Tissue Doppler echocardiography predicts acute myocardial infarction, heart failure, and cardiovascular death in the general population

Whole-cycle analysis of echocardiographic tissue Doppler velocities as a marker of biological age

Purpose

Tissue Doppler imaging (TDI) is a sensitive marker of impaired cardiac function and different phases of the TDI curve carry different prognostic information. It is not known how continuous TDI curves change with age in normal subjects, and whether these changes differ from changes seen in individuals at risk of future cardiac events.

Methods

A total of 1,763 individuals from the general population were examined with color TDI at the septal and lateral mitral sites. A low-risk group was defined as without cardiac risk factors (hypertension, diabetes or ischemic heart disease) at baseline and without any cardiac events (cardiovascular death or admission due to either heart failure or acute myocardial infarction) during 10-years follow-up. All TDI curves were corrected for heart rate, and whole-cycle analysis of age-related changes to TDI velocities was performed in both low-risk (n = 881) and high-risk individuals (n = 882).

Results

In the low-risk population, four phases where myocardial velocity differed most (p < 10^-10) according to age were identified [in a standardized cardiac cycle of 1 second (s)]: Systolic peak (0.09-0.13 s), systolic plateau (0.18-0.27 s), early diastole (0.43-0.54 s) and late diastole (0.88-0.95 s). With increasing age, systolic velocities decreased, early diastolic velocities decreased and had delayed peak, and late diastolic velocities increased until age 70 and then stopped increasing. In the high-risk population, comparison to corresponding age groups of the low-risk population showed: Lower early diastolic velocities in 20-40-year-olds; higher late diastolic velocities and lower peak systolic velocities in 40-60-year-olds; further decreased systolic velocities including the systolic plateau and decreased late diastolic velocities in 60-year-olds. The time segments around the systolic peak (p = 0.002) and early diastole (p < 0.001) differed significantly between the high-risk and low-risk population, thus making it possible to use the individual age gap between a TDI-derived biological age and the real chronological age as a tool to discriminate high-risk individuals from low-risk individuals.

Conclusion

We found that individuals with cardiac risk factors display findings compatible with an accelerated aging of the heart and thus propose TDI-derived biological age as a tool to identify high-risk patients.

The role of conventional echocardiographic parameters on detecting subclinical anthracycline therapy related cardiac dysfunction—The SATRACD study

Background

Subclinical anthracycline therapy related cardiac dysfunction (ATRCD) can be detected with speckle tracking echocardiographic image (STE), which is not widely available in Uganda. We aimed to investigate the role of the two conventional echocardiographic parameters [mitral annular plane systolic excursion (MAPSE) and mitral annular peak systolic tissue Doppler velocity (S’)] on diagnosing subclinical ATRCD.

Method and results

207 cancer patients who underwent anthracycline based chemotherapy were recruited at baseline and followed up until 6 months after ending anthracycline therapy. Comprehensive echocardiographic data were collected at each visit. Global longitudinal strain (GLS) by STE was used as the gold standard diagnostic test to define the case of subclinical ATRCD. Data of the 200 patients who had no evidence of clinical ATRCD were analyzed. One hundred and seventy-two (86.0%) were female, with a median age of 42 years and 47 (23.5%) patients were diagnosed with subclinical ATRCD at the end of anthracycline therapy by GLS criteria. The area under the curve (AUC), cutoff point, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of reduction of MAPSE (ΔMAPSE) were 0.6736 (95% CI: 0.5885, 0.7587), ≥ 2 mm, 74.5% (95% CI: 59.7%, 86.1%), 54.9% (95% CI: 46.7%, 63.0%), 33.7% (95% CI: 24.7%, 43.6%), and 87.5% (95% CI: 79.2%, 93.4%). The AUC, cutoff point, sensitivity, specificity, PPV, and NPV of reduction of S’ (ΔS’) were 0.6018 (95% CI: 0.5084, 0.6953), ≥ 0.5 cm/s, 61.7% (95% CI: 46.4%, 75.5%), 52.7% (95% CI: 44.4%, 60.9%), 29.0% (95% CI: 20.4%, 38.9%), and 76.1% (95% CI: 72.4%, 88.6%). When ΔMAPSE and ΔS’ are used as parallel test, the net sensitivity and specificity is 89.4% and 28.8%, respectively, the net PPV and NPV is 27.8% and 90.0%, respectively.

Conclusion

The ΔMAPSE and ΔS’ showed fairly good accuracy, sensitivity and NPV to detect subclinical ATRCD in Ugandan cancer patients. These conventional echocardiographic parameters may serve as screening tools for detecting subclinical ATRCD in resource limited settings.

