Global Longitudinal Strain at Rest for Detection of Coronary Artery Disease in Patients without Diabetes Mellitus

The 2-year postoperative left heart function in marginal donor heart recipients assessing by speckle tracking echocardiography

This study analyzed the differences and explored the donor/recipient factors between marginal and standard donor heart recipients after heart transplantation (HT) by speckle tracking echocardiography (STE). Seventy-two HT patients were enrolled: 25 standard and 47 marginal donor heart recipients. Thirty HT patients completed 2-year continuous follow-up (1, 6, 12, 24 months). Thirty healthy volunteers were controls. STE was used to track the strain characteristics of the left ventricle and atrium for detecting early changes in marginal donor heart recipients, including left ventricular global longitudinal, circumferential and radial strain (LVGLS, LVGCS, LVGRS) and left atrial strain in systole (LAS-S) and late diastole (LAS-A). The perioperative parameters were similar between the standard and marginal groups. No significant differences were found in left heart size, systolic and diastolic function parameters. Left ventricular systolic strain (LVGLS, LVGCS, LVGRS) and systolic and late diastolic left atrial strain (LAS-S, LAS-A) were lower in the HT recipients than the control group (P < 0.05), but there was no difference between the marginal and standard groups (P > 0.05). LVGLS, LVGCS, and LAS-S were low in the marginal group 1 month after surgery but recovered gradually at 6 months. The patients with donor/recipient body weight ratio < 0.8 group had lower LVGLS and LAS-S. STE showed no significant difference between marginal and standard donor recipients. The LVGLS and LAS-S were lower in those with a smaller donor/recipient body weight ratio. The cardiac function of HT patients was lower in the early postoperative period but gradually recovered over time.

Strain Rate Changes during Stress Echocardiography Are the Most Accurate Predictors of Significant Coronary Artery Disease in Patients with Previously Treated Acute Coronary Syndrome

BACKGROUND AND AIMS

Dobutamine stress echocardiography (DSE) is a well-established non-invasive investigation for the detection of ischemic myocardial dysfunction. The aim of this study was to evaluate the accuracy of myocardial deformation parameters measured by speckle tracking echocardiography (STE) in predicting culprit coronary artery lesions in patients with prior revascularization and acute coronary syndrome (ACS).

METHODS

We prospectively studied 33 patients with ischemic heart disease, a history of at least one episode of ACS and prior revascularization. All patients underwent a complete stress Doppler echocardiographic examination, including the myocardial deformation parameters of peak systolic strain (PSS), peak systolic strain rate (SR) and wall motion score index (WMSI). The regional PSS and SR were analyzed for different culprit lesions.

RESULTS

The mean age of patients was 59 ± 11 years and 72.7% were males. At peak dobutamine stress, the change in regional PSS and SR in territories supplied by the LAD showed smaller increases compared to those in patients without culprit LAD lesions (p < 0.05 for all). Likewise, the regional parameters of myocardial deformation were reduced in patients with culprit LCx lesions compared to those with non-culprit LCx lesions and in patients with culprit RCA legions compared to those with non-culprit RCA lesions (p < 0.05 for all). In the multivariate analysis, the △ regional PSS (1.134 (CI = 1.059-3.315, p = 0.02)) and the △ regional SR (1.566 (CI = 1.191-9.013, p = 0.001)) for LAD territories predicted the presence of LAD lesions. Similarly, in a multivariable analysis, the △ regional PSS and the △SR predicted LCx culprit lesions and RCA culprit lesions (p < 0.05 for all). In an ROC analysis, the PSS and SR had higher accuracies compared to the regional WMSI in predicting culprit lesions. A △ regional SR of -0.24 for the LAD territories was 88% sensitive and 76% specific (AUC = 0.75; p < 0.001), a △ regional PSS of -1.20 was 78% sensitive and 71% specific (AUC = 0.76, p < 0.001) and a △ WMSI of -0.35 was 67% sensitive and 68% specific (AUC = 0.68, p = 0.02) in predicting LAD culprit lesions. Similarly, the △ SR for LCx and RCA territories had higher accuracies in predicting LCx and RCA culprit lesions.

CONCLUSIONS

The myocardial deformation parameters, particularly the change in regional strain rate, are the most powerful predictors of culprit lesions. These findings strengthen the role of myocardial deformation in increasing the accuracy of DSE analyses in patients with prior cardiac events and revascularization.

