.5%, respectively, both p<0.01). Patients with RA in remission had similar scMWS and GLS as the controls. In multivariable analyses, having active RA was associated with lower GLS (β=0.21) and scMWS (β=-0.22, both p<0.05), both reflecting lower LV systolic myocardial function, independent of cardiovascular risk factors and LV ejection fraction. Classification of RA disease activity by other disease activity composite scores yielded similar results. CONCLUSIONS Active RA is associated with lower LV systolic myocardial function despite normal ejection fraction and independent of traditional cardiovascular risk factors.
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Affiliation(s)
- Helga Midtbø
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anne Grete Semb
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Knut Matre
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tore K Kvien
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Eva Gerdts
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Liou K, Negishi K, Ho S, Russell EA, Cranney G, Ooi SY. Detection of Obstructive Coronary Artery Disease Using Peak Systolic Global Longitudinal Strain Derived by Two-Dimensional Speckle-Tracking: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr 2016; 29:724-735.e4. [PMID: 27155815 DOI: 10.1016/j.echo.2016.03.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Indexed: 10/21/2022]
Abstract
BACKGROUND Global longitudinal strain (GLS) is well validated and has important applications in contemporary clinical practice. The aim of this analysis was to evaluate the accuracy of resting peak GLS in the diagnosis of obstructive coronary artery disease (CAD). METHODS A systematic literature search was performed through July 2015 using four databases. Data were extracted independently by two authors and correlated before analyses. Using a random-effect model, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and summary area under the curve for GLS were estimated with their respective 95% CIs. RESULTS Screening of 1,669 articles yielded 10 studies with 1,385 patients appropriate for inclusion in the analysis. The mean age and left ventricular ejection fraction were 59.9 years and 61.1%. On the whole, 54.9% and 20.9% of the patients had hypertension and diabetes, respectively. Overall, abnormal GLS detected moderate to severe CAD with a pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 74.4%, 72.1%, 2.9, and 0.35 respectively. The area under the curve and diagnostic odds ratio were 0.81 and 8.5. The mean values of GLS for those with and without CAD were -16.5% (95% CI, -15.8% to -17.3%) and -19.7% (95% CI, -18.8% to -20.7%), respectively. Subgroup analyses for patients with severe CAD and normal left ventricular ejection fractions yielded similar results. CONCLUSION Current evidence supports the use of GLS in the detection of moderate to severe obstructive CAD in symptomatic patients. GLS may complement existing diagnostic algorithms and act as an early adjunctive marker of cardiac ischemia.
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Affiliation(s)
- Kevin Liou
- Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
| | - Kazuaki Negishi
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Suyen Ho
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | | | - Greg Cranney
- Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia
| | - Sze-Yuan Ooi
- Eastern Heart Clinic, Prince of Wales Hospital, Sydney, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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128
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Evaluation of cardiac functions in juvenile systemic lupus erythematosus with two-dimensional speckle tracking echocardiography. Clin Rheumatol 2016; 35:1967-1975. [PMID: 27139514 DOI: 10.1007/s10067-016-3289-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/19/2016] [Accepted: 04/20/2016] [Indexed: 10/21/2022]
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129
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Biering-Sørensen T, Olsen FJ, Storm K, Fritz-Hansen T, Olsen NT, Jøns C, Vinther M, Søgaard P, Risum N. Prognostic value of tissue Doppler imaging for predicting ventricular arrhythmias and cardiovascular mortality in ischaemic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2016; 17:722-31. [DOI: 10.1093/ehjci/jew066] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 03/07/2016] [Indexed: 12/24/2022] Open
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Smiseth OA, Torp H, Opdahl A, Haugaa KH, Urheim S. Myocardial strain imaging: how useful is it in clinical decision making? Eur Heart J 2016; 37:1196-207. [PMID: 26508168 PMCID: PMC4830908 DOI: 10.1093/eurheartj/ehv529] [Citation(s) in RCA: 530] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/13/2015] [Accepted: 09/21/2015] [Indexed: 01/19/2023] Open
Abstract
Myocardial strain is a principle for quantification of left ventricular (LV) function which is now feasible with speckle-tracking echocardiography. The best evaluated strain parameter is global longitudinal strain (GLS) which is more sensitive than left ventricular ejection fraction (LVEF) as a measure of systolic function, and may be used to identify sub-clinical LV dysfunction in cardiomyopathies. Furthermore, GLS is recommended as routine measurement in patients undergoing chemotherapy to detect reduction in LV function prior to fall in LVEF. Intersegmental variability in timing of peak myocardial strain has been proposed as predictor of risk of ventricular arrhythmias. Strain imaging may be applied to guide placement of the LV pacing lead in patients receiving cardiac resynchronization therapy. Strain may also be used to diagnose myocardial ischaemia, but the technology is not sufficiently standardized to be recommended as a general tool for this purpose. Peak systolic left atrial strain is a promising supplementary index of LV filling pressure. The strain imaging methodology is still undergoing development, and further clinical trials are needed to determine if clinical decisions based on strain imaging result in better outcome. With this important limitation in mind, strain may be applied clinically as a supplementary diagnostic method.