Clinical Significance of Late Diastolic Tissue Doppler Velocity at 24 Hours or 14 Days After Onset of ST-Elevation Acute Myocardial Infarction

Background: The significance of late diastolic velocity (a') obtained by tissue Doppler imaging (TDI), which reveals atrial function, in ST-elevation myocardial infarction (STEMI) remains unclear. This study evaluated the association of TDI parameters determined either immediately or 2 weeks after percutaneous coronary intervention (PCI) with long-term outcomes. Methods and Results: In all, 740 patients with first-time STEMI underwent immediate PCI (i.e., within 12 h of onset). Echocardiography was performed in 307 patients 2 weeks after onset (Group A; mean age 64 years, 249 males), in 277 patients immediately after PCI (Group B; mean age 65 years, 229 males), and in 156 patients twice (i.e., immediately and 2 weeks after PCI; Group C; mean age 65 years, 135 males). Patients were followed-up for up to 10 years (mean 81 months). The primary endpoints were cardiac death or heart failure hospitalization. Major adverse cardiovascular events (MACE) occurred in 143 patients (19%) during the follow-up period. Both univariate and multivariate Cox hazard analyses were used to determine predictors of MACE. At 24 h and 2 weeks after STEMI onset, a' and E/e' were the strongest predictors of MACE, respectively. Conclusions: TDI parameters have different implications depending on the timing of echocardiography after a first-time STEMI. Based on the results of this study, atrial dysfunction measured by TDI 24 h after STEMI onset may indicate a poor prognosis.

Duration of early systolic lengthening: prognostic potential in the general population

BACKGROUND

When the left ventricle pressure rises during early systole, myocardial fibres with reduced contractility tend to stretch instead of shortening. This interval is known as duration of early systolic lengthening (DESL). We sought to investigate if DESL provides prognostic information on cardiovascular events.

METHODS AND RESULTS

In this prospective study we included 1210 participants from a low-risk general population who underwent speckle tracking echocardiography (men 41%, mean age 56 years, SD 16). Primary endpoints were incident heart failure (HF), myocardial infarction (MI), and cardiovascular death (CVD). We defined DESL as time from onset of Q-wave on the electrocardiogram to peak positive systolic strain. In addition, we assessed the ratio between DESL and duration of cardiac systole, DESLsystole.During median follow-up of 16 years, 90 (7%) developed HF, 50 (4%) MI, and 70 (6%) experienced CVD. Both DESL [hazard ratio (HR) 1.58 95%CI 1.16-2.15, P = 0.004 per 10 ms increase] and DESLsystole (HR 1.74 95%CI 1.24-2.47, P = 0.001 per 1% increase) were predictors of HF. Similarly, DESL (HR 1.40 95%CI 1.09-1.78, P = 0.007 per 10 ms increase) and DESLsystole (HR 1.58 95%CI 1.01-2.49, P = 0.047 per 1% increase) were predictors of MI. No associations were found with CVD. After adjusting for clinical and echocardiographic parameters, the associations remained significant. DESLsystole was superior to systolic echocardiographic parameters for predicting HF (P = 0.012).

CONCLUSION

DESL and the novel index of DESLsystole provide independent and novel prognostic information on the risk of HF and MI in the general population. Evaluation of DESL should be explored in future echocardiographic studies.

Prognostic value of left ventricular mitral annular longitudinal displacement obtained by tissue Doppler imaging in patients with heart failure with reduced ejection fraction

Background

Tissue Doppler imaging (TDI) can be used to measure the mitral annular longitudinal displacement (LD) during systole. However, the prognostic utility of global and regional LD in patients with heart failure with reduced ejection fraction (HFrEF) is unknown.

Methods

Echocardiographic examinations from 907 patients with HFrEF were analysed obtaining conventional echocardiographic measurements. Regional LD was obtained from colour TDI projections in six mitral annular regions and global LD was calculated as an average.

Results

Mean age was 67 years, 26.9% were women and mean left ventricular ejection fraction was 27%. During a median follow-up period of 40 months, 150 (16.5 %) patients died. The risk of dying increased with decreasing tertile of global LD and was approximately five times higher for patients in the lowest tertile compared with the highest (1. tertile vs 3. tertile, HR 4.9, 95% CI: 3.0 to 7.9, p<0.001).

Global LD was a significant independent predictor of mortality after adjusting for age, gender, body mass index, pacemaker, heart rate, atrial fibrillation, diabetes and conventional echocardiographic measures and global longitudinal strain: HR 1.16 (95% CI: 1.00 to 1.34, p=0.044) per 1 mm decrease.

For regional measures, inferior LD was also a significant independent predictor in the multivariable model: HR 1.16 (95% CI: 1.04 to 1.29, p=0.006) and adding inferior LD to the conventional measures yielded a significant increase in Harrell’s C-statistic (95% CI: 0.75 to 0.78, p=0.009).

Conclusion

In patients with HFrEF, global and inferior LD are independent predictors of all-cause mortality. Furthermore, inferior LD proved to be a significant prognosticator when compared with all the conventional echocardiographic parameters.