Myocardial strain analysis by 4D-speckle tracking echocardiography for prediction of coronary artery disease severity in patients with stable angina pectoris

OBJECTIVE

We sought to evaluate the myocardial strain by four-dimensional speckle-tracking echocardiography (4D-STE) in patients with stable angina pectoris (SAP) to determine the severity of coronary artery disease (CAD) based on the Gensini score.

METHODS

The present study comprised of 150 patients with SAP. Patients with history of SAP, normal left ventricular ejection fraction, and without regional wall motion abnormalities (RWMA) were scheduled for elective coronary angiography. Based on Gensini score, there were two groups: non-critical stenosis group [Gensini score (0-19), n=117] and critical stenosis group [Gensini score ≥20, n=33]. Correlation between Gensini score and 4D-STE strain parameters were investigated.

RESULTS

Out of 150 patients, critical stenosis group had significantly depressed values of all 4D-STE strain parameters than non-critical stenosis group (P <0.001), except global radial strain (GRS) parameter. Significant positive correlation was found between Gensini score and 4D global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS) with Spearman's correlation coefficient (ρ) as 0.626, 0.548, and 0.631, respectively (P <0.001), whereas significant negative correlation was found between Gensini score and GRS (ρ = -0.433, P <0.001). A 4D GLS value of ≥ -17 had 84.9% sensitivity and 97.4% specificity, GAS ≥ -31 (90.9% sensitivity, 78.6% specificity), GCS ≥ -17 (69.7% sensitivity, 92.3% specificity), and GRS < 47 (sensitivity 72.7%, specificity 76.1%) to detect critical CAD described by Gensini score ≥20.

CONCLUSION

The 4D-STE can aid in the assessment of severe CAD stenosis with good sensitivity and specificity in the patients with SAP without RWMA on traditional echocardiography.

The effect of type 2 diabetes mellitus on multiple obstructive coronary artery disease

BACKGROUND

Although type 2 diabetes mellitus (T2DM) individuals easily develop three-vessel disease (3VD) coronary artery disease (CAD), there is very little information available about their left ventricle (LV) functions. The purpose of this study is to evaluate the LV function using two-dimensional speckle tracking echocardiography (2-D STE) in T2DM patients with 3VD.

METHODS

One hundred and three consecutive patients with confirmed 3VD CAD were enrolled and divided into two groups, while 53 patients with DM and 50 patients without. The control group was composed of 30 age- and sex-matched healthy individuals. All patients underwent 2-D STE and standard echocardiograms. The durations of DM and the level of HbA1c were also recorded.

RESULT

Between the 3VD-DM and 3VD-non-DM groups, normal echocardiography did not reveal any appreciable differences. However, patients with 3VD-DM had significantly lower global longitudinal strain (GLS) than those with 3VD-non-DM (15.87 ± 2.51 vs.17.56 ± 2.72, p < .05) by 2-D STE strain measurement. Besides, patients whose duration of DM excess 5 years showed significant lower GLS than those with less than 5 years duration (14.25 ± 2.31 vs. 16.65 ± 1.96, p = .007). However, there was no difference in GLS between the 3VD-DM patients with HbA1c ≥ 7% and HbA1c < 7%.

CONCLUSIONS

Compared to patients with 3VD alone, those with 3VD-DM have a lower cardiac function. In 3VD-DM patients, the duration of DM is a significant factor that contributes to cardiac function deterioration, whereas, the glucose control state has limited influence.

Estimation of the segmental left ventricular physical and mechanical parameters using echocardiographic imaging for stent candidate patients

PURPOSE

Left ventricular (LV) dysfunction can be assessed by quantifying LV structure. In this study, physical parameters were extracted, including the systolic strain, wall stress, and elastic modulus of LV to diagnose stent candidate patients from the control group.

METHODS

Based on angiography results, 88 patients with coronary artery disease (CAD) were divided into 64 patients candidates for PCI (percutaneous coronary intervention) and 24 patients in the control group. With the thick-walled ellipsoidal model, the passive wall stresses at end-systole and end-diastole were estimated. Regional circumferential strain and regional longitudinal strain were obtained by speckle tracking technique.

