Incremental Value of Global Longitudinal Strain in the Long-Term Prediction of Heart Failure among Patients with Coronary Artery Disease

Global longitudinal strain in long-term risk prediction after acute coronary syndrome: an investigation of added prognostic value to ejection fraction

AIMS

This study aimed to investigate the additional value of global longitudinal strain (GLS) on top of left ventricular ejection fraction (LVEF) in long-term risk prediction of combined death and heart failure (HF) re-hospitalization after acute coronary syndrome (ACS).

METHOD AND RESULTS

This retrospective study included patients admitted with ACS between 2008 and 2014 from the three participating university hospitals. LVEF and GLS were assessed at a core lab from images acquired during the index hospital stay. Their prognostic value was studied with the Cox proportional hazards model (median follow-up 6.2 years). A nested model comparison was performed with C-statistics. A total of 941 patients qualified for multivariable analysis after multiple imputation of missing baseline covariables. The combined outcome was reached in 17.7% of the cases. Both GLS and LVEF were independent predictors of the combined outcome, hazard ratio (HR) 1.068 (95% CI 1.017-1.121) and HR 0.980 (95% CI 0.962-0.998), respectively. The C-statistic increased from 0.742 (95% CI 0.702-0.783) to 0.749 (95% CI 0.709-0.789) (P = 0.693) when GLS entered the model with clinical data and LVEF.

CONCLUSION

GLS emerged as an independent long-term risk predictor of all-cause death and HF re-hospitalization. However, there was no significant incremental predictive value of GLS when LVEF was already known.

Scoping review of the use of multimorbidity variables in cardiovascular disease risk prediction

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality globally. Many countries use pooled cohort equations or similar risk prediction models to assess atherosclerotic CVD risk to guide preventive measures. There is evidence that clinical CVD risk prediction equations are less accurate for adults with higher levels of multimorbidity (the co-occurrence of multiple long-term conditions). Operating within a single disease paradigm may not be appropriate for adults with multimorbidity who may be at higher risk of both CVD and non-CVD death. This scoping review was conducted to gather evidence on the inclusion of multimorbidity measures in CVD risk models to assess their methodology and identify evidence gaps in the literature.

METHODS

The review covers literature from 1 January 2012 to 23 September 2022, using the Arksey and O'Malley framework. We searched MEDLINE, Embase, and Cochrane databases published during this period and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting guidelines.

RESULTS

This review identified fourteen studies reporting multivariable prognostic CVD models that included a multimorbidity variable. Of these, four studies specifically looked at the added benefit of a multimorbidity variable in a CVD risk model. Only one of these studies was conducted in a primary prevention cohort (i.e., people were free of CVD at baseline). This scoping review revealed several primary evidence gaps, notably the limited literature on the topic, the model performance in ethnic subpopulations, and the comparative assessment of alternative multimorbidity variables beyond the Charlson Comorbidity Index.

CONCLUSIONS

Few studies have assessed the impact of incorporating multimorbidity indices in primary and secondary prevention cohorts. Future research is needed to evaluate the incremental value of multimorbidity indices in cardiovascular disease risk prediction models to inform risk stratification and management strategies in people with multimorbidity.

A Real-Time Computer-Aided Diagnosis System for Coronary Heart Disease Prediction Using Clinical Information

Background

It is important to establish a coronary heart disease (CHD) prediction model with high efficiency and precision for early diagnosis of CHD using clinical information. While existing deep learning-based CHD prediction models possess the limitations of large datasets and long training time, existing machine learning-based CHD prediction models have the limitations of low accuracy and robustness, which are unsuitable for clinical application. This study aimed to design a fast and high-precision intelligent model using clinical information to predict CHD.

Methods

Five public datasets, including 303, 293, 303, 200, and 123 patients with 55, 14, 14, 14, and 14 attributes, respectively, were used for model training and testing. After data preprocessing, the singular value decomposition method was utilized to extract features to build the CHD prediction model. Then, the CHD prediction model was established using the 5-fold cross-validation method with a multilayer perceptron approach.

Results

Results show that the established model performs better on the total dataset than the other models we built in this study. This machine learning-based CHD prediction model achieved an improved area under the curve (AUC) of 99.10%, with 96.63% accuracy, 96.50% precision, 97.4% recall, and 97.0% F 1-score on the total dataset.

Conclusions

This high precision and efficiency achieved by the proposed model on different datasets would be significant for the prediction of CHD for medical and clinical diagnosis purposes.

