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Ali SA, Arman HE, Shamseddeen H, Elsner N, Elsemesmani H, Johnson S, Zenisek J, Khemka A, Jarori U, Patidar KR, Orman E, Kubal C, Frick K. Cirrhotic cardiomyopathy: Predictors of major adverse cardiac events and assessment of reversibility after liver transplant. J Cardiol 2023; 82:113-121. [PMID: 37085028 DOI: 10.1016/j.jjcc.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/01/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Major adverse cardiac events (MACE) are a leading cause of morbidity and mortality after orthotopic liver transplantation (OLT). Cirrhotic cardiomyopathy (CCM), initially described in 2005 and revised in 2019, is a source of MACE in patients after OLT. We sought to identify CCM-related predictors of MACE at one-year follow-up after OLT and assess for reversibility of CCM post-OLT. METHODS This is a retrospective study of adult patients who underwent OLT between 2009 and 2019. All patients had transthoracic echocardiography pre-and post-OLT. Patients with a left ventricular ejection fraction <50 % pre-OLT were excluded. MACE was defined as death, myocardial infarction, congestive heart failure hospitalization, or cardiac arrest. RESULTS In total, 131 patients were included in this study, of whom 103 and 23 patients met the 2005 and 2019 criteria, respectively. During the follow-up period, 42 patients had MACE and these patients were more likely to have ascites (p = 0.003), hepatorenal syndrome (p = 0.019), and CCM per 2005 criteria (p = 0.023). There were no significant differences between pre-OLT CCM per 2019 criteria (19 % vs 17 %, p = 0.758) or MELD-Na score (21.24 vs 19.40, p = 0.166) for MACE post-OLT. Per the 2005 criteria, 35 of 103 patients recovered and these patients were less likely to have MACE post-OLT (p = 0.012). Per the 2019 criteria, 13 of 23 patients recovered post-OLT but this low number precluded further statistics. CONCLUSION The 2005 Montreal criteria for CCM were an independent predictor of MACE at one-year follow-up post-OLT while the 2019 CCC criteria for CCM were not. In addition, the 2005 Montreal criteria were more prevalent when compared to 2019 CCC criteria. Finally, the 2005 Montreal criteria were reversible post-OLT 34 % of the time compared to the 2019 CCC criteria which were reversible 57 % of the time.
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Affiliation(s)
- Saad A Ali
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Huseyin E Arman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hani Shamseddeen
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nathaniel Elsner
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hussein Elsemesmani
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sean Johnson
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joseph Zenisek
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abhishek Khemka
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Upasana Jarori
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar Kubal
- Division of Organ Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kyle Frick
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
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Tang S, Guan L, Tayier B, Mu Y. ECHO provides layer-specific insight of both myocardial deformation and microcirculation dysfunction in dilated cardiomyopathy patients: Clinical value of combined application of left ventricular layer-specific strain and myocardial contrast echocardiography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:753-761. [PMID: 36578173 DOI: 10.1002/jcu.23419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/12/2022] [Accepted: 11/24/2022] [Indexed: 06/02/2023]
Abstract
AIM To investigate the pattern of left ventricular (LV) function and myocardial perfusion and their relationship in dilated cardiomyopathy (DCM) patients using layer-specific speckle tracking imaging (STI) and layer-specific myocardial contrast echocardiography (MCE). MATERIAL AND METHODS Thirty DCM patients and 30 controls were recruited and underwent STI and MCE examination. The peak values of longitudinal strain (LS), circumferential strain (CS) of each layer of LV were recorded and compared between groups. Additionally, cross-sectional area of a microvessel (A) and average myocardial microvascular lesion (β) of each layer were measured, myocardial blood flow (MBF) was estimated using A × β, above parameters were compared between two groups. RESULTS The LS of endo- (LSendo ), mid- (LSmid ) and epicardium (LSepi ), as well as CS of endo- (RSendo ), mid- (RSmid ), (LSepi ) epicardium and LS endo/epi, CS endo/epi were significantly decreased in DCM patients. More importantly, DCM patients demonstrated decreased A, β and A × β in all three myocardium layers and A endo/epi, β endo/epi, A × β endo/epi compared to the controls. The time to peak and the cardiac cycle required to reach the peak were prolonged in DCM patients (p < 0.05). Longitudinal strain parameters of each layer had a negative relationship with perfusion parameter A and this relationship was strongest between LSendo and Aendo (r = 0.690, p < 0.01). CONCLUSIONS The cardiac strain and, more importantly, coronary microcirculation perfusion was impaired in each layer in DCM patients. The longitudinal function of the LV myocardium was closely related to changes in myocardial microcirculation perfusion.
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Affiliation(s)
- Sha Tang
- Department of Echocardiography, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Ultrasound Medicine, Urumqi, China
| | - Lina Guan
- Department of Echocardiography, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Ultrasound Medicine, Urumqi, China
| | - Baihetiya Tayier
- Department of Echocardiography, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Ultrasound Medicine, Urumqi, China
| | - Yuming Mu
- Department of Echocardiography, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Ultrasound Medicine, Urumqi, China
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Biering-Sørensen T, Lassen MCH, Shah A, Claggett B, Zile M, Pieske B, Pieske-Kraigher E, Voors A, Shi V, Lefkowitz M, Packer M, McMurray JJV, Solomon SD. The Effect of Sacubitril/Valsartan on Left Ventricular Myocardial Deformation in Heart Failure with Preserved Ejection Fraction (PARAMOUNT trial). J Card Fail 2023; 29:968-973. [PMID: 37031887 DOI: 10.1016/j.cardfail.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Global longitudinal strain (GLS) and global circumferential strain (GCS) have been shown to be impaired in heart failure with preserved ejection fraction. We sought to assess whether treating patients with heart failure with preserved ejection fraction with sacubitril/valsartan would significantly improve GLS and GCS compared with valsartan alone. METHODS AND RESULTS PARAMOUNT (Prospective Comparison of ARNI With ARB on Management of Heart Failure With Preserved Ejection Fraction Trial) was a phase II, randomized, parallel-group, double-blind multicenter trial in 301 patients with New York Heart Association functional class II-III heart failure, a left ventricular ejection fraction of 45%, and an N-terminal pro-B-type natriuretic peptide of ≥400 pg/mL. Participants were randomly assigned (1:1) to sacubitril/valsartan titrated to 200 mg twice daily or valsartan titrated to 160 mg twice daily for 36 weeks. We assessed changes in the GLS and the GCS from baseline to 36 weeks, adjusting for baseline value, in patients with sufficient imaging quality for 2-dimensitonal speckle tracking analysis at both timepoints (n = 60 sacubitril/valsartan, n = 75 valsartan only). GCS was significantly improved at 36 weeks in the sacubitril/valsartan group when compared with the valsartan group (Δ4.42%, 95% confidence interval [CI] 0.67-8.17, P = .021), with no significant difference observed in GLS (Δ0.25%, 95% CI, -1.19 to 1.70, P = .73). Patients with a history of hospitalization for heart failure had a differentially greater improvement in GCS when treated with sacubitril/valsartan. CONCLUSIONS In patients with heart failure with preserved ejection fraction, sacubitril/valsartan improved GCS but not GLS when compared with valsartan during a 36-week period. This trial is registered at ClinicalTrials.gov, NCT00887588.