Kidney function and the prognostic value of myocardial performance index

A decreased glomerular filtration rate (GFR) is a risk factor for cardiovascular disease even after adjustment for conventional risk factors. The myocardial performance index (MPI) is defined as (isovolumetric relaxation time (IVRT) + isovolumetric contraction time (IVCT))/ejection time (ET). It has been shown to be an independent predictor of cardiovascular events. We hypothesized the MPI could prove valuable for assessing cardiac risk in subjects of the general population with decreased estimated GFR (eGFR). MPI was measured in 1915 subjects from a large general population prospective cohort study using color tissue Doppler imaging (TDI) M-mode through the mitral valve. We compared the prognostic capabilities of the MPI between subjects with eGFR ≥ 75 mL/min/1.73 m² and subjects with eGFR < 75 mL/min/1.73 m² using multivariable adjusted Cox regression models. The composite endpoint was heart failure, myocardial infarction or cardiovascular death. Mean age was 58 years (SD 16.2), 58% were women, 42% had hypertension and 8.3% diabetes. During a median follow-up time of 12.4 years [IQR 10.6-12.7 years] 269 participants reached the combined endpoint. eGFR modified the prognostic capability of MPI (p-value for interaction < 0.001): After multivariable adjustment, MPI remained an independent predictor of the composite endpoint only in participants with eGFR < 75 mL/min/1.73 m²: HR 1.18 (95% CI 1.02-1.38), p = 0.03, vs. in subjects with eGFR ≥ 75 mL/min/1.73 m²: HR 1.14 (95% CI 0.94-1.39), p = 0.17. These results suggest the MPI could be particularly valuable for identifying elevated cardiac risk in individuals from the general population with decreased eGFR.

Right Ventricular Function Evaluated by Tricuspid Annular Plane Systolic Excursion Predicts Cardiovascular Death in the General Population

Background Cardiovascular disease remains a leading cause of death. Right ventricular ( RV ) function is a strong predictor of outcome in many cardiovascular diseases, but its significance is often neglected. Little is known about the prognostic value of RV systolic function in the general population. Therefore, we aimed to determine the prognostic value of RV systolic function, evaluated by tricuspid annular plane systolic excursion ( TAPSE ), in predicting cardiovascular death ( CVD ) in the general population. Methods and Results A total of 1039 participants from the general population without heart failure or atrial fibrillation had an echocardiogram performed and TAPSE measured. The end point was CVD . During a median follow-up of 12.7 years (interquartile range, 12.0-12.9 years), 69 participants (6.6%) experienced CVD , whereas 162 participants (15.6%) experienced non-CVD. Decreasing RV systolic function, assessed as TAPSE , was a univariable predictor of CVD (hazard ratio, 1.13; 95% CI , 1.07-1.20; P<0.001, per 1-mm decrease). TAPSE remained an independent predictor of CVD after adjusting for clinical and echocardiographic parameters (hazard ratio, 1.08; 95% CI , 1.01-1.15; P=0.017, per 1-mm decrease). Furthermore, in net reclassification analysis, decreasing RV systolic function, assessed as TAPSE, significantly improved risk classification with respect to CVD when added to established cardiovascular risk factors from the Systematic Coronary Risk Evaluation chart or a modified version of the American Heart Association/American College of Cardiology Pooled Cohort Equation. Decreasing RV systolic function, assessed as TAPSE , did not predict non-CVD, indicating specificity for CVD . Conclusions RV systolic function, as assessed by TAPSE , is associated with CVD in the general population. In the general population, assessment of RV systolic function may provide novel prognostic information about the risk of CVD .

Relationships of global longitudinal strain with s`, long-axis systolic excursion, left ventricular length and heart rate

Background

Longitudinal left ventricular (LV) contraction can be impaired in the presence of a normal LV ejection fraction (LVEF), and abnormalities have been reported in global longitudinal strain (GLS), long-axis systolic excursion (SExc), and the peak systolic velocity (s`) of mitral annular motion using tissue Doppler imaging (TDI). However, the relationships of GLS with s` and SExc have not been systematically evaluated in subjects with a normal LVEF, and whether these relationships might be affected by variations in LV end-diastolic length (LVEDL) and heart rate is unknown.

Methods

We investigated the univariate and multivariate correlations of GLS with TDI measurements of s` and SExc (both using averages of the septal and lateral walls), LVEDL and heart rate in subjects with a normal LVEF (>50%) but a low peak early diastolic mitral annular velocity (septal e`≤ 7.0 cm/s and lateral e`≤ 9 cm/s), and thus an increased risk of a future cardiac event.

Results

84 subjects (age 66±8 years, 29 males) with a LVEF of 62±6% and GLS of -17.5±2.3% were studied. On univariate analysis the absolute value of GLS was positively correlated with s`(r = 0.28, p<0.01) and SExc (r = 0.50, p<0.001) and inversely correlated with heart rate (r = -0.36, p = 0.001), but was not correlated with LVEDL (r = -0.15). In multivariate models, SExc explained more of the variance in GLS than s`, and absolute GLS was not only positively correlated with SExc, but also inversely correlated with LVEDL. Heart rate was an independent inverse correlate of GLS in conjunction with LVEDL and either s` or SExc, but made a larger contribution in models which included s`. Interobserver correlations were close for s` and SExc (r = 0.89–0.93), but only moderate for GLS (r = 0.71).

