Prognostic value of longitudinal strain of subepicardial myocardium in patients with hypertension

Assessment of Specific Biomarkers' Profile and Structural, Functional Parameters of the Left Ventricle in Patients With Lymphomas Undergoing Antitumor Therapy

AIM

To evaluate the dynamics of specific biomarkers for cardiotoxicity, endothelial dysfunction, fibrosis, systemic inflammation, and morpho-functional alterations in the left ventricular (LV) myocardium in patients with newly diagnosed lymphomas during 6 courses of polychemotherapy (PCT).

MATERIAL AND METHODS

The study included 30 patients with newly diagnosed lymphomas. All patients were evaluated for laboratory markers of cardiotoxicity at baseline and after 6 courses of chemotherapy (6 months), including N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity troponin I (hsTnI), endothelin-1 (ET-1), circulating cardiac biomarker ST-2, high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and LV structural and functional echocardiographic (EchoCG) parameters.

RESULTS

The changes in NT-proBNP and hsTnI concentrations during 6 courses of PCT were not statistically significant. Comparison of the baseline values with those after 6 courses of PCT showed increases in the median concentrations of ET-1 (3.38 and 5.5 pg/ml, respectively; p=0.438) and ST-2 (12.21 and 26.75 ng/ml, respectively; p=0.687). Markers of systemic inflammation were significantly decreased after 6 courses of PCT: the median CRP decreased from 15.2 to 0.72 mg/ml (p=0.006), and the median IL-6 decreased from 12.2 to 5.1 pg/ml (p=0.034). EchoCG data revealed a statistically significant impairment of the LV diastolic function parameters (E/A; E/e' lateral; E/e' average; left atrial volume index; isovolumic relaxation time). A moderate direct correlation was found between the ET-1 concentration and the isovolumic relaxation time at baseline and after 6 courses of PCT, respectively (r1 = 0.387, p=0.047 and r2 = 0.391, p=0.035). No changes in the LV systolic function were observed.

CONCLUSION

The study showed that patients with lymphoproliferative diseases had no signs of cardiotoxicity during PCT according to the accepted criteria. This study described and highlighted for the first time the interrelation of endothelial dysfunction, profibrotic status, and LV diastolic dysfunction as manifestations of cardiovascular toxicity in patients with lymphoproliferative diseases. It is advisable to supplement the integrated strategies for the prevention and monitoring of PCT cardiovascular toxicity with a thorough evaluation of instrumental parameters of diastolic dysfunction for timely initiation/correction of cardioprotective therapy.

Layer-specific fast strain-encoded cardiac magnetic resonance imaging aids in the identification and discrimination of acute myocardial injury: a prospective proof-of-concept study

BACKGROUND

Acute myocardial injury is a common diagnosis in the emergency department and differential diagnoses are numerous. Cardiac magnetic resonance (CMR) strain sequences, such as fast strain ENCoded (fSENC), are early predictors of myocardial function loss. This study assessed the potential diagnostic and prognostic benefits of a layer-specific approach.

METHODS

For this prospective study, patients in the emergency department fulfilling rule-in criteria for non-ST-elevation myocardial infarction (NSTEMI) received an ultra-fast fSENC CMR. Volunteers without cardiac diseases (controls) were recruited for comparison. Measurements were performed in a single heartbeat acquisition to measure global longitudinal strain (GLS) and segmental longitudinal strain and dysfunctional segments. The GLS was measured in two layers and a difference (GLSdifference = GLSepicardial - GLSendocardial) was calculated. The performance of those strain features was compared to standard care (physical examination, cardiac biomarkers, electrocardiogram). According to the final diagnosis after discharge, patients were divided into groups and followed up for 2 years.

RESULTS

A total of 114 participants, including 50 controls, were included. The 64 patients (51 male) were divided into a NSTEMI (25), myocarditis (16), and other myocardial injury group (23). GLS served as a potent predictor of myocardial injury (area under the curve (AUC) 91.8%). The GLSdifference provided an excellent diagnostic performance to identify a NSTEMI (AUC 83.2%), further improved by including dysfunctional segments (AUC 87.5%, p = 0.01). An optimal test was achieved by adding fSENC to standard care (AUC 95.5%, sensitivity 96.0%, specificity 86.5%, p = 0.03). No death occurred in 2 years for patients with normal GLS and ≤5 dysfunctional segments, while three patients died that showed abnormal GLS or >5 dysfunctional segments.

CONCLUSIONS

Layer-specific strain is a potential new marker with high diagnostic performance in the identification and differentiation of acute myocardial injuries.

Cardiac dysfunction and their determinants in patients treated for breast cancer and lymphoma: A cardio-oncology center experience

OBJECTIVE

Cancer and cardiovascular diseases both have adverse effects on each other. We aim in the current study to investigate cardiac dysfunction including its prevalence, and associated factors in patients treated for breast cancer and lymphoma in a unique cardiac oncology center.

METHODS

A single-center retrospective study included 180 patients with cancer breast and lymphoma who presented and were treated at our oncology center from January 2019 to February 2022.

RESULT

Out of 180 consecutive patients, 155 patients (86 %) were diagnosed with cancer breast and 25 patients (14 %) were diagnosed with lymphoma. Patients with lymphoma were older age, less obese, and showed more prevalence of diabetes mellitus (DM) (P = 0.026, 0.05, and 0.04 respectively). They also showed more post-therapy left ventricular (LV) dilatation and lower values of global longitudinal strain (GLS); however, they did not develop more LV dysfunction compared to cancer breast patients. Moreover, lymphoma patients showed poor in-hospital outcomes (P = 0.04, 0.001, and 0.015 for infection, pericardial effusion, and mortality respectively). Cancer therapy-related cardiac dysfunction (CTRCD) was observed in 41 patients (23 %) of our population. The independent predictors of CTRCD in the current study were DM, low body mass index (BMI), and the use of trastuzumab.

CONCLUSIONS

Some patients treated for breast cancer and lymphoma develop LV dysfunction. Lymphoma patients showed more subclinical LV dysfunction and poor in-hospital outcomes compared to patients with cancer breast. DM, low body mass index (BMI), and the use of trastuzumab were the independent predictors of cardiac dysfunction among our patients.

Myocardial Injury in Rats Exposed to High-Intensity Exercise Evaluated by 2-D Speckle Tracking Imaging

OBJECTIVE

The aim of the work described here was to evaluate strain and morphological change of the left ventricle in Sprague Dawley (SD) rats at different exercise intensities by 2-D speckle tracking imaging (STI).

METHODS

Seventy-two 8-wk-old SD rats were divided into four groups on the basis of exercise intensity: sedentary (SED), low-intensity running, medium-intensity running (MIR) and high-intensity running (HIR). Each group was further sub-divided into three groups of different exercise lengths: 1, 4 and 8 wk. The structural measurements of the left ventricle and left ventricular ejection fraction (LVEF) were obtained by echocardiography. Systolic peak values of global longitudinal, circumferential and radial strains (GLS, GCS and GRS) were obtained. Histopathological results of the cross-sectional area (CSA) of myocardial cells, collagen volume fraction (CVF) of the myocardium and perivascular collagen area (PVCA) were also observed.

