Increase in intracellular and extracellular myocardial mass in patients with acromegaly: a cardiac magnetic resonance imaging study

Acromegaly in Speckle Tracking Echocardiography-A New Cardiac Hypertrophy Phenotype? Case Report and Review

BACKGROUND

This study aims to provide a comprehensive overview of speckle tracking echocardiography (STE) findings in patients diagnosed with acromegaly, exploring a potential application for the differential diagnosis of cardiac hypertrophy and guiding clinicians in patient management. To our knowledge, this is the first review showcasing changes in the bull's-eye pattern in myocardial function after acromegaly treatment, suggesting a possible pattern in this aetiology of left ventricular hypertrophy.

METHODS

A review of PubMed articles using the search term "speckle tracking echocardiography acromegaly" yielded 11 relevant papers published between 2017 and 2023. The final analysis evaluated each paper's substantial value and summarised pertinent information. A clinical case of myocardial strain changes before and after pharmacological and neurosurgical treatment is also described.

RESULTS

The 11 analysed papers, with patient groups ranging from 19 to 50 individuals, revealed varying results in STE parameters between acromegalic and control groups. Left ventricular strain parameters were commonly assessed, showing discrepancies in different studies. Notably, the MAGYAR-Path Study emphasised left ventricular twist and radial strain abnormalities in acromegaly patients. Furthermore, the interplay between acromegaly and diabetes influenced myocardial function. Drug treatment with somatostatin receptor ligands demonstrated a favourable impact on left ventricular systolic function. The case study we describe in this manuscript showed changes in the posterior basal LV segment, which may be a specific pattern of acromegaly remodelling. Somatostatin therapy and neurosurgery led to the normalisation of global longitudinal strain (GLS) and improvement in myocardial work, as well as improved diastolic function, including enhanced left atrial strain (LAS) as well as a visible elastic recoil sign (ERS).

CONCLUSIONS

While the available literature on STE in acromegaly is limited, our analysis suggests potential applications in differentiating hypertrophy aetiologies and monitoring cardiac function post-treatment. The results underscore the need for more interdisciplinary research to optimise patient management. The bull's-eye pattern with posterior basal segment strain impairment we describe may be used to differentiate this entity.

Myocardial Mechanics in Acromegaly: A Meta-Analysis of Echocardiographic Studies

INTRODUCTION

Evidence on myocardial deformation, detected by speckle tracking echocardiography (STE), in patients with acromegaly is scanty.

AIM

The aim of the present meta-analysis was to provide an updated information on left ventricular (LV) systolic function assessed by global longitudinal strain (GLS) in patients with acromegaly and preserved LVEF.

METHODS

Following the PRISMA guidelines, systematic searches were conducted across bibliographic databases (Pub-Med, OVID, EMBASE and Cochrane library) to identify eligible studies from inception up to June 30-2024. Clinical studies published in English reporting data on LV mechanics in patients with acromegaly and controls were included. The statistical difference of the echocardiographic variables of interest between groups such as LVEF and global longitudinal strain (GLS) was calculated by standardized mean difference (SMD) with 95% confidence interval (CI) by using random-effects models.

RESULTS

Seven studies including 288 patients with acromegaly and 294 healthy individuals were considered for the analysis. Pooled average LVEF values were 64.6 ± 1.5% in the healthy control group and 64.0 ± 1.3% in the acromegaly group (SMD: - 0.21 ± 0.22, CI -0.62/0.22, p = 0.34); the corresponding values of GLS were - 19.1.1 ± 1.2% and - 17.5 ± 1.2% (SMD: -0.52 ± 0.27, CI - 1.05/0.01, p = 0.05). No difference was found between the two groups for both global circumferential strain (GCS) and global radial strain (GRS).

CONCLUSIONS

Our findings suggest that patients with acromegaly in which LVEF is completely comparable to healthy controls show an impairment in GLS of borderline statistical significance. Whether GLS assessment can actually unmask early alterations of systolic function in patients with acromegaly better than LVEF will need to be investigated by future studies.

The spectrum of cardiac abnormalities in patients with acromegaly: results from a case-control cardiac magnetic resonance study

PURPOSE

Cardiac abnormalities are common in patients with acromegaly, contributing to the increased morbidity and mortality. Cardiac magnetic resonance (CMR) is the gold standard for measuring cardiac morpho-functional changes. This study aims to detect cardiac alterations in acromegaly through CMR, even when the disease is adequately controlled.

METHODS

In this, multicentre, case-control study, we compared consecutive patients with acromegaly, cured after surgery or requiring medical treatment, with matched controls recruited among patients harbouring non-functioning adrenal incidentalomas.

RESULTS

We included 20 patients with acromegaly (7 females, mean age 50 years) and 17 controls. Indexed left ventricular-end-diastolic volume (LV-EDVi) and LV-end-systolic volume (LV-ESVi) were higher in patients than in controls (p < 0.001), as were left ventricular mass (LVMi) (p = 0.001) and LV-stroke volume (LV-SVi) (p = 0.028). Right ventricle (RV) EDVi and ESVi were higher, whereas RV-ejection fraction (RV-EF) was lower (p = 0.002) in patients than in controls (p < 0.001). No significant differences were observed in the prevalence of cardiometabolic comorbidities, including hypertension, glucose and lipid metabolism impairment, obstructive sleep apnoea syndrome, and obesity. IGF1 x upper limit of normal significantly predicted LVMi (b = 0.575; p = 0.008). Subgroup analysis showed higher LVMi (p = 0.025) and interventricular septum thickness (p = 0.003) in male than female patients, even after adjusting cardiac parameters for confounding factors.

CONCLUSIONS

The CMR analysis reveals a cluster of biventricular structural and functional impairment in acromegaly, even when the biochemical control if achieved. These findings appear specifically triggered by the exposure to GH-IGF1 excess and show sex-related differences advocating a possible interaction with sex hormones in cardiac disease progression.

Acromegalic Cardiomyopathy: An Entity on its own? The Effects of GH and IGF-I Excess and Treatment on Cardiovascular Risk Factors

Acromegaly is a chronic disease resulting from constantly elevated concentrations of growth hormone (GH) and insulin-like growth factor I (IGF-I). If not adequately treated, GH and IGF-I excess is associated with various cardiovascular risk factors. These symptoms mainly include hypertension and impaired glucose metabolism, which can be observed in approximately one-third of patients. Other comorbidities are dyslipidemia and the presence of obstructive sleep apnea syndrome. However, even in the absence of conventional cardiovascular risk factors, myocardial hypertrophy can occur, which reflects the impact of GH and IGF-I excess itself on the myocardium and is defined as acromegalic cardiomyopathy. Whereas previous echocardiography-based studies reported a high prevalence of cardiomyopathy, this prevalence is much lower in cardiac magnetic resonance imaging-based studies. Myocardial hypertrophy in acromegaly is due to a homogeneous increase in the intracellular myocardial mass and extracellular myocardial matrix and improves following successful treatment through intracellular changes. Intramyocardial water retention or ectopic lipid accumulation might not be of relevant concern. Successful treatment significantly improves myocardial morphology, as well as cardiovascular risk factors. In addition to GH/IGF-I-lowering therapy, the diagnosis and treatment of cardiovascular complications is crucial for the successful management of acromegaly.