Conclusion

In subjects with a normal LVEF but reduced e`, the absolute value of GLS is more closely related to SExc than s`, and is also independently and inversely related to LVEDL and heart rate. Measurement of SExc may provide a useful additional or alternative technique to GLS for the assessment of LV long-axis function.

Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling

BACKGROUND

In recent decades, novel echocardiographic measures have constantly emerged. It is still unclear which echocardiographic measures have the most significant prognostic value in the general population. Accordingly, the aim of this study was to compare the prognostic value of a large panel of echocardiographic measures to identify the most promising measures.

METHODS

A total of 1,497 Framingham study participants (mean age, 65 years; 55.4% women) who underwent echocardiographic measurements of left ventricular ejection fraction, left ventricular mass index, global longitudinal strain, global circumferential strain, mitral annular plane systolic excursion, mitral E/e' ratio, maximum and minimum left atrial (LA) volume index, LA emptying fraction, and left ventricular longitudinal synchrony were evaluated. These measures were related to the incidence of two composite outcomes: cardiovascular disease (CVD) or death and atrial fibrillation (AF) or congestive heart failure (CHF).

RESULTS

On follow-up (mean, 8.3 years), there were 241 CVD events or deaths and 139 AF or CHF events. In multivariate-adjusted Cox models, higher LA emptying fraction was associated with a lower risk (hazard ratios per SD, 0.80 and 0.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) while higher minimum LA volume index (hazard ratios per SD, 1.32 and 1.70 for CVD or death and AF or CHF, respectively; P ≤ .001 for both) and maximum LA volume index (hazard ratios per SD, 1.26 and 1.54 for CVD or death and AF or CHF, respectively; P ≤ .002 for both) were associated with a higher risk for both composite outcomes.

CONCLUSIONS

In this community-based sample, LA volumes and function were the best echocardiographic predictors of clinical outcomes. Therefore, these values should be considered for inclusion in standard echocardiographic assessments for the purpose of risk stratification.

Association of cardiovascular magnetic resonance-derived circumferential strain parameters with the risk of ventricular arrhythmia and all-cause mortality in patients with prior myocardial infarction and primary prevention implantable cardioverter defibrillator

BACKGROUND

Impaired left ventricular (LV) contraction and relaxation may further promote adverse remodeling and may increase the risk of ventricular arrhythmia (VA) in ischemic cardiomyopathy. We aimed to examine the association of cardiovascular magnetic resonance (CMR)-derived circumferential strain parameters for LV regional systolic function, LV diastolic function and mechanical dispersion with the risk of VA in patients with prior myocardial infarction and primary prevention implantable cardioverter defibrillator (ICD).

METHODS

Patients with an ischemic cardiomyopathy who underwent CMR prior to primary prevention ICD implantation, were retrospectively identified. LV segmental circumferential strain curves were extracted from short-axis cine CMR. For LV regional strain analysis, the extent of moderately and severely impaired strain (percentage of LV segments with strain between - 10% and - 5% and > - 5%, respectively) were calculated. LV diastolic function was quantified by the early and late diastolic strain rate. Mechanical dispersion was defined as the standard deviation in delay time between each strain curve and the patient-specific reference curve. Cox proportional hazard ratios (HR) (95%CI) were calculated to assess the association between LV strain parameters and appropriate ICD therapy.

RESULTS

A total of 121 patients (63 ± 11 years, 84% men, LV ejection fraction (LVEF) 27 ± 9%) were included. During a median (interquartile range) follow-up of 47 (27;69) months, 30 (25%) patients received appropriate ICD therapy. The late diastolic strain rate (HR 1.1 (1.0;1.2) per - 0.25 1/s, P = 0.043) and the extent of moderately impaired strain (HR 1.5 (1.0;2.2) per + 10%, P = 0.048) but not the extent of severely impaired strain (HR 0.9 (0.6;1.4) per + 10%, P = 0.685) were associated with appropriate ICD therapy, independent of LVEF, late gadolinium enhancement (LGE) scar border size and acute revascularization. Mechanical dispersion was not related to appropriate ICD therapy (HR 1.1 (0.8;1.6) per + 25 ms, P = 0.464).

CONCLUSIONS

In an ischemic cardiomyopathy population referred for primary prevention ICD implantation, the extent of moderately impaired strain and late diastolic strain rate were associated with the risk of appropriate ICD therapy, independent of LVEF, scar border size and acute revascularization. These findings suggest that disturbed LV contraction and relaxation may contribute to an increased risk of VA after myocardial infarction.

Left ventricular concentric geometry predicts incident diabetes mellitus independent of established risk factors in the general population: the Copenhagen City Heart Study

Background

Subtle impairments in left ventricular (LV) function and geometry are common findings in individuals with diabetes. However, whether these impairments precede the development of diabetes mellitus (DM) is not entirely clear.

