Diagnostic accuracy of left ventricular longitudinal function by speckle tracking echocardiography to predict significant coronary artery stenosis. A systematic review

Assessment of cardiac adverse events following COVID-19 vaccination by speckle tracking echocardiography

Cardiac discomfort has been reported periodically in COVID-19-vaccinated individuals. Thus, this study aimed to evaluate the role of myocardial strains in the early assessment of the clinical presentations after COVID-19 vaccination. Totally, 121 subjects who received at least one dose of vaccine within 6 weeks underwent laboratory tests, electrocardiogram (ECG), and echocardiogram. Two-dimensional speckle tracking echocardiography (2D-STE) was implemented to analyze changes in the left ventricular myocardium. After vaccination, 66 individuals (55.4 ± 17.4 years) developed cardiac discomforts, such as chest tightness, palpitations, dyspnea, and chest pain. The ECG readings exhibited both premature ventricular contractions and premature atrial contractions (n = 24, 36.4%), while none of the individuals in the control group manifested signs of cardiac arrhythmia. All had normal serum levels of creatine phosphokinase, creatine kinase myocardial band, troponin, N-terminal pro b-type natriuretic peptide, platelets, and D-dimer. Left ventricular ejection fraction in the symptomatic group (71.41% ± 7.12%) and the control group (72.18% ± 5.11%) (p = 0.492) were normal. Use of 2D-STE presented global longitudinal strain (GLS) and global circumferential strain (GCS) was reduced in the symptomatic group (17.86% ± 3.22% and 18.37% ± 5.22%) compared to the control group (19.54% ± 2.18% and 20.73% ± 4.09%) (p = 0.001 and p = 0.028). COVID-19 vaccine-related cardiac adverse effects can be assessed early by 2D-STE. The prognostic implications of GLS and GCS enable the evaluation of subtle changes in myocardial function after vaccination.

The relationship between coronary artery calcium and layer-specific global longitudinal strain in patients with suspected coronary artery disease

PURPOSE

Layer-specific global longitudinal strain (GLS) may provide important insights in patients with suspected coronary artery disease (CAD). We aimed to investigate the association between layer-specific GLS and coronary artery calcium score (CACS) in patients suspected of CAD.

METHODS

We performed a retrospective study of patients suspected of CAD who underwent both an echocardiogram and cardiac computed tomography (median 42 days between). Layer-specific (endocardial-, whole-layer-, and epicardial-) GLS was measured using speckle tracking echocardiography. We assessed the continuous association between layer-specific GLS and CACS by negative binomial regression, and the association with high CACS (≥400) using logistic regression.

RESULTS

Of the 496 patients included (mean age 59 years, 56% male), 64 (13%) had a high CACS. Those with high CACS had reduced GLS in all layers compared to those with CACS < 400 (endocardial GLS: -20.5 vs. -22.7%, whole-layer GLS: -17.7 vs. -19.4%, epicardial GLS: -15.3 vs. -16.9%, p < .001 for all). Negative binomial regression revealed a significant continuous association showing increasing CACS with worsening GLS in all layers, which remained significant after multivariable adjustment including SCORE chart risk factors. All layers of GLS were associated with high CACS in univariable analyses, which was consistent after multivariable adjustment (endocardial GLS: OR = 1.11 (1.03-1.20); whole-layer GLS: OR = 1.14 (1.04-1.24); epicardial GLS: OR = 1.16 (1.05-1.29), per 1% absolute decrease).

CONCLUSION

In this study population with patients suspected of CAD and normal systolic function, impaired layer-specific GLS was continuously associated with increasing CACS, and decreasing GLS in all layers were associated with presence of high CACS.

Segmental and global longitudinal strain measurement by 2-dimensional speckle tracking echocardiography in severe rheumatic mitral stenosis

BACKGROUND

The present study aimed to detect subtle left ventricular (LV) dysfunction in patients with severe rheumatic mitral stenosis (MS) by measuring global and segmental longitudinal strain with a two-dimensional speckle tracking echocardiography (2D-STE) method.

METHODS

In this case-control study, 65 patients with severe rheumatic MS and preserved ejection fraction (EF ≥ 50% measured by conventional echocardiographic methods) were compared with 31 otherwise healthy control subjects. All patients underwent LV strain measurement by the 2D-STE method in addition to conventional echocardiography using a VIVID S60 echocardiography device.

RESULTS

Absolute strain values in myocardial segments 1-8, 10, and 12 (all basal, mid anterior, mid anteroseptal, mid inferior, and mid anterolateral segments) were significantly lower in patients with severe MS compared with the control group (P < 0.05 for all). The absolute global longitudinal strain (GLS) value was higher in the control group (-19.56 vs. -18.25; P = 0.006). After adjustment for age, gender, and systolic blood pressure, the difference in GLS between the two groups was as follows: mean difference=-1.16; 95% CI: -2.58-0.25; P = 0.110.

CONCLUSION

In patients with severe rheumatic MS and preserved EF, the absolute GLS tended to be lower than healthy controls. Furthermore, the segmental strain values of LV were significantly lower in most of the basal and some mid-myocardial segments. Further studies are warranted to investigate the underlying pathophysiology and clinical implications of this subclinical dysfunction in certain segments of patients with severe rheumatic MS.

Predictive value of speckle tracking technique for coronary artery stenosis in patients with coronary heart disease

OBJECTIVE

To observe the predictive value of speckle tracking technique (STI) for the degree of coronary artery stenosis in patients with coronary heart disease (CHD).