RESULTS

Structural measurements of the left ventricle and LVEF did not change with different exercise intensities or lengths. GLS of the HIR8 wk sub-group was significantly lower than those of the SED8 wk and MIR8 wk sub-groups. Conversely, the GLS and GCS of the HIR8 wk sub-group were lower than those of the HIR1 wk and HIR4 wk sub-groups. Histopathologically, the CSA of myocardial cells significantly increased across all HIR sub-groups and the MIR4 wk and MIR8 wk sub-groups. CVFendo and PVCA were also significantly increased in the HIR4 wk and HIR8 wk sub-groups. The HIR8 wk group also had regional swelling and ill-defined boundaries of myocardial cells.

CONCLUSION

Prolonged, high-intensity exercise may lead to exercise-induced injury of the myocardium. Two-dimensional STI can be used as a non-invasive early detection method for exercise-induced injury of myocardial function, compared with LVEF.

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

Speckle tracking echocardiography in early disease stages: a therapy modifier?

Echocardiography has been included as a first-line tool in several international guidelines for the management of patients with various cardiac diseases. Beyond diagnosis, echocardiographic examination helps in characterizing the severity of the condition since the very first stages. In particular, the application of second-level techniques, speckle tracking echocardiography in particular, can also reveal a subclinical dysfunction, while the standard parameters are in the normality range. The present review describes the potentialities of advanced echocardiography in different settings, including arterial hypertension, atrial fibrillation, diastolic dysfunction, and oncological patients, thus opening up potential starting points for its application as a clinical routine changer.

From Structural to Functional Hypertension Mediated Target Organ Damage—A Long Way to Heart Failure with Preserved Ejection Fraction

Arterial hypertension (AH) is a major risk factor for the development of heart failure (HF) which represents one of the leading causes of mortality and morbidity worldwide. The chronic hemodynamic overload induced by AH is responsible for different types of functional and morphological adaptation of the cardiovascular system, defined as hypertensive mediated target organ damage (HMOD), whose identification is of fundamental importance for diagnostic and prognostic purposes. Among HMODs, left ventricular hypertrophy (LVH), coronary microvascular dysfunction (CMVD), and subclinical systolic dysfunction have been shown to play a role in the pathogenesis of HF and represent promising therapeutic targets. Furthermore, LVH represents a strong predictor of cardiovascular events in hypertensive patients, influencing per se the development of CMVD and systolic dysfunction. Clinical evidence suggests considering LVH as a diagnostic marker for HF with preserved ejection fraction (HFpEF). Several studies have also shown that microalbuminuria, a parameter of abnormal renal function, is implicated in the development of HFpEF and in predicting the prognosis of patients with HF. The present review highlights recent evidence on the main HMOD, focusing in particular on LVH, CMD, subclinical systolic dysfunction, and microalbuminuria leading to HFpEF.

Is myocardial strain an early marker of systolic dysfunction in obstructive sleep apnoea? Findings from a meta-analysis of echocardiographic studies

AIM

We investigated the association between obstructive sleep apnoea (OSA) and subclinical systolic dysfunction through a meta-analysis of echocardiographic studies that provided data on left ventricular (LV) mechanics as assessed by global longitudinal strain (GLS).

DESIGN

The PubMed, OVID-MEDLINE, and Cochrane library databases were systematically analyzed to search English-language articles published from inception to 31 December 2021. Studies were detected by using the following terms: 'obstructive sleep apnea', 'sleep quality', 'sleep disordered breathing', 'cardiac damage', 'left ventricular hypertrophy', 'systolic dysfunction', 'global longitudinal strain', 'left ventricular mechanics', 'echocardiography' and 'speckle tracking echocardiography'.

RESULTS

The meta-analysis included 889 patients with OSA and 364 non-OSA controls from 12 studies. Compared with controls, GLS was significantly reduced in the pooled OSA group (SMD -1.24 ± 0.17, CI: -1.58 to -0.90, P  < 0.0001), as well as in the normotensive OSA subgroup (SMD: -1.17 ± 0.12 CI:-1.40 to -0.95, P  < 0.0001). Similar findings were obtained in sub-analyses performed separately in mild, moderate and severe OSA. This was not the case for LV ejection fraction (LVEF) (i.e. comparisons between controls vs. mild OSA, mild vs. moderate OSA, moderate vs. severe OSA).

CONCLUSION

GLS is impaired in patients with OSA (independently from hypertension), worsening progressively from mild to moderate and severe forms, thus allowing to identify subclinical alterations of the systolic function not captured by LVEF. Therefore, myocardial strain assessment should be implemented systematically in the OSA setting to timely detect systolic dysfunction.

Longitudinal strain by speckle tracking and echocardiographic parameters as predictors of adverse cardiovascular outcomes in chronic Chagas cardiomyopathy

To analyze the prognostic value of left ventricular global longitudinal strain (LV-GLS) and other echocardiographic parameters to predict adverse outcomes in chronic Chagas cardiomyopathy (CCM). Prospective cohort study conducted in 177 consecutive patients with different CCM stages. Transthoracic echocardiography measurements were obtained following the American Society of Echocardiography recommendations. By speckle-tracking echocardiography, LV-GLS was obtained from the apical three-chamber, apical two-chamber, and apical four-chamber views. The primary composite outcome (CO) was all-cause mortality, cardiac transplantation, and a left ventricular assist device implantation. After a median follow-up of 42.3 months (Q1 = 38.6; Q3 = 52.1), the CO incidence was 22.6% (95% CI 16.7-29.5%, n = 40). The median LV-GLS value was - 13.6% (Q1 =  - 18.6%; Q3 =  - 8.5%). LVEF, LV-GLS, and E/e' ratio with cut-off points of 40%, - 9, and 8.1, respectively, were the best independent CO predictors. We combined these three echocardiographic markers and evaluated the risk of CO according to the number of altered parameters, finding a significant increase in the risk across the groups. While in the group of patients in which all these three parameters were normal, only 3.2% had the CO; those with all three abnormal parameters had an incidence of 60%. We observed a potential incremental prognostic value of LV-GLS in the multivariate model of LVEF and E/e' ratio, as the AUC increased slightly from 0.76 to 0.79, nevertheless, this difference was not statistically significant (p = 0.066). LV-GLS is an important predictor of adverse cardiovascular events in CCM, providing a potential incremental prognostic value to LVEF and E/e' ratio when analyzed using optimal cut-off points, highlighting the potential utility of multimodal echocardiographic tools for predicting adverse outcomes in CCM.

Strain Imaging for the Early Detection of Cardiac Remodeling and Dysfunction in Primary Aldosteronism

Speckle tracking echocardiography is a novel technique to quantify cardiac function and deformation. It has been applied in a series of cardiovascular diseases for the evaluation of early cardiac impairment. We recently used this technique to investigate cardiac structure and function in patients with primary aldosteronism. Cardiac damage usually occurs earlier in patients with primary aldosteronism than those with primary hypertension, probably because aldosterone hypersecretion is more commonly observed in the former than the latter patients. In this article, we will review the imaging studies, especially with speckle tracking echocardiography, for the detection of early cardiac dysfunction in primary aldosteronism as a disease model.

Role of strain echocardiography in patients with hypertension

Hypertension is a well-recognized risk factor for the development of cardiovascular disease, and the early detection of cardiac changes from hypertension can allow reversing these. Hypertensive heart diseases (HHD) refer to the complex and diverse change of the cardiac structure and function secondary to hypertension. Although conventional echocardiography is the most common imaging modality in detecting HHD, it cannot detect subtle changes of cardiac structure in subclinical states. Because strain echocardiography is another echocardiographic modality can detect subclinical myocardial dysfunction by measuring intrinsic myocardial deformation, it became more and more popular in clinical and research fields. In this review article, we described the basic concept of strain echocardiography and summarized several clinical studies showing its clinical utilities in the detection of HHD.

