Redefining anthracycline-related subclinical cardiotoxicity: 'Absolute' and 'relative' change in longitudinal strain.

AIMS: Anthracycline chemotherapy (AC) for breast cancer can cause cancer therapy-related cardiac dysfunction (CTRCD) with resultant heart failure, traditionally defined as a reduction in left ventricular (LV) ejection fraction on echocardiography. In recent years, global longitudinal systolic strain (GLS) has been used to identify subclinical cardiac dysfunction prior to development of overt CTRCD. Recent harmonized guidelines have incorporated GLS into definitions for CTRCD to identify cardiac dysfunction and inform decisions regarding cardioprotective strategies. METHODS AND RESULTS: We evaluated subclinical dysfunction in breast cancer patients treated with AC and determined the echocardiographic and patient factors associated with significant GLS changes. One hundred fourteen HER2 negative patients treated with AC were prospectively recruited and underwent serial echocardiograms (LVEF and LVGLS) at three time points (prior to AC, 3 months, and 1 year). CTRCD was defined as an asymptomatic reduction in LVEF of 10% or symptomatic drop of 5% to LVEF <53%. Subclinical LV dysfunction was defined as a reduction of ≥10% in GLS compared with baseline, recognizing that this cut off identified an 'at risk cohort' rather than patients with established CTRCD. No participant demonstrated CTRCD by reduction in LVEF. Forty-three patients (38%) demonstrated a ≥10% relative reduction in GLS at 12 months; 20/43 (47%) had a reduced absolute GLS to <16%, and were older, had hypertension, increased LV mass, lower baseline e' velocity and GLS. GLS ≥20.5% at baseline yielded a sensitivity of 79% and specificity of 87% for a normal GLS (i.e., ≥16%) at 1 year despite a ≥10% reduction from baseline. CONCLUSIONS: We present a stepwise evaluation for subclinical LV dysfunction using both a relative reduction in GLS combined with an absolute reduction in GLS. We believe our findings may re-stratify patients with a high baseline GLS into a lower risk group despite transient relative GLS decrements ≥10%.

Correlation Of Global Longitudinal Systolic Strain With Severity Of Coronary Artery Disease In Non-Stelevation Acute Coronary Syndrome Having Normal Ejection Fraction.

BACKGROUND: In patients of non-ST-elevation acute coronary syndrome (NSTEACS), the global longitudinal peak systolic strain (GLPS) has been used to detect the presence of coronary artery disease (CAD) before left ventricular ejection fraction (LVEF) is affected. We tried to find out the correlation between the GLPS and severity of CAD in such patients. METHODS: A descriptive correlational study was conducted from March 2018 to January 2020 at Jinnah Hospital Lahore. Two hundred and sixteen patients of NSTEACS with EF of ≥60% were included. Patients were divided according to angiographic results into those having non-significant, one-vessel, two-vessel or three-vessel disease. These four groups were compared regarding left ventricular end-systolic dimension (LVESD), left ventricular end-diastolic dimension (LVEDD), LVEF, global longitudinal peak systolic strains in apical long axis view (GLPS-APLEX), in apical 4-chamber view (GLPS-A4C), in apical 2-chamber view (GLPS-A2C) and average of these (GLPS-AVG). All these parameters were also compared between patients having and those not having left main coronary artery (LMCA) disease. RESULTS: Out of 216 patients, males and females were 124(57.4%) and 92 (42.6%) respectively. There were 28 (13.0%), 83 (38.4%), 62 (28.7%) and 43 (19.9%) patients who had non-significant, one-vessel, two-vessel and three-vessel CAD respectively. With increase in severity of CAD, GLPS-AVG progressively decreased from nonsignificant CAD being 20.6±0.7 to three-vessel CAD being 16.1±0.7. There was a significant negative correlation between severity of CAD and all of the GLPS-APLEX, GLPS-A4C, GLPSA2C and GLPS-AVG (p<0.001 in all). GLPS-AVG was significantly low in patients having LMCA disease (16.5±0.7) than those not having LMCA disease (18.2±1.5) with p-value of <0.001. All other types of GLPSs showed the similar trend. CONCLUSIONS: Global longitudinal peak systolic strain has a significant negative correlation with severity of coronary artery disease in non-ST-elevation acute coronary syndrome having normal ejection fraction.

Carotid intima-media thickness and subclinical left heart dysfunction in the general population.

