Association of myocardial strain with left ventricular geometry and progression of hypertensive heart disease

Link between myocardial deformation phenotyping using longitudinal and circumferential strain and risk of incident heart failure and cardiovascular death

AIMS

Left ventricular (LV) systolic deformation is altered early in the ventricular disease process despite normal LV ejection fraction (LVEF). These alterations seem to be characterized by decreased global longitudinal strain (GLS) and augmented global circumferential strain (GCS). This study aimed to investigate the link between myocardial deformation phenotyping using longitudinal and circumferential strain and risk of incident heart failure (HF) and cardiovascular death (CD).

METHODS AND RESULTS

The study sample was based on the prospective cohort study the 5th Copenhagen City Heart Study (2011-15). All participants were examined with echocardiography following a pre-defined protocol. A total of 2874 participants were included. Mean age was 53±18 years and 60% were female. During a median follow-up of 3.5 years, a total of 73 developed HF/CD. A U-shaped relationship between GCS and HF/CD was observed. LVEF significantly modified the association between GCS and HF/CD (P for interaction <0.001). The optimal transition point for the effect modification was LVEF < 50%. In multivariable Cox regressions, increasing GCS was significantly associated with HF/CD in participants with LVEF ≥ 50% (hazard ratio [HR]=1.12 [95% confidence interval (CI): 1.02; 1.23] per 1% increase), while decreasing GCS was associated with a higher risk of HF/CD in individuals with LVEF < 50% [HR=1.18 (95% CI: 1.05; 1.31) per 1% decrease].

CONCLUSIONS

The prognostic utility of GCS is modified by LVEF. In participants with normal LVEF, higher GCS was associated with increased risk of HF/CD, while the opposite was observed in participants with abnormal LVEF. This observation adds important information to our understanding of the pathophysiological evolution of myocardial deformation in cardiac disease progression.

Minor ST-T changes on electrocardiograms are associated with reduced constructive myocardial work in hypertensive patients with a preserved ejection fraction

Minor ST-T changes on electrocardiograms are observed in patients with hypertensive heart disease with a preserved left ventricular ejection fraction (LVEF); however, the relationship between minor ST-T changes and global myocardial work on echocardiograms remains unclear. We evaluated the global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) in 186 hypertensive patients with preserved LVEF (>50%) using an offline analysis system (View Pal, GE). Minor ST-T changes as well as major ST-T changes (depression in ST in lead V5 > 1 mV) were also evaluated by electrocardiography. The mean age was 79.4 ± 8.2 years (men 37.6%). Patients with minor and major ST-changes had a smaller absolute GLS (-20.3 ± 3.1, -18.2 ± 3.7, and -15.2 ± 5.0%, P < 0.001) and a smaller constructive workload [GWI (2148 ± 486, 1938 ± 462, and 1685 ± 701 mmHg%, P = 0.002) and GCW (2419 ± 510, 2185 ± 466, and 1865 ± 702 mmHg%, P < 0.001)] than those with no ST-T changes. Additionally, patients with minor and major ST-T changes had increased wasted myocardial work [GWW (87 ± 61, 105 ± 56, and 127 ± 75 mmHg%, P = 0.045)], which resulted in reductions in the myocardial work efficiency [GWE (95 ± 4, 94 ± 3, and 89 ± 12%, P < 0.001)]. Even after adjustments for confounding factors, including EF, diastolic function parameters, LV hypertrophy, history of heart failure and atrial fibrillation, patients with minor ST-T changes had significantly smaller LV global constructive work in comparison to those without [GWI (2260 ± 33 vs. 2025 ± 76 mmHg%, P = 0.007) and GCW (2501 ± 45 vs. 2210 ± 105 mmHg%, P = 0.003)]. In conclusion, in hypertensive patients with preserved LVEF, minor ST-T changes on electrocardiograms were associated with reduced constructive work in the LV.

Left ventricular and atrial global strain evaluation within subtypes of ventricular remodeling

BACKGROUND

Left ventricular hypertrophy is associated with poor prognosis and adverse events. Left ventricular and left atrial global strain and left atrial reservoir strain (LV-GS; LA-GS; LA-RS) could be used as markers for myocardial function in different ventricular remodeling forms. This study aimed to evaluate LV-GS and LA-GS scores in different ventricular remodeling variants and identify risk factors for myocardial dysfunction.