Advanced imaging tools for evaluating cardiac morphological and functional impairment in hypertensive disease

Arterial hypertension represents a systemic burden, and it is responsible of various morphological, functional and tissue modifications affecting the heart and the cardiovascular system. Advanced imaging techniques, such as speckle tracking and three-dimensional echocardiography, cardiac magnetic resonance, computed tomography and PET-computed tomography, are able to identify cardiovascular injury at different stages of arterial hypertension, from subclinical alterations and overt organ damage to possible complications related to pressure overload, thus giving a precious contribution for guiding timely and appropriate management and therapy, in order to improve diagnostic accuracy and prevent disease progression. The present review focuses on the peculiarity of different advanced imaging tools to provide information about different and multiple morphological and functional aspects involved in hypertensive cardiovascular injury. This evaluation emphasizes the usefulness of the emerging multiimaging approach for a comprehensive overview of arterial hypertension induced cardiovascular damage.

Myocardial strain in hypertension: a meta-analysis of two-dimensional speckle tracking echocardiographic studies

AIM

Available evidence on systolic dysfunction in systemic hypertension, as assessed by left ventricular (LV) mechanics, is still based on single studies. Thus, we performed a systematic meta-analysis of two-dimensional speckle-tracking studies in order to provide an updated comprehensive information on this issue.

METHODS

The PubMed, OVID-MEDLINE, and Cochrane library databases were analyzed to search English language articles published from the inception up to 31 December 2020. Studies were identified by using MeSH terms and crossing the following search items: 'myocardial strain', 'left ventricular mechanics', 'speckle tracking echocardiography', 'systolic dysfunction', 'hypertensive heart disease', 'systemic hypertension', 'essential hypertension'.

RESULTS

Data from 4276 individuals (2089 normotensive controls and 2187 mostly uncomplicated hypertensive patients) were included. Left ventricular (LV) mass index, relative wall thickness, left atrial volume index and E/e' ratio were significantly higher in hypertensive patients than in normotensive controls. LV ejection fraction did not differ in the two pooled groups (SMD -0.048 ± 0.054, 95% CI -0.20 to 0.10, P = 0.30), whereas LV global longitudinal strain (GLS) was significantly impaired in the hypertensive group (SMD: 1.07 ± 0. 15, 95% CI 0.77-1.36, P < 0.0001). Similar findings were obtained in a sub-analysis restricted to 15 studies in which mean age was similar in cases and controls (SMD 1.21 ± 0.23, 95% CI 0.76-1.67, P = 0.002).

CONCLUSION

The present meta-analysis suggests that GLS assessment unmasks systolic dysfunction undetected by conventional ejection fraction in the uncomplicated hypertension setting and that this parameter should be incorporated into routine work-up aimed to identify hypertension-mediated cardiac damage.

Assessing left ventricular systolic function: from ejection fraction to strain analysis

The measurement of left ventricular ejection fraction (LVEF) is a ubiquitous component of imaging studies used to evaluate patients with cardiac conditions and acts as an arbiter for many management decisions. This follows early trials investigating heart failure therapies which used a binary LVEF cut-off to select patients with the worst prognosis, who may gain the most benefit. Forty years on, the cardiac disease landscape has changed. Left ventricular ejection fraction is now a poor indicator of prognosis for many heart failure patients; specifically, for the half of patients with heart failure and truly preserved ejection fraction (HF-PEF). It is also recognized that LVEF may remain normal amongst patients with valvular heart disease who have significant myocardial dysfunction. This emphasizes the importance of the interaction between LVEF and left ventricular geometry. Guidelines based on LVEF may therefore miss a proportion of patients who would benefit from early intervention to prevent further myocardial decompensation and future adverse outcomes. The assessment of myocardial strain, or intrinsic deformation, holds promise to improve these issues. The measurement of global longitudinal strain (GLS) has consistently been shown to improve the risk stratification of patients with heart failure and identify patients with valvular heart disease who have myocardial decompensation despite preserved LVEF and an increased risk of adverse outcomes. To complete the integration of GLS into routine clinical practice, further studies are required to confirm that such approaches improve therapy selection and accordingly, the outcome for patients.

Relationship Between Masked Hypertension Measured by Ambulatory Blood Pressure Monitoring and Left Ventricular Global Longitudinal Strain: A Retrospective Study

Purpose

Masked hypertension (MHT), as an independent clinical entity, the cardiac dysfunction caused by it can be early detected through left ventricular global longitudinal strain (GLS), yet the quantitative relation between MHT and GLS is still unclear. Therefore, we tried to conduct a community-based retrospective study to define this relationship.

Patients and Methods

A total of 308 enrolled participants from Dongguan, China, were divided into non-hypertension (NHT) and MHT groups. Baseline characteristics were recorded, and echocardiography and 24-hour ambulatory blood pressure monitoring were performed. Linear regression analysis and receiver-operating characteristic (ROC) curve analysis were used to assess the associations between MHT and GLS in univariate and multivariate models, and the dose–response curve was plotted to demonstrate their relationship.

Results

The mean age of the NHT and MHT groups was 57 and 60 years, respectively. Signs of left ventricular diastolic function, E/A was reduced and E/e’ was increased in the MHT group while those of the NHT group were nearly normal. The MHT group also showed a significantly lower (“worse”) GLS than NHT (−15.2% vs −19.9%, P < 0.001) while left ventricular ejection fraction (LVEF) did not differ between the groups. Worse GLS was independently and significantly associated with MHT both in univariate (odds ratio [OR]: 1.97, P < 0.001) and stepwise multivariate regression analysis (OR: 1.99, P < 0.001). Comparison of ROC curve results showed that area under curve of GLS was larger than that of E/e’ both in unadjusted (0.8673 vs 0.6831) and adjusted model (0.9178 vs 0.8284). Further analysis showed adjusted nonlinear correlation between MHT and GLS.

Conclusion

Based on the relationship between MHT and GLS, in clinical practice, GLS measurement could facilitate diagnosis for suspected MHT patients and could define the extent of left ventricular dysfunction for diagnosed MHT patients.

Myocardial Strain Imaging in Resistant Hypertension

PURPOSE OF REVIEW

Resistant hypertension (RH) is a major contributor to cardiovascular diseases and is associated with increased all-cause and cardiovascular mortality. Cardiac changes such as impaired left ventricular (LV) function, left ventricular hypertrophy (LVH), myocardial fibrosis, and enlarged left atrium (LA) are consequences of chronic exposure to an elevated blood pressure. The purpose of this review article is to demonstrate the potential benefits of using STE as a non-invasive imaging technique in the assessment of cardiac remodeling in patients with hypertension and specifically in uncontrolled and RH population.

RECENT FINDINGS

It is well-recognized that conventional transthoracic echocardiography is a useful analytic imaging modality to evaluate hypertension-mediated organ damage (HMOD) and in a resistant hypertensive population. More recently two-dimensional speckle tracking echocardiography (STE) has been utilized to provide further risk assessment to this population. Recent data has shown that STE is a new promising echocardiographic marker to evaluate early stage LV dysfunction and myocardial fibrosis over conventional 2D parameters in patients with cardiovascular diseases.

Speckle Tracking Echocardiography in Hypertensive Pregnancy Disorders: A Systematic Review

Importance

Hypertensive pregnancy disorders (HPDs) are associated with an increased risk of long-term cardiovascular disease. Speckle tracking echocardiography (STE) might be useful in the early detection of preclinical cardiac changes in women with HPDs.