METHODS

The clinical data of 120 patients with coronary artery stenosis admitted to Affiliated Hospital of Chengde Medical University from Feb. 2022 to Sep. 2022 was analyzed retrospectively. The other 63 patients who sought for medical help because of chest pain underwent Coronary Arteriography (CAG) examination during the same period but with Gensini score > 0 were selected as the control group. Coronary artery stenosis was divided into three subgroups according to the coronary Gensini score: mild, moderate, and severe stenosis. Routine ultrasound and STI techniques were performed in all patients. In addition, left ventricular global radial peak systolic strain (GRS), left ventricular global longitudinal peak systolic strain (GLS), left ventricular global peak systolic strain (GAS) and left ventricular global circumferential peak systolic strain (GCS) were measured and compared between the two groups and among the three subgroups.

RESULTS

There were no marked differences identified in conventional ultrasound parameters between the coronary artery stenosis group and control group, but the absolute values of GLS, GRS, GCS, and GAS were lower in the former group compared to control group; and the severe group had the lowest levels of above indexes, followed by moderate group, then mild group and control group (all P < 0.05). The results showed that the area under the curve (AUC) for GLS, GRS, GCS, and GAS in diagnosing coronary artery stenosis were 0.973, 0.933, 0.947, and 0.901, respectively. The AUCs of GLS, GRS, GCS, and GAS for the diagnosis of moderate/severe coronary artery stenosis were 0.968, 0.908, 0.901, and 0.942, respectively, with GAS and GLS assessed with the largest AUC values and higher sensitivity and specificity than other parameters.

CONCLUSION

The global longitudinal strain of left ventricle obtained by STI technique was more sensitive to coronary artery stenosis than that by ultrasound technique, and it had a higher predictive value for coronary artery stenosis.

Comparison of two ellipsoidal models for the estimation of left ventricular end-systolic stress in patients with significant coronary artery disease

Background

The shape of the left ventricle (LV) is an important index to explore cardiac pathophysiology. A comparison was provided to estimate circumferential, longitudinal, and radial wall stress in LV based on the thick-walled ellipsoidal models of Mirsky and Ghista-Sandler for discriminating significant coronary artery disease (CAD) patients from no CAD patients.

Materials and Methods

According to the angiography findings, 82 patients with CAD were divided into two groups: 25 patients without significant CAD and 57 patients with significant CAD of single vessel and multivessel. An ellipsoidal LV geometry was used to calculate end-systolic passive stress as the mechanical behavior of LV. Echocardiographic views-based measurements of LV diameters used to estimate the end-systolic wall stress.

Results

Circumferential wall stress between the control group and significant CAD groups was significantly elevated for the Ghista model (P = 0.008); also, radial and longitudinal stress of the multi-vessel CAD group was significantly higher than the control group (P = 0.01 and P = 0.005, respectively). All stress parameters of the multi-vessel CAD group were statistically significant compared to the control group for the Mirsky model. Receiver operating characteristics curve analysis was shown the circumferential stress of multi-vessel CAD with an area under the curve (AUC) of 0.736 for the Ghista model and an AUC of 0.742 for the Mirsky model.

Conclusion

These results indicated that Ghista and Mirsky model estimates of circumferential passive stress were the potential biomechanical markers to predict patients with multi-vessel CAD. It could be a noninvasive and helpful tool to quantify the contractility of LV.

Diagnostic accuracy of global longitudinal strain in prediction of severity and extent of coronary artery stenosis in patients with acute coronary syndrome

BACKGROUND

2 D Speckle tracking echocardiography (STE) is a non-invasive, angle-independent, semiautomatic and objective technique that quantitatively assesses global and regional longitudinal systolic strain and provides a single bull's eye map for segmental wall strain of the left ventricle.

OBJECTIVES

assessment of the accuracy of global longitudinal strain (GLS) using STE in the detection of resting myocardial ischaemia and its severity compared with visual assessment of wall motion score index by conventional 2 D echo.

PATIENTS AND METHODS

100 patients who presented with ACS were included. Wall motion score index (WMSI) was calculated in a 16-segment model and compared with GLS assessed in left ventricle 17 segments and calculated automatically by summation of regional longitudinal peak systolic strain (RLS) using STE. Quantitative coronary angiography was performed on clinical indication and significant stenosis was defined as a 70% reduction of the arterial lumen.

RESULTS

56 patients (56%) of patients were males with a mean age of 58.3 years. GLS showed a significant positive correlation between ejection fraction (EF) and GLS (p < 0.05), (r value 0.514) and a good significant negative correlation between WMSI and GLS (p < 0.05), (r value 0.593). And a good significant correlation between GLS and both severity of the lesion and the number of affected vessels was found (p < 0.05). ROC curves showed the cut-off point of GLS was (-15.9) for predicting lesion ≥70% with 88.1% sensitivity, 90.2% specificity respectively.

CONCLUSION

GLS has higher specificity, sensitivity, and diagnostic accuracy for the detection of the severity of lesion and number of the vessel affected than WMSI.

Comparison between Visual Assessment and Longitudinal Strain during Dobutamine Stress Echocardiography

Background

The relationship between visual assessment and longitudinal strain during dobutamine stress echocardiography (DSE) remains poorly investigated. This study assessed wall motion segments visually graded as normokinetic, hypokinetic, and akinetic at baseline and the peak of DSE and compared with longitudinal strain between segments with and without induced impaired contractility and improved contractility during DSE.

Methods

This study included 112 patients examined by DSE, consisting of 58 patients referred for diagnostic study and 54 patients referred for viability study. Regional left ventricular (LV) contractility was assessed visually and longitudinal strain was measured using echocardiography transthoracic.