Global longitudinal strain as an early marker of cardiac damage after cardiotoxic medications, a state-of-the-art review

Ejection fraction (EF) is the principal parameter used clinically to assess cardiac function and provides prognostic information. However, significant myocardial damage can be present despite preserved EF. Recently, the measurement of left ventricle (LV) deformation by global longitudinal strain (GLS) has been introduced as a novel early marker of cardiac dysfunction. Cardiotoxicity is a frequent side effect of several drugs most notably those used in the treatment of cancer. Although oncology drugs remain the best known cardiotoxic medications, many other drugs can potentially affect LV function. The early recognition of LV dysfunction due to cardiotoxicity is important and of increasing clinical relevance particularly with the rapid pace of development of new drugs. The aim of our review is to provide an overview of the current literature regarding utility of GLS to assess drug-induced myocardial damage. We propose that GLS is a sensitive early marker of myocardial dysfunction associated with the use of certain medications with high risk of cardiotoxicity. Thus, the use of this technique can potentially alert the clinician to myocardial toxicity before reductions in EF are seen.

Left ventricular global longitudinal strain using a novel fully automated method: A head-to-head comparison with a manual layer-specific strain and establishment of normal reference ranges

BACKGROUND

A novel automated method for measuring left ventricular (LV) global longitudinal strain (GLS) along the endocardium has advantages in terms of its rapid application and excellent reproducibility. However, it remains unclear whether the available normal range for conventional GLS using the manual method is applicable to the automated GLS method. This study aimed to compare automated GLS head-to-head with manual layer-specific GLS, and to identify whether a specialized normal reference range for automated GLS is needed and explore the main determinants.

METHODS

In total, 1683 healthy volunteers (men, 43%; age, 18-80 years) were prospectively enrolled from 55 collaborating laboratories. LV GLS was measured using both manual layer-specific and automated methods.

RESULTS

Automated GLS was higher than endocardial, mid-myocardial, and epicardial GLS. Women had a higher automated GLS than men. GLS had no significant age dependency in men, but first increased and then decreased with age in women. Accordingly, sex- and age-specific normal ranges for automated GLS were proposed. Moreover, GLS appeared to have different burdens in relation to dominant determinants between the sexes. GLS in men showed no dominant determinants; however, GLS in women correlated with age, body mass index, and heart rate.

CONCLUSIONS

Using the novel automated method, was LV GLS higher than when using the manual GLS method. The normal ranges of automated GLS stratified according to sex and age were provided, with dominant determinants showing sex disparities that require full consideration in clinical practice.

Relationship between serum soluble suppression of tumorigenicity (ST) 2 and global longitudinal strain in early onset preeclampsia

BACKGROUND

Preeclampsia is one of the leading causes of death in childbearing women worldwide. Hemodynamic changes in preeclampsia can trigger cardiac remodeling as indicated by increase of soluble-ST2 (sST2). Global longitudinal strain were able to detect systolic dysfunction better than the ejection fraction. This study aims to evaluate the correlation between serum levels of sST2 towards GLS in patients with early-onset preeclampsia.

METHODS

This is a cross-sectional observational study with correlation analysis. Subjects were patients with severe preeclampsia with gestational age before 34 weeks at Dr. Hasan Sadikin Central General Hospital Bandung and Bandung Kiwari Regional General Hospital from June to August 2022. Examination of sST2 was carried out through blood samples using the ELISA method. sST2 was measured using Presage ST2 Assay reagent. GLS examination was carried out using speckle tracking technique with EchoPAC. Correlation analysis was conducted using the Pearson test if normally distributed, otherwise Spearman's correlation was conducted. Correlation analysis was followed by linear regression.

RESULTS

A total of 30 patients met the inclusion criteria. The mean age was 30.83 ± 7.09, with 17 (56.7%) multiparous patients. The median sST2 was 145.75 ng/mL, and the median GLS was - 17.4%. Spearman correlation analysis showed that there was a significant positive correlation with moderate strength between sST2 and GLS (r = 0.583; p < 0.002). Linear regression showed that every 1 ng/ml increase in sST2 would give an increase in GLS of 0.014%.

CONCLUSION

There is a significant correlation between sST2 and GLS in patients with early onset severe preeclampsia.

Incremental prognostic utility of left ventricular and left atrial strains in coronary artery disease patients with reduced systolic function

OBJECTIVE

This study aimed to investigate the predictive value of left ventricular global longitudinal strain (GLS) and left atrial reservoir strain (LARS) on adverse events in chronic coronary artery disease (CAD) patients with reduced systolic function.

METHODS

A total of 192 consecutive patients clinically diagnosed with chronic CAD and left ventricular ejection fraction (LVEF) ≤ 50% were finally included. Multiple strain parameters were analyzed with speckle tracking echocardiography. The composite endpoint included all-cause mortality, rehospitalization due to heart failure, myocardial infarction, and stroke.