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Affiliation(s)
- Otto A Smiseth
- Division of Cardiovascular and Pulmonary Diseases, Department of Cardiology and Institute for Surgical Research, Center for Heart Failure Research, Center for Cardiological Innovation and KG Jebsen Cardiac Research Centre Oslo, Oslo University Hospital, University of Oslo, Rikshospitalet, N-0027 Oslo, Norway
| | - Hans Torp
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, 7489 Trondheim, Norway
| | - Anders Opdahl
- Division of Cardiovascular and Pulmonary Diseases, Department of Cardiology and Institute for Surgical Research, Center for Heart Failure Research, Center for Cardiological Innovation and KG Jebsen Cardiac Research Centre Oslo, Oslo University Hospital, University of Oslo, Rikshospitalet, N-0027 Oslo, Norway
| | - Kristina H Haugaa
- Division of Cardiovascular and Pulmonary Diseases, Department of Cardiology and Institute for Surgical Research, Center for Heart Failure Research, Center for Cardiological Innovation and KG Jebsen Cardiac Research Centre Oslo, Oslo University Hospital, University of Oslo, Rikshospitalet, N-0027 Oslo, Norway
| | - Stig Urheim
- Division of Cardiovascular and Pulmonary Diseases, Department of Cardiology and Institute for Surgical Research, Center for Heart Failure Research, Center for Cardiological Innovation and KG Jebsen Cardiac Research Centre Oslo, Oslo University Hospital, University of Oslo, Rikshospitalet, N-0027 Oslo, Norway
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131
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Sengeløv M, Jørgensen PG, Jensen JS, Bruun NE, Olsen FJ, Fritz-Hansen T, Nochioka K, Biering-Sørensen T. The Authors Reply. JACC Cardiovasc Imaging 2016; 9:901-902. [PMID: 26971000 DOI: 10.1016/j.jcmg.2016.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 01/27/2016] [Indexed: 11/25/2022]
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Olsen FJ, Jørgensen PG, Dons M, Svendsen JH, Køber L, Jensen JS, Biering-Sørensen T. Echocardiographic quantification of systolic function during atrial fibrillation: probing the ‘ten heart cycles’ rule. Future Cardiol 2016; 12:159-65. [DOI: 10.2217/fca.15.77] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
It is often difficult to provide an exact echocardiographic measure of left ventricular systolic function in patients with atrial fibrillation, partly because of the varying cycle length affecting pre and afterload and partly because of the increased heart rate often accompanying this arrhythmia. We sought to elucidate two points: whether it would be possible to correct for the cyclic variance in systolic output, and if global longitudinal strain is preferable to the left ventricular ejection fraction at evaluating systolic function during atrial fibrillation.