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Affiliation(s)
- Tor Biering-Sørensen
- Brigham and Women's Hospital, Cardiovascular Division, Boston, Massachusetts; Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Mats C Højbjerg Lassen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Amil Shah
- Brigham and Women's Hospital, Cardiovascular Division, Boston, Massachusetts
| | - Brian Claggett
- Brigham and Women's Hospital, Cardiovascular Division, Boston, Massachusetts
| | - Michael Zile
- RHJ Department of Veterans Affairs, Medical Center and Medical University of South Carolina, Charleston, South Carolina
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow Klinikum, Berlin, Germany; German Heart Center, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Elisabeth Pieske-Kraigher
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow Klinikum, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | | | - Victor Shi
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | | | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Brigham and Women's Hospital, Cardiovascular Division, Boston, Massachusetts
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Sharma S, Lassen MCH, Nielsen AB, Skaarup KG, Biering-Sørensen T. The clinical application of longitudinal layer specific strain as a diagnostic and prognostic instrument in ischemic heart diseases: A systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:980626. [PMID: 37051064 PMCID: PMC10083306 DOI: 10.3389/fcvm.2023.980626] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 02/20/2023] [Indexed: 03/28/2023] Open
Abstract
Background2-dimensional Speckle-Tracking Echocardiography, to obtain longitudinal layer specific strain (LSS), has recently emerged as a novel and accurate non-invasive imaging technique for diagnosis as well as for prediction of adverse cardiac events. This systematic review and meta-analysis aimed to give an overview of the possible clinical implication and significance of longitudinal LSS.MethodsWe conducted a systematic review and meta-analysis with all the studies involving layer specific strain in patients with ischemic heart disease (IHD). Of 40 eligible studies, 9 met our inclusion criteria. Studies that were included either investigated the prognostic value (n = 3) or the diagnostic value (n = 6) of longitudinal LSS.ResultsThe pooled meta-analysis showed that longitudinal LSS is a significant diagnostic marker for coronary artery disease (CAD) in patients with IHD. Endocardial LSS was found to be a good diagnostic marker for CAD in IHD patients (OR: 1.28, CI95% [1.11–1.48], p < 0.001, per 1% decrease). Epicardial (OR: 1.34, CI95% [1.14–1.56], p < 0.001, per 1% decrease), Mid-Myocardial (OR: 1.24, CI95% [1.12–1.38], p < 0.001, per 1% decrease) and endocardial (OR: 1.21, CI95% [1.09–1.35], p < 0.001, per 1% decrease) LSS all entailed diagnostic information regarding CAD, with epicardial LSS emerging as the superior diagnostic marker for CAD in patients with SAP. Endocardial LSS proved to be the better diagnostic marker of CAD in patients with non-ST elevation acute coronary syndrome (NSTE-ACS). LSS was shown to be a good prognostic maker of adverse cardiac events in IHD patients. Two studies found endocardial circumferential strain to be the good predictor of outcome in CAD patients and when added to baseline characteristics. Epicardial LSS emerged as best predictor in acute coronary syndrome (ACS) patients.ConclusionIn patients with SAP, epicardial LSS was the stronger diagnostic marker while in NSTE-ACS patients, endocardial LSS was the stronger diagnostic marker. In addition, endocardial circumferential strain is the better predictor of adverse outcome in CAD patients whilst in ACS patients, epicardial LSS was found to be a better predictor of outcome.
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Affiliation(s)
- Shreeya Sharma
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark
- Correspondence: Shreeya Sharma
| | - Mats Christian Højbjerg Lassen
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Anne Bjerg Nielsen
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark
| | - Kristoffer Grundtvig Skaarup
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Copenhagen City Heart Study, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
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Ma C, Sanderson JE, Chen Q, Liang Z, Zhan X, Wu C, Liu H, Xiao L, Fang F. Fast assessment of left ventricular systolic function in obstructive sleep apnea patients with automated function imaging: Comparison with mitral annular plane systolic excursion. Echocardiography 2022; 39:426-433. [PMID: 35128719 DOI: 10.1111/echo.15308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/17/2021] [Accepted: 01/01/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Early detection of left ventricular (LV) subclinical dysfunction is clinically relevant before developing irreversible impairment in obstructive sleep apnea (OSA) patients. Mitral annulus plane systolic excursion (MAPSE) is a fast tool for OSA due to high prevalent obesity; another quick but more comprehensive tool is LV global longitudinal stain (GLS) based on automated function imaging (AFI). We therefore aimed to compare the feasibility and reproducibility of AFI to MAPSE in OSA patients, as a good model in whom obesity is common. METHODS A comprehensive echocardiographic examination was done in 186 consecutive patients having polysomnography for suspected OSA. MAPSE was measured by using M-mode to calculate excursion of mitral annulus. GLS was derived by offline analysis of three long-axis views that semi-automatically detects LV endocardial boundary, which is adjusted manually as necessary with AFI measurement. Variability of AFI and MAPSE were compared among the different subgroups. RESULTS Despite a relatively high obesity rate (42.9%), the feasibility of AFI was 94% (175/186) and that of 100% in MAPSE. AFI showed excellent correlation (r = .882) superior to MAPSE (r = .819) between the Expert and Beginner. Intra- and inter- observer variability of AFI and MAPSE in Bland-Altman analysis were 5.5% and 6.5%; 6.2% and 8.8%, respectively. In repeated measurements, AFI showed higher intra-class correlation (ICC = .95) than MAPSE (ICC = .87) (p < 0.05). Furthermore, analysis showed that AFI was feasible even in more obese patients (BMI≥28 kg/m2 ). CONCLUSIONS Even in obese patients with OSA, AFI-GLS is feasible and more reliable for less expert operators than MAPSE in detecting LV longitudinal dysfunction.
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Affiliation(s)
- ChenYao Ma
- Sleep Medicine Center, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.,Department of Ultrasound, Beijing DiTan Hospital, Capital Medical University, Beijing, China
| | - John E Sanderson
- Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Qi Chen
- Sleep Medicine Center, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Zhe Liang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - XiaoJun Zhan
- Sleep Medicine Center, Department of Otorhinolaryngology Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Chan Wu
- Sleep Medicine Center, Department of Otorhinolaryngology Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Hu Liu
- Sleep Medicine Center, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Lei Xiao
- Sleep Medicine Center, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Fang Fang
- Sleep Medicine Center, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
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Espersen C, Modin D, Hoffmann S, Hagemann CA, Hagemann RA, Olsen FJ, Fritz-Hansen T, Platz E, Møgelvang R, Biering-Sørensen T. Layer-specific and whole wall global longitudinal strain predict major adverse cardiovascular events in patients with stable angina pectoris. Int J Cardiovasc Imaging 2021; 38:131-140. [PMID: 34415451 DOI: 10.1007/s10554-021-02382-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
Global longitudinal strain (GLS) has proven to be a powerful prognostic marker in various patient populations, but the prognostic value of layer-specific GLS has not yet been investigated in patients with suspected stable angina pectoris (SAP). We sought to investigate the prognostic value of layer-specific and whole wall GLS in patients with suspected SAP. From September 2008 to March 2011, 296 consecutive patients with clinically suspected SAP, normal ejection fraction, and no previous cardiac history were enrolled in a prospective cohort study. Patients underwent echocardiography including two-dimensional speckle tracking at rest, exercise stress test, and coronary angiography. The end-point was a composite of incident heart failure, acute myocardial infarction, and cardiovascular death (MACE). Out of the 285 included patients (mean age 61 years, 50% male), 24 (8%) developed MACE during a median follow-up of 3.5 years. Both endocardial [hazard ratio (HR) 1.21, 95% CI 1.08-1.35, p = 0.001], epicardial (HR 1.29, 95% CI 1.12-1.50, p = 0.001) and whole wall GLS (HR 1.25, 1.10-1.42, p = 0.001) were significantly associated with an increased risk of developing MACE during follow-up in univariable Cox regression analysis. In multivariable analysis, only epicardial (HR 1.23, 95% CI 1.00-1.51, p = 0.046) and whole wall GLS (HR 1.20, 95% CI 1.00-1.43, p = 0.049) remained significantly associated with an increased risk of MACE independent of various baseline clinical variables, left ventricular ejection fraction (LVEF), E/e' and Duke Score. Layer-specific and whole wall GLS were significant predictors of MACE in this cohort of patients with suspected SAP independent of various baseline clinical variables, LVEF, E/e' and Duke Score.