Results

At baseline, the strain of LV segments was -16.33 ± 6.26 in visually normokinetic, 13.05 ± 6.44 in visually hypokinetic, and -8.46 ± 5.69 in visually akinetic segments. During peak dose, the strain of LV segments was -15.37 ± 6.89 in visually normokinetic, -11.37 ± 5.11 in visually hypokinetic, and -7.37 ± 3.92 in visually akinetic segments. In segments with visually observed impaired contractility, the median longitudinal strain was significantly lower than in segments without impaired contractility. For segments with visually observed improved contractility, the median longitudinal strain was significantly higher than for segments without improved contractility. In diagnostic study, sensitivity of visual assessment for absolute decrease of >2% longitudinal strain was 77%, respectively. In the viability study, the sensitivity was 82% for an absolute decrease of ≥2% longitudinal strain.

Conclusions

There is good association between strain analysis value and visually assessed wall motion contractility.

Association of resting left ventricular global longitudinal strain with myocardial perfusion abnormalities evaluated by 13 N-ammonia positron emission tomography in patients with stable angina pectoris and normal left ventricular ejection fraction

AIMS

Little is known about whether resting left ventricular global longitudinal strain (GLS) impairment is associated with myocardial perfusion abnormalities evaluated using ¹³ N-ammonia positron emission tomography (¹³ N-NH₃ -PET)-myocardial perfusion imaging (MPI). This study aimed to investigate the correlation between resting GLS and myocardial perfusion parameters in patients with a normal left ventricular ejection fraction (LVEF). We evaluated whether resting GLS can predict myocardial perfusion abnormalities in these patients.

METHODS AND RESULTS

We selected 157 patients with suspected stable angina pectoris who underwent both ATP-stress NH₃ -PET-MPI and 2-dimentional speckle tracing echocardiography. All subjects had a preserved LVEF and no known history of myocardial infarction. Patients were stratified into Group N (normal perfusion; summed stress score [SSS], 0-3; n = 101), Group M (mildly to moderately abnormal perfusion; SSS, 4-11; n = 41), or Group S (severely abnormal perfusion; SSS, 12+; n = 15). GLS was more impaired as myocardial perfusion abnormality severity increased (-17.9 ± 2.9% for Group N, -16.8 ± 3.1% for Group M, and -14.2 ± 3.5% for Group S; p < .001). GLS was weakly but significantly correlated with SSS (R = .32, p < .001), summed difference score (R = .32, p < .001), and myocardial blood flow during stress (R = -0.27, p < .001). Multivariate logistic regression analysis showed that male sex, diabetes mellitus, systolic blood pressure, and GLS were independent predictors of myocardial perfusion abnormality defined as Groups M and S. Additionally, the area under the curve for GLS for detecting myocardial perfusion abnormality was .65, and the optimal cutoff value for GLS was -16.5%, with sensitivity and specificity of 59% and 66%, respectively.

CONCLUSION

In patients with suspected angina pectoris, resting GLS impairment despite a normal LVEF might aid the detection of hemodynamically significant coronary artery disease.

Value of myocardial deformation parameters for detecting significant coronary artery disease

Introduction: The study aimed to evaluate the diagnostic value of global and regional myocardial deformation parameters derived from two-dimensional speckle-tracking echocardiography to detect functionally significant coronary artery stenosis.

Methods: Dobutamine stress echocardiography and cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) were performed on 145 patients with a moderate and high probability of coronary artery disease (CAD) and LVEF≥55%. Significant CAD was defined as>50% stenosis of the left main stem,>70% stenosis in a major coronary vessel, or in the presence of intermediate stenosis (50-69%) validated as hemodynamically significant by CMRMPI. Patients were divided in two groups: non-pathological (48.3%) vs pathological (51.7%), according to CAG and CMR-MPI results. Afterwards, off-line speckle-tracking analysis was performed to analyse myocardial deformation parameters.

Results: There were no differences in myocardial deformation parameters at rest between groups, except global longitudinal strain (GLS) and global radial strain (GRS) were significantly lower in the CAD (+) group: -21.3±2.2 vs.-16.3±2.3 (P<0.001) and 39.7±23.2 vs. 24.5±15.8 (P<0.001). GLS and regional longitudinal strain rate (SR) had the highest diagnostic value at high dobutamine dose with AUC of 0.902 and 0.878, respectively. At early recovery, GLS was also found to be the best myocardial deformation parameter with a sensitivity of 78%, specificity 67%, AUC 0.824.

Conclusion: Global and regional myocardial deformation parameters are highly sensitive and specific in detecting functionally significant CAD. The combination of deformation parameters and WMA provides an incremental diagnostic value for patients with a moderate and high probability of CAD, especially the combination with regional longitudinal SR.

Novel regional longitudinal strain by speckle tracking to detect significant coronary artery disease in patients admitted to the emergency department for chest pain suggestive of acute coronary syndrome

Background

Global longitudinal strain has shown variable results in detecting ischemia in patients admitted to the emergency department with chest pain, but without other clear evidence of coronary artery disease (CAD). Our aim was to investigate whether assessment of regional longitudinal myocardial function could assist in detecting significant CAD in these patients.

Methods

Clinical evaluation, electrocardiogram, echocardiogram and troponin T were evaluated in 126 patients admitted with chest pain. A subsequent invasive coronary angiography divided patients into two groups: significant CAD (CAD+) or non-significant CAD (CAD−). Global and regional myocardial function were evaluated by speckle tracking echocardiography. Regional longitudinal strain was defined as the highest longitudinal strain values in four adjacent left ventricular segments and termed 4AS.