METHODS AND RESULTS

This cross-sectional study was divided into four groups of ventricular remodeling: normal geometry, eccentric hypertrophy (EH), concentric hypertrophy (CH), and concentric remodeling (CR). Strain analysis was obtained using standardized protocols. We included 121 subjects, 33 with previous myocardial infarction (MI). We found that EH had the lowest LV-GS and CH, the lowest LA-GS, and LA-RS. Atrial and ventricular dysfunction was present in 40 (33%) and 14 (11.5%) subjects, respectively. Smoking, male sex, and previous MI were associated with LV dysfunction and smoking and dyslipidemia with LA dysfunction; EH was closely associated with LV dysfunction and CH with LA dysfunction.

CONCLUSIONS

We conclude that different ventricular geometry types had echocardiographic profiles associated with different risk factors for dysfunction assessed by strain. The assessment of ventricular remodeling by global strain could be used as a complementary tool in the echocardiographic evaluation of ventricular and atrial function.

Factors associated with global longitudinal strain decline in hypertensive patients with normal left ventricular ejection fraction

Background

Early detection of risk factors for left ventricular (LV) dysfunction may be useful in patients with high blood pressure (HBP).

Methods

Patient from an outpatient HBP clinic underwent a two-dimensional Doppler-coupled echocardiography with determination of LV global longitudinal strain (GLS) by speckle-tracking.

Results

Among 200 patients (mean age 61.7 ± 9.7 years), 155 were overweight, 93 had diabetes, 83 had dyslipidemia, and 109 had uncontrolled HBP. LV hypertrophy (LVH) was found in 136 patients (68%), including concentric (n = 106) and eccentric (n = 30) LVH. Diastolic dysfunction patterns were observed in 178 patients (89%), and increased filling pressures were observed in 37 patients (18.5%). GLS ranged from –25% to –11.6% (mean –16.9 ± 3.2%). Low GLS values (&gt;–17%) were found in 91 patients (45.5%), 68 with and 23 without LVH. In univariate analysis, a reduced GLS was associated with HBP lasting for &gt;10 years (odds ratio (OR) = 3.51, 95% confidence interval (CI) 1.73–7.09; p = 0.002), uncontrolled HBP (OR = 3.55, 95% CI 1.96–6.43; p &lt; 0.0001), overweight (OR = 2.01, 95% CI 0.93–4.31; p = 0.0028), diabetes (OR = 2.21, 95% CI 1.25–3.90; p = 0.006), dyslipidemia (OR = 2.16, 95% CI 1.22–3.84; p = 0.008), renal failure (OR = 4.27, 95% CI 1.80–10.10; p = 0.001), an increased Cornell index (OR = 3.70, 95% CI 1.98–6.90; p &lt; 0.0001), concentric LVH (OR = 9.26, 95% CI 2.62–32.73; p = 0.001), remodeling (OR = 8.51, 95% CI 2.18–33.23; p = 0.002), and filling pressures (OR = 7.1, 95% CI 2.9–17.3; p &lt; 0.0001). In multivariable analysis, duration of HBP (p = 0.038), uncontrolled BP (p = 0.006), diabetes (p = 0.023), LVH (p = 0.001), and increased filling pressures (p = 0.003) remained associated with GLS decline.

Conclusion

Early impairment of LV function, detected by a reduced GLS, is associated with long-lasting, uncontrolled HBP, overweight, related metabolic changes, and is more pronounced in patients with LVH.

Global Longitudinal Strain Analysis Using Cardiac MRI in Aortic Stenosis: Comparison with Left Ventricular Remodeling, Myocardial Fibrosis, and 2-year Clinical Outcomes

Purpose

To use global longitudinal strain (GLS) as a marker of left ventricular decompensation in aortic stenosis and to investigate the relationship of GLS measured with cardiac MRI with markers of myocardial fibrosis, symptom development, remodeling, and clinical outcomes.

Materials and Methods

Patients with aortic stenosis and healthy control subjects were assessed. GLS was assessed by using cardiac MRI feature tracking, diffuse fibrosis by T1 mapping, and replacement fibrosis using late gadolinium enhancement. Follow-up was prospective for the primary endpoint of all-cause mortality.

Results

GLS was reduced in aortic stenosis (n = 159) compared with control subjects (n = 41) (-17.6% ± 3.1 [standard deviation] vs -18.9% ± 2.6, P = .02). GLS demonstrated weak associations with aortic stenosis severity (V_max; r = 0.24, P = .0005) but showed moderate correlation with T1 mapping measures of myocardial fibrosis (eg, indexed extracellular volume [iECV]; r = 0.43, P < .0001). Moreover, GLS was reduced in patients with midwall fibrosis compared with control subjects (P < .001), although values were similar to those of patients with myocardial infarction (P = .25). In adjusted analyses, GLS was associated with total myocardial fibrosis burden (iECV) and ejection fraction (both P < .001). GLS offered poor discrimination between disease states, inability to distinguish between control subjects and patients (area under the curve [AUC], 0.60), presence or absence of fibrosis (AUC, 0.63), or symptomatic severity (left ventricular decompensation AUC, 0.64). At follow-up (median, 1466 days), 21 patients died. GLS did not independently predict clinical outcomes.

