Inter-vendor variability and reproducibility of subcostal left ventricular longitudinal strain.

Left ventricular longitudinal strain (LVLS) performed using subcostal windows is a novel alternative for patients who require strain imaging but have poor apical windows. We investigated the reproducibility and inter-vendor variability of subcostal LVLS. One hundred and twenty-four echocardiographic studies were analysed from 73 women with early stage HER2-positive breast cancer. Speckle tracking strain was performed offline using EchoPAC and TomTec on subcostal 4-chamber and 3-chamber views to obtain subcostal 4-chamber (SC4_LS) and 3-chamber (SC3_LS) LVLS which was then averaged (SCav_LS). Reproducibility of subcostal single chamber and averaged LVLS were assessed. Measurements between platforms were compared. Strain was reported in absolute magnitude. EchoPAC measurements of SC3_LS (20.5 ± 2.4% vs. 21.2 ± 2.5%, p = 0.002) and SCav_LS (20.9 ± 2.1% vs. 21.2 ± 2.1%, p = 0.02) were lower than TomTec measurements while SC4_LS was similar (21.3 ± 2.7% vs. 21.3 ± 2.5%, p = 0.94). Mean differences between EchoPAC and TomTec were ≤ 0.6% strain units for all subcostal LVLS measurements; SCav_LS showed the narrowest limits of agreement (LOA) (mean difference - 0.3%, LOA - 3.2 to 2.6%). EchoPAC and TomTec measurements of SCav_LS showed good correlation (r = 0.76, p < 0.001). Intra-observer and inter-observer analysis showed good reproducibility. Inter-observer variability was lower than inter-vendor variability; SCav_LS was most reproducible: inter-observer relative mean error was 3.6% for EchoPAC and 4.3% for TomTec and inter-observer LOA were ± 2.1% for EchoPAC and ± 2.6% for TomTec. Averaged subcostal LVLS was highly reproducible with inter-observer variability comparable to GLS. Inter-vendor differences in averaged subcostal LVLS were small but statistically significant.

Heart failure prevention and monitoring strategies in HER2-positive breast cancer: a narrative review.

PURPOSE: Cardiotoxicity from anti-human epidermal growth factor receptor 2 (HER2) therapy carries a short- and long-term risk of incident heart failure and increased cardiovascular mortality in patients with breast cancer. Interruptions in anti-HER2 therapy due to cardiotoxicity can lead to suboptimal cancer treatment. The purpose of this narrative review is to outline opportunities to optimize cardiovascular care in patients with HER2-positive breast cancer to prevent interruptions in therapy. METHODS: This case-based review presents the current literature on evidence-based strategies for personalized cardiotoxicity risk assessment, risk mitigation interventions, cardiac function surveillance tools, and management of asymptomatic left ventricular dysfunction in breast cancer patients receiving anti-HER2 therapy. RESULTS: Pretreatment cardiac risk assessment incorporates both treatment-related risk factors and patient-related risk factors for the development of cardiac dysfunction. Prevention and monitoring strategies while on treatment utilize risk factor modification, imaging and biomarker surveillance. Management of asymptomatic left ventricular dysfunction due to anti-HER2 therapy is evolving. Permissive cardiotoxicity in asymptomatic patients while starting cardioprotective therapies requires close collaboration between oncology and cardiology, and referral to cardio-oncology if available. CONCLUSIONS: Patient-centered, multimodal strategies to prevent, detect, and manage cardiotoxicity from anti-HER2 therapy are necessary to improve outcomes in patients with HER2-positive breast cancer.

Refocusing on the Primary Prevention of Heart Failure.

PURPOSE OF REVIEW: The burden of heart failure (HF) is a significant national and global public health problem, with prevalence rates on the rise. Given the significant morbidity, mortality, and healthcare costs attributable to HF, it is of utmost importance to utilize preventive strategies to prevent the development of HF. Therefore, we sought to address how a multi-modal risk assessment approach can be used to stratify patients for HF risk and guide implementation of therapeutic strategies to prevent HF. RECENT FINDINGS: New externally validated, multivariate prediction models for incident HF can be applied in the general population and may be used to aide clinicians in assessing individualized HF risk and screening for HF. Recent clinical trial data suggest a natriuretic peptide biomarker-based screening approach coupled with team-based cardiovascular care to focus on optimization of guideline-directed medical therapy may help prevent new-onset HF. However, widespread implementation of clinical risk scores and/or biomarkers is needed. SUMMARY: In addition to promoting a heart healthy lifestyle, prevention and management of modifiable risk factors, including intensive blood pressure lowering and use of sodium-glucose cotransporter-2 inhibitors, can prevent incident HF.

Subcostal View-Based Longitudinal Strain in Patients With Breast Cancer Is an Alternative to Conventional Apical View-Based Longitudinal Strain.

BACKGROUND: Strain imaging is a robust clinical tool in cardiac surveillance of patients with breast cancer. However, image quality and therefore ability to accurately measure strain are often limited in this patient group because of tissue expanders, implants, and/or flap reconstruction. The aim of the present study was to evaluate the feasibility of measuring left ventricular longitudinal strain (LVLS) in the echocardiographic subcostal view in female patients with breast cancer. METHODS: A total of 110 studies from 68 female patients with breast cancer were included. The feasibility of LVLS speckle-tracking measurements in the apical three-chamber (3C) and four-chamber (4C) views and in the subcostal 3C and 4C views was evaluated. The LVLS speckle-tracking measurements obtained in these two echocardiographic views were compared using intraclass correlation coefficients and Bland-Altman analyses. RESULTS: The feasibility of LVLS in the apical 3C and 4C views was 98.1% and 98.1%, respectively. In comparison, the feasibility of LVLS in the subcostal 3C and 4C views was 93.6% and 96.3%, respectively. A high degree of reliability was found between apical and subcostal LVLS 3C and 4C measurements. For the 3C view, the average measure intraclass correlation coefficient was 0.81 (95% CI, 0.72-0.88). For the 4C view, the average measure intraclass correlation coefficient was 0.80 (95% CI, 0.70-0.87). Bland-Altman analysis showed good agreement between apical and subcostal measurements in both the 3C and 4C views. CONCLUSIONS: Subcostal 3C and 4C LVLS can be reliably measured, with good agreement with conventional LVLS from the apical views, in female patients with breast cancer. Importantly, the subcostal view may provide a novel alternative for trending LVLS in patients with breast cancer who have technically limited apical windows.