Results

CAD+ was found in 37 patients (29%) of which 51% had elevated troponin. Mean 4AS was − 13.1% (± 3.5) in the CAD+ and − 15.2% (± 2.7) (p = 0.002) in the CAD− group. Predictors for CAD+ were age [OR 1.06 (1.01–1.11, p = 0.026)], smoking [OR 3.39 (1.21–9.51, p = 0.020)], troponin [OR 3.32 (1.28–8.60, p = 0.014)) and 4AS (OR 1.24 (1.05–1.46, p = 0.010)]. A cutoff for 4AS of > − 15% showed the best diagnostic performance with event-reclassification of 0.41 (p < 0.001), non-event-reclassification of − 0.34 (p < 0.001) and net reclassification improvement 0.07 (p = 0.60).

Conclusion

Decreased myocardial function in four adjacent LV segments assessed by strain has the potential to detect significant CAD in patients admitted with chest pain and negative/slightly elevated initial troponin.

Trial registration: Current Research information system in Norway (CRISTIN). Id: 555249.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12574-022-00568-7.

Speckle Tracking Stress Echocardiography on Treadmill in Assessment of the Functional Significance of the Degree of Coronary Artery Disease

Aim        To determine diagnostic capabilities of left ventricular (LV) global longitudinal systolic strain (GLSS) in stress echocardiography (stress-EchoCG) with a treadmill test for diagnosing the functional significance of the degree of coronary stenosis.Material and methods        The study included 121 patients (73 men aged 68.3±7.7 years) with suspected or previously diagnosed ischemic heart disease (IHD). Speckle-tracking stress-EchCG (method of tracking speckles on two-dimensional gray-scale ultrasonic images) with a treadmill test and coronarography was performed for all patients. The patients were divided into 3 groups based on the severity of coronary artery (CA) stenosis according to the Gensini scale.Results   LV GLSS at rest did not significantly differ between the study groups. After the exercise, LV GLSS was significantly lower in patients with pronounced CA stenosis than in patients without or with moderate CA stenosis (15.9±4.6 % vs. 20.6±3.7 % (p&lt;0.001) and 19.6±3.0 % (p=0.003), respectively). Postexercise LV GLSS &lt;16.9% suggested a pronounced CA stenosis with a sensitivity of 80% and a specificity of 70% (area under the curve, AUC, 0.76±0.06 at 95 % confidence interval, CI, 0.63-0.89; р&lt;0.001). In the patient group without CA stenosis, LV GLSS showed a significant increase after completion of the exercise (from 19.1±3.1 to 20.6±3.7; p=0.04).Conclusion            Evaluation of LV GLSS and its dynamics in stress-EchoCG with a treadmill test may be promising in patients with IHD, since in most patients with pronounced CA stenosis, LV GLSS is reduced at baseline and further reduces in response to exercise. In patients without CA stenosis, LV GLSS increases after completing the exercise.

Diagnostic Accuracy of Global Longitudinal Strain for Detecting Significant Coronary Artery Disease in Diabetic Patients without Regional Wall Motion Abnormality

AIMS

Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this prospective study was to assess the diagnostic accuracy of global longitudinal strain (GLS) and regional longitudinal strain (RLS) parameters at rest in comparison to stress echocardiography findings for detecting significant coronary artery disease (CAD) in patients with diabetes mellitus (DM).

METHODS

We prospectively studied echocardiographic characteristics at rest with Speckle tracking echocardiography (2D STE) measures; then stress echocardiography and coronary angiography data in 34 diabetic patients without regional wall motion abnormality (RWMA) at rest. Patients were grouped according to coronary angiography and stress echocardiography results into two groups CAD (+) vs control group CAD (-).

RESULTS

GLS at rest was lower in the CAD (+) group ((-14.2 % ± 3.1 vs -17.8 % ± 3.1 in the control group CAD (-), P=0.004). GLS at rest had the highest area under the ROC curve (AUC) (AUC 0.78, sensitivity 61%, specificity 91%,P=0.009) with the cut-off of -14.5% which is equal to predictive power of wall motion scoring index (WMSI) at peak stress to detect significant CAD (AUC=0.76 (95% CI 0.58-0.94, P= 0.016) with the cut-off value of 1.21).

CONCLUSIONS

Global longitudinal strain at rest by STE showed excellent specificity (>90%) and good sensitivity (60%) for the diagnosis of severe CAD among the diabetic population with unknown CAD. This is the first study showing that GLS at rest with cutoff value at -14.5% had good and equal diagnostic accuracy as WMSI at peak stress to detect significant CAD among the diabetic population.

Comparison of mitral annular displacement and global longitudinal strain imaging for predicting significant coronary atherosclerotic disease in patients of chronic stable angina pectoris