Conclusion

GLS correlates with established markers of myocardial fibrosis. However, widespread utility of single GLS measurements may be limited by overlap between disease states and its inability to predict clinical outcomes beyond current established markers.© RSNA, 2019Supplemental material is available for this article.

Utility of speckle tracking echocardiography imaging in patients with asymptomatic and symptomatic arrhythmogenic right ventricular cardiomyopathy

BACKGROUND

Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by the progressive replacement of ventricular myocytes with variable amounts of fibrous and adipose tissue. Several studies have suggested that speckle tracking echocardiographic (STE) parameters such as strain (S) and strain rate (SR) may prove useful in the early detection of right ventricular (RV) dysfunction. Therefore, the aim of this study was to evaluate RV myocardial function using the STE method in both asymptomatic and symptomatic patients with ARVD and to assess its potential role in the differential diagnosis of these two presentations.

METHODS

We recruited 34 patients with ARVD. Seventeen patients were symptomatic, and seventeen were asymptomatic.

RESULTS

The RV free wall global longitudinal S and SR were significantly lower in symptomatic patients with ARVD than in asymptomatic patients. According to a cutoff value of 1.35 per seconds for RV global SR, the sensitivity and specificity for predicting ARVD were 88% and 77%, respectively. According to a cutoff value of 17.3% for RV S, the sensitivity and specificity for predicting ARVD were 82% and 77%, respectively.

CONCLUSION

In conclusion, we present strong evidence that STE-derived global S and SR in the RV free wall are decreased in symptomatic patients with ARVD compared with asymptomatic patients.

Alterations in regional myocardial deformation assessed by strain imaging in cardiac amyloidosis

BACKGROUND

Cardiac amyloidosis results in increased left ventricular (LV) wall thickness and diastolic dysfunction (DD). Strain measurements using velocity vector imaging (VVI) may further characterize myocardial dysfunction.

METHODS

A total of 43 AL amyloidosis patients were compared to age-matched normals and hypertensive patients (HT). Subgroup analysis within the amyloid group was performed based on LV wall thickness (≤14 mm, >14 mm) and diastolic dysfunction (DD) (Group 1: normal and impaired relaxation, Group 2: pseudonormal, Group 3: restrictive). LV strain (longitudinal, circumferential, and radial strain (S) and strain rate [Sr]) were measured using velocity vector imaging (VVI).

RESULTS

Increased LV wall thickness and DD were observed in the amyloid group. Global longitudinal (-13.9±4.1% vs -16.7±3.8%; P=.002) and radial (27.4±13.4% vs 38.8±15.7%; P<.001) strain were lower in the amyloid group vs normal controls, while circumferential strain was similar. Segmental analysis demonstrated reduced mid- and basal segmental strain with relative sparing of apical segments in the amyloid group. Reduced longitudinal and radial strain, with preserved circumferential strain, were observed in patients with wall thickness >14 mm; however, circumferential strain was also altered when severe DD (restrictive filling) was present.

CONCLUSION

Reduction in longitudinal and radial S and Sr was evident using VVI strain analysis in amyloidosis, with segmental heterogeneity in longitudinal S. There was relative preservation of circumferential strain, which was reduced only in patients with severe DD.

Important advances in technology: echocardiography

Echocardiography has evolved over the past 45 years from a simple M-mode tracing to an array of technologies that include two-dimensional imaging, pulsed and continuous wave spectral Doppler, color flow and tissue Doppler, and transesophageal echocardiography. Together, these modalities provide a comprehensive anatomic and functional evaluation of cardiac chambers and valves, pericardium, and ascending and descending aorta. The switch from analog to digital signal processing revolutionized the field of ultrasound, resulting in improved image resolution, smaller instrumentation that allows bedside evaluation and diagnosis of patients, and digital image storage for more accurate quantification and comparison with previous studies. It also opened the door for new advances such as harmonic imaging, automated border detection and quantification, 3-dimensional imaging, and speckle tracking. This article offers an overview of some newer developments in echocardiography and their promising applications.

Race-ethnic differences in subclinical left ventricular systolic dysfunction by global longitudinal strain: A community-based cohort study

BACKGROUND

Race-ethnic differences exist in the epidemiology of heart failure, with blacks experiencing higher incidence and worse prognosis. Left ventricular (LV) systolic dysfunction (LVSD) detected by speckle-tracking global longitudinal strain (GLS) is a predictor of cardiovascular events including heart failure. It is not known whether race-ethnic differences in GLS-LVSD exist in subjects without overt LV dysfunction.