BACKGROUND AND AIMS: Although carotid intima-media thickness (IMT) is an established marker of atherosclerosis and carries independent risk for cardiovascular disease, its possible association with subclinical cardiac dysfunction has not been extensively evaluated. Left ventricular global longitudinal strain (LVGLS) and peak left atrial longitudinal systolic strain (PALS) can detect subclinical left heart dysfunction. This study aimed to investigate the association between carotid IMT and subclinical left heart dysfunction in a sample of the general population without overt cardiac disease. METHODS: We examined 1161 participants who underwent extensive cardiovascular examination. Ultrasonography of common carotid artery was performed for the measurement of maximal carotid IMT. LVGLS and PALS were assessed by 2-dimensional speckle-tracking echocardiography. RESULTS: Mean age was 62 ± 12 years, and 56% were male. The prevalence of abnormal LVGLS (>-18.6%) and PALS (<31.4%) was greatest in the upper quartile of carotid IMT (both p < 0.001). In multivariable analyses, carotid IMT was associated with abnormal LVGLS (adjusted odds ratio = 1.33 per 1SD increase of IMT, p = 0.003) as well as PALS (adjusted odds ratio = 1.33 per 1SD increase of IMT, p = 0.005) independent of traditional cardiovascular risk factors, echocardiographic parameters including LV ejection fraction, LV mass index and diastolic dysfunction, and pertinent laboratory parameters. The independent association between carotid IMT and PALS persisted even after adjustment for LVGLS. CONCLUSIONS: Participants with increased IMT had significantly impaired LV and LA function in an unselected community-based cohort. This association may be involved in the higher incidence of cardiovascular disease in individuals with increased carotid IMT.

Independent Association of Overhydration with All-Cause and Cardiovascular Mortality Adjusted for Global Left Ventricular Longitudinal Systolic Strain and E/E' Ratio in Maintenance Hemodialysis Patients.

BACKGROUND/AIMS: Fluid overload is common and associated with morbidity and mortality in patients with end-stage renal disease. The relationship between fluid overload and cardiac function is complex, and whether fluid overload is associated with adverse outcomes in patients undergoing hemodialysis (HD) independently of systolic and diastolic function of the left ventricle (LV) remains unclear. METHODS: The present study aimed to investigate the relationship between overhydration and all-cause and cardiovascular (CV) mortality after adjusting for LV function in 178 maintenance HD patients. The relative hydration status (overhydration/ extracellular water, ∆HS) was measured using a body composition monitor, and then used to assess the fluid status. A ∆HS ≥7% was defined as fluid overload. Global left ventricular longitudinal systolic strain (GLS), and the early filling and early diastolic mitral annular velocity (E/E') ratio were assessed using speckle-tracking and tissue Doppler echocardiography. RESULTS: During a mean follow-up period of 2.7 years, 24 patients died, including 11 CV deaths. An increased ∆HS was significantly associated with all-cause and CV mortality in the univariate analysis. This prognostic significance remains after multivariate adjusting for GLS and E/E' ratio for all-cause (HR, 1.123; 95% CI, 1.063-1.186; p-value < 0.001) and CV (HR, 1.088; 95% CI, 1.005-1.178; p-value =0.037) mortality. Moreover, ∆HS significantly improved the prognostic value beyond conventional clinical and echocardiographic parameters. CONCLUSION: A higher ∆HS was independently associated with increased all-cause and CV mortality after adjusting for systolic and diastolic function of the LV. This suggests that ∆HS may be a relevant target for improving outcomes in maintenance HD patients.

Deformación sistólica longitudinal del ventrículo izquierdo en pacientes pediátricos con antecedente de enfermedad de Kawasaki / Left ventricular longitudinal systolic strain in children with history of Kawasaki disease

Resumen Objetivo La enfermedad de Kawasaki (EK) es una vasculitis sistémica cuya complicación más grave es la formación de lesiones coronarias, las cuales pueden llevar a infarto del miocardio y muerte súbita. El estudio ecocardiográfico es parte del seguimiento obligado de los pacientes con EK. La deformación sistólica longitudinal (DSL) medida mediante speckle tracking es una herramienta precisa para evaluar la función de la fibra miocárdica (longitudinal) del ventrículo izquierdo. No se ha establecido la utilidad en la práctica clínica de la DSL en niños con antecedente de EK. El objetivo de este estudio fue analizar si la presencia de lesiones coronarias condiciona alteraciones en la DSL segmentaria y su correspondencia con el territorio coronario en donde se encuentra la lesión. Método Serie de casos. Se realizó un estudio ecocardiográfico completo y la evaluación de la DSL a niños con antecedente de EK al menos 6 meses después de la fase aguda. Resultados Se estudiaron 9 pacientes. La mediana de edad fue de 6 años (mínimo 2 y máximo 17). El 56% era de sexo masculino. El 77% presentó aneurismas coronarios. La DSL resultó alterada en el 56% de la muestra estudiada. Dentro de los pacientes que presentaron una DSL anormal, todos mostraron aneurismas coronarios y lesiones estenóticas u oclusivas demostradas mediante cateterismo de arterias coronarias, además de alteraciones de la perfusión miocárdica en estudio de Medicina Nuclear. Conclusiones En la muestra estudiada, los pacientes en quienes se encontró una DSL anormal, resultaron tener lesiones coronarias que condicionaban isquemia o infarto.