RESULTS

Patients experiencing the endpoint showed lower LVEF, lower absolute GLS and LARS than those without events. Both GLS (AUC = 0.82 [GLS] vs. 0.58 [LVEF], p < 0.001) and LARS (AUC = 0.71 [LARS] vs. 0.58 [LVEF], p = 0.033) were superior to LVEF in predicting adverse events. Multivariate cox regression analysis showed that both GLS (hazard ratio, 0.71; 95% CI, 0.63-0.79; p < 0.001) and LARS (hazard ratio, 0.96; 95% CI, 0.93-0.98; p < 0.001) were independent predictors for the endpoint. The addition of LARS (global chi-squared, 35.7 vs. 17.4; p < 0.05), GLS (global chi-squared, 58.6 vs. 17.4; p < 0.05) or both LARS and GLS (global chi-squared, 79.6 vs. 17.4; p < 0.05) to LVEF in the prediction model significantly improved its performance. The same significant improvement was also shown in the subgroups of mild (30% < LVEF ≤ 50%) and severe (LVEF ≤ 30%) reduced systolic function.

CONCLUSIONS

Regarding CAD patients with reduced LVEF, both GLS and LARS are superior to LVEF in predicting adverse events, providing significant incremental value to LVEF.

Strain Assessment in Aortic Stenosis: Pathophysiology and Clinical Utility

Contemporary echocardiographic criteria for grading aortic stenosis severity have remained relatively unchanged, despite significant advances in noninvasive imaging techniques over the last 2 decades. More recently, attention has shifted to the ventricular response to aortic stenosis and how this might be quantified. Global longitudinal strain, semiautomatically calculated from standard two-dimensional echocardiographic images, has been the focus of extensive research. Global longitudinal strain is a sensitive marker of subtle hypertrophy-related impairment in left ventricular function and has shown promise as a relatively robust prognostic marker, both independently and when added to severity classification systems. Herein we review the pathophysiological basis underpinning the potential utility of global longitudinal strain in the assessment of aortic stenosis, as well as its potential role in quantifying myocardial recovery and prognostic discrimination following aortic valve replacement.

Impact of enzyme replacement therapy and migalastat on left atrial strain and cardiomyopathy in patients with Fabry disease

Aims

Cardiomyopathy in Fabry disease (FD) is a major determinant of morbidity and mortality. This study investigates the effects of FD-specific treatment using enzyme replacement therapy (ERT) and chaperone therapy on left atrial (LA) function using two-dimensional speckle tracking echocardiography (2DSTE).

Methods and results

In this prospective observational single-center study, 20 FD patients [10 (50%) females] treated with migalastat, 48 FD patients [24 (50%) females] treated with ERT (agalsidase-alfa and agalsidase-beta), and 30 untreated FD patients (all females) as controls were analyzed. The mean follow-up time ranged from 26 to 81 months. 2DSTE was performed for left ventricle strain, right ventricle strain, and LA strain (LAS). FD-specific treated patients presented with increased left ventricular mass index (LVMi) and higher frequency of left ventricular hypertrophy at baseline, whereas untreated control patients showed normal baseline values. FD-specific treated (including migalastat and ERT) patients showed stabilization of LAS over time (p > 0.05). LVMi was also stable in treated FD patients during observation (p > 0.05).

Conclusion

In patients with FD, treated with either ERT or chaperone therapy, LAS values measured by echocardiographic speckle tracking were stable over time, pointing toward disease stabilization.

Quantifying left ventricular myocardial strain in patients with different CAD-RADS levels based on computed tomography feature tracking technology

To evaluate myocardial strain in patients with different coronary artery disease-reporting and data system (CAD-RADS) levels using the computed tomography (CT) feature tracking technology and to investigate the relationship of myocardial strain with coronary artery calcium scores (CACs) and the degree of coronary artery stenosis. We prospectively enrolled 237 consecutive patients to undergo coronary CT angiography. The participants were divided into the following groups: control (n = 87), CAD-RADS 1 (n = 43), CAD-RADS 2 (n = 43), CAD-RADS 3 (n = 38), and CAD-RADS 4 and above (n = 26). Myocardial strains were analyzed by commercial software, and CACs and coronary stenosis were assessed on post-processing stations. Differences between multiple groups were analyzed using one-way analysis of variance or the Kruskal-Wallis test. Logistic regression were used to analyze the effects of dichotomous variables. As the CAD-RADS level increased, the global circumferential strain (GCS), global longitudinal strain (GLS) and global radial strain (GRS) of the left ventricle based on CT gradually decreased. A significant correlation was observed between global myocardial strain and CACs (GRS: r =  - 0.219, GCS: r = 0.189, GLS: r = 0.491; P < 0.05). The independent predictors of obstructive CAD were age (β = 0.065, odds ratio [OR] = 1.067, P = 0.005), left ventricular ejection fraction (β = 0.145, OR = 1.156, P = 0.047), and GLS (β = 0.232, OR = 1.261, P = 0.01). CT-derived GLS of the left ventricle is correlated with CAD-RADS levels and CACs. It may be a better indicator than CACs to reflect the severity of CAD.