METHODS

Participants from a triethnic community-based study underwent 2-dimensional echocardiography with assessment of LV ejection fraction (LVEF) and GLS by speckle-tracking. Participants with LVEF <50% were excluded. Left ventricular systolic dysfunction by GLS was defined as GLS >95% percentile in a healthy sample (-14.7%).

RESULTS

Of the 678 study participants (mean age 71 ± 9 years, 61% women), 114 were blacks; 464, Hispanics; and 100, whites. Global longitudinal strain was significantly lower in blacks (-16.5% ± 3.5%) than in whites (-17.5% ± 3.0%) and Hispanics (-17.3% ± 2.9%) in both univariate (P = .015) and multivariate analyses (P = .011), whereas LVEF was not significantly different between the 3 groups (64.3% ± 4.6%, 63.4% ± 4.9%, 64.7% ± 4.9%, respectively, univariate P = .064, multivariate P = .291). Left ventricular systolic dysfunction by GLS was more frequent in blacks (27.2%) than in whites (19.0%) and Hispanics (14.9%, P = .008). In multivariate analysis adjusted for confounders and cardiovascular risk factors, blacks were significantly more likely to have GLS-LVSD (adjusted odds ratio 2.6, 95% CIs 1.4-4.7, P = .002) compared to the other groups.

CONCLUSIONS

Among participants from a triethnic community cohort, black race was associated with greater degree of subclinical LVSD by GLS than other race-ethnic groups. This difference was independent of confounders and cardiovascular risk factors.

The effect of indapamide versus hydrochlorothiazide on ventricular and arterial function in patients with hypertension and diabetes: results of a randomized trial

OBJECTIVE

The objective of this study is to compare the effects of 2 types of diuretics, indapamide and hydrochlorothiazide, added to an angiotensin-converting enzyme inhibitor, on ventricular and arterial functions in patients with hypertension and diabetes.

METHODS

This is a prospective, randomized, active-controlled, PROBE design study in 56 patients (57 ± 9 years, 52% men) with mild-to-moderate hypertension and type 2 diabetes, with normal ejection fraction, randomized to either indapamide (1.5 mg Slow Release (SR)/day) or hydrochlorothiazide (25 mg/d), added to quinapril (10-40 mg/d). All patients had conventional, tissue Doppler and speckle tracking echocardiography and assessment of endothelial and arterial functions and biomarkers, at baseline and after 6 months.

RESULTS

Baseline characteristics were similar between groups; systolic and diastolic blood pressures decreased similarly, by 15% and 9% on indapamide and by 17% and 10% on hydrochlorothiazide (P < .05). Mean longitudinal systolic velocity and longitudinal strain increased by 7% and 14% on indapamide (from 5.6 ± 1.8 to 6.0 ± 1.1 cm/s and from 16.2% ± 1.8% to 18.5% ± 1.1%, both P < .05), but did not change on hydrochlorothiazide (P < .05 for intergroup differences), whereas ejection fraction and radial systolic function did not change. Similarly, mean longitudinal early diastolic velocity increased by 31% on indapamide (P < .05), but did not change on hydrochlorothiazide (P < .05 for intergroup differences). These changes were associated with improved endothelial and arterial functions on indapamide, but not on hydrochlorothiazide.

CONCLUSION

Indapamide was found to improve measures of endothelial and arterial functions and to increase longitudinal left ventricular function compared with hydrochlorothiazide in patients with hypertension and diabetes, after 6 months of treatment. This study suggests that indapamide, a thiazide-like diuretic, has important vascular effects that can improve ventriculoarterial coupling.

Prevalence and prognostic value of subclinical left ventricular systolic dysfunction by global longitudinal strain in a community-based cohort

AIMS

Global longitudinal strain (GLS) assessed by speckle-tracking echocardiography has been proposed as a parameter able to reflect early changes in left ventricular systolic function at a stage when left ventricular ejection fraction (LVEF) is still normal. This study aimed at assessing prevalence and prognostic value of left ventricular systolic dysfunction (LVSD) assessed by echocardiographic speckle-tracking GLS in a community-based cohort.