Objective

The aim of this study was to study whether STE is a suitable method to detect differences in cardiac function in pregnant women with HPD compared with normotensive pregnant women or between women with a history of a pregnancy complicated by HPD compared with women with a history of an uncomplicated pregnancy.

Evidence Acquisition

The databases Medline, EMBASE, and Central were systematically searched for studies comparing cardiac function measured with STE in pregnant women with HPD or women with a history of HPD and women with a history of normotensive pregnancies.

Results

The search identified 16 studies, including 870 women with a history of HPD and 693 normotensive controls. Most studies during pregnancy (n = 12/13) found a decreased LV-GLS (left ventricular global longitudinal strain) in HPD compared with normotensive pregnant controls. LV-GRS (left ventricular global radial strain) and LV-GLCS (left ventricular global circumferential strain) are decreased in women with early-onset and severe preeclampsia. Women with a history of early-onset preeclampsia show lasting myocardial changes, with significantly decreased LV-GLS, LV-GLCS, and LV-GRS.

Conclusions and Relevance

LV-GLS is significantly decreased in pregnant women with HPD compared with normotensive pregnant women. Other deformation values show a significant decrease in women with severe or early-onset preeclampsia, with lasting myocardial changes after early-onset preeclampsia.

Subtle cardiac dysfunction in lymphoma patients receiving low to moderate dose chemotherapy

Left ventricular (LV) global peak systolic longitudinal strain (GLS) is a sensitive measurement for detecting subtle LV systolic dysfunction and a powerful prognostic predictor. However, the clinical implication of LV GLS in lymphoma patients receiving cancer therapy remains unknown. We prospectively enrolled 74 lymphoma patients (57.9 ± 17.0 years old, 57% male). We performed echocardiographic studies after the 3rd and 6th cycles and 1 year after chemotherapy and a cardiopulmonary exercise test upon completion of 3 cycles of anticancer therapy. Cancer therapy-related cardiac dysfunction (CTRCD) was defined as a ≥ 15% relative reduction in GLS value from baseline. The primary outcome was a composite of all-cause mortality and heart failure events. Thirty-six patients (49%) had CTRCD (LV GLS: baseline vs. after 3rd cycle of therapy: 20.1 ± 2.6 vs. 17.5 ± 2.3%, p < 0.001). CTRCD was detected after the 3rd cycle of anticancer therapy. CTRCD patients had impaired exercise capacity (minute oxygen consumption/kg, CTRCD vs. CTRCD (-): 13.9 ± 3.1 vs. 17.0 ± 3.9 ml/kg/min, p = 0.02). More primary outcome events occurred in the CTRCD group (hazard ratio 3.21; 95% confidence interval 1.04–9.97; p = 0.03). LV GLS could detect subtle but clinically significant cardiac dysfunction in lymphoma patients in the early stage of anticancer therapy. CTRCD may be associated with not only a reduced exercise capacity but also a worse prognosis.

Layer-specific strain in patients with heart failure using cardiovascular magnetic resonance: not all layers are the same

BACKGROUND

Global longitudinal strain (GLS), most commonly measured at the endocardium, has been shown to be superior to left ventricular (LV) ejection fraction (LVEF) for the identification of systolic dysfunction and prediction of outcomes in heart failure (HF). We hypothesized that strains measured at different myocardial layers (endocardium = ENDO, epicardium = EPI, average = AVE) will have distinct diagnostic and predictive performance for patients with HF.

METHODS

Layer-specific GLS, layer-specific global circumferential strain (GCS) and global radial strain (GRS) were evaluated by cardiovascular magnetic resonance imaging (CMR) feature tracking in the Alberta HEART study. A total of 453 subjects consisted of healthy controls (controls, n = 77), at-risk for HF (at-risk, n = 143), HF with preserved ejection fraction (HFpEF, n = 87), HF with mid-range ejection fraction (HFmrEF, n = 88) and HF with reduced ejection fraction (HFrEF, n = 58). For outcomes analysis, CMR-derived imaging parameters were adjusted with a base model that included age and N-terminal prohormone of b-type natriuretic peptide (NT-proBNP) to test their independent association with 5-year all-cause mortality.

RESULTS

GLS_EPI distinguished all groups with preserved LVEF (controls - 16.5 ± 2.4% vs. at-risk - 15.5 ± 2.7% vs. HFpEF - 14.1 ± 3.0%, p < 0.001) while GLS_ENDO and all GCS (all layers) were similar among these groups. GRS was reduced in HFpEF (41.1 ± 13.8% versus 48.9 ± 10.7% in controls, p < 0.001) and the difference between GLS_EPI and GLS_ENDO were significantly larger in HFpEF as compared to controls. Within the preserved LVEF groups, reduced GRS and GLS_EPI were significantly associated with increased LV mass (LVM) and LVM/LV end-diastolic volume EDV (concentricity). In multivariable analysis, only GLS_AVE and GRS predicted 5-year all-cause mortality (all ps < 0.05), with the strongest association with 5-year all-cause mortality by Akaike Information Criterion analysis and significant incremental value for outcomes prediction beyond LVEF or GLS_ENDO by the likelihood ratio test.

CONCLUSION

Global strains measured on endocardium, epicardium or averaged across the wall thickness are not equivalent for the identification of systolic dysfunction or outcomes prediction in HF. The endocardium-specific strains were shown to have poorest all-around performance. GLS_AVE and GRS were the only CMR parameters to be significantly associated with 5-year all-cause mortality in multivariable analysis. GLS_EPI and GRS, as well as the difference in endocardial and epicardial strains, were sensitive to systolic dysfunction among HF patients with normal LVEF (> 55%), in whom lower strains were associated with increased concentricity.

Automated Recognition of Regional Wall Motion Abnormalities Through Deep Neural Network Interpretation of Transthoracic Echocardiography

BACKGROUND

Automated interpretation of echocardiography by deep neural networks could support clinical reporting and improve efficiency. Whereas previous studies have evaluated spatial relationships using still frame images, we aimed to train and test a deep neural network for video analysis by combining spatial and temporal information, to automate the recognition of left ventricular regional wall motion abnormalities.

METHODS

We collected a series of transthoracic echocardiography examinations performed between July 2017 and April 2018 in 2 tertiary care hospitals. Regional wall abnormalities were defined by experienced physiologists and confirmed by trained cardiologists. First, we developed a 3-dimensional convolutional neural network model for view selection ensuring stringent image quality control. Second, a U-net model segmented images to annotate the location of each left ventricular wall. Third, a final 3-dimensional convolutional neural network model evaluated echocardiographic videos from 4 standard views, before and after segmentation, and calculated a wall motion abnormality confidence level (0-1) for each segment. To evaluate model stability, we performed 5-fold cross-validation and external validation.

RESULTS

In a series of 10 638 echocardiograms, our view selection model identified 6454 (61%) examinations with sufficient image quality in all standard views. In this training set, 2740 frames were annotated to develop the segmentation model, which achieved a Dice similarity coefficient of 0.756. External validation was performed in 1756 examinations from an independent hospital. A regional wall motion abnormality was observed in 8.9% and 4.9% in the training and external validation datasets, respectively. The final model recognized regional wall motion abnormalities in the cross-validation and external validation datasets with an area under the receiver operating characteristic curve of 0.912 (95% CI, 0.896-0.928) and 0.891 (95% CI, 0.834-0.948), respectively. In the external validation dataset, the sensitivity was 81.8% (95% CI, 73.8%-88.2%), and specificity was 81.6% (95% CI, 80.4%-82.8%).