Abstract Objective Kawasaki disease (KD) is a systemic vasculitis that affects young children. Coronary artery aneurisms, ectasia and stenosis are its main complications and may lead to ischemic heart disease or sudden death. Echocardiography evaluation it's mandatory in all patients with history of KD. Left ventricular longitudinal systolic strain (LVLSS) measured by speckle tracking it's an accurate tool to evaluate global and segmental left ventricle mechanics. Clinical utility of LVLSS in children with KD hasn't been established. The goal of this study was to analyse if the presence of coronary lesions alters segmental LVLSS and if there is a relationship with the affected coronary territory. Method Case series. A complete transthoracic echocardiography with LVLSS was performed in children with history of KD with at least 6 months after the acute phase. Results Nine patients where studied, with a median age of 6 years (minimum 2 and maximum 17). A percentage of 56 were male, and 77% had coronary aneurisms. An abnormal LVLSS was found in 56% of the population studied. All of the patients that had an abnormal LVLSS had coronary aneurisms with stenosis or complete occlusion confirmed by invasive coronary angiography and abnormal Nuclear Medicine perfusion scans. Conclusions On the population studied, all patients with an abnormal LVLSS had obstructive coronary lesions and ischemic heart disease.

[Left ventricular longitudinal systolic strain in children with history of Kawasaki disease]. / Deformación sistólica longitudinal del ventrículo izquierdo en pacientes pediátricos con antecedente de enfermedad de Kawasaki.

OBJECTIVE: Kawasaki disease (KD) is a systemic vasculitis that affects young children. Coronary artery aneurisms, ectasia and stenosis are its main complications and may lead to ischemic heart disease or sudden death. Echocardiography evaluation it's mandatory in all patients with history of KD. Left ventricular longitudinal systolic strain (LVLSS) measured by speckle tracking it's an accurate tool to evaluate global and segmental left ventricle mechanics. Clinical utility of LVLSS in children with KD hasn't been established. The goal of this study was to analyse if the presence of coronary lesions alters segmental LVLSS and if there is a relationship with the affected coronary territory. METHOD: Case series. A complete transthoracic echocardiography with LVLSS was performed in children with history of KD with at least 6 months after the acute phase. RESULTS: Nine patients where studied, with a median age of 6 years (minimum 2 and maximum 17). A percentage of 56 were male, and 77% had coronary aneurisms. An abnormal LVLSS was found in 56% of the population studied. All of the patients that had an abnormal LVLSS had coronary aneurisms with stenosis or complete occlusion confirmed by invasive coronary angiography and abnormal Nuclear Medicine perfusion scans. CONCLUSIONS: On the population studied, all patients with an abnormal LVLSS had obstructive coronary lesions and ischemic heart disease.

Influence of microvascular obstruction on regional myocardial deformation in the acute phase of myocardial infarction: a speckle-tracking echocardiography study.

BACKGROUND: In the acute phase of myocardial infarction (MI), infarct size and microvascular obstruction (MVO) are important prognostic factors for cardiovascular outcome. MI size is a major determinant of myocardial function, but the specific effect of MVO is less documented. The aim of this study was to evaluate the impact of MVO on longitudinal myocardial strain assessed by speckle-tracking echocardiography. METHOD: Speckle-tracking echocardiography and contrast-enhanced cardiac magnetic resonance studies were performed in 69 patients 72 hours after first acute MI. Segmental and global longitudinal systolic strain (εL) was measured using speckle-tracking echocardiography. Transmural extent of MI, MI size, and the presence or absence of MVO were assessed using contrast-enhanced cardiac magnetic resonance. Left ventricular (LV) ejection fraction was assessed at 6 months using echocardiography. RESULTS: The mean infarct size was 23 ± 13% of LV mass. MVO was present in 64% of patients. MVO was significantly associated with εL impairment (-7.8 ± 4.9% vs -16.3 ± 6.4%, P < .001), and εL remained significantly worse in MVO-positive segments after adjustment for transmural extent of MI. A εL value > -12.5% predicted the presence of MVO with 83% sensitivity and 75% specificity. On multivariate analysis, global εL and MI size, but not MVO, were identified as independent predictors of LV ejection fraction at follow-up (ß = -0.9, P = .023, and ß = -0.2, P = .034, respectively). CONCLUSION: In the acute phase of MI, segmental and global εL is significantly altered by the presence of MVO, in addition to MI size. However, MI size but not MVO independently predicts LV ejection fraction at follow-up.