METHODS AND RESULTS

Participants from the community-based prospective Northern Manhattan Study underwent two-dimensional transthoracic echocardiography as part of the Cardiovascular Abnormalities and Brain Lesions study. Left ventricular systolic function was assessed by LVEF and speckle-tracking GLS. Subjects were followed annually (mean = 4.8 ± 1.5 years) and incident vascular events (ischaemic stroke, myocardial infarction, and vascular death) were reviewed and adjudicated. Of the 708 study participants, 114 (16.1%) had abnormal GLS but normal LVEF (GLS-LVSD), 30 (4.2%) had abnormal LVEF (LVEF-LVSD), and 564 (79.7%) had normal GLS and LVEF (no-LVSD). In multivariate analysis, risk of events was significantly greater in GLS-LVSD [adjusted hazard ratio (HR) = 2.39, 95% confidence interval (CI) = 1.20-4.77] and in LVEF-LVSD (adjusted HR = 3.51, 95% CI = 1.25-9.88) compared with no-LVSD. Among participants with normal LVEF, lower GLS was significantly associated with events (adjusted HR/unit decrease = 1.15, 95% CI = 1.03-1.28) whereas LVEF was not (adjusted HR/unit decrease = 1.01, 95% CI = 0.94-1.07). The GLS prognostic value was incremental to risk factors and LVEF both in the overall population (chi-square change = 7.406, P = 0.006) and in participants with normal LVEF (chi-square change = 6.357, P = 0.012).

CONCLUSION

In a community-based cohort, GLS-LVSD was four times more frequent than LVEF-LVSD. GLS-LVSD was a powerful and independent predictor of cardiovascular events. Left ventricular function assessment by GLS may improve cardiovascular risk stratification in subjects with normal LVEF.

Evaluation of left atrial function in hypertensive patients with and without left ventricular hypertrophy using velocity vector imaging

To study left atrial deformation characteristics using Velocity vector imaging (VVI) in hypertensive patients with and without left ventricular hypertrophy (LVH), and to explore its value for detection of left atrial dysfunction in these patients. Sixty-four patients with essential hypertension were divided into normal left ventricular geometry (LVN, 37 cases) and LVH (27 cases) groups, according to their left ventricular mass index. Twenty-five age-matched healthy participants were included as control group. Two-dimensional dynamic images of the apical four- and two-chamber echocardiographic views were obtained, and strain/strain rate (SR) curves of eight atrial segments were derived by VVI software. Peak systolic strain (ε(sys)), systolic SR (SRs), early and late diastolic SR (SRe, SRa) were measured and calculated. Peak early diastolic mitral inflow and annulus velocities were also measured and their ratio (E/E') calculated. Compared with the control group, SRe decreased and SRa increased significantly in LVH group (P < 0.05), while no significant difference was found between LVN and control groups with respect to SRe, SRa, SRs and ε(sys) (P > 0.05). Also, no significant difference was observed in SRe, SRa, SRs and ε(sys) between LVH and LVN groups (P > 0.05). SRe and SRa correlated significantly with E/E' (r = -0.634, r = 0.609; both P < 0.001). Strain/SR parameters derived from VVI may reflect decreased conduit, increased booster pump function of the left atrium in hypertensive patients with LVH and correlate with left ventricular diastolic function.

Longitudinal myocardial strain alteration is associated with left ventricular remodeling in asymptomatic patients with type 2 diabetes mellitus

BACKGROUND

In normal subjects, left ventricular (LV) dimensions have been shown to decrease over time, while wall thickness is increasing. The aim of this study was to investigate LV remodeling in a cohort of patients with type 2 diabetes mellitus during a 3-year follow-up period and its potential association with decreased longitudinal systolic strain (εL).

METHODS

One hundred seventy-two patients with type 2 diabetes without overt heart disease were prospectively enrolled and underwent echocardiography with speckle-tracking imaging to assess global LV εL at baseline and at 3 years. The associations between alteration in εL (defined as |εL| < 18%), LV geometry at baseline, and LV remodeling over time were evaluated.

RESULTS

Among the 172 enrolled patients, 154 completed 3-year follow-up. At baseline, patients with εL alteration had higher LV end-systolic volumes (28 ± 11 vs 23 ± 9 mL, P < .001) and relative wall thicknesses (RWT; 0.44 ± 0.06 vs 0.40 ± 0.07, P = .008) compared with those with normal εL. At 3-year follow-up, RWTs remained stable in both groups. LV volumes significantly decreased in patients with normal εL but not in patients with εL alteration. Multivariate analysis showed that εL alteration was independently associated with LV end-systolic volume (β = 5.0, P = .006) and RWT (β = 0.03, P = .03) at baseline and with changes in both LV end-diastolic volume (β = 19.1, P = .001) and LV end-systolic volume (β = 2.6, P = .047) over 3 years.

CONCLUSIONS

In patients with type 2 diabetes, εL alteration was associated with higher RWT and LV volumes and with the absence of decreases in LV volumes over time, which might be an early sign of adverse LV remodeling.