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Affiliation(s)
- Caroline Espersen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark.
| | - Daniel Modin
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | - Søren Hoffmann
- Department of Anesthesiology and Intensive Care Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Christoffer A Hagemann
- Center for Clinical Metabolic Research, Herlev & Gentofte Hospital, Copenhagen, Denmark.,Gubra Aps, Hørsholm, Denmark
| | - Rikke A Hagemann
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | - Flemming J Olsen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | - Thomas Fritz-Hansen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | - Elke Platz
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | - Tor Biering-Sørensen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abou R, Goedemans L, Montero-Cabezas JM, Prihadi EA, el Mahdiui M, Schalij MJ, Ajmone Marsan N, Bax JJ, Delgado V. Prognostic Value of Multilayer Left Ventricular Global Longitudinal Strain in Patients with ST-segment Elevation Myocardial Infarction with Mildly Reduced Left Ventricular Ejection Fractions. Am J Cardiol 2021; 152:11-18. [PMID: 34162486 DOI: 10.1016/j.amjcard.2021.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Abstract
Multilayer (epi-, mid- and endocardium) left ventricular (LV) global longitudinal strain (GLS) reflects the extent of myocardial damage after ST-segment myocardial infarction (STEMI). However, the prognostic implications of multilayer LV GLS remain unclear. We studied the association between multilayer LV GLS and prognosis in patients with mildly reduced or preserved LV ejection fraction (EF) after STEMI. Patients with first STEMI and LVEF>45% were evaluated retrospectively. Baseline multilayer (endocardial, mid-myocardial and epicardial) LV GLS were measured on 2-dimensional speckle tracking echocardiography. Patients were followed up for of all-cause mortality. A total of 569 patients (77% male, 60 ± 11 years) were included. After a median follow-up of 117 (interquartile range 106-132) months, 95 (17%) patients died. We observed no differences in baseline LVEF and peak troponin levels between survivors and non-survivors. However, non-survivors showed more impaired GLS at all layers (epicardium: -11.9 ± 2.8% vs. -13.4 ± 2.8%; mid-myocardium: -14.2 ± 3.2% vs. -15.6 ± 3.2%; endocardium: -16.5 ± 3.7% vs. -17.7 ± 3.6%, p <0.05, for all). On multivariable analysis, increasing age (hazard ratio 1.095; p<0.001) and impaired LV GLS of the epicardial layer (hazard ratio 1.085; p = 0.047) were independently associated with higher risk of all-cause mortality. In addition, LV GLS at the epicardium had incremental prognostic value for all-cause mortality (χ2 = 114, p = 0.044). In conclusion, in contemporary STEMI patients with mildly reduced or preserved LVEF, ageing and reduced LV GLS of the epicardium (reflecting transmural scar formation) were independently associated with all-cause mortality after adjusting for clinical and echocardiographic variables.
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8
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Massera D, Hu M, Delaney JA, Bartz TM, Bach ME, Dvorak SJ, DeFilippi CR, Psaty BM, Gottdiener JS, Kizer JR, Shah SJ. Adverse cardiac mechanics and incident coronary heart disease in the Cardiovascular Health Study. Heart 2021; 108:529-535. [PMID: 34257074 DOI: 10.1136/heartjnl-2021-319296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/14/2021] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Speckle-tracking echocardiography enables detection of abnormalities in cardiac mechanics with higher sensitivity than conventional measures of left ventricular (LV) dysfunction and may provide insight into the pathogenesis of coronary heart disease (CHD). We investigated the relationship of LV longitudinal strain, LV early diastolic strain rate (SR) and left atrial (LA) reservoir strain with long-term CHD incidence in community-dwelling older adults. METHODS The association of all three strain measures with incidence of non-fatal and fatal CHD (primary outcome of revascularisation, non-fatal and fatal myocardial infarction) was examined in the population-based Cardiovascular Health Study using multivariable Cox proportional hazards models. Follow-up was truncated at 10 years. RESULTS We included 3313 participants (mean (SD) age 72.6 (5.5) years). During a median follow-up of 10.0 (25th-75th percentile 7.7-10.0) years, 439 CHD events occurred. LV longitudinal strain (HR=1.25 per SD decrement, 95% CI 1.09 to 1.43) and LV early diastolic SR (HR=1.31 per SD decrement, 95% CI 1.14 to 1.50) were associated with a significantly greater risk of incident CHD after adjustment for potential confounders. By contrast, LA reservoir strain was not associated with incident CHD (HR=1.06 per SD decrement, 95% CI 0.94 to 1.19). Additional adjustment for biochemical and echocardiographic measures of myocardial stress, dysfunction and remodelling did not meaningfully alter these associations. CONCLUSION We found an association between echocardiographic measures of subclinically altered LV mechanics and incident CHD. These findings inform the underlying biology of subclinical LV dysfunction and CHD. Early detection of asymptomatic myocardial dysfunction may offer an opportunity for prevention and early intervention.
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Affiliation(s)
- Daniele Massera
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York, USA
| | - Mo Hu
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joseph A Delaney
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Traci M Bartz
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Megan E Bach
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Stephen J Dvorak
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Bruce M Psaty
- Cardiovascular Health Research Unit, Departments of Epidemiology, Medicine, and Health Services, University of Washington, Seattle, Washington, USA
| | - John S Gottdiener
- Division of Cardiology, Department of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Jorge R Kizer
- Departments of Medicine, Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Seyyed Mohammadzad MH, Khademvatani K, Gardeshkhah S, Sedokani A. Echocardiographic and laboratory findings in coronary slow flow phenomenon: cross-sectional study and review. BMC Cardiovasc Disord 2021; 21:230. [PMID: 33952204 PMCID: PMC8097949 DOI: 10.1186/s12872-021-02044-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/28/2021] [Indexed: 11/24/2022] Open
Abstract
Background Coronary sow-flow phenomenon (CSFP) is defined as slow passage of the contrast injected into the coronary arteries without distal obstruction of the vessel. Methods The present study was a cross-sectional, descriptive-analytical study performed at the Seyed-al-Shohada Heart Center during 2018–2019. The eligible patients based on the inclusion and exclusion criteria were divided into the study group showing the CSFP and the control group with normal epicardial coronary arteries. Results The study included 124 patients. 67.9% of the study group and 39.4% of the control group were male patients (p-value = 0.001), and the mean patient age was 52.18 ± 12.55 and 51.77 ± 10.36 years in the study and control groups, respectively (p-value = 0.18). The study group had a significantly higher BMI than the control group (p < 0.05) and also a higher prevalence of smoking and hypertension. The variables of ALC, Hct, Plt, MPV, RDW, Cr, triglyceride, TC, and LDL, were higher in the study group. Given the echocardiographic findings, the mean E wave was significantly lower in the study group, while the control group had a significantly higher GLS (p-value = 0.01). Also, left anterior descending artery was the most common artery involved with CSFP. Conclusion The CSFP was significantly more common in men, smokers, hypertensive patients, and patients with high BMI. Moreover, these patients had significantly higher platelet count, MPV, LDL, and FBS. Some other laboratory variables were also higher in these patients. Given the echocardiographic findings, mild diastolic dysfunction and low GLS were also observed in the study group.
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Affiliation(s)
- Mir Hosein Seyyed Mohammadzad
- Cardiology Department, Medical Faculty, Urmia University of Medical Sciences, 17 Shahrivar St., 571478334, Urmia, Iran
| | - Kamal Khademvatani
- Cardiology Department, Medical Faculty, Urmia University of Medical Sciences, 17 Shahrivar St., 571478334, Urmia, Iran
| | - Salar Gardeshkhah
- Cardiology Department, Medical Faculty, Urmia University of Medical Sciences, 17 Shahrivar St., 571478334, Urmia, Iran
| | - Amin Sedokani
- Cardiology Department, Medical Faculty, Urmia University of Medical Sciences, 17 Shahrivar St., 571478334, Urmia, Iran.