Myocardial strain by two-dimensional speckle-tracking echocardiography (2D-STE) is a validated clinical index of myocardial deformation, for predicting CAD in patients with chronic stable angina pectoris (CSAP) with preserved ejection fraction (EF). However, it is complex, imaging dependant with intra and intervendor variability. The mitral annulus displacement (MAD) has been correlated to left ventricular (LV) longitudinal deformation and may be interchanged with strain imaging. This cross-sectional study was conducted on patients with suspected CSAP (n = 146) and preserved LVEF without wall motion abnormalities. We excluded patients with prior heart disease, ACS, arrhythmia, heart failure or poor imaging. GLS, Average MAD and normalized MAD were calculated using 2D-STE by automated function imaging. CAG was gold standard. MAD had significantly lesser dropout due to suboptimal imaging. Receiver operating characteristic (ROC) analysis showed that GLS had significantly better area under curve (AUC) compared to Normalised MAD and Average MAD (P = 0.035) in predicting significant CAD in patients of CSAP. The optimal cut-off of GLS, normalized MAD and Average MAD were ≥  - 20.67% (sensitivity 94.2%, specificity 86.7%), ≤ 15.22% (sensitivity 90.7%, specificity 80%) and ≤ 11.18 mm (sensitivity 83.7%, specificity 71.1%) respectively. GLS showed strong correlation with Normalised MAD (R = 0.669, P < 0.001) and good correlation to Average MAD (R 0.572, P < 0.001). Absolute GLS and Normalised MAD showed significant inverse correlation to SYNTAX score. GLS is a more accurate measure for predicting presence and severity of CAD then MAD however latter is a reliable simpler, robust, and expeditious tool with lesser dropouts. It can be at least of complementary value to other imaging markers for myocardial function when LV curvatures are poorly visualized or in busy outdoors with time constraint.

Correlation between Myocardial Strain by 2-D Speckle-Tracking Echocardiography and Angiographic findings by Coronary Angiogram in Stable Angina

Background and aims: Identification of coronary artery disease by non-invasive means is a subject of interest for all. Myocardial strain has shown some promising results. This study intends to see if change in strain value correlates with the angiographic findings in patients with stable angina. It is also assessing whether myocardial strain can predict the presence of coronary artery disease (CAD) in stable angina patients. Method: This cross-sectional study was carried out on 84 stable angina patients with no previous cardiac history and normal LV function undergoing coronary angiogram for guideline-based indication. After careful history, clinical examination and investigations, including conventional echocardiography, selected participants underwent 2-D speckle tracking echocardiography for measurement of myocardial strain by automated functional imaging. All participants underwent coronary angiogram and stenosis >70% was considered significant. Gensini score was calculated. The myocardial strain value and Gensini score were correlated. Results: Global longitudinal strain (GLS) was significantly lower in patients with significant CAD than those with non-significant CAD (-16.1±2.6% vs -19.4±2.2%; p < 0.001). The optimal cut-off value of GLS, which discriminated between patients with and without significant coronary artery disease, was -18.05% (sensitivity=81.8% and specificity=85%). Also, GLS declined incrementally with the increasing severity of CAD defined by increasing number of stenotic vessels. There was an inverse correlation between GLS and severity of CAD (expressed in Gensini score) in this study (r = 0.669, p< 0.001), meaning that GLS decreased with increasing severity of CAD. GLS remained an independent predictor for the presence of significant CAD after multivariate adjustment for other significant baseline characteristics and echocardiographic parameters. Conclusions: The myocardial strain by 2DSE correlates with the angiographic severity by coronary angiogram in patients with stable angina. It is an independent predictor of significant coronary artery disease, which it can detect with good sensitivity and specificity.

Correlation between global longitudinal strain and SYNTAX score in coronary artery disease evaluation

BACKGROUND

Speckle tracking echocardiography may allow the evaluation of myocardial systolic and diastolic dynamics across different physiologic and pathologic conditions beyond traditional echocardiographic techniques. The use of STE longitudinal strain in identification and risk stratification of CAD has good reproducibility and accuracy. The study aims to detect the relationship between SYNTAX score and global longitudinal peak systolic strain (GLPSS) in patients undergoing coronary angiography, with no history of myocardial infarction.

RESULTS

The study included 70 symptomatic patients suspected to have chronic coronary syndrome aging 20-80 years (excluding those with significant structural heart disease). All patients underwent clinical evaluation, surface ECG, laboratory assessment, transthoracic echocardiographic (TTE), color TDI tracings, two-dimensional speckle tracking, and conventional coronary angiography with SYNTAX score calculation. Patients were divided into 3 groups based on the results of the coronary angiogram: normal CAD on angiogram (n = 10, control group), low SS (n = 25, SS < 22), and high SS (n = 35, SS ≥ 22). The mean age was 55 ± 9.6 years; 54% were males; two third of patients were hypertensive; 52% were diabetic; high percentage of high syntax score were noticed among males, diabetic patients, and smokers; and also low mean of GLS was noticed among diabetic patients and smokers. There was a statistically significant positive correlation between syntax score and each of LVEDD and LVESD and, on the other hand, statistically significant negative correlation between syntax score and each of E/A, GLS, AP2LS, AP3LS, and AP4LS was noticed. Peak GLS cutoff value of 17.8 and 16.5 showed 84% and 93% sensitivity and 70% and 91% specificity to detect high and low syntax score, respectively.

CONCLUSION

2D longitudinal strain analysis has incremental diagnostic value over visual assessment during echocardiography in predicting significant coronary artery disease; GLS may offer a potential sensitive tool to detect significant CAD.

Diabetes as an independent predictor of left ventricular longitudinal strain reduction at rest and during dobutamine stress test in patients with significant coronary artery disease

Aims

Diabetes (DM) is a strong cardiovascular risk factor modifying also the left ventricular (LV) function that may be objectively assessed with echocardiographic strain analysis. Although the impact of isolated DM on myocardial deformation has been already studied, few data concern diabetics with coronary artery disease (CAD), especially in all stages of dobutamine stress echocardiography (DSE). We compared LV systolic function during DSE in CAD with and without DM using state-of-the art speckle-tracking quantification and assessed the impact of DM on LV systolic strain.