Correlation between systolic deformation and dyssynchrony indices and the grade of left ventricular hypertrophy in hypertensive patients with a preserved systolic ejection fraction undergoing coronary angiography, based on tissue Doppler imaging

OBJECTIVES

The purpose of this study was to investigate whether systolic mechanical dyssynchrony occurs in hypertensive patients with a normal coronary artery and a normal ejection fraction and its relationship with different degrees of left ventricular (LV) hypertrophy.

METHODS

A total of 125 angiographically normal coronary patients (42.4% male; mean age ± SD, 57.16 ± 8.26 years) with an ejection fraction greater than 50% were included, of which 84 were hypertensive and 41 normotensive. The hypertensive patients were categorized into 3 groups: no, mild, and moderate LV hypertrophy. Tissue Doppler and deformation imaging parameters were measured in the 6 LV basal segments at peak systole.

RESULTS

The frequency of dyssynchrony was 40.5% in the hypertensive patients compared to 19.5% in the control patients (P = .020). Among the hypertensive patients, LV dyssynchrony was found in 5 patients (20%) with no hypertrophy, 20 (42.6%) with mild hypertrophy, and 9 (75%) with moderate hypertrophy. There was a moderate correlation between the grade of hypertrophy and septal-lateral wall delay (r = 0.497), 6-basal segment delay (r = 0.454), overall strain (r = 0.453), overall peak systolic velocity (r = -0.430), and standard deviation of the time to peak systolic velocity in the basal segments (r = 0.429). After adjustment for the LV end-systolic diameter and body surface area, overall strain was the best correlate of the hypertrophy grade (odds ratio, 7.043; 95% confidence interval, 1.839-26.980; P = .0044).

CONCLUSIONS

Among tissue Doppler and deformation indices, overall peak systolic strain was the strongest correlate of the LV hypertrophy grade. Therefore, in hypertensive patients with normal cardiac systolic function, a reduction in overall strain in the 6 basal LV segments may be a good indicator of progression of the LV hypertrophy grade and systolic dysfunction.

Relationship of multidirectional myocardial strain with radial thickening and ejection fraction and impact of left ventricular hypertrophy: a study in a community-based cohort

BACKGROUND

Left ventricular (LV) systolic strain provides additional prognostic value to LV ejection fraction (LVEF) and wall motion analysis. However, the relationship between myocardial multidirectional strain and LVEF, and the effect of LV hypertrophy on this relationship, are not completely understood especially in unselected populations.

METHODS

LV global longitudinal (εL ) and circumferential (εC ) systolic strain analysis was performed by two-dimensional speckle tracking echocardiography in 215 participants from a community-based study. LV radial wall thickening was measured as global radial strain (εR ), and LVEF was assessed by biplane Simpson's method.

RESULTS

εR was significantly associated with εC (β = -0.56, P < 0.01) and with εL (β = -0.18, P < 0.01). The contribution of εL to εR was especially evident in subjects with lower εC and in presence of LV hypertrophy (β = -0.30, P < 0.01). εL and εC were significantly associated with LVEF (β = -0.36 and β = -0.49, both P < 0.01) independent of LV mass and other confounders, and their interaction significantly improved the prediction of LVEF (R(2) -change = 0.14) but not of εR (R(2) -change = 0.002).

CONCLUSIONS

εR is mainly related to εC with a smaller contribution of εL , which becomes especially evident in subjects with lower εC and in presence of LV hypertrophy. Therefore, radial thickening may not detect subclinical LV longitudinal function reduction in normal ventricles and when εC is preserved. While a reduction in εL has a limited impact on εR , it exerts a greater effect on global LVEF, therefore for a more accurate LVEF prediction both εL and εC need to be considered.

Evaluation of right and left ventricular function using speckle tracking echocardiography in patients with arrhythmogenic right ventricular cardiomyopathy and their first degree relatives

Introduction and aim

The identification of right ventricular abnormalities in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) in early stages is still difficult. The aim of this study was to investigate if longitudinal strain based on speckle tracking can detect subtle right (RV) or left ventricular (LV) dysfunction as an early sign of ARVC.

Methods and results

Seventeen male patients, fulfilling Task force criteria for ARVC, 49 (32–70) years old, nineteen male first degree relatives 29 (19–73) y.o. and twenty-two healthy male volunteers 36 (24–66) y.o participated in the study. Twelve-lead and signal-averaged electrocardiograms were recorded. All subjects underwent echocardiography. LV and RV diameters, peak systolic velocity from tissue Doppler and longitudinal strain based on speckle tracking were measured from the basal and mid segments in both ventricles. RV longitudinal strain measurement was successful in first degree relatives and controls (95 resp. 86%) but less feasible in patients (59%). Results were not systematically different between first degree relatives and controls. Using discriminant analysis, we then developed an index based on echocardiographic parameters. All normal controls had an index < l while patients with abnormal ventricles had an index between 1–4. Some of the first degree relatives deviated from the normal pattern.