CONCLUSIONS

In echocardiographic examinations of sufficient image quality, it is feasible for deep neural networks to automate the recognition of regional wall motion abnormalities using temporal and spatial information from moving images. Further investigation is required to optimize model performance and evaluate clinical applications.

The relationship between functional capacity and left ventricular strain in patients with uncomplicated type 2 diabetes

OBJECTIVE

We aimed to evaluate the association between functional capacity and left ventricular (LV) mechanics in the patients with uncomplicated type 2 diabetes.

METHODS

The present cross-sectional study included 80 controls and 70 uncomplicated diabetic patients. These participants underwent laboratory analysis, comprehensive echocardiographic examination and cardiopulmonary exercise testing.

RESULTS

Global longitudinal (-21.6 ± 2.8 vs. -18.4 ± 2.3%, P < 0.001) and circumferential (-22.0 ± 2.9 vs. -19.5 ± 2.6%, P < 0.001) strains were significantly reduced in diabetic participants. The same was found for longitudinal and circumferential endocardial, mid-myocardial and epicardial strains. Peak oxygen uptake (27.0 ± 4.3 vs. 20.7 ± 4.0 ml/kg/min, P < 0.001) and oxygen pulse (14.1 ± 3.0 vs. 11.6 ± 3.2 ml/beat, P < 0.001) were significantly lower in the diabetic group, while ventilation/carbon dioxide slope was significantly higher in these patients. In the whole study population glycosylated hemoglobin, as well as LV endocardial longitudinal and circumferential strains were independently of other clinical and echocardiographic parameters of LV structure, systolic and diastolic function associated with peak oxygen consumption and oxygen pulse.

CONCLUSION

Our investigation showed that diabetes equally affected all LV myocardial layers. Endocardial LV longitudinal and circumferential strains, as well as glycosylated hemoglobin - main parameter of glucose regulation, were independently associated with functional capacity in the whole study population. These findings indicate that determination of LV strain and functional capacity could detect subclinical target organ damage and prevent development of further complications in uncomplicated diabetes mellitus patients.

Global longitudinal strain is associated with better outcomes in transcatheter aortic valve replacement

Background

Parameters that mark the timing of left ventricular (LV) reverse remodeling following transcatheter aortic valve replacement (TAVR) are incompletely defined. This study aims to identify the dynamics of LV strain derived from speckle tracking echocardiography in a cohort of patients with severe aortic stenosis (AS) who underwent TAVR and its correlation with postprocedural outcomes.

Methods

We selected 150 consecutive patients (82 ± 4 years old, STS score 6.4 ± 6.2) who underwent transfemoral TAVR between 07/2016 and 12/2017 at our tertiary care center. All patients were evaluated at baseline, 1 week after TAVR, and 3 months following TAVR.

Results

The global longitudinal strain (GLS) 1 week following TAVR was comparable to that at baseline (− 15,9 ± 4.3 vs − 16.8 ± 4.1; p = NS) but significantly improved at 3 months following TAVR (− 15.9 ± 4.3% vs. -19.5 ± 3.5%; p < 0.001). No significant changes in global circumferential strain (GCS) and global radial strain (GRS) were detectable. The ejection fraction was significantly improved 1 week after the TAVR procedure. The baseline GLS correlated directly with the complication rate (R = 0.36, p = 0.005). The linear regression analysis showed that the main predictors of the improvement in the GLS at 3 months in our cohort were baseline GRS and GCS.

Conclusion

GLS improves at 3 months after TAVR, while LV ejection fraction does not show a substantial change, signaling an early recovery of LV longitudinal function after the intervention. Additionally, GLS has a direct correlation with the postprocedural outcomes. GLS improvement might emerge as a valuable parameter for a tailored follow-up in TAVR patients.

Asymptomatic Left Ventricle Systolic Dysfunction

Heart failure is a common debilitating illness, associated with significant morbidity and mortality, rehospitalisation and societal costs. Current guidelines and position statements emphasise the management of patients with overt symptomatic disease, but the increasing prevalence of congestive heart failure underscores the need to identify and manage patients with early left ventricular dysfunction prior to symptom onset. Asymptomatic left ventricular systolic dysfunction (ALVSD), classified as stage B heart failure, is defined as depressed left ventricular systolic function in the absence of clinical heart failure. Early initiation of therapies in patients with presumed ALVSD has been shown to lead to better outcomes. In this article, the authors clarify issues surrounding the definition and natural history of ALVSD, outline clinical tools that may be of value in identifying patients with ALVSD and highlight potential opportunities for future investigations to better address aspects of our understanding of this complex syndrome.

Early and Quantitative Assessment of Myocardial Deformation in Essential Hypertension Patients by Using Cardiovascular Magnetic Resonance Feature Tracking

The aims of the study were to identify subclinical global systolic function abnormalities and evaluate influencing factors associated with left ventricular (LV) strain parameters in hypertensive subjects using cardiovascular magnetic resonance imaging feature tracking (CMR-FT). The study enrolled 57 patients with essential hypertension (mean age: 43.04 ± 10.90 years; 35 males) and 26 healthy volunteers (mean age: 38.69 ± 10.44 years; 11 males) who underwent clinical evaluation and CMR examination. Compared with controls, hypertensive patients had significantly impaired myocardial strain values while ejection fraction (EF) did not differ. After multivariate regression analyses adjustment for confounders, the global radial strains (GRS) was independently associated with the mean arterial pressure (MAP) and left ventricular mass index (LVMI) (β = -0.219, p = 0.009 and β = -0.224, p = 0.015, respectively; Adjusted R² = 0.4); the global circumferential strains (GCS) was also independently associated with the MAP and LVMI (β = 0.084, p = 0.002 and β = 0.073, p = 0.01, respectively; Adjusted R² = 0.439); the global longitudinal strains (GLS) was independently associated with the Age and MAP (β = 0.065, p = 0.021 and β = 0.077, p = 0.009, respectively; Adjusted R² = 0.289). Myocardial strain can early detect the myocardial damage and may be an appropriate target for preventive strategies before abnormalities of EF.

The Effect of Antihypertensive Therapy on Left Ventricular Longitudinal Strain: Missing Part of the Puzzle

There is no consensus regarding the benefit of antihypertensive therapy on left ventricular structure and function. The most of studies investigated the effect of therapy on left ventricular hypertrophy, less studies were focused on left ventricular diastolic dysfunction and the minority on left ventricular mechanics. The majority of investigations showed positive effect of antihypertensive therapy on regression of left ventricular remodeling. Nevertheless, it is very difficult to distinguish the effect of antihypertensive medication from the effect of blood pressure reduction on left ventricular improvement. The other important issue in these studies is difficulty to distinguish the effect of left ventricular hypertrophy regression from the effect of antihypertensive medications on left ventricular diastolic function and mechanics. The novel findings suggest that the cascade of left ventricular remodeling in hypertensive heart disease begins with mechanical changes, continuous with diastolic dysfunction, and ends with left ventricular hypertrophy. This is very important paradigm because it enables early and timely diagnosis of subclinical left ventricular damage in hypertensive patients and should provide rapid detection of left ventricular function improvement during antihypertensive therapy.

Myocardial Strain in the Assessment of Patients With Heart Failure: A Review

Importance

The cornerstones of imaging in heart failure (HF) are the measurement of systolic and diastolic function and left ventricular (LV) filling pressure.