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10
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Grove GL, Pedersen S, Olsen FJ, Skaarup KG, Jørgensen PG, Shah AM, Biering-Sørensen T. Layer-specific global longitudinal strain obtained by speckle tracking echocardiography for predicting heart failure and cardiovascular death following STEMI treated with primary PCI. Int J Cardiovasc Imaging 2021; 37:2207-2215. [PMID: 33689098 DOI: 10.1007/s10554-021-02202-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 02/22/2021] [Indexed: 11/24/2022]
Abstract
The aim of this study was to evaluate layer-specific global longitudinal strain (GLS), obtained by speckle tracking, in predicting outcomes following ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). Echocardiography, including layer-specific GLS, was performed at median two days after the STEMI in a prospective study of STEMI patients treated with pPCI between September 2006 and December 2008. The outcome was the composite of heart failure hospitalization and/or cardiovascular death (HF/CVD). A total of 349 patients were included. Mean age was 62.2 ± 11.5 years, 76% were male, and mean ejection fraction (LVEF) was 46 ± 9. Seventy-seven (22%) patients developed HF/CVD during median follow-up 5.4 years. Patients with HF/CVD had lower absolute values for all GLS-layers: endocardial (GLSEndo) 11.4%vs 14.5% (p < 0.001), midmyocardial (GLSMid) 9.8% vs 12.5% (p < 0.001) and epicardial (GLSEpi) 8.5% vs 10.9% (p < 0.001). In unadjusted analysis, all layers were significant predictors of HF/CVD; hazard ratio (HR) per 1% decrease for GLSEndo: HR 1.18 (95%CI 1.11-1.25), GLSMid: HR 1.22 (95%CI 1.14-1.30) and GLSEpi: HR 1.26 (95%CI 1.16-1.36), p < 0.0001 for all. The risk of HF/CVD increased incrementally with increasing tertiles for all layers, being more than three times higher in 3rd tertile compared to 1st tertile. In multivariable models, including baseline clinical and echocardiographic parameters, only GLSMid and GLSEpi remained independent predictors of HF/CVD. Global longitudinal strain obtained from all myocardial layers were significant predictors of incident HF and CVD following STEMI, however, only GLSMid and GLSEpi remained independent predictors after multivariable adjustment.
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Affiliation(s)
- Gabriela Lladó Grove
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28Post 835, 2900, Copenhagengen, Denmark.
| | - Sune Pedersen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28Post 835, 2900, Copenhagengen, Denmark
| | - Flemming Javier Olsen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28Post 835, 2900, Copenhagengen, Denmark
| | - Kristoffer Grundtvig Skaarup
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28Post 835, 2900, Copenhagengen, Denmark
| | - Peter Godsk Jørgensen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28Post 835, 2900, Copenhagengen, Denmark
| | - Amil M Shah
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tor Biering-Sørensen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28Post 835, 2900, Copenhagengen, Denmark
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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11
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Fischer K, Obrist SJ, Erne SA, Stark AW, Marggraf M, Kaneko K, Guensch DP, Huber AT, Greulich S, Aghayev A, Steigner M, Blankstein R, Kwong RY, Gräni C. Feature Tracking Myocardial Strain Incrementally Improves Prognostication in Myocarditis Beyond Traditional CMR Imaging Features. JACC Cardiovasc Imaging 2020; 13:1891-1901. [PMID: 32682718 DOI: 10.1016/j.jcmg.2020.04.025] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study investigated the association of cardiovascular cardiac magnetic resonance (CMR) feature tracking (FT) with outcome in a patient cohort with myocarditis and evaluated the possible incremental prognostic benefit beyond clinical features and traditional CMR features. BACKGROUND CMR is used to diagnose and risk stratify patients with myocarditis. CMR-FT allows quantitative strain analysis of myocardial function; however, its prognostic benefit in myocarditis is unknown. METHODS Consecutive patients with clinically suspected myocarditis and presence of midmyocardial or epicardial late gadolinium enhancement (LGE) and/or myocardial edema in CMR were included. Clinical and CMR features were analyzed with regard to major adverse cardiovascular events (MACE) (i.e., hospitalization for heart failure, sustained ventricular tachycardia, and all-cause mortality). RESULTS Of 740 patients with clinically suspected myocarditis, 455 (61%) met our final diagnostic criteria based on CMR tissue characterization. At a median follow-up of 3.9 years, MACE occurred in 74 (16%) patients. In the univariable analysis, CMR-FT global longitudinal peak strain (GLS) was significantly associated with MACE. In a multivariable model adjusting for clinical variables (age, sex, body mass index, and acuteness of symptoms) and traditional CMR features (left ventricular ejection fraction [LVEF] and LGE extent), GLS remained independently associated with outcome (GLS hazard ratio: 1.21; 95% confidence interval: 1.08 to 1.36; p = 0.001) and incrementally improved prognostication (chi-square increases from 42.6 to 79.8 to 88.5; p < 0.001). CONCLUSIONS Myocardial strain using CMR-FT provides independent and incremental prognostic value over clinical features, LVEF, and LGE in patients with myocarditis. CMR-FT may serve as a novel marker to improve risk stratification in myocarditis. (CMR Features in Patients With Suspected Myocarditis [CMRMyo]; NCT03470571).
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Affiliation(s)
- Kady Fischer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sarah J Obrist
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sophie A Erne
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anselm W Stark
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maximilian Marggraf
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kyoichi Kaneko
- Non-invasive Cardiovascular Imaging, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dominik P Guensch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adrian T Huber
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Greulich
- Department of Cardiology and Angiology, University of Tübingen, Tübingen, Germany
| | - Ayaz Aghayev
- Non-invasive Cardiovascular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Steigner
- Non-invasive Cardiovascular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Non-invasive Cardiovascular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raymond Y Kwong
- Non-invasive Cardiovascular Imaging, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Non-invasive Cardiovascular Imaging, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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12
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Yousefi K, Irion CI, Takeuchi LM, Ding W, Lambert G, Eisenberg T, Sukkar S, Granzier HL, Methawasin M, Lee DI, Hahn VS, Kass DA, Hatzistergos KE, Hare JM, Webster KA, Shehadeh LA. Osteopontin Promotes Left Ventricular Diastolic Dysfunction Through a Mitochondrial Pathway. J Am Coll Cardiol 2020; 73:2705-2718. [PMID: 31146816 DOI: 10.1016/j.jacc.2019.02.074] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) and coincident heart failure with preserved ejection fraction (HFpEF) may constitute a distinct HFpEF phenotype. Osteopontin (OPN) is a biomarker of HFpEF and predictive of disease outcome. We recently reported that OPN blockade reversed hypertension, mitochondrial dysfunction, and kidney failure in Col4a3-/- mice, a model of human Alport syndrome. OBJECTIVES The purpose of this study was to identify potential OPN targets in biopsies of HF patients, healthy control subjects, and human induced pluripotent stem cell-derived cardiomyocytes (hiPS-CMs), and to characterize the cardiac phenotype of Col4a3-/- mice, relate this to HFpEF, and investigate possible causative roles for OPN in driving the cardiomyopathy. METHODS OGDHL mRNA and protein were quantified in myocardial samples from patients with HFpEF, heart failure with reduced ejection fraction, and donor control subjects. OGDHL expression was quantified in hiPS-CMs treated with or without anti-OPN antibody. Cardiac parameters were evaluated in Col4a3-/- mice with and without global OPN knockout or AAV9-mediated delivery of 2-oxoglutarate dehydrogenase-like (Ogdhl) to the heart. RESULTS OGDHL mRNA and protein displayed abnormal abundances in cardiac biopsies of HFpEF (n = 17) compared with donor control subjects (n = 12; p < 0.01) or heart failure with reduced ejection fraction patients (n = 12; p < 0.05). Blockade of OPN in hiPS-CMs conferred increased OGDHL expression. Col4a3-/- mice demonstrated cardiomyopathy with similarities to HFpEF, including diastolic dysfunction, cardiac hypertrophy and fibrosis, pulmonary edema, and impaired mitochondrial function. The cardiomyopathy was ameliorated by Opn-/- coincident with improved renal function and increased expression of Ogdhl. Heart-specific overexpression of Ogdhl in Col4a3-/- mice also improved cardiac function and cardiomyocyte energy state. CONCLUSIONS Col4a3-/- mice present a model of HFpEF secondary to CKD wherein OPN and OGDHL are intermediates, and possibly therapeutic targets.