RESULTS

The inferoseptal circumferential wall stress in end-systole was statistically significant for the PCI group compared to the control group (p = .026). Anterior and inferoseptal circumferential strain for the PCI group (-17.25 ± 4.22 and -18.21 ± 4.04%) compared to the control group (-21.71 ± 4.74 and 20.58 ± 3.04%) were statistically significant, respectively (p = .000 and p = .011). Anterior and inferoseptal circumferential elastic modulus were statistically significant (p = .000 and p = .005). The receiver operator characteristic (ROC) curve analysis revealed that anterior and inferoseptal circumferential elastic modulus had the highest area under the curve with 76.6% sensitivity, 83.3% specificity for anterior circumferential, 68.8% sensitivity, and 70.8% specificity for inferoseptal circumferential, for the diagnosis of stent candidate patients.

CONCLUSIONS

Regional elastic modulus parameter is suggested as a noninvasive and quantitative method for measuring LV function. Strain and stress parameters using the STE method and geometrical model can be helpful for diagnostic stent candidate patients.

Diagnostic Accuracy of Global Longitudinal Strain for Detecting Exercise Intolerance in Patients with Ischemic Heart Disease

Objective: Global longitudinal strain (GLS) is a sensitive and reproducible predictive factor in patients with ischemic heart disease (IHD), although its correlation with exercise tolerance is unknown. We aimed to identify the correlation between global longitudinal strain (GLS) and cardiopulmonary exercise testing (CPX) parameters and assess the prognostic implications and accuracy of GLS in predicting exercise intolerance in populations with ischemic heart disease (IHD) using CPET criteria. Methods: Prospectively, 108 patients with IHD underwent CPX and 2D speckle-tracking echocardiography. Correlation between GLS and multiple CPX variables was assessed using Spearman’s correlation analysis and univariate regression analysis. A receiver operating characteristic (ROC) curve analysis was performed on GLS to detect exercise intolerance. Results: GLS was correlated with peak oxygen uptake (peak VO2; r = −0.438, p = 0.000), %PPeak VO2 (−0.369, p = 0.000), peak metabolic equivalents (METs@peak; r = −0.438, p < 0.01), and the minute ventilation−carbon dioxide production (VE/VCO2) slope (r = 0.257, p < 0.01). Weak-to-moderate correlations were also identified for the respiratory exchange rate at the anaerobic threshold (RER@AT), end-tidal carbon dioxide at the anaerobic threshold (PETCO2@AT), oxygen consumption at the anaerobic threshold (VO2@AT), carbon dioxide production at the anaerobic threshold (VCO2@AT), and metabolic equivalents at the anaerobic threshold (METs@AT; p < 0.01). On multivariate analysis, the results showed that age, the BMI, and GLS are independent predictors for reduced exercise capacity in patients with IHD (p < 0.01). The area under the ROC curve value of GLS for identifying patients with a peak VO2 of <14 mL/kg/min was 0.73 (p = 0.000). Conclusion: As a sensitive echocardiographic assessment of patients with ischemic heart disease, global longitudinal strain is an independent predictor of reduced exercise capacity and has a sensitivity of 74.2% and a specificity of 66.7% to detect exercise intolerance.

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

Background

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

Results

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

Conclusion

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

The evaluation of right ventricular function in patients with diabetes mellitus and significant stenosis at the proximal portion of the right coronary artery

PURPOSE

Previous studies have indicated that right ventricular (RV) function is damaged in diabetes mellitus (DM); however, it is not clear whether in the presence of chronic ischemia, RV function is different between patients with and without DM (DM + and DM - , respectively).

METHODS

This cross-sectional study enrolled 90 consecutive candidates for coronary artery bypass graft surgery and allocated them to 3 groups: 24 DM - patients with the absence of stenosis of more than 50% in the proximal and mid parts of the right coronary artery (the DM - RCA - group [control]), 33 DM - patients with the presence of significant stenosis (> 70%) in the proximal part of RCA (the DM - RCA + group), and 33 DM + patients with RCA + (the DM + RCA + group). RV function was evaluated based on longitudinal deformation markers, measured via the 2D speckle-tracking echocardiographic examination of right ventricular free wall (RVFW).