Observations

Ejection fraction and the assessment of LV filling pressure and diastolic dysfunction using the ratio of early transmitral flow and LV relaxation (E/e') are conventional imaging markers of LV function. Despite their extensive use in HF guidelines, both have significant detractions, especially in an era when HF with preserved ejection fraction is becoming the dominant presentation. In contrast, strain imaging has provided a new window into myocardial mechanics. Myocardial strain is now well validated, robust, and can easily be performed on most modern echocardiography machines. This Review summarizes the evidence in 9 situations across the stages of HF where LV global longitudinal strain and other strain parameters may provide information on risk prediction, diagnosis, assessment of treatment response, and follow-up.

Conclusions and Relevance

The evolution of myocardial deformation imaging from research tool to clinical practice will provide clinicians with a useful additional imaging parameter to facilitate the assessment and risk evaluation of patients with HF.

The influence of sex on left ventricular strain in hypertensive population

OBJECTIVE

The aim of this study was to evaluate the influence of sex on left ventricular mechanics in hypertensive individuals.

METHODS

This cross-sectional study included 171 untreated hypertensive patients and 112 normotensive controls who underwent a 24-h ambulatory blood pressure monitoring and comprehensive echocardiographic examination including strain assessment.

RESULTS

Hypertensive women and men had significantly lower left ventricular global longitudinal and circumferential strains than their normotensive counterparts. Left ventricular global longitudinal strain was lower in hypertensive men than in women (-19.8 ± 2.2 vs. -17.9 ± 2.1%; P < 0.01). Left ventricular global circumferential strain was also reduced in hypertensive men in comparison with women (-21.0 ± 2.5 vs. -18.7 ± 2.3%; P < 0.01). The difference in left ventricular radial strain was not discovered between hypertensive women and men. Furthermore, left ventricular twist was significantly higher in hypertensive women than in hypertensive men (21.9 ± 4.1° vs. 20.6 ± 3.8°; P = 0.034). Female sex and arterial hypertension, and also their interaction, were associated with lower left ventricular mass index, increased left ventricular global longitudinal, and circumferential strains and increased left ventricular twist compared with hypertensive men.

CONCLUSION

Left ventricular longitudinal and circumferential strains were significantly reduced in hypertensive patients. However, the changes are more pronounced in hypertensive men than in women. Sex has a significant effect on the association between hypertension, and longitudinal and circumferential strain.

Evaluation of Cardiac Function in Women With a History of Preeclampsia: A Systematic Review and Meta-Analysis

Background

Women with a history of preeclampsia are at increased risk of cardiovascular morbidity and mortality. However, the underlying mechanisms of disease association, and the ideal method of monitoring this high‐risk group, remains unclear. This review aims to determine whether women with a history of preeclampsia show clinical or subclinical cardiac changes when evaluated with an echocardiogram.

Methods and Results

A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify studies that examined cardiac function in women with a history of preeclampsia, in comparison with those with normotensive pregnancies. In the 27 included studies, we found no significant differences between preeclampsia and nonpreeclampsia women with regard to left ventricular ejection fraction, isovolumetric relaxation time, or deceleration time. Women with a history of preeclampsia demonstrated a higher left ventricular mass index and relative wall thickness with a mean difference of 4.25 g/m² (95% CI, 2.08, 6.42) and 0.03 (95% CI, 0.01, 0.05), respectively. In comparison with the nonpreeclampsia population, they also demonstrated a lower E/A and a higher E/e′ ratio with a mean difference of −0.08 (95% CI, −0.15, −0.01) and 0.84 (95% CI, 0.41, 1.27), respectively.

Conclusions

In comparison with women who had a normotensive pregnancy, women with a history of preeclampsia demonstrated a trend toward altered cardiac structure and function. Further studies with larger sample sizes and consistent echocardiogram reporting with the use of sensitive preclinical markers are required to assess the role of echocardiography in monitoring this high‐risk population group.

Stage I hypertension is associated with impaired systolic function by strain imaging compared with prehypertension: A report from the prever study

High blood pressure (BP) is associated with higher rates of cardiovascular events, even in stage I hypertension (HTN) and prehypertension (preHTN). Lower left ventricular (LV) systolic function, assessed by global longitudinal strain (GLS), has been demonstrated in individuals with HTN compared to individuals with normal BP, but a comparison of individuals with preHTN and stage I HTN was not described to date. The PREVER study includes two randomized double-blind controlled trials, performed in volunteers with preHTN (PREVER-prevention trial) or stage I HTN (PREVER-treatment trial), aged 30-70 years. A subsample of patients of both trials had GLS measured from 2D echocardiograms performed at baseline and after 18 months of follow-up. We compared baseline data from both studies and, among stage I HTN patients, clinical and echocardiographic correlates of GLS were determined. Participants with preHTN (n = 91;53% female; 55 ± 9 yo) and stage I HTN (n = 105; 44% female; 55 ± 8 yo) had similar clinical parameters beyond the expected differences in BP levels. Participants with stage I HTN had lower GLS (-17.5 ± 2.5% vs -18.2 ± 2.4%, P = .03) compared with those with preHTN. In stage I HTN, lower GLS was associated with lower e' and lower LV ejection fraction. In conclusion, patients in Stage I HTN may already express changes in GLS compared with individuals with preHTN, suggesting that even mildly difference in BP can be impact in subclinical systolic function.

Aldosterone induces left ventricular subclinical systolic dysfunction: a strain imaging study

BACKGROUND

Primary aldosteronism is associated with a higher incidence of left ventricular (LV) hypertrophy and diastolic dysfunction than essential hypertension. However, systolic function via endocardial measurements is similar between patients with primary aldosteronism and essential hypertension. Speckle-tracking echocardiography is a sensitive tool which can detect subclinical impairments in systolic function. The aim of this study was to investigate aldosterone-induced subclinical impairments in systolic function.

METHODS

We prospectively enrolled patients with primary aldosteronism and essential hypertension and analyzed their clinical data, biochemical data, and echocardiographic parameters, including myocardial strain [global longitudinal strain (GLS)].

RESULTS

Thirty-six patients with primary aldosteronism and 31 patients with essential hypertension were enrolled for analysis. The patients with primary aldosteronism had significantly lower serum potassium levels, lower plasma renin activity, higher aldosterone-to-renin ratio (ARR), and higher 24-h urinary aldosterone levels than patients with essential hypertension. With regards to echocardiographic parameters, the patients with primary aldosteronism had a thicker ventricular wall and higher LV mass index than those with essential hypertension. Most importantly, we found significant degradation of GLS in the patients with primary aldosteronism compared with those with essential hypertension (-17.84 ± 2.36 vs. -20.13 ± 2.32, P < 0.001). In correlation analysis, GLS was significantly correlated with serum potassium level, LV mass index, log-transformed plasma renin activity, log-transformed ARR, and log-transformed 24-h urinary aldosterone levels (all P < 0.05). Multivariate linear regression analysis further identified log-transformed ARR (β = 0.771, 95% confidence interval: 0.011-1.530, P = 0.047), and log-transformed 24-h urinary aldosterone level (β = 1.765, 95% confidence interval: 0.01-3.529, P = 0.050) as independent factors correlated with GLS.

CONCLUSION

Patients with primary aldosteronism have a lower magnitude of GLS than patients with essential hypertension, suggesting that aldosterone induces a subclinical decline in LV systolic function.

Value of layer-specific strain distribution patterns in hypertrophied myocardium from different etiologies

BACKGROUND

Intrinsic myocardial mechanics might have different patterns because of the different etiologies of myocardial hypertrophy. We used layer-specific strain to compare those with aortic stenosis (AS) and hypertrophic cardiomyopathy (HCM) and examined the differences in strain distribution pattern and for their clinical implications.

