Ischemic heart disease and early diagnosis. Study on the predictive value of 2D strain

Preliminary Feasibility of Stress Myocardial Elastography for the Detection of Coronary Artery Disease

Myocardial elastography (ME) is a cardiac strain imaging technique that has been found capable of detecting a decrease in radial strain caused by ischemia or infarction in patients with coronary artery disease (CAD) as well as in a canine model. Prior studies have focused on rest imaging, but stress testing can reveal functional deficits caused by stenoses that are asymptomatic at rest. Therefore, it has been proposed that stress ME (S-ME) improves the detection of CAD. A novel strain difference (Δε) metric is presented and investigated in a canine model of induced ischemia, as well as in a study in human patients with CAD validated by myocardial perfusion imaging. In the canine model study, flow-limiting stenosis was induced by partial ligation in n = 2 canines, and stenosis was found to consistently reduce Δε in the affected myocardial regions compared with baseline, as well as compared to myocardial regions that are remote to the induced stenosis. In the clinical study, the median Δε was significantly lower (p < 0.05) in infarcted myocardial regions (-6.29%) than in those with normal perfusion (4.62%), with Δε in ischemic regions falling in between (-2.91%). The same trend was observed when considering radial strain during stress and, to a lesser degree, at rest alone. The results indicate that S-ME may be more sensitive to mild cases of CAD that are functionally asymptomatic at rest.

Value of myocardial deformation parameters for detecting significant coronary artery disease

Introduction: The study aimed to evaluate the diagnostic value of global and regional myocardial deformation parameters derived from two-dimensional speckle-tracking echocardiography to detect functionally significant coronary artery stenosis.

Methods: Dobutamine stress echocardiography and cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) were performed on 145 patients with a moderate and high probability of coronary artery disease (CAD) and LVEF≥55%. Significant CAD was defined as>50% stenosis of the left main stem,>70% stenosis in a major coronary vessel, or in the presence of intermediate stenosis (50-69%) validated as hemodynamically significant by CMRMPI. Patients were divided in two groups: non-pathological (48.3%) vs pathological (51.7%), according to CAG and CMR-MPI results. Afterwards, off-line speckle-tracking analysis was performed to analyse myocardial deformation parameters.

Results: There were no differences in myocardial deformation parameters at rest between groups, except global longitudinal strain (GLS) and global radial strain (GRS) were significantly lower in the CAD (+) group: -21.3±2.2 vs.-16.3±2.3 (P<0.001) and 39.7±23.2 vs. 24.5±15.8 (P<0.001). GLS and regional longitudinal strain rate (SR) had the highest diagnostic value at high dobutamine dose with AUC of 0.902 and 0.878, respectively. At early recovery, GLS was also found to be the best myocardial deformation parameter with a sensitivity of 78%, specificity 67%, AUC 0.824.

Conclusion: Global and regional myocardial deformation parameters are highly sensitive and specific in detecting functionally significant CAD. The combination of deformation parameters and WMA provides an incremental diagnostic value for patients with a moderate and high probability of CAD, especially the combination with regional longitudinal SR.

Prognostic value of two-dimensional strain in early ischemic heart disease: A 5-year follow-up study

INTRODUCTION

Two-dimensional strain echocardiography (2D-SE) is a reliable method for measuring deformation of the left ventricle.

AIM OF THE STUDY

Aim of the study was to determine changes in 2D-SE parameters over time collected during dipyridamole stress echo-cardiography (dipy-stress) and prognosis of patients with non-diagnostic dipy-stress results.

METHODS

In the first phase of the study, assessment of a prospective enrolled population with a non-diagnostic dipy-stress test result was conducted, checking through coronary CT angiography (CCTA) the presence of coronary artery disease (CAD). In the follow-up phase, an echocardiographic re-evaluation and outcome analysis during a mean follow-up of 78 months was carried out.

RESULTS

In the first phase, Global Circumferential Strain (GCS) values were similar in the CCTA positive and CCTA negative groups at rest and after stress. For Global Longitudinal Strain (GLS), there was a significant reduction (p < .0001) in the CCTA positive group compared to the CCTA negative group. After 78 ± 9 months none of the enrolled patients experimented cardiac events. Values of GCS, both at rest and after stress, did not differ statistically comparing follow-up values with baseline ones. No statistically significant changes were seen in the same analysis for GLS rest and stress values, between baseline and follow-up in the two groups.

CONCLUSIONS

Performing 2D-SE during dipy-stress can detect mild CAD that conventional stress-tests miss. Patients with mild coronary stenosis may have a favorable mid-term prognosis, but efforts should be made to investigate the decrease trend in GLS, at rest and after stress, reported in this patient group.