Conclusion

Longitudinal strain of LV and RV segments was significantly lower in patients than in relatives and controls. An index was developed incorporating dimensional and functional echocardiographic parameters. In combination with genetic testing this index might help to detect early phenotype expression in mutation carriers.

Reversal of subclinical left ventricular dysfunction by antihypertensive treatment: a prospective trial of nebivolol against metoprolol

OBJECTIVES

To assess the effects of antihypertensive treatment on subclinical left ventricular dysfunction and to compare the effects of nebivolol with metoprolol.

METHODS

This is a prospective, randomized, parallel, active-controlled, PROBE design study (ClinicalTrials.org: NCT00942487) in 60 patients (53±9 years, 67% men) with arterial hypertension, left ventricular hypertrophy, normal ejection fraction, and no coronary heart disease, randomized to either a nebivolol-based or a metoprolol-based treatment, who had conventional and tissue Doppler echocardiography, at rest and during dobutamine stress, at baseline and after 6 months.

RESULTS

SBP and DBP, and resting heart rate decreased by 13, 13, and 12%, respectively, on nebivolol, and by 11, 13, and 7%, respectively, on metoprolol (all, P<0.01). Mean longitudinal early diastolic velocity increased by 16% (P<0.05) on nebivolol compared with 9% (P=not significant) on metoprolol (P=not significant for intergroup differences), whereas flow propagation velocity increased by 34% on nebivolol (P<0.05) and did not change on metoprolol (P<0.01 for intergroup differences). Mean longitudinal displacement increased by 10% on nebivolol (P<0.05) and did not change on metoprolol (P<0.05 for intergroup differences), whereas ejection time increased by 5% on nebivolol (P<0.05) and did not change on metoprolol. All the other parameters of left ventricular function were not different between the two treatment arms.

CONCLUSION

Patients with mild-to-moderate hypertension have a beneficial effect from 6-month antihypertensive treatment on diastolic longitudinal left ventricular function; effects are significant with nebivolol, but not with metoprolol.

Relation of left ventricular twist and global strain with right ventricular dysfunction in patients after operative "correction" of tetralogy of fallot

In patients with corrected tetralogy of Fallot (cToF), left ventricular (LV) dysfunction is closely related to right ventricular (RV) dysfunction, indicating adverse ventricular-ventricular interactions. However, the mechanism that links RV dysfunction to LV dysfunction remains unclear. In this prospective study, 32 patients with cToF and 19 controls were enrolled. With cardiac magnetic resonance imaging, biventricular ejection fractions were assessed. Using 2-dimensional speckle tracking, global and regional RV and LV strains and LV twist were assessed. To detect and characterize ventricular-ventricular interaction, the relation between global and regional RV mechanics and global and regional LV mechanics was assessed. Global RV strain, global LV strain, and LV twist were decreased in patients with cToF. Global RV strain correlated with global LV strain (r = 0.66, p <0.001) and LV twist (r = -0.72, p <0.001), indicating the presence of adverse ventricular-ventricular interaction. Furthermore, close relations were observed between apical RV strain and apical LV strain (r = 0.62, p <0.001) and apical LV rotation (r = -0.67, p <0.001). In conclusion, RV strain was significantly related to LV strain and LV twist in patients with cToF and controls. Furthermore, apical RV strain correlated with apical LV strain and apical LV rotation, indicating adverse apical ventricular-ventricular interactions.

Relationship between left ventricular hypertrophy, hypertensive retinopathy, microalbuminuria and echocardiographic modalities in newly diagnosed hypertensive patients