METHODS

Comprehensive echocardiography was done in 3 groups: 129 with moderate-to-severe AS, 172 consecutive patients with HCM, and 58 healthy controls. Left ventricle (LV) layer-specific deformation parameters were obtained using two-dimensional speckle tracking echocardiography. The transmural strain gradient was defined as the strain difference between subendocardial and subepicardial myocardium. Both diseased groups were further divided based on the median value of transmural strain gradient for the hemodynamics correlation.

RESULTS

Compared with the HCM group, the AS group had more preserved transmural longitudinal strain gradient (4.49 ± 1.3% vs. 3.61 ± 1.2%, p < 0.001), which was not significantly different from that of the healthy controls (4.49 ± 1.3% vs. 4.54 ± 1.0%, p = 0.975). And only in AS group the transmural circumferential strain correlated with myocardium mass index (r = -0.237, p = 0.008), and the hemodynamic profiles (LV ejection fraction and LA pressure) were correlated well with transmural strain gradient, in that the lower subgroup had a significantly lower LV ejection fraction and higher average E/E'.

CONCLUSIONS

Myocardium hypertrophy from different etiology resulted in different layer-specific strain distribution pattern. The loss of an adequate transmural strain gradient correlated with hemodynamics and might reflect intrinsic myocardial dysfunction.

Myocardial Strain and Stiffness Parameters as a Novel Target of Antihypertensive Treatment

In the review, the clinical significance of increased myocardial stiffness and strain impairment in the settings of arterial hypertension is considered. The mechanisms of increasing myocardial stiffness as a part of hypertensive heart disease are presented. Particular attention is paid to the role of the sympathetic nervous system activation as one of the triggers that induce the connective tissue alteration of cardiac interstitium. The possibilities of echocardiography in the early noninvasive detection of myocardial strain abnormalities are discussed. New ultrasound parameters for describing stiffness properties of the heart are presented. From the evidence-based medicine point of view, the prognostic significance of increasing myocardial stiffness as a risk factor of the adverse cardiovascular events, as well as the possibility of its management with different antihypertensive drugs, is considered. Finally, there are presented clinical trials data, indicating high potential of the highly selective ^1-adrenoblocker bisoprolol for of correction myocardial stiffness and strain impairment.

Systemic sclerosis impacts right heart and cardiac autonomic nervous system

AIM

To evaluate the influence of systemic sclerosis (SSc) on right ventricular (RV) remodeling by two- and three-dimensional echocardiography (2DE and 3DE) and heart rate variability (HRV).

METHODS

Forty-five SSc patients and 35 age- and gender-matched healthy controls underwent clinical examination, 24-h Holter monitoring, and comprehensive 2DE and 3DE.

RESULTS

2DE RV global and RV free wall longitudinal strains, as well as 2DE RV endocardial, mid-myocardial, and epicardial longitudinal strains were lower in SSc subjects, who exhibited greater 3DE RV volumes but lower 3DE RV ejection fraction than controls. HRV indices were impaired in SSc subjects. These differences in RV global and free wall longitudinal strain, layer-specific strains, and ejection fraction, were associated with HRV indices independently of demographic, clinical, and echocardiographic parameters. Modified Rodnan Skin Score, clinical indicator of skin involvement in SSc, was associated with HRV parameters, RV layer-specific mechanics, and RV ejection fraction.

CONCLUSION

SSc affects RV function and mechanics of all myocardial layers, as well as cardiac autonomic nervous function. HRV indices are significantly associated with RV function, RV deformation, and skin involvement in SSc patients.

Layer-specific systolic and diastolic strain in hypertensive patients with and without mild diastolic dysfunction

This study sought to examine layer-specific longitudinal and circumferential systolic and diastolic strain, strain rate (SR) and diastolic time intervals in hypertensive patients with and without diastolic dysfunction. Fifty-eight treated hypertensive patients were assigned to normal diastolic function (NDF, N = 39) or mild diastolic dysfunction (DD, N = 19) group. Layer-specific systolic and diastolic longitudinal and circumferential strains and SR were assessed. Results showed no between-group difference in left ventricular mass index (DD: 92.1 ± 18.1 vs NDF: 88.4 ± 16.3; P = 0.44). Patients with DD had a proportional reduction in longitudinal strain across the myocardium (endocardial for DD -13 ± 4%; vs NDF -17 ± 3, P < 0.01; epicardial for DD -10 ± 3% vs NDF -13 ± 3%, P < 0.01; global for DD: -12 ± 3% vs NDF: -15 ± 3, P = 0.01), and longitudinal mechanical diastolic impairments as evidenced by reduced longitudinal strain rate of early diastole (DD 0.7 ± 0.2 L/s vs NDF 1.0 ± 0.3 L/s, P < 0.01) and absence of a transmural gradient in the duration of diastolic strain (DD endocardial: 547 ± 105 ms vs epicardial: 542 ± 113 ms, P = 0.24; NDF endocardial: 566 ± 86 ms vs epicardial: 553 ± 77 ms, P = 0.03). Patients with DD also demonstrate a longer duration of early circumferential diastolic strain (231 ± 71 ms vs 189 ± 58 ms, P = 0.02). In conclusion, hypertensive patients with mild DD demonstrate a proportional reduction in longitudinal strain across the myocardium, as well as longitudinal mechanical diastolic impairment, and prolonging duration of circumferential mechanical relaxation.

Prognostic Value of Echocardiography in Hypertensive Versus Nonhypertensive Participants From the General Population

Hypertension may be the most significant cardiovascular risk factor. Few studies have assessed the prognostic value of echocardiography in hypertensive individuals. This study examines the incremental prognostic value of adding echocardiographic parameters to established risk factors in individuals from the general population with and without hypertension. A total of 1294 individuals from the general population underwent a health examination and an echocardiogram including 2-dimensional speckle tracking. Outcome was a composite of ischemic heart disease and heart failure. The prevalence of hypertension was 38.3%. During a median follow-up of 12.5 years (interquartile range, 9.4-12.8 years), 222 participants (17.2%) developed the outcome. Out of these 222 events, 145 (65%) occurred in hypertensive participants, whereas 77 (35%) occurred in nonhypertensive individuals, corresponding to an incidence rate of 32/(1000×person-years) and 8/(1000×person-years), respectively. Follow-up was 100%. After multivariable adjustment, only left ventricular mass index predicted the outcome in hypertensive individuals, whereas only global longitudinal strain predicted the outcome in nonhypertensive individuals. In hypertensive individuals the prognostic value of left ventricular mass index was incremental to SCORE and abnormal ECG status. In nonhypertensive individuals the prognostic value of global longitudinal strain was incremental to SCORE and abnormal ECG status. The prognostic value of echocardiography in predicting cardiovascular outcomes in the general population is altered by hypertension. In hypertensive individuals, left ventricular mass index added incremental prognostic value in addition to established risk factors. In nonhypertensive individuals, global longitudinal strain added incremental prognostic value in addition to established risk factors.

Does Masked Hypertension Cause Early Left Ventricular Impairment in Youth?