Prognostic value of temporal patterns of global longitudinal strain in patients with chronic heart failure

Background

We investigated whether repeatedly measured global longitudinal strain (GLS) has incremental prognostic value over repeatedly measured left ventricular ejection fraction (LVEF) and N-terminal pro B-type natriuretic peptide (NT-proBNP), and a single "baseline" GLS value, in chronic heart failure (HF) patients.

Methods

In this prospective observational study, echocardiography was performed in 173 clinically stable chronic HF patients every six months during follow up. During a median follow-up of 2.7 years, a median of 3 (25th-75th percentile:2-4) echocardiograms were obtained per patient. The endpoint was a composite of HF hospitalization, left ventricular assist device, heart transplantation, cardiovascular death. We compared hazard ratios (HRs) for the endpoint from Cox models (used to analyze the first available GLS measurements) with HRs from joint models (which links repeated measurements to the time-to-event data).

Results

Mean age was 58 ± 11 years, 76% were men, 81% were in New York Heart Association functional class I/II, and all had LVEF < 50% (mean ± SD: 27 ± 9%). The endpoint was reached by 53 patients. GLS was persistently decreased over time in patients with the endpoint. However, temporal GLS trajectories did not further diverge in patients with versus without the endpoint and remained stable during follow-up. Both single measurements and temporal trajectories of GLS were significantly associated with the endpoint [HR per SD change (95%CI): 2.15(1.34-3.46), 3.54 (2.01-6.20)]. In a multivariable model, repeatedly measured GLS maintained its prognostic value while repeatedly measured LVEF did not [HR per SD change (95%CI): GLS:4.38 (1.49-14.70), LVEF:1.14 (0.41-3.23)]. The association disappeared when correcting for repeatedly measured NT-proBNP.

Conclusion

Temporal evolution of GLS was associated with adverse events, independent of LVEF but not independent of NT-proBNP. Since GLS showed decreased but stable values in patients with adverse prognosis, single measurements of GLS provide sufficient information for determining prognosis in clinical practice compared to repeated measurements, and temporal GLS patterns do not add prognostic information to NT-proBNP.

Left ventricular dysfunction and intra-ventricular dyssynchrony in idiopathic pulmonary arterial hypertension

BACKGROUND

Left ventricular (LV) filling pressures are normal in idiopathic pulmonary arterial hypertension (IPAH). However, direct and indirect interactions between the RV and LV can affect LV performance. We explored LV strain and LV intra-ventricular dyssynchrony in IPAH using feature tracking CMR (CMR-FT).

METHODS

Seventy IPAH patients and 40 healthy volunteers were included. Patients underwent CMR and right heart catheterisation. The 4-chamber cine was used to calculate LV longitudinal strain (Ell_LV). LV circumferential (Ecc_LV) and radial strain (Err_LV) were derived from a short axis cine. LV longitudinal, circumferential and radial intra-ventricular dyssynchrony indices were calculated.

RESULTS

There were no differences between the IPAH and healthy volunteer group in LV ejection fraction (66.1% vs 64.2% p = 0.6672). Ecc_LV (-29.1 vs -32.1 p = 0.0323) and Ell_LV (-16.6 vs -23.7 p < 0.0001) were lower in IPAH. In patients with more severe disease, there was greater impairment of Err_LV compared to mild disease (50.9 vs 87.5 P < 0.0001). LV synchrony was impaired in all directions in IPAH. Err_LV was associated with RV ejection fraction (r = 0.66), RV end-systolic volume index (r = -0.59), pulmonary vascular resistance (PVR)(r = 0.51) and stroke volume index (SVI)(r = 0.44). In a multivariate model with age, SVI and PVR, Err_LV (HR 0.970 p = 002) and radial dyssynchrony (HR 3.759 p < 0.0001) independently predicted survival.

CONCLUSION

In IPAH, LV is dyssynchronous with impaired function. Measures of LV strain and intraventricular synchrony were associated with known markers of disease severity. These LV variables which are likely to be related to ventricular interaction, may add incremental value to known prognostic variables in IPAH.

Clinical implications of the universal definition for the prevention and treatment of heart failure

The diagnosis of heart failure (HF) primarily relies on signs and symptoms that are neither sensitive nor specific. This impedes timely diagnosis and delays effective therapies or interventions, despite the availability of several evidence-based treatments for HF. Through monumental collaborative efforts from representatives of HF societies worldwide, the universal definition of HF was published in 2021, to provide the necessary standardized framework required for clinical management, clinical trials, and research. This review elaborates the key concepts of the new universal definition of HF, highlighting the key merits and potential avenues, which can be nuanced further in future iterations. We also discuss the key implications of the universal definition document from the perspectives of various stakeholders within the healthcare framework, including patients, care providers, system/payers and policymakers.