Longitudinal myocardial function (LMF) may be impaired while systolic function is still normal. We investigated relationship between LMF and hypertensive organ damage in newly diagnosed stage I hypertensive patients. A total of 57 patient with never treated stage I hypertension and 48 matched healthy control subject were enrolled in the study. Conventional 2-D, Doppler and tissue wave Doppler imaging (TDI) echocardiography were used. LMF was evaluated by the septal and lateral strain (S) and strain rate (SR) measurements. Hypertensive complications were evaluated by the urine microalbumin levels and retinal examination. A multivariate regression analysis was perfomed to assess the relation between the variables. Ejection fraction, mid-wall fractional shortenning, systolic movement rates (TDs) in TDI were similar both in hypertensive and control groups. In patients with left ventricular hypertrophy, septal TDs (7.29 +/- 1.28 vs. 8.06 +/- 1.19 cm, P = 0.03), lateral TDs (8.46 +/- 1.83 vs. 9.87 +/- 2.42 cm, P = 0.01) and lateral S (-13.02 +/- 7.83 vs. -18.86 +/- 8.60%, P = 0.01) values were significantly lower. Septal S (-13.67 +/- 3.52 vs. -19.09 +/- 5.96%, P < 0.01) and SR (-0.83 +/- 0.29 vs. -1.22 +/- 0.28 1/S, P < 0.01) were significantly decreased in hypertensive patients with microalbuminuria. Septal S value was also significantly decreased in patients with retinopathy (-14.76 +/- 5.55 vs. -20.20 +/- 5.44%, P = 0.01). Multivariate analysis showed that only septal and lateral S values were independent factors for the retinopathy and left ventricular hypertrophy, respectively. In hypertensive patients, LMF established by the measurement of S and SR, might be impaired and also related with end organ damage while global circumferential function is preserved.

Advances in echocardiography

PURPOSE OF REVIEW

This study will outline recent advances in echocardiography and their impact in the understanding of cardiac morphology and ventricular function.

RECENT FINDINGS

Evaluation of morphologic abnormalities in pediatric cardiology has benefited greatly from three-dimensional echocardiography, particularly with the introduction of high-frequency transducers. The size of cardiovascular structures is frequently affected by heart disease, and a systematic approach to adjust measurements for the effects of body size and age has helped to distinguish a normal structure from an abnormal one. Quantification of diastolic and systolic function continues to be a major focus in echocardiography. New modalities such as tissue Doppler imaging and speckle tracking echocardiography have provided new parameters to assess myocardial performance, and these parameters include myocardial velocities, ventricular twist and torsion, strain and strain rate, and mechanical dyssynchrony. Mechanical dyssynchrony analysis has been particularly useful in cardiac resynchronization therapy, a novel treatment for heart failure which shows great promise.

SUMMARY

Improved delineation of cardiac morphology has greatly augmented the current understanding of congenital heart diseases, and management strategies have been modified based on three-dimensional echocardiographic findings. The introduction of new parameters to evaluate ventricular function has provided early markers for cardiovascular impairment in several disease states, thereby allowing clinicians to monitor these patients more closely.

Hypertension and myocardial ischemia

Detailed studies over the past 30 years have built up an impressive evidence base for the presence of myocardial ischemia in patients who have hypertension. This relationship ranges from the obvious association with obstructive coronary artery disease to mechanisms related to hemodynamic, microcirculatory, and neuroendocrine abnormalities. All of these factors serve to destabilize the critical balance between myocardial oxygen supply and demand. We have at our disposal a range of sophisticated investigations that allow us to demonstrate the presence and extent of the ischemia and therefore to target specific therapies to reduce the risk to these patients. Achieving target BP and managing all reversible components of the patient's cardiovascular risk status reduce to a minimum the clinical sequelae of myocardial ischemia in this vulnerable population..

Strain and strain rate imaging by echocardiography - basic concepts and clinical applicability

Echocardiographic strain and strain-rate imaging (deformation imaging) is a new non-invasive method for assessment of myocardial function. Due to its ability to differentiate between active and passive movement of myocardial segments, to quantify intraventricular dyssynchrony and to evaluate components of myocardial function, such as longitudinal myocardial shortening, that are not visually assessable, it allows comprehensive assessment of myocardial function and the spectrum of potential clinical applications is very wide. The high sensitivity of both tissue Doppler imaging (TDI) derived and two dimensional (2D) speckle tracking derived myocardial deformation (strain and strain rate) data for the early detection of myocardial dysfunction recommend these new non-invasive diagnostic methods for extensive clinical use. In addition to early detection and quantification of myocardial dysfunction of different etiologies, assessment of myocardial viability, detection of acute allograft rejection and early detection of allograft vasculopathy after heart transplantation, strain and strain rate data are helpful for therapeutic decisions and also useful for follow-up evaluations of therapeutic results in cardiology and cardiac surgery. Strain and strain rate data also provide valuable prognostic information, especially prediction of future reverse remodelling after left ventricular restoration surgery or after cardiac resynchronization therapy and prediction of short and median-term outcome without transplantation or ventricular assist device implantation of patients referred for heart transplantation.The Review explains the fundamental concepts of deformation imaging, describes in a comparative manner the two major deformation imaging methods (TDI-derived and speckle tracking 2D-strain derived) and discusses the clinical applicability of these new echocardiographic tools, which recently have become a subject of great interest for clinicians.