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Affiliation(s)
- Keyvan Yousefi
- Department of Molecular and Cellular Pharmacology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Camila I Irion
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Lauro M Takeuchi
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Wen Ding
- Department of Molecular and Cellular Pharmacology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Guerline Lambert
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Trevor Eisenberg
- Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Sarah Sukkar
- Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Henk L Granzier
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | - Mei Methawasin
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | - Dong I Lee
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Virginia S Hahn
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David A Kass
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Konstantinos E Hatzistergos
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Department of Cell Biology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Joshua M Hare
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Keith A Webster
- Department of Molecular and Cellular Pharmacology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Vascular Biology Institute and Peggy and Harold Katz Family Drug Discovery Center, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Lina A Shehadeh
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida; Vascular Biology Institute and Peggy and Harold Katz Family Drug Discovery Center, University of Miami Leonard M. Miller School of Medicine, Miami, Florida.
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13
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Hansen S, Brainin P, Sengeløv M, Jørgensen PG, Bruun NE, Olsen FJ, Fritz-Hansen T, Schou M, Gislason G, Biering-Sørensen T. Prognostic utility of diastolic dysfunction and speckle tracking echocardiography in heart failure with reduced ejection fraction. ESC Heart Fail 2019; 7:147-157. [PMID: 31814331 PMCID: PMC7083408 DOI: 10.1002/ehf2.12532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/10/2019] [Accepted: 09/17/2019] [Indexed: 01/20/2023] Open
Abstract
Aims We hypothesized that grading of diastolic dysfunction (DDF) according to two DDF grading algorithms and strain imaging yields prognostic information on all‐cause mortality in patients with heart failure with reduced ejection fraction (HFrEF). Methods and results We enrolled ambulatory HFrEF (left ventricular ejection fraction < 45%; N = 1 065) patients who underwent echocardiography and speckle tracking assessment of global longitudinal strain (GLS). Patients were stratified according to DDF grades (Grades I–III) according to two contemporary DDF grading algorithms. Prognostic performance was assessed by C‐statistics. Of the originally 1 065 enrolled patients, a total of 645 (61%) patients (age: 67 ± 11 years, male: 72%, ejection fraction: 27 ± 9%) were classified according to both DDF grading algorithms. Concordance between the algorithms was moderate (kappa = 0.48) and the reclassification rate was 33%. During a median follow‐up of 3.3 years (1.9, 4.7 years), 101 (16%) died from all causes. When comparing DDF Grade I vs. Grade III, both algorithms provided prognostic information [Nagueh: (hazard ratio) HR 2.09, 95% confidence interval (CI),1.32–3.31, P = 0.002; Johansen: HR 2.47, 95% CI, 1.57–3.87, P < 0.001]. However, when comparing DDF Grade II vs. Grade III, only the Johansen algorithm yielded prognostic information (Nagueh: HR 1.04, 95% CI, 0.60–1.77, P = 0.90; Johansen: HR 2.26, 95% CI, 1.35–3.77, P = 0.002). We found no difference in prognostic performance between the two algorithms (C‐statistics: 0.604 vs. 0.623, P = 0.24). Assessed by C‐statistics, the most powerful predictors of the endpoint from the two algorithms were E/e'‐ratio (C‐statistics: 0.644), tricuspid regurgitation velocity (C‐statistics: 0.625) and E/A‐ratio (C‐statistics: 0.602). When adding GLS to a combination of these predictors, the prognostic performance increased significantly (C‐statistics: 0.705 vs. C‐statistics: 0.634, P = 0.028). Conclusions Evaluation of DDF in patients with HFrEF yields prognostic information on all‐cause mortality. Furthermore, adding GLS to contemporary algorithms of DDF adds novel prognostic information.
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Affiliation(s)
- Sune Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Philip Brainin
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Morten Sengeløv
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Godsk Jørgensen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Niels Eske Bruun
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Zealand University Hospital, Roskilde, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Fritz-Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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14
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Cardiac function assessed by myocardial deformation in adult polycystic kidney disease patients. BMC Nephrol 2019; 20:324. [PMID: 31419965 PMCID: PMC6697983 DOI: 10.1186/s12882-019-1500-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 07/29/2019] [Indexed: 01/19/2023] Open
Abstract
Background Patients with autosomal dominant polycystic kidney disease (ADPKD) have an increased risk of cardiovascular morbidity and mortality. Impaired left ventricular (LV) global longitudinal strain (GLS) can be a sign of subclinical cardiac dysfunction even in patients with otherwise preserved ejection fraction (EF). Transmitral early filling velocity to early diastolic strain rate (E/SRe) is a novel measure of LV filling pressure, which is often affected early in cardiac disease. Methods A total of 110 ADPKD patients not on dialysis were included in this prospective study. All patients underwent an extensive echocardiographic examination including two-dimensional speckle tracking. GLS and strain rates were measured. The distribution of GLS and E/SRe was determined and patient characteristics were compared by median levels of GLS (− 17.8%) and E/SRe (91.4 cm). Twenty healthy participants were included as control group. Results There was a significantly worse GLS in the ADPKD patients (mean: − 17.8 ± 2.5%) compared to the healthy controls (mean: − 21.9 ± 1.9%), p < 0.001. The same was true for E/SRe (mean: 10.0 ± 0.3 cm) compared to the control group (mean: 6.5 ± 0.3 cm), p < 0.001. In simple logistic regression, male gender (OR: 4.74 [2.10–10.71], p < 0.001), fasting glucose (odds ratio (OR) 1.05 [1.01–1.10], p = 0.024), htTKV (OR: 1.07 [1.01–1.13], p = 0.013), HDL cholesterol (OR: 0.97 [0.94, 0.996], p = 0.025), triglycerides (OR: 1.01 [1.00–1.02], p = 0.039), hemoglobin (OR: 1.50 [1.11–2.04], p = 0.009), and β-blocker use (OR: 1.07 [1.01, 1.13], p = 0.013) were all associated with higher GLS. After multivariate logistic regression with backward model selection, only male gender (OR: 5.78 [2.27–14.71], p < 0.001) and β-blocker use (OR: 14.00 [1.60, 122.51], p = 0.017) remained significant. In simple logistic regression models, BMI (OR: 1.11 [1.02–1.20], p = 0.015), systolic blood pressure (OR: 1.03 [1.00–1.06], p = 0.027) and β-blocker use (OR: 17.12 [2.15–136.20], p = 0.007) were associated with higher E/SRe - a novel measure of left ventricular filling pressure. After backward elimination, only β-blocker use (OR: 17.22 [2.16, 137.14], p = 0.007) remained significant. Conclusion Higher GLS and E/SRe are common in ADPKD patients, even in patients with preserved eGFR and normal left ventricular EF. GLS and E/SRe may aid in cardiovascular risk stratification in patients with ADPKD as they represent early markers of cardiac dysfunction. Electronic supplementary material The online version of this article (10.1186/s12882-019-1500-1) contains supplementary material, which is available to authorized users.