The fundamental role of stress echo in evaluating coronary artery disease in specific patient populations

Stress echocardiography (SE) was initially used for assessing patients with known or suspected coronary heart disease by detecting and evaluating myocardial ischemia and viability. The implementation of SE has gradually been extended to several cardiovascular diseases beyond coronary artery disease, and SE protocols have been modified and adapted for the detection of coronary artery disease (CAD) or other cardiovascular diseases in specific patient populations. This review attempts to summarize current data concerning SE implementation and clinical value in these specific and diverse populations: patients with an intramural course of a coronary artery - known as a myocardial bridge, chronic severe or end-stage hepatic disease, chronic severe or end-stage kidney disease, cardiac allograft vasculopathy, patients scheduled for solid-organ transplantation and other intermediate and high-risk surgery and, finally, patients treated with anticancer drugs or radiotherapy.

Non-Invasive Evaluation of Patients Undergoing Percutaneous Coronary Intervention for Chronic Total Occlusion

Background: As percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) gains wider acceptance as a therapeutic option for coronary artery disease, the importance of appropriate patient selection has increased. Although cardiovascular magnetic resonance imaging (MRI) allows segmental and quantitative analyses of myocardial ischemia and scar transmurality, it has limitations, including contraindications, cost, and accessibility. This study established a non-invasive method to evaluate patients undergoing CTO-PCI using two-dimensional speckle-tracking echocardiography (2D-STE). Methods: Overall, we studied 55 patients who underwent successful CTO-PCI. Cardiovascular MRI and 2D-STE were performed before and 8 ± 2 months after CTO-PCI. Segmental findings of strain parameters were compared with those obtained with late gadolinium enhancement and stress-perfusion MRI. Results: With a cutoff of −10.7, pre-procedural circumferential strain (CS) showed reasonable sensitivity (71%) and specificity (73%) for detecting segments with transmural scar. The discriminatory ability of longitudinal strain (LS) for segments with transmural scar significantly improved during follow-up after successful CTO-PCI in the territory of the recanalized artery (area under the curve (AUC) 0.70 vs. 0.80, p < 0.001). LS accuracy was lower than that of CS at baseline (AUC 0.70 vs. 0.79, p = 0.048), and was increased at follow-up (AUC 0.80 vs. 0.82, p = 0.81). Changes in myocardial perfusion reserve from baseline to follow-up were significantly associated with those in LS but not in CS. Conclusions: Use of 2D-STE may allow the non-invasive evaluation of patients undergoing CTO-PCI to assess the indication before the procedure and treatment effects at follow-up.

Effects of Sacubitril/Valsartan in Patients with High Arrhythmic Risk and an ICD: A Longitudinal Study

PURPOSE

Patients affected by heart failure with reduced ejection fraction (HFrEF) receive clinical and functional beneficial effects from treatment with sacubitril/valsartan. However previous studies have shown that patients with an implantable cardioverter defibrillator (ICD) could obtain even greater benefit, but only make up a only a small proportion of patients. In the current study we evaluated the effect of sacubitril/valsartan in patients with an ICD.

METHODS

Thirty-five outpatients with HFrEF (aged 60 ± 11 years, 28 were males), on optimal medical therapy were studied. All patients received an ICD at least 6 months before enrollment or were non-responders to ICD plus resynchronization (CRT-D). An open-label sacubitril/valsartan treatment was established at the maximum tolerated dose. Clinical assessment, 6-min walk test (6MWT) and echocardiography, were performed during follow-up at 90, 180, and 360 days. Quality of life score and perceived fatigue on exercise were assessed.

RESULTS

Clinical conditions dramatically improved in most patients, especially within the first 6 months of therapy (76 % were in NYHA-I and 24 % in NYHA-II at the end of study vs 71 % NYHA-II and 29 % NYHA III at enrollment, p < 0.001). Quality of life and exercise performance significantly improved according to N-terminal pro-brain natriuretic peptide (NT-proBNP) serum levels lowering. Walking distance at 6MWT increased from 274 ± 97 to 389 ± 53 m and walking speed from 0.74 ± 0.27 to 1.07 ± 0.15 m/s (p < 0.001), while oxygen saturation did not differ significantly (from 90 ± 1 % to 91 ± 2 %). More gradual was left ventricular reverse remodeling. Ejection fraction improved mildly (+ 5 points %, p < 0.001). Global longitudinal strain and diastolic function were also assessed over time.

CONCLUSION

Sacubitril/valsartan therapy for HFrEF may lead to significant clinical and functional improvements even in patients with ICD at greater arrhythmic risk. Clinical improvement is obtained within the first 6 months of treatment while reverse remodeling needs more time.

Cardiovascular Disease in Spondyloarthritides

The spondyloarthritides are a group of chronic systemic inflammatory joint diseases, the main types being ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Evidence accumulating during the last decades suggests that patients with AS or PsA carry an increased risk for cardiovascular disease and cardiovascular death. This risk appears to be mediated by systemic inflammation over and above classical cardiovascular risk factors. The excess cardiovascular risk in those patients has been formally acknowledged by scientific organizations, which have called physicians' attention to the matter. The application by Rheumatologists of new effective anti-rheumatic treatments and treat-to-target strategies seems to benefit patients from a cardiovascular point of view, as well. However, more data are needed in order to verify whether anti-rheumatic treatments do have an effect on cardiovascular risk and whether there are differences among them in this regard. Most importantly, a higher level of awareness of the cardiovascular risk is needed among patients and healthcare providers, better tools to recognize at-risk patients and, ultimately, commitment to address in parallel both the musculoskeletal and the cardiovascular aspect of the disease.