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Affiliation(s)
- Flemming Javier Olsen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Denmark, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Peter Godsk Jørgensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Denmark, Niels Andersens Vej 65, 2900 Hellerup, Denmark
- Institute of Clinical Medicine, Faculty of Health & Medical Sciences, University of Copenhagen, Denmark
| | - Maria Dons
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Denmark, Niels Andersens Vej 65, 2900 Hellerup, Denmark
| | - Jesper Hastrup Svendsen
- Institute of Clinical Medicine, Faculty of Health & Medical Sciences, University of Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | - Lars Køber
- Institute of Clinical Medicine, Faculty of Health & Medical Sciences, University of Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | - Jan Skov Jensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Denmark, Niels Andersens Vej 65, 2900 Hellerup, Denmark
- Institute of Clinical Medicine, Faculty of Health & Medical Sciences, University of Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Denmark, Niels Andersens Vej 65, 2900 Hellerup, Denmark
- Department of Medicine, Cardiovascular Medicine Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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133
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Biering-Sørensen T, Solomon SD. Assessing Contractile Function When Ejection Fraction Is Normal. Circ Cardiovasc Imaging 2015; 8:e004181. [DOI: 10.1161/circimaging.115.004181] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Tor Biering-Sørensen
- From the Cardiovascular Medicine Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., S.D.S.); and Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S)
| | - Scott D. Solomon
- From the Cardiovascular Medicine Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., S.D.S.); and Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S)
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134
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Norum IB, Ruddox V, Edvardsen T, Otterstad JE. Diagnostic accuracy of left ventricular longitudinal function by speckle tracking echocardiography to predict significant coronary artery stenosis. A systematic review. BMC Med Imaging 2015. [PMID: 26204938 PMCID: PMC4513709 DOI: 10.1186/s12880-015-0067-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Patients evaluated for acute and chronic chest pain comprise a large, heterogeneous group that often provides diagnostic challenges. Although speckle tracking echocardiography (STE) has proved to have diagnostic value in acute coronary syndrome it is not commonly incorporated in everyday practice. The purpose of the present systematic review was to assess the diagnostic accuracy of left ventricular (LV) longitudinal function by STE to predict significant coronary artery stenosis (CAD+) or not (CAD-) verified by coronary angiography in patients with chest pain suspected to be of cardiac ischemic origin. Methods 4 electronic databases; Embase, Medline, Cochrane and PubMed ahead-of print were searched for per 19.05.14. Only full-sized articles including > 40 patients were selected. Results A total of 166 citations were identified, 16 full-size articles were assessed of which 6 were found eligible for this review. Of 781 patients included 397 (60 %) had CAD+. The overall weighted mean global longitudinal strain (GLS) was −17.2 % (SD = 2.6) among CAD+ vs. -19.2 % (SD = 2.8) in CAD- patients. Mean area under curve in 4 studies for predicting CAD+ ranged from 0.68 to 0.80. The study cut-off levels for prediction of CAD+ in the ROC analysis varied between −17.4 % and −19.7 % with sensitivity from 51 % to 81 % and specificity between 58 % and 81 %. In 1 study GLS obtained during dobutamine stress echocardiography (DSE) had the best accuracy. Regional strain measurements were not uniform, but may have potential in detecting CAD. Conclusions GLS measurements at rest only have modest diagnostic accuracy in predicting CAD+ among patients presenting with acute or chronic chest pain. The results from regional strain, layer specific strain and DSE need to be verified in larger studies. Electronic supplementary material The online version of this article (doi:10.1186/s12880-015-0067-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingvild Billehaug Norum
- Department of Cardiology, Vestfold Hospital Trust, Pb 2168, 3103, Tønsberg, Norway. .,University of Oslo, Faculty of Medicine, Pb 1078 , Blindern, 0316, Oslo, Norway.
| | - Vidar Ruddox
- Department of Cardiology, Vestfold Hospital Trust, Pb 2168, 3103, Tønsberg, Norway. .,University of Oslo, Faculty of Medicine, Pb 1078 , Blindern, 0316, Oslo, Norway.
| | - Thor Edvardsen
- University of Oslo, Faculty of Medicine, Pb 1078 , Blindern, 0316, Oslo, Norway. .,Department of Cardiology, Oslo University Hospital, Rikshospitalet, Pb 4950, Nydalen, 0424, Oslo, Norway.
| | - Jan Erik Otterstad
- Department of Cardiology, Vestfold Hospital Trust, Pb 2168, 3103, Tønsberg, Norway.
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Stankovic I, Putnikovic B, Janicijevic A, Jankovic M, Cvjetan R, Pavlovic S, Kalezic-Radmili T, Panic M, Milicevic P, Ilic I, Cvorovic V, Neskovic AN. Myocardial mechanical and QTc dispersion for the detection of significant coronary artery disease. ACTA ACUST UNITED AC 2015; 16:1015-22. [DOI: 10.1093/ehjci/jev029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/03/2015] [Indexed: 11/13/2022]
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136
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Opdahl A, Helle-Valle T, Skulstad H, Smiseth OA. Strain, Strain Rate, Torsion, and Twist: Echocardiographic Evaluation. Curr Cardiol Rep 2015; 17:568. [DOI: 10.1007/s11886-015-0568-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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137
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Caselli S, Montesanti D, Autore C, Di Paolo FM, Pisicchio C, Squeo MR, Musumeci B, Spataro A, Pandian NG, Pelliccia A. Patterns of Left Ventricular Longitudinal Strain and Strain Rate in Olympic Athletes. J Am Soc Echocardiogr 2015; 28:245-53. [DOI: 10.1016/j.echo.2014.10.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Indexed: 02/06/2023]