Methods and results

DSE was performed in 250 patients with angina who afterwards had coronarography with ≥50% stenosis in the left main artery and ≥70% in other arteries considered as significant. In this analysis, we included 127 patients with confirmed CAD: 42 with DM [DM(+); mean age 64 ± 9 years] and 85 patients without DM [DM(-); mean age 63 ± 9 years]. The severity of CAD and LV ejection fraction (EF) were similar in both groups. Global and regional LV peak systolic longitudinal strain (PSLS) revealed in all DSE phases lower values in DM(+) group: 14.5 ± 3.6% vs. 17.4 ± 4.0% at rest; P = 0.0001, 13.8 ± 3.9% vs. 16.7 ± 4.0% at peak stress; P = 0.0002, and 14.2 ± 3.1% vs. 15.5 ± 3.5% at recovery; P = 0.0432 for global parameters, although dobutamine challenge did not enhance further resting differences. LV EF, body surface area, and diabetes were independent predictors for strain in 16-variable model (R2 = 0, 51, P < 0.001).

Conclusion

PSLS although diminished in both groups with CAD was lower in diabetics at all DSE stages, and DM was an independent predictor of this impairment. However, the dobutamine challenge did not deepen the resting differences, suggesting that the direct impact of coronary stenoses effaces the influence of DM during DSE. The comparison with our previous data revealed synergistic, detrimental effect of coexisting CAD and DM on myocardial strain.

Determinants of Myocardial Strain in Experimental Chronic Myocardial Infarction

We evaluated the relationships between regional myocardial strain measured by speckle tracking echocardiography and viability, fibrosis, hypertrophy and oxygen consumption in the infarcted or remote myocardium in a pig model of chronic myocardial infarction (MI). Thirteen farm pigs with surgical occlusion of the left anterior descending coronary artery and five sham-operated pigs were studied 3 mo post-MI. Computed tomography revealed significant left ventricle remodeling. Reduced radial or circumferential strain identified areas of transmural infarction (area under the curve: 0.82 and 0.79, respectively). In the remote non-infarcted area, radial strain correlated inversely with the amount of fibrosis (r = -0.66, p = 0.04) and myocyte hypertrophy (r = -0.68, p = 0.03). Radial strain rate inversely correlated with myocardial resting oxygen consumption assessed with ¹¹C-labeled acetate positron emission tomography (r = -0.71, p = 0.006). In conclusion, myocardial strain and strain rate reflect fibrosis, hypertrophy and oxygen consumption of the remote areas after MI.

Layer-specific strain analysis of left ventricular myocardium after alcohol septal ablation for hypertrophic obstructive cardiomyopathy

INTRODUCTION

We aimed to explore the layer-specific systolic strain of left ventricular (LV) myocardium in patients with hypertrophic obstructive cardiomyopathy (HOCM) before and after alcohol septal ablation (ASA).The routine 2D (frame rate: >50 Hz) data sets were acquired using GE Vivi7 system for 44 consecutive HOCM patients and 21 matched normal subjects. Fifteen of HOCM patients had serial echocardiograms available for speckle tracking analyses before and 1 year after ASA. 2D strain was analyzed by EchoPAC software.The layer strain from inner to mid-myocardial and outer layers in basal and middle segments in HOCM patients continuously declined. The absolute values of peak systolic strains from the endocardium to mid-myocardium and epicardium in the basal septum of the HOCM group were significantly lower than those of the normal group (P <.01). Meanwhile, the layer systolic strain of LV endocardium in the basal septum increased significantly during a 1-year follow-up (P <.05).

CONCLUSIONS

The layer-specific strains of HOCM patients measured by tissue Doppler echocardiography decreased significantly compared to those of normal individuals. The increased specific layer strain of LV endocardium in the basal septum may be a valid marker of echocardiographic improvement in HOCM patients receiving ASA.

Ascending Aortic Strain Analysis Using 2-Dimensional Speckle Tracking Echocardiography Improves the Diagnostics for Coronary Artery Stenosis in Patients With Suspected Stable Angina Pectoris

Background

Arterial stiffening and atherosclerosis tend to coexist. Strain imaging, using a 2‐dimensional speckle tracking (2D‐ST) method, has been used for arterial stiffness assessment and early identification of atherosclerosis. We investigated whether the ascending aortic strain assessed by 2D‐ST echocardiography at rest can predict the presence of coronary artery disease (CAD).

Methods and Results

Two hundred seventy‐one consecutive patients with suspected stable angina pectoris sequentially underwent exercise treadmill testing, 2‐dimensional echocardiography, M‐mode echocardiography, 2D‐ST echocardiography, and coronary angiography. Circumferential ascending aortic strain (CAAS) and radial ascending aortic strain were assessed by 2D‐ST echocardiography. Ninety‐two patients with coronary lumen area stenosis ≥70% were categorized as having significant CAD. Global CAAS was significantly lower in patients with significant CAD (7.41±2.30% versus 11.54±4.03%; P<0.001) and remained an independent predictor of significant CAD (odds ratio, 0.64 [0.54–0.75]; P<0.001) after multivariate regression. Based on the receiver operating characteristic curve for diagnosing significant CAD, the optimal cut‐off value of global CAAS was ≤9.22% (sensitivity, 86%; specificity, 70%; area under curve=0.82; P<0.001). Global CAAS decreased with increasing severity of CAD and was significantly associated with 3‐vessel disease (odds ratio, 0.58 [0.42–0.79]; P<0.001). Diagnostics for significant CAD were remarkably better for global CAAS combined with exercise treadmill testing than for exercise treadmill testing alone (area under curve=0.88 versus 0.78; P<0.001).