Methods

Echocardiograms from 1710 individuals from the general population free of prevalent diabetes mellitus were analyzed. Left ventricular (LV) concentric geometry was defined as either LV concentric remodeling or LV concentric hypertrophy as directed in contemporary guidelines. The severity of LV concentricity was assessed by relative wall thickness (RWT) calculated as posterior wall thickness (PWT) indexed to left ventricular internal diameter at end diastole (LVIDd) (RWT = 2 * PWT/LVIDd). End-point was incident DM.

Results

Median follow-up time was 12.6 years (IQR: 12.0–12.8 years). Follow-up was a 100%. A total of 55 participants (3.3%) developed DM during follow-up. At baseline, the prevalence of a concentric LV geometric pattern was significantly higher (41.8% vs 20.3%, p < 0.001) in individuals who developed DM during follow-up. In a final multivariable model adjusting for established DM risk factors including HbA1c, BMI and plasma glucose, LV concentric geometry and RWT remained significantly associated with incident DM (LV concentric geometry: HR 1.99, 95% CI 1.11–3.57, p = 0.021) (RWT: HR 1.41, 95% CI 1.06–1.86, p = 0.017, per 0.1 increase). This association remained despite adjustment for established risk factors for DM.

Conclusion

Altered LV geometry may precede the development of DM. LV concentric geometry determined by echocardiography and the severity of LV concentricity evaluated as RWT are associated with incident DM in the general population.

Electronic supplementary material

The online version of this article (10.1186/s12933-019-0842-0) contains supplementary material, which is available to authorized users.

Correlation between Myocardial Velocity Measured using Tissue Doppler Imaging in the Left Ventricular Lead-Implanted Segment and Response to Cardiac Resynchronization Therapy

OBJECTIVES

This study investigated whether tissue Doppler imaging parameters, especially the peak systolic velocity of the left ventricular lead-implanted segment (Ss), affect cardiac resynchronization therapy response.

METHODS

In this case-control study, 110 enrolled patients were divided into cases (responder group, n=65) and controls (nonresponder group, n=45) based on whether their left ventricular end-systolic volume was reduced by ≥15% at 6 months after surgery. Preoperative clinical and echocardiographic data were collected. Multivariate logistic regression models were used to analyze the factors affecting the response to cardiac resynchronization therapy, and receiver operating characteristic curves were plotted to evaluate their diagnostic values.

RESULTS

The proportion of patients with left bundle branch block in the case group was higher than that in the control group. The control group showed a higher left atrial volume index, E/A ratio and E/Em ratio but lower Ss than that of the case group. A multivariate regression analysis showed that left bundle branch block, Ss, and an E/Em ratio>14 were independent risk factors affecting the response to cardiac resynchronization therapy. Ss=4.1 cm/s was the best diagnostic threshold according to the receiver operating characteristic curve.

CONCLUSIONS

Ss is an important factor affecting the response to cardiac resynchronization therapy. Patients with heart failure associated with Ss<4.1 cm/s have a higher risk of nonresponse.

Association of isolated minor nonspecific ST-T abnormalities with left ventricular hypertrophy and diastolic dysfunction

The aim of this study was to examine the associations of isolated minor nonspecific ST-T abnormalities (NSSTTA) on 12-lead electrocardiogram (ECG) with left ventricular (LV) diastolic function and LV geometry on echocardiography. A cross-sectional study comprised of 74,976 Koreans who underwent ECG and echocardiography as part of a comprehensive health examination between March 2011 and December 2014. ECG was coded using Minnesota Code criteria. The frequencies of NSSTTA, impaired LV relaxation, and echocardiographic LVH were 1,139 (1.5%), 21,118 (28.2%), and 1,687 (2.3%) patients, respectively. The presence of NSSTTA was positively associated with the prevalence of impaired LV relaxation and LVH on echocardiography. In a multivariable-adjusted model, the odds ratio (95% CIs) comparing patients with NSSTTA to control patients was 1.55 (1.33-1.80) for impaired LV relaxation and 3.15 (2.51-3.96) for echocardiographic LVH. The association between NSSTTA and impaired LV relaxation was stronger in the intermediate to high cardiovascular disease-risk group than in the low-risk group according to Framingham Risk Score stratification (P for interaction = 0.02). NSSTTA were associated with increased prevalence of impaired LV relaxation and LVH, suggesting NSSTTA as an early indicator of subclinical cardiac dysfunction and geometric abnormalities.

Light-moderate alcohol consumption and left ventricular function among healthy, middle-aged adults: the HUNT study

OBJECTIVES

To investigate the association between alcohol consumption and left ventricular (LV) function in a population with low average alcohol intake.

DESIGN, SETTING AND PARTICIPANTS

A total of 1296 healthy participants, free from cardiovascular diseases, were randomly selected from the third wave of the Norwegian HUNT study (2006-2008) and underwent echocardiography. After validation of the inclusion criteria, 30 participants were excluded due to arrhythmias or myocardial or valvular pathology. Alcohol consumption, sociodemographic and major cardiovascular risk factors were assessed by questionnaires and clinical examination in the HUNT3. General linear models were used to analyse the cross-sectional associations between alcohol intake and LV indices.