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138
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Carstensen HG, Larsen LH, Hassager C, Kofoed KF, Jensen JS, Mogelvang R. Association of ischemic heart disease to global and regional longitudinal strain in asymptomatic aortic stenosis. Int J Cardiovasc Imaging 2014; 31:485-95. [DOI: 10.1007/s10554-014-0572-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 11/10/2014] [Indexed: 11/30/2022]
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Gaibazzi N, Pigazzani F, Reverberi C, Porter TR. Rest global longitudinal 2D strain to detect coronary artery disease in patients undergoing stress echocardiography: a comparison with wall-motion and coronary flow reserve responses. Echo Res Pract 2014; 1:61-70. [PMID: 26693302 PMCID: PMC4676453 DOI: 10.1530/erp-14-0020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/26/2014] [Accepted: 11/03/2014] [Indexed: 11/30/2022] Open
Abstract
Myocardium subtended by obstructive coronary artery disease (CAD) may show reduced left ventricle (LV) global longitudinal strain (GLS), as well as early systolic lengthening (ESL) before shortening; these can be measured at rest and may predict obstructive CAD. This study investigated whether baseline resting LV longitudinal strain measurements may be able to detect significant CAD in patients undergoing stress echocardiography (SE) and coronary angiography, who have normal resting wall motion. We selected patients with a clinical indication of coronary angiography who were previously referred for SE. Patients with known CAD, rest wall-motion (WM) abnormalities, or rhythm/conduction abnormalities were excluded. Speckle tracking strain analyses were retrospectively performed on digitally archived 2D video-loops, using vendor independent software. Peak GLS and duration of ESL were recorded. Diagnostic accuracy of each parameter to predict obstructive (≥50%) CAD was assessed and multivariate logistic regression models fitted and compared. Eighty-two patients were enrolled and 49 had significant CAD by quantitative angiography. Patients with CAD were more often male (P=0.01) and more frequently presented with typical angina (P<0.01). Among rest and stress variables, GLS showed a Youden index of 0.665, while SE WM assessment showed a Youden index of 0.599. These were the only two parameters that remained predictive in multivariate analyses. In conclusion, rest GLS demonstrated comparable accuracy with stress-echo data for prediction of angiographically obstructive CAD; it also added significant CAD prediction when combined with clinical data, similar to SE WM assessment.
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Affiliation(s)
- Nicola Gaibazzi
- Parma University Hospital , Via Gramsci, 14, Parma, 43124 , Italy
| | | | | | - Thomas R Porter
- University of Nebraska Medical Center , Omaha, Nebraska , USA
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140
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Stankovic I, Putnikovic B, Cvjetan R, Milicevic P, Panic M, Kalezic-Radmili T, Mandaric T, Vidakovic R, Cvorovic V, Neskovic AN. Visual assessment vs. strain imaging for the detection of critical stenosis of the left anterior descending coronary artery in patients without a history of myocardial infarction. Eur Heart J Cardiovasc Imaging 2014; 16:402-9. [PMID: 25336543 DOI: 10.1093/ehjci/jeu206] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS We sought to determine the prevalence of overt and subclinical LV dysfunction in patients with critical left anterior descending coronary artery (LAD) stenosis but without a history of myocardial infarction and to compare diagnostic value of routine echocardiographic parameters with myocardial strain analysis for detection of critical LAD stenosis. METHODS AND RESULTS We retrospectively studied 269 patients with suspected coronary artery disease (CAD)-209 consecutive patients with critical LAD stenosis and 60 consecutive patients with atypical chest pain and without CAD. Conventional visual assessment of LV asynergy in the LAD territory was compared with global, regional, and segmental peak systolic longitudinal strain (PSLS) parameters derived by two-dimensional speckle tracking echocardiography (2D STE). Wall motion abnormalities in the LAD territory were found in 41% of patients with critical LAD stenosis, whereas, depending on the cut-off value, global longitudinal strain (GLS) was impaired in 42-69% of patients. GLS with an area under the receiver operating characteristic curve (AUC) of 0.85 showed better discriminative power for detecting critical LAD stenosis than conventional wall motion score index (AUC 0.73, P < 0.05, for the difference between the AUCs). PSLS values were significantly lower in basal and midventricular segments supplied by critically narrowed LAD, particularly if they also appeared dysfunctional on visual assessment. CONCLUSIONS Detection of subclinical LV dysfunction by 2D STE might improve identification of patients with critical LAD stenosis, although visually apparent regional LV dysfunction in the LAD territory is not uncommon finding in this subset of patients.
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Affiliation(s)
- Ivan Stankovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Biljana Putnikovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Radosava Cvjetan
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Predrag Milicevic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Milos Panic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Tijana Kalezic-Radmili
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Tijana Mandaric
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Radosav Vidakovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Vojkan Cvorovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
| | - Aleksandar N Neskovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Vukova 9, Belgrade 11070, Serbia
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