Objectives: Masked hypertension (MH) is not uncommon in the youth and may increase risks of long-term cardiovascular impairment. However, little is known about the subclinical heart damage in this group of patients. Currently, 3-layer speckle tracking imaging based on two-dimensional echocardiography is feasible to detect the early signs of myocardial damage. We therefore aimed to investigate whether subtle changes of cardiac function occurred in the young MH patients by using advanced quantification with layer-specific speckle tracking. Methods: A total of 40 adolescents with MH (age 18 ± 3 years, 73% males) and 40 age-, gender-, race-, and height-matched normotensive volunteers were enrolled in our study. MH was defined as one or more of the ambulatory blood pressure (BP) parameters (24-h, daytime and night-time average BPs) higher than ≥ 95th percentile for gender and height according to the local reference. Both comprehensive two-dimensional echocardiography with layer-specific strain analysis and 24-h ambulatory BP monitoring were performed. Longitudinal strain and circumferential strain in endocardial, mid-myocardial, and epicardial layers were determined accordingly with the dedicated software (EchoPAC software version 201, GE Healthcare, Horten, Norway). Results: Compared with normotensive controls, youths with MH had higher ambulatory pulse rate and left ventricular mass index, and were more obese. Interestingly, similar ventricular volumes and ejection fraction were observed in the study groups, but further analysis with layer-specific strains revealed that endocardial and mid-myocardial longitudinal and circumferential mechanical function were decreased in the young MH subjects when compared to normotensive individuals (all p < 0.05). However, there were no difference regarding radial strain and apical rotation derived from traditional speckle tracking analysis. Conclusion: Subclinical change of LV mechanic function assessed by layer-specific speckle tracking is present in youth with MH despite considered as normal with conventional ways.Thus, MH in youth should be monitored closely instead of labeling as an entirely benign entity.

Differences in left ventricular functional adaptation to arterial stiffness and neurohormonal activation in patients with hypertension: a study with two-dimensional layer-specific speckle tracking echocardiography

Background

Arterial stiffness increases pressure load to the left ventricle (LV), leading to LV hypertrophy and subendocardial ischemia. Neurohormones stimulate myocardial fibrosis and LV dysfunction. We aimed to explore the associations of arterial stiffness and plasma aldosterone with multi-directional, layer-specific LV, and left atrial (LA) mechanical function in hypertensive patients.

Methods

Layer-specific LV global longitudinal strain (GLS-trans, GLS-endo, GLS-epi), global circumferential strain (GCS-trans, GCS-endo, GCS-epi), LV torsional parameters, and LA global longitudinal strain (LA GLS) were analyzed by two-dimensional speckle tracking echocardiography in 195 hypertensive patients (110 men, mean age 55 years). Pulse wave velocity (PWV) was analyzed as a measure of arterial stiffness, and plasma aldosterone was measured for evaluation of neurohormonal activation.

Results

In a simple correlation, PWV significantly correlated with LV GLS-endo and LA GLS. Log aldosterone correlated with both LV GCS-endo and LV GCS-trans. Multiple regression analysis revealed that LV GLS-endo (β = 0.223, p = 0.031) and LA GLS (β = −0.311, p = 0.002) were independently correlated with PWV even after controlling for confounding factors.

Conclusions

In hypertensive patients without clinically apparent target organ damage, LV GLS, especially endocardium, and LA GLS were more dominantly affected by arterial stiffness because, among the three myocardial layers, the endocardium is most susceptible to pressure overload. Two-dimensional layer-specific speckle-tracking echocardiography sensitively detects LV mechanical dysfunction and provides pathophysiologic insights into LV mechanical adaptations in hypertension.

The relationship between right ventricular deformation and heart rate variability in asymptomatic diabetic patients

OBJECTIVE

To investigate heart rate variability (HRV) and right ventricular (RV) remodeling in asymptomatic diabetic patients, as well as the relationship between HRV indices and RV structure, function and deformation.

METHOD

This cross-sectional study included 59 asymptomatic patients with type 2 diabetes and 45 healthy controls without cardiovascular risk factors. All study subjects underwent 24-h Holter monitoring, laboratory analyses and complete two-dimensional echocardiography examination (2DE).

RESULTS

RV diastolic function and longitudinal deformation were significantly impaired in diabetic individuals comparing with controls. RV global longitudinal strain and layer-specific longitudinal strains were significantly decreased in diabetic group. The same trend of changes in RV deformation was observed for global RV and lateral wall. All parameters of time and frequency domain of HRV were reduced in diabetic subjects. RV endocardial longitudinal strain together with LV mass index, mitral E/e' ratio and HbA1c correlated with HRV parameters. However, multivariate linear regression analysis showed that only RV endocardial longitudinal strain and LV mass index are associated with HRV parameters independently of age, BMI, HbA1c, RV free wall thickness and pulmonary artery pressure.

CONCLUSIONS

RV subendocardial strain is independently associated with HRV parameters in the whole study population. This reveals potentially important role of determination of layer-specific RV longitudinal function as important marker of preclinical cardiac damage, but also indirectly show the impairment of cardiac autonomic function in diabetic patients.

Left ventricular functional, structural and energetic effects of normal aging: Comparison with hypertension

Objectives

Both aging and hypertension are significant risk factors for heart failure in the elderly. The purpose of this study was to determine how aging, with and without hypertension, affects left ventricular function.

Methods

Cross-sectional study of magnetic resonance imaging and ³¹P spectroscopy-based measurements of left ventricular structure, global function, strains, pulse wave velocity, high energy phosphate metabolism in 48 normal subjects and 40 treated hypertensive patients (though no other cardiovascular disease or diabetes) stratified into 3 age deciles from 50–79 years.

Results

Normal aging was associated with significant increases in systolic blood pressure, vascular stiffness, torsion, and impaired diastolic function (all P<0.05). Age-matched hypertension exacerbated the effects of aging on systolic pressure, and diastolic function. Hypertension alone, and not aging, was associated with increased left ventricular mass index, reduced energetic reserve, reduced longitudinal shortening and increased endocardial circumferential shortening (all P<0.05). Multiple linear regression analysis showed that these unique hypertensive features were significantly related to systolic blood pressure (P<0.05).

Conclusions

1) Hypertension adds to the age-related changes in systolic blood pressure and diastolic function; 2) hypertension is uniquely associated with changes in several aspects of left ventricular structure, function, systolic strains, and energetics; and 3) these uniquely hypertensive-associated parameters are related to the level of systolic blood pressure and so are potentially modifiable.

Does masked hypertension impact left ventricular deformation?

Our aim was to compare left ventricular (LV) deformation in subjects with masked hypertension (MH) to normotensive and sustained hypertensive patients. This cross-sectional study included 185 untreated subjects who underwent 24-hour ambulatory blood pressure (BP) monitoring and complete two-dimensional echocardiographic (2DE) examination including multilayer strain analysis. MH was diagnosed if clinic BP was normal (<140/90 mm Hg), and 24-hour BP was increased (≥130/80 mm Hg). 2DE LV longitudinal and circumferential strains gradually and significantly decreased from normotensive controls across MH individuals to sustained hypertensive patients. 2DE radial strain was not different between groups. 2DE longitudinal and circumferential endocardial and midmyocardial layer strains progressively decreased from normotensive control to sustained hypertensive individuals. Longitudinal and circumferential epicardial layer strains were lower in sustained hypertensive patients than in normotensive controls. Clinic and 24-hour systolic BP were associated with 2DE LV longitudinal endocardial strain, midmyocardial strain, and 2DE circumferential endocardial strain in the whole-study population independent of LV structure and diastolic function. MH significantly affect LV deformation assessed by 2DE traditional strain and 2DE multilayer strain. Clinic and 24-hour systolic BP were associated with LV mechanics evaluated with comprehensive 2DE strain analysis independent of LV structure and diastolic function.