PRIMARY AND SECONDARY OUTCOME MEASURES

LV functional and structural indices were measured with tissue Doppler and speckle tracking echocardiography.

RESULTS

We observed no associations between alcohol consumption and multivariable-adjusted LV functional indices. Excluding abstainers who reported regular alcohol consumption 10 years prior to the baseline did not change the results. Alcohol consumption was positively associated with LV mass indices (p<0.01 for linear trend of the means); there was no such association among participants with non-risky drinking characteristics (p=0.67 for linear trend of the means).

CONCLUSIONS

We found no clear evidence that light-moderate alcohol consumption is associated with measures of LV function, although our results indicate that consumption, especially when marked by binge drinking, is progressively associated with greater LV mass.

Postsystolic Shortening by Speckle Tracking Echocardiography Is an Independent Predictor of Cardiovascular Events and Mortality in the General Population

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.

Cardiovascular risks in chronic kidney disease pediatric patients

One of the common factors for the premature death in children is advanced chronic kidney disease (CKD). Most often cardiovascular disease (CVD) is the reason for mortality. The cardiovascular (CV) morbidity starts early in the disease process and renal transplanted children (CKD-T) are also at risk. The present review is focused on the current views of the cardiovascular risks during CKD in pediatric patients. Variable data sources for the latest literature collection were explored which mainly included PubMed and Google Scholar. The most important risk factors for subclinical CVD were a young age, elevated BMI and systolic blood pressure z-scores as well as a low GFR and present albuminuria. Increasing blood pressure and BMI over follow-up were also important cardiac risk factors longitudinally. The present review concludes that altered cardiac function and remodeling are a concurrent part of the CKD process, start early in the disease development, and persist after renal transplantation. The findings suggest that children with CKD or CKD-T are at high risk for future CVD where younger patients with elevated BMI and slightly increased blood pressures, as well as present albuminuria, are those at greatest risk, thus indicating targets for future interventions.

Left ventricular ejection time is an independent predictor of incident heart failure in a community-based cohort

AIMS

Systolic time intervals change in the progress of cardiac dysfunction. The usefulness of left ventricular ejection time (LVET) to predict cardiovascular morbidity, however, is unknown.

METHODS AND RESULTS

We studied middle-aged African-Americans from one of four cohorts of the Atherosclerosis Risk in Communities study (Jackson cohort, n=1980) who underwent echocardiography between 1993 and 1995. Left ventricular ejection time was measured by pulsed-wave Doppler of the left ventricular outflow tract and related to outcomes. A shorter LVET was associated with younger age, male sex, higher diastolic blood pressure, higher proportion of diabetes, higher heart rate, higher blood glucose levels and worse fractional shortening. During a median follow-up of 17.6 years, 384 (19%) had incident heart failure (HF), 158 (8%) had a myocardial infarction, and 587 (30%) died. In univariable analysis, a lower LVET was significantly associated with increased risk of all events (P<0.05 for all). However, after multivariable adjustment for age, sex, hypertension, diabetes, body mass index, heart rate, systolic and diastolic blood pressure, fractional shortening and left atrial diameter, LVET remained an independent predictor only of incident HF [hazard ratio 1.07 (1.02-1.14), P=0.010 per 10 ms decrease]. In addition, LVET provided incremental prognostic information to the known risk factors included in the Framingham risk score, in regard to predicting all outcomes except for myocardial infarction.

CONCLUSION

Left ventricular ejection time is an independent predictor of incident HF in a community-based cohort and provides incremental prognostic information on the risk of future HF and death when added to known risk prediction models.

Risk stratification in patients with heart failure: the value of considering both global longitudinal left ventricular strain and mechanical dispersion

In previous studies, mechanical dispersion (MD) predicted ventricular arrhythmias independently of left ventricular ejection fraction (LVEF). Moreover, the combination of MD and global longitudinal strain (GLS) increased the prediction of arrhythmic events. We investigated the prognostic value of a new 2-dimensional strain index, GLS/MD, in patients with heart failure (HF). We analyzed 340 consecutive HF outpatients in sinus rhythm. Echocardiography was performed at 1.6 ± 0.4 months after hospital discharge. The end point included sudden cardiac death, ventricular fibrillation, and sustained ventricular tachycardia (SCD/VA). During the follow-up period (36 ± 9 months), SCD/VA occurred in 48 patients (14.1%). A multivariate Cox regression analysis, which included LVEF, early diastolic transmitral / mitral annular velocity ratio (E/E'), GLS, MD, and GLS/MD in the model, revealed that GLS/MD was the best independent predictor of SCD/VA (HR = 3.22, 95% confidence interval = 1.72-6.15, p = 0.03). Separate inclusion of LVEF, systolic mitral annular velocity, E/E', GLS, and MD together with GLS/MD showed that GLS/MD remained the best predictor of SCD/VA (each p < 0.05). The optimal GLS/MD cutoff value to predict SCA/VA was -0.20%/ms (80% sensitivity, 76% specificity). Irrespective of LVEF, free survival was significantly better in patients with GLS/MD ≤ -0.2%/ms (log-rank test, p < 0.001). In conclusion, GLS/MD may improve cardiovascular risk stratification in subjects with HF.