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15
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Hagemann CA, Hoffmann S, Hagemann RA, Fritz-Hansen T, Olsen FJ, Jørgensen PG, Biering-Sørensen T. Usefulness of layer-specific strain in diagnosis of coronary artery disease in patients with stable angina pectoris. Int J Cardiovasc Imaging 2019; 35:1989-1999. [DOI: 10.1007/s10554-019-01652-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 06/15/2019] [Indexed: 11/29/2022]
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16
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Lassen MC, Skaarup KG, Iversen AZ, Jørgensen PG, Olsen FJ, Galatius S, Biering-Sørensen T. Ratio of Transmitral Early Filling Velocity to Early Diastolic Strain Rate as a Predictor of Cardiovascular Morbidity and Mortality Following Acute Coronary Syndrome. Am J Cardiol 2019; 123:1776-1782. [PMID: 30952381 DOI: 10.1016/j.amjcard.2019.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 11/24/2022]
Abstract
The ratio of early mitral inflow velocity (E) to early diastolic strain rate (E/e'sr) is a significant predictor of cardiac outcomes in various patient populations. This study aims to evaluate the predictive value of E/e'sr for heart failure, acute myocardial infarction, and death due to cardiovascular disease following acute coronary syndrome (ACS). In total, 432 ACS patients underwent echocardiography following percutaneous coronary intervention. The end point was the composite of heart failure, acute myocardial infarction, and death due to cardiovascular disease. Median follow-up was 4.4 (interquartile range 0.2 to 6.3) years. During the follow-up period, 199 (46.1%) met the composite outcome. Mean value of E/e'sr in patients was 0.70 ± 0.37 m. In univariable Cox regression, E/e'sr was a predictor of the composite outcome (hazard ratio [HR] 1.05 95% confidence interval [CI] 1.03 to 1.07, p <0.001, per 0.10 m increase). After multivariable adjustment for demographic and clinical parameters, E/e'sr remained an independent predictor (HR 1.03; 95% CI 1.01 to 1.06; p = 0.013, per 0.10 m increase). Global longitudinal strain (GLS) modified the relation between E/e'sr and outcome (p value for interaction = 0.011). In ACS patients with a relatively preserved systolic function assessed by GLS (GLS ≥ 13.2%), E/e'sr showed to be a significant predictor (HR 1.20; 95% CI 1.06 to 1.36; p = 0.005, per 0.10 m increase). In contrast, E/e'sr was not a significant predictor in ACS patients with impaired systolic function (GLS < 13.2%; HR 1.02; 95% CI 0.99 to 1.04; p = 0.28). In conclusion, E/e'sr provides important prognostic information regarding cardiovascular morbidity and mortality in ACS patients. However, E/e'sr was not an independent predictor over that of echocardiographic parameters. Furthermore, E/e'sr is a stronger prognosticator in patients with relatively preserved systolic function as opposed to patients with impaired systolic function.
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Minatoguchi S, Yoshizane T, Tanaka R, Iwama M, Watanabe T, Sato H, Nagaya M, Ono K, Noda T, Watanabe S, Minatoguchi S, Kawasaki M. Left Ventricular Torsion in Hypertension and Hypertensive Heart Failure ― 3-Dimensional Speckle Tracking Echocardiography Assessment ―. Circ Rep 2019; 1:78-86. [PMID: 33693117 PMCID: PMC7890276 DOI: 10.1253/circrep.cr-19-0001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background:
Left ventricular (LV) torsion by contraction of inner and outer oblique muscles contributes to EF. Outer muscle plays a predominant role in torsion. We evaluated the impact of LV remodeling by hypertension (HTN) on torsion using 3-dimensional speckle tracking echocardiography (3D-STE). Methods and Results:
LV strain, strain rate during systole (SR-S) and torsion at endocardium, mid-wall and epicardium were assessed on 3D-STE in 53 controls and 186 HTN patients. Torsion was defined as the difference between apical and basal rotation divided by long axis length. LVEF and strain, SR-S and torsion in all 3 layers in HTN without LV hypertrophy (LVH) were similar to those in controls. LV longitudinal strain at endocardium in HTN with LVH decreased, whereas LVEF was similar to that in controls and, which was associated with increased torsion at epicardium. Reduced LVEF in hypertensive HF was associated with reduced strain, SR-S and torsion in all layers and with LV dilation. On multivariate analysis, epicardial torsion was an independent determinant of LVEF. At epicardial torsion cut-off 0.41, the sensitivity and specificity for the identification of HFrEF were 88% and 68%. Conclusions:
Torsion on 3D-STE may represent a compensatory mechanism to maintain LVEF despite reduced endocardial function, suggesting that the deterioration of torsion caused by insult to outer muscle and dilation may lead to HFrEF.
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Affiliation(s)
| | | | | | - Makoto Iwama
- Department of Cardiology, Gifu Prefectural General Medical Center
| | - Takatomo Watanabe
- Department of Cardiology, Gifu University Graduate School of Medicine
| | | | - Maki Nagaya
- Department of Cardiology, Gifu Prefectural General Medical Center
| | - Koji Ono
- Department of Cardiology, Gifu Prefectural General Medical Center
| | - Toshiyuki Noda
- Department of Cardiology, Gifu Prefectural General Medical Center
| | - Sachiro Watanabe
- Department of Cardiology, Gifu Prefectural General Medical Center
| | | | - Masanori Kawasaki
- Department of Cardiology, Gifu University Graduate School of Medicine
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18
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Abstract
Heart failure (HF) has evolved in an epidemic manner and constitutes a major public health issue. Currently, several prognostic markers and treatment options exist to guide treatment of HF with reduced ejection fraction, but echocardiographic deformation imaging suggests novel pathophysiologic aspects that could help optimize treatment further. Even though no formal treatment options currently exist for patients with HF with preserved ejection fraction, some HF medication does seem to attenuate strain measures. Speckle tracking has furthermore helped characterize this condition and to confer prognostic information. Thus, strain imaging could facilitate novel trials, and thereby hopefully introduce treatment opportunities.
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Affiliation(s)
- Flemming J Olsen
- Gentofte Hospital, Department of Cardiology, Niels Andersens Vej 65, Hellerup 2900, Denmark
| | - Tor Biering-Sørensen
- Gentofte Hospital, Department of Cardiology, Niels Andersens Vej 65, Hellerup 2900, Denmark.
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19
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Dons M, Jensen JS, Olsen FJ, de Knegt MC, Fritz-Hansen T, Vazir A, Biering-Sørensen T. Global longitudinal strain corrected by RR-interval is a superior echocardiographic predictor of outcome in patients with atrial fibrillation. Int J Cardiol 2018; 263:42-47. [DOI: 10.1016/j.ijcard.2018.02.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/29/2017] [Accepted: 02/09/2018] [Indexed: 12/16/2022]
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20
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Modin D, Andersen DM, Biering-Sørensen T. Echo and heart failure: when do people need an echo, and when do they need natriuretic peptides? Echo Res Pract 2018; 5:R65-R79. [PMID: 29691224 PMCID: PMC5958420 DOI: 10.1530/erp-18-0004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 12/25/2022] Open
Abstract
Heart failure (HF) is a threat to public health. Heterogeneities in aetiology and phenotype complicate the diagnosis and management of HF. This is especially true when considering HF with preserved ejection fraction (HFpEF), which makes up 50% of HF cases. Natriuretic peptides may aid in establishing a working diagnosis in patients suspected of HF, but echocardiography remains the optimal choice for diagnosing HF. Echocardiography provides important prognostic information in both HF with reduced ejection fraction (HFrEF) and HFpEF. Traditionally, emphasis has been put on the left ventricular ejection fraction (LVEF). LVEF is useful for both diagnosis and prognosis in HFrEF. However, echocardiography offers more than this single parameter of systolic function, and for optimal risk assessment in HFrEF, an echocardiogram evaluating systolic, diastolic, left atrial and right ventricular function is beneficial. In this assessment echocardiographic modalities such as global longitudinal strain (GLS) by 2D speckle-tracking may be useful. LVEF offers little value in HFpEF and is neither helpful for diagnosis nor prognosis. Diastolic function quantified by E/e′ and systolic function determined by GLS offer prognostic insight in HFpEF. In HFpEF, other parameters of cardiac performance such as left atrial and right ventricular function evaluated by echocardiography also contribute with prognostic information. Hence, it is important to consider the entire echocardiogram and not focus solely on systolic function. Future research should focus on combining echocardiographic parameters into risk prediction models to adopt a more personalized approach to prognosis instead of identifying yet another echocardiographic biomarker.