Conclusions

Global CAAS assessed by 2D‐ST echocardiography at rest was able to predict the presence of significant CAD and identify multivessel disease. In addition, global CAAS combined with exercise treadmill testing remarkably improved the diagnostics for significant CAD.

Multimodality imaging for evaluation of chest pain using strain analysis at rest and peak exercise

BACKGROUND

Exercise stress echocardiography (SE) is commonly used for diagnosing coronary artery disease (CAD). The use of quantitative echocardiographic measures such as strain imaging is expected to improve the sensitivity of conventional SE which relies on the visual diagnosis of wall-motion abnormalities (WMAs). This study is set to demonstrate the added value of resting and exercise strain analysis to detect underlying microangiopathy and inducible myocardial ischemia during a resting and SE in comparison with the results of coronary computed tomographic angiogram (CCTA).

METHODS

A total of 103 consecutive outpatients from the executive screening program were identified and underwent resting and SE. Global longitudinal strain (GLS) and wall-motion changes at rest and peak exercise were analyzed and compared. Baseline demographics, heart rate, and blood pressure measurements were retrospectively extracted for analysis. CCTA was chosen as an alternative test to match with wall motion and strain imaging.

RESULTS

Patients who had abnormal CCTA had lower resting GLS (14.85% ± 3.05 vs 17.99% ± 2.88, P-value = .001) when compared to patients with normal CCTA. All patients who had abnormal CCTA had higher wall-motion score index (1.35 ± 0.2 vs 1.00, P-value < .0001) and lower and abnormal peak stress GLS (pGLS) as compared to patients with normal CCTA (14.89% ± 3.35 vs 18.44% ± 4.27, P-value = .007). However, all patients with pGLS ≥ 20% had normal/nonobstructive CCTA. Patients with multiple comorbidities showed reduced and lower values of resting and pGLS (P-value < .0001), suggesting associated subclinical left ventricular dysfunction.

CONCLUSIONS

Global longitudinal strain offers quantitative interpretation of the resting and SE study, detects underlying subclinical left ventricular dysfunction and a peak stress value more than 20% excludes obstructive CAD on CCTA.

The correlation between speckle tracking echocardiography and coronary artery disease in patients with suspected stable angina pectoris

Background

To examine the value of speckle tracking echocardiography to detect the presence, extent and severity of coronary artery affection in patients with suspected stable angina pectoris.

Methods

Two hundred candidates with suspected stable angina pectoris and normal resting conventional echocardiography were subjected to speckle tracking echocardiography and coronary angiography. Global and segmental longitudinal peak systolic strain were assessed and were correlated to the results of coronary angiography for each patient.

Results

There was a statistically significant difference in the mean of global longitudinal peak systolic strain between normal coronaries and different degrees of coronary artery disease (CAD) (−20.11 ± 0.8 for normal, −18.34 ± 2.52 for single vessel, −16.14 ± 2.85 for two vessels, −14.81 ± 2.12 for three vessels, −13.01 ± 2.92 for left main disease). GLPSS showed high sensitivity for the diagnosis of single vessel CAD (90%, specificity 95.1%, cutoff value: −18.44, AUC: 0.954); two vessels disease (90%, sensitivity 88.9%, cutoff value −17.35, AUC: 0.906) and for three vessels CAD (cutoff value −15.33, sensitivity 63% and specificity 72.2% AUC 0.681) segmental LPSS also showed statistical significance for localization of the affected vessel for left anterior descending, left circumflex and right coronary artery (ρ = 0.001) and inverse correlation with syntax score that was significant with high and intermediate score (ρ = 0.001) and insignificant for low syntax score (ρ value 0.05).

Conclusion

Two-dimensional speckle tracking echocardiography has good sensitivity and specificity to predict the presence, extent and severity of CAD.

Longitudinal two-dimensional strain for the diagnosis of left ventricular segmental dysfunction in patients with acute myocardial infarction

The objectives of this study were to assess whether 2-dimensional strain (2DS) can detect left ventricular (LV) segmental dysfunction and to compare the diagnostic accuracy of various 2DS parameters. Multiple segmental longitudinal 2DS parameters were measured in 54 patients with a first myocardial infarction and single vessel coronary artery disease (age: 56 ± 11 years, 74% men, LV ejection fraction: 47 ± 10%, left anterior descending artery occlusion in 63%) and 14 age-matched subjects. 2DS parameters were compared to visual assessment of segmental function by multiple observers. Using receiver-operating characteristics analysis, the area under the curve (AUC) for peak systolic strain in diagnosing segmental dysfunction (akinetic or hypokinetic LV segments) and for diagnosing akinetic segments was 0.85 (95% confidence interval 0.83-0.88) and 0.88 (0.85-0.90), respectively (all P values < 0.001). Other 2DS strain parameters had similar (peak strain, peak strain rate) or lower (post-systolic shortening, time-to-peak strain, diastolic 2DS parameters) AUC values. An absolute value of peak systolic strain <16.8% (25th percentile in normal subjects) had high sensitivity (0.89) and negative predictive values (0.88), but low specificity (0.55) and positive predictive values (0.59) for diagnosing segmental dysfunction. Similar findings were observed using a cutoff of <13.3% (absolute value of 10th percentile) for diagnosing akinetic segments. Diagnostic accuracy was significantly worse for segments in which visual segmental assessment was discordant between observers. In conclusion, 2DS can be used to diagnose segmental LV dysfunction with high sensitivity but limited specificity. The diagnostic limitation of 2DS is partially related to the visual echocardiographic definition of segmental abnormality.