Longitudinal strain curves in the RV free wall differ in morphology in patients with pulmonary hypertension compared to controls.

BACKGROUND: Previous studies using speckle tracking-derived strain for quantification of right ventricular (RV) function in pulmonary hypertension (PHT) have focused on the magnitude of global and regional peak longitudinal systolic strains (PLSS) and systolic strain-related indices of dyssynchrony. The aim of our study was to investigate the pattern of RV contraction and relaxation with the use of the contour and timing of strain and velocity curves in PHT. METHODS: The study population consisted of thirty-seven patients with PHT (45 ± 18 years, 16 women) and thirty-seven controls. A complete two-dimensional echo with speckle-tracking-derived longitudinal strain of the basal RV free wall and interventricular septum (IVS) was performed and the cycle length-corrected time to PLSS (SST) and time from PLSS to 50% of PLSS (systolic strain half time-SSHT) in both regions were calculated. RESULTS: Patients with PHT had significantly reduced PLSS (-24.9 ± 2.0% vs -43.2 ± 3.0%, p<0.001) and increased SST (0.47 ± 0.02 vs 0.39 ± 0.02, p=0.043) and SSHT (0.22 ± 0.02 vs 0.16 ± 0.02, p=0.047) in the basal RV free wall compared to controls. Furthermore, peak systolic velocities were observed earlier in the cardiac cycle in both regions in patients with PHT compared to controls. CONCLUSIONS: Longitudinal strain curves in the RV free wall reach peak values later in the cardiac cycle and return slower towards the baseline in PHT. Furthermore, peak systolic velocities are observed earlier in the cardiac cycle in both the basal RV free wall and the basal IVS. The above observations effectively illustrate changes in patterns of RV contraction and relaxation caused by PHT.

Correlation between left ventricular global and regional longitudinal systolic strain and impaired microcirculation in patients with acute myocardial infarction.

OBJECTIVES: We investigated the correlation between left ventricular global and regional longitudinal systolic strain (GLS and LRS) and coronary flow reserve (CFR) assessed by transthoracic echocardiography (TTE) in patients with a recent acute myocardial infarction (AMI). Furthermore, we investigated if LRS and GLS imaging is superior to conventional measures of left ventricle (LV) function. METHODS: In a consecutive population of first time AMI patients, who underwent successful revascularization, we performed comprehensive TTE. GLS and LRS were obtained from the three standard apical views. Assessment of CFR by TTE was performed in a modified apical view using color Doppler guidance. RESULTS: The study population consisted of 183 patients (51 females) with a median age of 63 [54;70] years. Eighty-nine (49%) patients had a non-ST elevation myocardial infarction and 94 (51%) patients had a ST elevation myocardial infarction. The GLS was -15.2 [-19.3;-10.1]% in the total population of 183 patients. Total wall motion score index (WMSI) in the population was 1.19 [1;1.5]. Eighty-five patients suffered from culprit lesion in left anterior descending artery (LAD). The CFR in these patients was 1.86 [1.36;2.35] and the GLS was -14.3 [-18.9; -9.8]%. A significant difference was observed in the LRS in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (-9.6 [-13.77;-6.44]) compared with the LRS in LAD territory in culprit LAD infarction patients with a CFR > 2 (-19.33 [-21.1;-16.5]), P < 0.0001. We found no significant difference between WMSI in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (1.56 [1.06;2.23]) compared with WMSI in LAD territory in culprit LAD infarction patients with a CFR > 2 (1.37 [1.03;2.11]); P = 0.18. The same pattern was observed in both circumflex coronary artery (CX) and right coronary artery (RCA) territories. In the total population, we found a strong correlation between CFR and GLS (r = -0.85, P < 0.0001). This was also seen in the multivariate regression model adjusting for possible confounders including WMSI (P < 0.001). CONCLUSION: In this study, we have shown a close association between myocardial deformation in patients with a recent AMI and the degree of diminished microcirculation. We found that both GLS and LRS correlated with CFR. We conclude that GLS and LRS are significantly better tools to assess impaired CFR and LV function after a recent AMI, than conventional echocardiographic measurements.