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

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.

Contemporary Assessment of Left Ventricular Diastolic Function in Older Adults: The Atherosclerosis Risk in Communities Study

BACKGROUND

Although age-associated changes in left ventricular diastolic function are well recognized, limited data exist characterizing measures of diastolic function in older adults, including both reference ranges reflecting the older adult population and prognostically relevant values for incident heart failure (HF), as well as their associations with circulating biomarkers of HF risk.

METHODS

Among 5801 elderly participants in the ARIC study (Atherosclerosis Risk in Communities; age range, 67-90 years; mean age, 76±5 years; 42% male; 21% black), we determined the continuous association of diastolic measures (tissue Doppler imaging [TDI] e', E/e', and left atrial size) with concomitant N-terminal pro-brain natriuretic peptide and subsequent HF hospitalization or death. We also determined sex-specific 10th and 90th percentile limits for these measures using quantile regression in 401 participants free of prevalent cardiovascular disease and risk factors.

RESULTS

Each measure of diastolic function was robustly associated with N-terminal pro-brain natriuretic peptide and incident HF or death. ARIC-based reference limits for TDI e' (4.6 and 5.2 cm/s for septal and lateral TDI e', respectively) were substantially lower than guideline cut points (7 and 10 cm/s, respectively), whereas E/e' and left atrial size demonstrated good agreement with guideline cut points. TDI e' was nonlinearly associated with incident HF or death, with inflection points for risk supportive of ARIC-based limits. ARIC-based limits for diastolic function improved risk discrimination over guideline-based cut points based on the integrated discrimination improvement (P<0.001) and continuous net reclassification improvement (P<0.001), reclassifying 42% of the study population as having normal diastolic function. We replicate these findings in the Copenhagen City Heart Study. With these limits, 46% had normal diastolic function and were at low risk of HF hospitalization or death (1%/y over a mean 1.7-year follow-up), 49% had 1 or 2 abnormal measures and were at intermediate risk (2.4%/y), and all 3 diastolic measures were abnormal in 5% who were at high risk (7.5%/y).

CONCLUSIONS

Our findings suggest that left ventricular longitudinal relaxation velocity declines as a part of healthy aging and is largely prognostically benign. The use of age-based normative values when considering an elderly population improves the risk discrimination of diastolic measures for incident HF or death.

Total average diastolic longitudinal displacement by colour tissue doppler imaging as an assessment of diastolic function

Background

The current method for a non-invasive assessment of diastolic dysfunction is complex with the use of algorithms of many different echocardiographic parameters. Total average diastolic longitudinal displacement (LD), determined by colour tissue Doppler imaging (TDI) via the measurement of LD during early diastole and atrial contraction, can potentially be used as a simple and reliable alternative.

Methods

In 206 patients, using GE Healthcare Vivid E7 and 9 and Echopac BT11 software, we determined both diastolic LD, measured in the septal and lateral walls in the apical 4-chamber view by TDI, and the degree of diastolic dysfunction, based on current guidelines. Of these 206 patients, 157 had cardiac anomalies that could potentially affect diastolic LD such as severe systolic heart failure (n = 45), LV hypertrophy (n = 49), left ventricular (LV) dilation (n = 30), and mitral regurgitation (n = 33). Intra and interobserver variability of diastolic LD measures was tested in 125 patients.

Results

A linear relationship between total average diastolic LD and the degree of diastolic dysfunction was found. A total average diastolic LD of 10 mm was found to be a consistent threshold for the general discrimination of patients with or without diastolic dysfunction. Using linear regression, total average diastolic LD was estimated to fall by 2.4 mm for every increase in graded severity of diastolic dysfunction (β = −0.61, p-value <0.001). Patients with LV hypertrophy had preserved total average diastolic LD despite being classified as having diastolic dysfunction. Reproducibility of LD measures was acceptable.

Conclusions

There is strong evidence suggesting that patients with a total average diastolic LD under 10 mm have diastolic dysfunction.

Electronic supplementary material

The online version of this article (doi:10.1186/s12947-016-0083-2) contains supplementary material, which is available to authorized users.

Cardiac Time Intervals by Tissue Doppler Imaging M-Mode: Normal Values and Association with Established Echocardiographic and Invasive Measures of Systolic and Diastolic Function

PURPOSE

To define normal values of the cardiac time intervals obtained by tissue Doppler imaging (TDI) M-mode through the mitral valve (MV). Furthermore, to evaluate the association of the myocardial performance index (MPI) obtained by TDI M-mode (MPITDI) and the conventional method of obtaining MPI (MPIConv), with established echocardiographic and invasive measures of systolic and diastolic function.