The additional utility of two-dimensional strain in detection of coronary artery disease presence and localization in patients undergoing dobutamine stress echocardiogram

BACKGROUND

Dobutamine stress echocardiogram (DSE) is a feasible and safe exercise-independent stress modality for diagnoses of coronary artery disease (CAD), but it is subjective, and operator dependant. Two-dimensional strain at peak stress could overcome these limitations and thus increase the accuracy of DSE.

METHODS AND RESULTS

This was a prospective observational study in which 80 patients underwent DSE, two-dimensional strain at peak stress, and coronary angiography. Global longitudinal strains (GLS) cutoff point of -16.75 had 77.42% sensitivity and 83.33% specificity to detect significant CAD. Global circumferential strain (GCS) cutoff point of -20.75 had 93.55% sensitivity and 66.67% specificity to detect significant CAD (P=.003, areas under the curve [AUC]=0.73). The average territorial strain cutoff point for significant left anterior descending (LAD) lesion was -15.4 with 77.78% sensitivity and 82.86% specificity (P=.0001, AUC=0.78) and for non-LAD lesion was -16.9 with 82.93% sensitivity and 53.85% specificity (P=.0009, AUC=0.69). Two-dimensional strain at peak stress showed better agreement than DSE as regard number of vessels affected (K=0.579 vs 0.107), LAD lesion detection (K=0.783 vs 0.438), and non-LAD lesion detection (K=0.699 vs 0.233). Global longitudinal strain (GLS) at peak stress reduced DSE false positivity by 83%; the number of false-positive patients was reduced from 18 patients to only three patients.

CONCLUSION

Two-dimensional strain at peak stress had an incremental value over DSE visual assessment/ wall-motion score index (WMSI) in reducing false-positive results of DSE. Two-dimensional strain at peak stress had greater accuracy than DSE alone not only in detection of significant CAD but also in detection of number of vessels with significant lesion as well as CAD localization.

Diagnostic value of layer-specific global longitudinal strain during adenosine stress in patients suspected of coronary artery disease

Speckle tracking global longitudinal strain (GLS) from dobutamine stress echocardiography (SE) predicts coronary artery disease (CAD). The diagnostic value of GLS from vasodilator SE and the additional value of layer-specific speckle tracking analysis are unclear. We explored the usefulness of layer-specific GLS and non-layer-specific strain (automated functional imaging, AFI) from adenosine SE. The included 132 patients (67% male, 62.6 (9.0) years), of which 46 (35%) had CAD defined as ≥1 stenosis ≥70% (≥50% in the left main), underwent adenosine SE and invasive coronary angiography. Resting AFI and layer-specific GLS were similar in patients with or without CAD (p > 0.05). The stress-rest difference (Δvalue = stress-value - rest-value) in patients with CAD was less pronounced compared to patients without proved CAD (Δendocardial GLS: -1.2 (3.5)% vs. -5.0 (3.2)%; Δmidventricular GLS: -0.95 (3.0)% vs. -4.2 (2.7)%; Δepicardial GLS: -0.7 (2.5)% vs. -3.4 (2.3)%; ΔAFI: -0.8 (2.9)% vs. -3.6 (3.1)%, p < 0.00001 for all comparisons). The diagnostic value of the three layer-specific GLS values and AFI were statistically similar (p = 0.19). The four Δvalues provided independent predictive value to the risk assessment given by gender, age, wall motion and ΔEF (p = 0.002, AFI and p < 0.0001, layer-specific GLS). The accuracies were acceptable (71-80%) with modest sensitivities (54-65%) and high specificities (80-91%). The deformation response to vasodilator infusion was associated with the presence of CAD. Endocardial, midventricular and epicardial GLS and AFI from adenosine SE had similar diagnostic values. The specificities were high, but the modest sensitivities are a limitation to the clinical application.

Value of global longitudinal strain by two dimensional speckle tracking echocardiography in predicting coronary artery disease severity

Background

Significant coronary artery stenosis might cause persistently impaired longitudinal left ventricle (LV) function at rest. LV global longitudinal strain (LVGLS) can be accurately assessed by 2D speckle-tracking strain echocardiography(2D-STE).

Objective

We aimed to evaluate the diagnostic accuracy of LV global longitudinal strain obtained by 2D-STE in prediction of severity of CAD.

Methods

Eighty patients with suspected stable angina pectoris were included. They underwent transthoracic echocardiography (TTE) to measure LV ejection fraction, 2-D-STE to measure GLS and coronary angiography (CA). The patients were divided into two groups: group 1 (58 patients) with significant (>70%) CAD, and group 2 (22 patients) with non-significant (<70%) CAD. Images were obtained in the apical long-axis, four-chamber, and two chamber views. Regional longitudinal systolic strain was measured in 17 myocardial segments and averaged to provide global longitudinal strain (LVGLS).

Results

There was significant decrease in GLS in group 1 compared to group 2 (−11.86 ± 2.89% versus −18.65 ± 0.79%, P < 0.000). The optimal cutoff value of GLS for prediction of significant CAD was −15.6% [AUC 0.88, 95% CI 0.78–0.96 p < 0.000]. The sensitivity, specificity and accuracy of GLS for detecting significant CAD were 93.1%, 81.8%,and 90% respectively.There was a significant positive correlation between GLS and EF (r = 0.33; p = 0.036).There was incremental significant decrease in GLS with increasing number of coronary vessels involved.

Conclusion

Measurement of global longitudinal strain using 2D speckle tracking echocardiography is sensitive and accurate tool in the prediction of severe CAD.