RESULTS

The systolic strain value, systolic strain rate, and late diastolic strain rate of RVFW were not statistically significantly different between the three groups. Our adjusted post hoc analysis showed that the early diastolic strain rate of RVFW in the DM + RCA + group was lower than that in the DM - RCA + and DM - RCA - groups (1.5 s^-1 ± 0.4 vs 1.7 s^-1 ± 0.5 vs 1.7 s^-1 ± 0.4).

CONCLUSIONS

Diastolic function in the presence of DM was impaired irrespective of RCA - or RCA + . Additionally, RCA + had no effect on systolic and diastolic RV functions at rest in our DM - patients.

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

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

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multilayer global longitudinal strain assessment of subclinical myocardial dysfunction related to insulin resistance

Myocardial tissue is sensitive to insulin resistance (IR) due to its interactions with insulin levels. Previous studies demonstrated that heart failure prevalence was higher in IR patients. Evaluation of myocardial deformation by multilayer global longitudinal strain (MGLS) might provide more information about IR related left ventricular dysfunction. In this study, we aimed to investigate subclinical LV dysfunction with MGLS in patients with IR. The study was designed as a prospective cross-sectional study. The present study included 64 patients with IR (+), and 54 subjects without IR (-) prospectively. The homeostasis model of insulin resistance (HOMA-IR) was used to quantify insulin resistance. Specific analysis for endocardial, mid-myocardial and epicardial layers were performed by two-dimensional (2D) speckle tracking echocardiography (STE) for multilayer global longitudinal strain. MGLS (Endocard-Mid-myocard-Epicard) values were significantly lower in the IR (+) group compared to IR (-) group ((GLS-endocard; - 15.1 ± 1.5 vs. - 18.7 ± 1.3, p < 0.001), (GLS-mid-myocard; - 16.0 ± 2.0 vs. - 18.0 ± 2.0, p < 0.001), (GLS-epicard; - 17.0 ± 1.7 vs. - 18.01 ± 1.94, p = 0.004)). GLS-endocard levels were significantly and positively correlated with HOMA-IR levels (r = 0.643, p < 0.001). HOMA-IR and age were found to be independent factors in detecting a decrease in GLS-endocard level in regression analysis. In conclusion, our data reveal that IR (+) patients had significantly lower strain values compared to IR (-) group. Besides, we presented that the HOMA-IR value was an independent predictor of subclinical left ventricular dysfunction.

Myocardial Deformation Pattern Differs between Ischemic and Non-ischemic Dilated Cardiomyopathy: The Diagnostic Value of Longitudinal Strains

Both ischemic cardiomyopathy (ICM) and non-ischemic cardiomyopathy (NICM) are characterized by left ventricular (LV) dysfunction and dilation. Differentiation between ICM and NICM using non-invasive image modalities is a clinical challenge. This study compared the myocardial deformation patterns of ICM and NICM using 2-D speckle tracking echocardiography (2-D STE) and sought to find parameters valuable in the diagnosis and management of dilated cardiomyopathy. The study population comprised 84 consecutive patients with LV end-diastolic dimension >55 mm and ejection fraction (EF) <45 %. Of these patients, 41 were diagnosed with ICM and 43 with NICM by coronary angiography. 2-D STE was performed in all patients. The LV dimension did not differ between ICM and NICM. Compared with patients with ICM, patients with NICM had lower EF (29.0% vs. 33.0%, p = 0.024), lower global longitudinal strain (-5.4 ± 2.6% vs. -7.0 ± 2.5%, p = 0.006) and lower global radial strain (7.5 ± 4.5% vs. 10.7 ± 4.7%, p = 0.019). In contrast, global longitudinal strains did not differ significantly. However, NICM patients had higher apical and lower basal longitudinal strains compared with those with ICM. The ratio of basal to sum of mid- and apical longitudinal strains could predict NICM with a sensitivity of 63.4% and specificity of 88.4% by receiver operating characteristic curve analysis (cutoff value: 0.47, area under the curve: 0.792). Moreover, the concomitant presence of non-significant coronary artery stenosis (>50% and <70%) had no significant influence on global longitudinal strain in NICM. In conclusion, LV dilation and systolic dysfunction, relative apical sparing and a basal worsening pattern of LV longitudinal strain by 2-D STE were observed in patients with NICM but not ICM. The ratio of basal to sum of mid- and apical longitudinal strains could help differentiate NICM from ICM.