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Affiliation(s)
- Daniel Modin
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ditte Madsen Andersen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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21
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Vallabhajosyula S, Pruthi S, Shah S, Wiley BM, Mankad SV, Jentzer JC. Basic and advanced echocardiographic evaluation of myocardial dysfunction in sepsis and septic shock. Anaesth Intensive Care 2018; 46:13-24. [PMID: 29361252 DOI: 10.1177/0310057x1804600104] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Sepsis continues to be a leading cause of mortality and morbidity in the intensive care unit. Cardiovascular dysfunction in sepsis is associated with worse short- and long-term outcomes. Sepsis-related myocardial dysfunction is noted in 20%-65% of these patients and manifests as isolated or combined left or right ventricular systolic or diastolic dysfunction. Echocardiography is the most commonly used modality for the diagnosis of sepsis-related myocardial dysfunction. With the increasing use of ultrasonography in the intensive care unit, there is a renewed interest in sepsis-related myocardial dysfunction. This review summarises the current scope of literature focused on sepsis-related myocardial dysfunction and highlights the use of basic and advanced echocardiographic techniques for the diagnosis of sepsis-related myocardial dysfunction and the management of sepsis and septic shock.
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22
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Skaarup KG, Iversen A, Jørgensen PG, Olsen FJ, Grove GL, Jensen JS, Biering-Sørensen T. Association between layer-specific global longitudinal strain and adverse outcomes following acute coronary syndrome. Eur Heart J Cardiovasc Imaging 2018; 19:1334-1342. [DOI: 10.1093/ehjci/jey004] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/08/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Kristoffer Grundtvig Skaarup
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, Copenhage Denmark
| | - Allan Iversen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, Copenhage Denmark
| | - Peter Godsk Jørgensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, Copenhage Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, Copenhage Denmark
| | - Gabriela Llado Grove
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, Copenhage Denmark
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Jan Skov Jensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, Copenhage Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 3B, Copenhagen N., Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, Copenhage Denmark
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA, USA
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23
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Biering-Sørensen F, Biering-Sørensen T, Liu N, Malmqvist L, Wecht JM, Krassioukov A. Alterations in cardiac autonomic control in spinal cord injury. Auton Neurosci 2018; 209:4-18. [DOI: 10.1016/j.autneu.2017.02.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 01/30/2017] [Accepted: 02/14/2017] [Indexed: 01/22/2023]
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24
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Lin J, Wang F, Weiner RB, DeLuca JR, Wasfy MM, Berkstresser B, Lewis GD, Hutter AM, Picard MH, Baggish AL. Blood Pressure and LV Remodeling Among American-Style Football Players. JACC Cardiovasc Imaging 2017; 9:1367-1376. [PMID: 27931524 DOI: 10.1016/j.jcmg.2016.07.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/07/2016] [Accepted: 07/29/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study sought to determine the relationships among American-style football (ASF) participation, acquired left ventricular (LV) hypertrophy, and LV systolic function as assessed using contemporary echocardiographic parameters. BACKGROUND Participation in ASF has been associated with development of hypertension and LV hypertrophy. To what degree these processes impact LV function is unknown. METHODS This was a prospective, longitudinal cohort study evaluating National Collegiate Athletic Association Division I football athletes stratified by field position (linemen: n = 30; vs. nonlinemen, n = 57) before and after a single competitive season, using transthoracic echocardiography. LV systolic function was measured using complementary parameters of global longitudinal strain (GLS) (using 2-dimensional speckle-tracking) and ejection fraction (EF) (2-dimensional biplane). RESULTS ASF participation was associated with field position-specific increases in systolic blood pressure (SBP) (a Δ SBP of 10 ± 8 mm Hg in linemen vs. a Δ SBP of 3 ± 7 mm Hg in nonlinemen; p < 0.001) and an overall increase in incident LV hypertrophy (pre-season = 8% vs. post-season = 25%, p < 0.05). Linemen who developed LV hypertrophy had concentric geometry (9 of 11 [82%]) with decreased GLS (Δ = -1.1%; p < 0.001), whereas nonlinemen demonstrated eccentric LV hypertrophy (8 of 10 [80%]) with increased GLS (Δ = +1.4%; p < 0.001). In contrast, LV ejection fraction in the total cohort, stratified by field position, was not significantly affected by ASF participation. Among the total cohort, lineman field position, post-season weight, SBP, average LV wall thickness, and relative wall thickness were all independent predictors of post-season GLS. CONCLUSIONS ASF participation at a lineman field position may lead to a form of sport-related myocardial remodeling that is pathologic rather than adaptive. Future study will be required to determine if targeted efforts to control blood pressure, minimize weight gain, and to include an element of aerobic conditioning in this subset of athletes may attenuate this process and translate into tangible downstream health benefits.
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Affiliation(s)
- Jeffrey Lin
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Francis Wang
- Harvard University Health Services, Cambridge, Massachusetts
| | - Rory B Weiner
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts; Harvard University Health Services, Cambridge, Massachusetts
| | - James R DeLuca
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Meagan M Wasfy
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Gregory D Lewis
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Adolph M Hutter
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Picard
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Aaron L Baggish
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts; Harvard University Health Services, Cambridge, Massachusetts.
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25
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Solomon SD, Biering-Sørensen T. LA Strain When Ejection Fraction Is Preserved. JACC Cardiovasc Imaging 2017; 10:744-746. [DOI: 10.1016/j.jcmg.2016.09.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 09/29/2016] [Indexed: 11/27/2022]
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26
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Biering-Sørensen T, Biering-Sørensen SR, Olsen FJ, Sengeløv M, Jørgensen PG, Mogelvang R, Shah AM, Jensen JS. Global Longitudinal Strain by Echocardiography Predicts Long-Term Risk of Cardiovascular Morbidity and Mortality in a Low-Risk General Population: The Copenhagen City Heart Study. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005521. [PMID: 28264868 DOI: 10.1161/circimaging.116.005521] [Citation(s) in RCA: 262] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 01/20/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Global longitudinal strain (GLS) is prognostic of adverse cardiovascular outcomes in various patient populations, but the prognostic utility of GLS for long-term cardiovascular morbidity and mortality in the general population is unknown. METHODS AND RESULTS A total of 1296 participants in a general population study underwent a health examination, including echocardiography measurement of GLS. The primary end point was the composite of incident heart failure, acute myocardial infarction, or cardiovascular death. During a median follow-up of 11 years, 149 (12%) participants were diagnosed with heart failure, acute myocardial infarction, or cardiovascular death. Lower GLS was associated with a higher risk of the composite end point (hazard ratio, 1.12; 95% confidence interval, 1.08-1.17; P<0.001 per 1% decrease), an association that persisted after multivariable adjustment for age, sex, heart rate, hypertension, systolic blood pressure, left ventricular ejection fraction, left ventricular mass index, left ventricular dimension, deceleration time, left atrium dimension, E/e', and pro B-type natriuretic peptide (hazard ratio, 1.05; 95% confidence interval, 1.00-1.11; P=0.045 per 1% decrease). GLS provided incremental prognostic information beyond the Framingham Risk Score, the Systemic Coronary Evaluation risk chart, and the modified American College of Cardiology/American Heart Association Pooled Cohort Equation for the composite outcome and incident heart failure. Sex modified the relationship between GLS and outcome such that after multivariable adjustment, GLS was an independent predictor of outcomes in men but not in women (hazard ratio, 1.14; 95% confidence interval, 1.06-1.24; P=0.001, and hazard ratio, 0.99; 95% confidence interval, 0.92-1.07; P=0.81, respectively; P for interaction =0.032). CONCLUSIONS In the general population, GLS provides independent and incremental prognostic information regarding long-term risk of cardiovascular morbidity and mortality. GLS seems to be a stronger prognosticator in men than in women.
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Affiliation(s)
- Tor Biering-Sørensen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.).
| | - Sofie Reumert Biering-Sørensen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Flemming Javier Olsen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Morten Sengeløv
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Peter Godsk Jørgensen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Rasmus Mogelvang
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Amil M Shah
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
| | - Jan Skov Jensen
- From the Department of Cardiology, Herlev and Gentofte Hospital (T.B.-S., S.R.B.-S., F.J.O., M.S., P.G.J., R.M., J.S.J.), The Copenhagen City Heart Study, Frederiksberg Hospital (T.B.-S., S.R.B.-S., P.G.J., R.M., J.S.J.), and Institute of Clinical Medicine, Faculty of Health Sciences (J.S.J.), University of Copenhagen, Denmark; and Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (T.B.-S., A.M.S.)