METHODS

In a large community based population study (n = 974), where all are free of any cardiovascular disease and cardiovascular risk factors, cardiac time intervals, including isovolumic relaxation time (IVRT), isovolumic contraction time (IVCT), and ejection time (ET) were obtained by TDI M-mode through the MV. IVCT/ET, IVRT/ET and the MPI ((IVRT+IVCT)/ET) were calculated. We also included a validation population (n = 44) of patients who underwent left heart catheterization and had the MPITDI and MPIConv measured.

RESULTS

IVRT, IVRT/ET and MPI all increased significantly with increasing age in both genders (p<0.001 for all). IVCT, ET, IVRT/ET, and MPI differed significantly between males and females, displaying that women, in general exhibit better cardiac function. MPITDI was significantly associated with invasive (dP/dt max) and echocardiographic measures of systolic (LVEF, global longitudinal strain and global strainrate s) and diastolic function (e', global strainrate e)(p<0.05 for all), whereas MPIConv was significantly associated with LVEF, e' and global strainrate e (p<0.05 for all).

CONCLUSION

Normal values of cardiac time intervals differed between genders and deteriorated with increasing age. The MPITDI (but not MPIConv) is associated with most invasive and established echocardiographic measures of systolic and diastolic function.

Cardiac function associated with previous, current and repeated depression and anxiety symptoms in a healthy population: the HUNT study

OBJECTIVE

Symptoms of anxiety and depression often co-exist with cardiovascular disease (CVD), yet little is known about the association with left ventricular (LV) subclinical dysfunction. We aimed to study the cross-sectional associations of previous, current and repeated depression or anxiety symptoms, with sensitive indices of LV systolic and diastolic function, based on tissue Doppler (TD) and speckle tracking (ST) imaging methods.

METHODS

A random selection of 1296 individuals free from known CVD, hypertension and diabetes were examined with echocardiography at baseline of the third Nord-Trøndelag Health Study, (HUNT3, 2006-2008). The primary outcomes were LV diastolic function (e') and LV systolic function (longitudinal global strain). The primary exposures were self-report on the Hospital Anxiety and Depression Scale (HADS). Associations between outcomes and baseline exposures were available for 1034 (80%), and with previous and repeated exposures for 700 participants who also participated in HUNT2 (1995-1997).

RESULTS

Previous and repeated depression symptoms, but not current depression, were linearly associated with a reduction in e'. The average sum of two repeated HADS-D scores 10 years apart had the strongest effect on e' (-8.3%; 95% CI -13.9% to -2.7%) per 5 units. We observed a sex difference between depression symptoms and longitudinal global strain (p for interaction 0.019), where women had a marginal negative effect. Anxiety symptoms, neither previous, current nor repeated were associated with subclinical LV dysfunction.

CONCLUSIONS

In a healthy sample, confirmed free of CVD, past and repeated depression symptoms were associated with subclinical LV dysfunction. Thus, depression symptoms might represent a modifiable risk factor for future CVD.

Cardiac Time Intervals Measured by Tissue Doppler Imaging M-mode: Association With Hypertension, Left Ventricular Geometry, and Future Ischemic Cardiovascular Diseases

BACKGROUND

We hypothesized that the cardiac time intervals reveal reduced myocardial function in persons with hypertension and are strong predictors of future ischemic cardiovascular diseases in the general population.

METHODS AND RESULTS

In a large community-based population study, cardiac function was evaluated in 1915 participants by using both conventional echocardiography and tissue Doppler imaging (TDI). The cardiac time intervals, including the isovolumic relaxation time (IVRT), isovolumic contraction time (IVCT), and ejection time (ET), were obtained by TDI M-mode through the mitral leaflet. IVCT/ET, IVRT/ET, and myocardial performance index [MPI=(IVRT+IVCT)/ET] were calculated. After multivariable adjustment for clinical variables the IVRT, IVRT/ET, and MPI, remained significantly impaired in persons with hypertension (n=826) compared with participants without hypertension (n=1082). Additionally, they displayed a significant dose-response relationship, between increasing severity of elevated blood pressure and increasing left ventricular mass index (P<0.001 for all). Further, during follow-up of a median of 10.7 years, 435 had an ischemic cardiovascular disease (ischemic heart disease, peripheral arterial disease, or stroke). The IVRT/ET and MPI were powerful and independent predictors of future cardiovascular disease, especially in participants with known hypertension. They provide prognostic information incremental to clinical variables from the Framingham Risk Score, the SCORE risk chart, and the European Society of Hypertension/European Society of Cardiology risk chart.

CONCLUSION

The cardiac time intervals identify impaired cardiac function in individuals with hypertension, not only independent of conventional risk factors but also in participants with a normal conventional echocardiographic examination. The IVRT/ET and MPI are independent predictors of future cardiovascular disease especially in participants with known hypertension.