Non-Invasive Imaging for Evaluating Cardiovascular Involvement in Patients with Primary and Lupus Nephritis

Background:

Evidence suggests that proteinuric diseases, such as primary or secondary glomerulonephritis, increase cardiovascular risk, but few studies confirmed this association.

Methods:

This is a cross-sectional, observational study on 32 patients, 17 with Primary Glomerulonephritis (PG) and 15 with Lupus Glomerulonephritis (LG). The control group consisted of 32 healthy individuals. Intima-media thickness (IMT) of the left common carotid artery, carotid bifurcation and internal carotid artery was measured by ultrasound. Left ventricular myocardial deformation was assessed by the use of the Global Circumferential Strain (GCS) and the Global Longitudinal Strain (GLS) following 2-Dimensional (2D) echocardiography in all participants.

Results:

Patients with glomerulonephritis in both groups showed significantly lower GLS compared with controls (p=0.0005). There was also a significant difference in common carotid IMT values between the LG and GP group (0.45±0.09 vs. 0.58±0.17 mm, respectively; p=0.01), but there was no difference with the control group. In patient group (n=32), a significantly positive correlation was observed between C-reactive protein and proteinuria (r=0.98; p<0.0001), whereas negative correlations were found between common carotid IMT and creatinine clearance (r=-0.97; p<0.0001) and between carotid bifurcation IMT and phosphate levels (r=-0.97; p<0.0001)

Conclusion:

Subclinical systolic myocardial dysfunction is present early in the course of glomerular disease. The use of 2D GLS revealed that LG and PG patients with no cardiovascular symptoms or history and a preserved left ventricle ejection fraction on conventional echocardiography had subclinical reduction in LV global longitudinal systolic function compared with controls.

Improvement of left ventricular function assessment by global longitudinal strain after successful percutaneous coronary intervention for chronic total occlusion

The benefit of revascularization of chronic total occlusion (CTO) in percutaneous coronary intervention (PCI) is controversial. On the other hand, left ventricular (LV) global longitudinal strain (GLS) is a more sensitive marker of LV myocardial ischemia and LV function than LV ejection fraction (EF). The purpose of this study was to investigate the impact of revascularization of CTO on LV function using LV GLS. A total of 70 consecutive patients (65.1±8.9 years, 59 males, LVEF 51.0±12.0%) with CTO who had a positive functional ischemia and underwent PCI, were included in this study. Echocardiography was performed before and 9 months after the procedure with conventional assessment including LV end-diastolic and end-systolic volume (LVEDV, LVESV), LVEF, and with 2DSTE analysis of GLS. Successful PCI was obtained in 60 patients (86%). There were no stent thromboses during follow-up. GLS showed a significant improvement 9 months after successful PCI (pre-PCI -12.4±4.1% vs. post-PCI -14.5±4.1%, P< 0.01), whereas in failed PCI group that did not change significantly (pre-PCI -13.2±4.2% vs. post-PCI -14.0±4.7%, P = 0.64). LVEF, LVEDV and LVESV did not change significantly during follow-up in both successful and failed groups. Successful PCI for CTO improved LV function, assessed by LV GLS.

Psoriasis and Cardiovascular Risk: Correlation Between Psoriasis and Cardiovascular Functional Indices

Evidence suggests that psoriasis together with other cardiovascular (CV) risk factors is associated with increased vascular morbidity, but it is not clear whether psoriasis is an independent risk factor. Consecutive patients (n = 33; 35.6 ± 5.7 years; 13 females) with mild psoriasis (Psoriasis Area and Severity Index <10) without comorbidities and 33 healthy participants (36.3 ± 5.9 years; 15 females) were enrolled. Both groups underwent echocardiography, speckle tracking (2-dimensional strain echocardiography [2D-SE]), and pulse wave velocity (PWV) testing. Clinical and conventional echocardiographic characteristics were comparable between both groups. Global longitudinal strain (GLS) was significantly lower ( P = .002) in the psoriasis group (22.39% ± 2.28%) than in controls (24.15% ± 2.17%). The PWV was significantly lower ( P = .004) in controls (8.06 ± 1.68 m/s) than in the psoriasis group (9.23 ± 1.53 m/s). Significant correlations between GLS and disease duration ( r = −.66, P < .0001) and between GLS and patient age at diagnosis ( r = .48, P = .0043) were found. Psoriasis may be an independent CV risk factor, causing cardiac and vascular impairment. Both 2D-SE and PWV may be useful tools for the screening of CV risk in these patients.