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Biering-Sørensen T, Knappe D, Pouleur AC, Claggett B, Wang PJ, Moss AJ, Solomon SD, Kutyifa V. Regional Longitudinal Deformation Improves Prediction of Ventricular Tachyarrhythmias in Patients With Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005096. [DOI: 10.1161/circimaging.116.005096] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 10/18/2016] [Indexed: 11/16/2022]
Abstract
Background—
Left ventricular dysfunction is a known predictor of ventricular arrhythmias. We hypothesized that measures of regional longitudinal deformation by speckle-tracking echocardiography predict ventricular tachyarrhythmias and provide incremental prognostic information over clinical and conventional echocardiographic characteristics.
Methods and Results—
We studied 1064 patients enrolled in the MADIT-CRT trial (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy) with speckle-tracking data available. Peak longitudinal strain was obtained for the septal, lateral, anterior, and inferior myocardial walls at baseline. The end point was the first event of ventricular tachycardia (VT) or fibrillation (VF). During the median follow-up of 2.9 years, 254 (24%) patients developed VT/VF. Patients with VT/VF had significantly lower left ventricular ejection fraction (28.3% versus 29.5%;
P
<0.001) and longitudinal strain in all myocardial walls compared with patients without VT/VF (anterior-strain, −7.7% versus −8.8%;
P
<0.001; lateral-strain, −7.3% versus −7.9%;
P
=0.022; inferior-strain, −8.3% versus −9.9%;
P
<0.001; septal-strain, −9.1% versus −10.0%;
P
<0.001). After multivariate adjustment, only anterior and inferior longitudinal strain remained independent predictors of VT/VF (anterior: hazard ratio, 1.08 [1.03–1.13];
P
=0.001; inferior: hazard ratio, 1.08 [1.04–1.12];
P
<0.001; per 1% absolute decrease for both). When including B-type natriuretic peptide in the model, only a decreasing myocardial function in the inferior myocardial wall predicted VT/VF (hazard ratio, 1.05 [1.00–1.11];
P
=0.039). Only strain obtained from the inferior myocardial wall provided incremental prognostic information for VT/VF over clinical and echocardiographic parameters (C statistic 0.71 versus 0.69;
P
=0.005).
Conclusions—
Assessment of regional longitudinal myocardial deformation in the inferior region provided incremental prognostic information over clinical and echocardiographic risk factors in predicting ventricular tachyarrhythmias.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00180271.
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Affiliation(s)
- Tor Biering-Sørensen
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Dorit Knappe
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Anne-Catherine Pouleur
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Brian Claggett
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Paul J. Wang
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Arthur J. Moss
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Scott D. Solomon
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
| | - Valentina Kutyifa
- From the Department of Medicine, Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (T.B.-S., D.K., A.-C.P., B.C., S.D.S.); Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark (T.B.-S.); Stanford University of Medicine, Palo Alto, CA (P.J.W.); and University of Rochester Medical Center, NY (A.J.M., V.K.)
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Zoghbi WA. Cardiac Remodeling in American-Style Football Players: Field Position Matters. JACC. CARDIOVASCULAR IMAGING 2016; 9:1377-1379. [PMID: 27931525 DOI: 10.1016/j.jcmg.2016.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 09/14/2016] [Indexed: 11/27/2022]
Affiliation(s)
- William A Zoghbi
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
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Biering-Sørensen T, Santos M, Rivero J, McCullough SD, West E, Opotowsky AR, Waxman AB, Systrom DM, Shah AM. Left ventricular deformation at rest predicts exercise-induced elevation in pulmonary artery wedge pressure in patients with unexplained dyspnoea. Eur J Heart Fail 2016; 19:101-110. [PMID: 27878925 DOI: 10.1002/ejhf.659] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/01/2016] [Accepted: 08/15/2016] [Indexed: 11/09/2022] Open
Abstract
AIMS Impaired left ventricular (LV) deformation despite preserved LV ejection fraction (LVEF) is common and predicts outcomes in heart failure with preserved LVEF. We hypothesized that impaired LV deformation at rest is a marker of impaired cardiac systolic and diastolic reserve, and aimed to determine whether resting longitudinal (LS) and circumferential strain (CS) are associated with invasively measured haemodynamic response to exercise in patients with dyspnoea and a normal LVEF. METHODS AND RESULTS We studied 85 patients with LVEF ≥50% and free of significant valvular disease who were referred for evaluation of dyspnoea. All patients underwent rest echocardiography followed by right heart catheterization and cardiopulmonary exercise testing with concomitant invasive haemodynamic monitoring. The LS, CS and CS/LS ratio were measured by two-dimensional speckle-tracking echocardiography at rest. Lower absolute LS at rest was associated with greater increase in pulmonary arterial wedge pressure (PAWP) from rest to peak exercise (r = 0.23, P = 0.034). In contrast, higher absolute CS at rest predicted a greater increase in PAWP (r = - 0.27, P = 0.032) and greater stroke volume augmentation with exercise (r = - 0.26, P = 0.021). Higher CS/LS ratio was most predictive of elevation in PAWP with exercise (r = 0.30, P = 0.015). Of the measures of LV systolic and diastolic function assessed, the CS/LS ratio resulted in the highest area under the curve and specificity for the presence of rest- or exercise-induced pulmonary venous hypertension. CONCLUSION Left ventricular deformation at rest predicts exercise-induced rise in PAWP among patients with dyspnoea and a preserved LVEF. A pattern of rest deformation characterized by worse LS and exaggerated CS is most strongly associated with exercise-induced rise in PAWP.
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Affiliation(s)
- Tor Biering-Sørensen
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.,Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Mário Santos
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal
| | - Jose Rivero
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Shane D McCullough
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Erin West
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Alexander R Opotowsky
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.,Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Olsen FJ, Pedersen S, Jensen JS, Biering-Sørensen T. Global longitudinal strain predicts incident atrial fibrillation and stroke occurrence after acute myocardial infarction. Medicine (Baltimore) 2016; 95:e5338. [PMID: 27858918 PMCID: PMC5591166 DOI: 10.1097/md.0000000000005338] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Patients with acute myocardial infarction are at increased risk of developing atrial fibrillation. We aimed to evaluate whether speckle tracking echocardiography improves risk stratification for atrial fibrillation in these patients.The study comprised of 373 patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention. Patients had an echocardiogram performed at a median of 2 days after their STEMI. The echocardiograms consisted of conventional measurements and myocardial strain analysis by speckle tracking from 3 apical projections. The endpoint was a composite of new-onset atrial fibrillation and ischemic stroke. At a median follow-up time of 5.5 years (interquartile range 4.9, 6.1 years), 44 patients developed the endpoint (atrial fibrillation: n = 24, ischemic stroke: n = 24, both: n = 4). Patients who reached the endpoint had significantly reduced systolic function by the left ventricular ejection fraction (LVEF) (43% vs 46%; P = 0.042) and global longitudinal strain (10.9% vs 12.6%; P = 0.004), both being univariable predictors. However, only global longitudinal strain remained a significantly independent predictor (hazard ratio 1.12, 95% confidence interval 1.00; 1.25, P = 0.042, per 1% decrease) after multivariable adjustment for baseline predictors (age, sex, diabetes, hypertension, diastolic dysfunction, and LVEF) using Cox regression. Furthermore, global longitudinal strain resulted in significantly higher c-statistics for prediction of outcome compared with LVEF <45% (0.63 vs 0.52; P = 0.026). When stratified into tertiles of global longitudinal strain, it became evident that patients in the lowest tertile mediated this signal with a 2-fold increased risk compared with the highest tertile (hazard ratio 2.10, 95% confidence interval 1.04; 4.25).Global longitudinal strain predicts atrial fibrillation after STEMI and may add valuable information which can help facilitate arrhythmia detection in these patients.
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Affiliation(s)
- Flemming Javier Olsen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Correspondence: Flemming Javier Olsen, Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Denmark. Niels Andersens Vej 65, 2900 Hellerup, Denmark (e-mail: )
| | - Sune Pedersen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jan Skov Jensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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