Predictive Value of Echocardiographic Strain for Myocardial Fibrosis and Adverse Outcomes in Autoimmune Diseases

Assessment of Left Ventricular Strain Echocardiography in Individuals with Hashimoto's Thyroiditis and Its Association with Serum TIMP-1 Concentration

Background: Hashimoto's thyroiditis (HT), which is an autoimmune condition and the primary cause of hypothyroidism, has numerous impacts on the cardiovascular system. This research aimed to compare TIMP-1 levels and LV strain values in euthyroid HT, hypothyroid HT, and healthy control persons. Materials and Methods: This study included 40 hypothyroid HT patients, 42 HT patients who became euthyroid with thyroid hormone replacement therapy, and 40 healthy controls. All subjects had conventional echocardiography and STE. Global and segmental LV longitudinal strain values (LVGLS) were calculated. Participants' blood was tested for TIMP-1, thyroid function, and anti-TPO. Results: Higher serum TIMP-1 levels were found in euthyroid and hypothyroid HT patients than in the control group. Additionally, patients with euthyroid and hypothyroid HT displayed lower segmental and global LV strain values than the control group. A negative correlation was observed between strain values and TIMP-1 and anti-TPO levels. No significant difference was observed in serum TIMP-1 and strain values between euthyroid and hypothyroid HT patients. Patients with hypothyroid HT exhibited impaired diastolic function and reduced ejection fraction when compared to both euthyroid HT and control groups. However, euthyroid HT patients and the controls had similar diastolic function and ejection fractions. Conclusions: Hashimoto's thyroiditis causes impairment of LV strain, regardless of thyroid hormone levels. Additionally, the condition is associated with elevated TIMP-1 levels. The relationship between LV strain values and anti-TPO levels indicates that the autoimmune component of the disease may be responsible for the impaired LV strain.

Unmasking the Hidden Threat: The Role of Left Ventricular Subendocardial Involvement in Autoimmune Rheumatic Disease

BACKGROUND

Late gadolinium enhancement (LGE) has been found in patients with autoimmune rheumatic disease (ARD). However, the prognostic implications of some specific LGE patterns in ARD patients remain unclear.

PURPOSE

To investigate the prevalence and prognostic significance of left ventricular (LV) subendocardium-involved LGE (LGEse) in a cohort of ARD patients.

MATERIALS AND METHODS

This retrospective study evaluated 176 patients diagnosed with ARD with clinically suspected cardiac involvement between 2018 and 2023. LV LGEse was defined as LGE involving the LV subendocardium that did not correspond to a coronary vascular distribution. The endpoints included a composite of cardiac death, heart failure-related admission, cardiogenic shock, and appropriate pacemaker or implantable cardioverter-defibrillator therapy.

RESULTS

Of the 176 consecutive patients, LV LGEse was observed in 22 patients (13%). During a median follow-up of 776 days (interquartile range, 395-1405 days), 20 patients (11%) experienced a composite endpoint. Compared with those without LV LGEse, the LV LGEse group had a greater proportion of men (64% vs. 14%; p < 0.001), lower LV ejection fraction (50% vs. 60%; p = 0.001), greater LV end-diastolic volume index (78 vs. 75; p = 0.043), and more adverse outcomes (32% vs. 8%; p = 0.005). In the univariable and multivariable Cox regression analyses, the LV LGEse showed independent prognostic value. In the sensitivity analyses, the prognostic difference in terms of LV subendocardial involvement remained.

CONCLUSION

In our cohort, LV subendocardial involvement, an underrecognized LGE pattern, was observed in 13% of all patients with autoimmune disease and indicated a worse prognosis.

Arrhythmic mitral valve prolapse: a practical approach for asymptomatic patients

Mitral valve prolapse (MVP) is usually regarded as a benign condition though the proportion of patients with a life-threatening arrhythmic MVP form remains undefined. Recently, an experts' consensus statement on arrhythmic MVP has proposed approaches for risk stratification across the spectrum of clinical manifestation. However, sudden cardiac death may be the first presentation, making clinicians focused to early unmasking this subset of asymptomatic patients. Growing evidence on the role of cardiac imaging in the in-deep stratification pathway has emerged in the last decade. Pathology findings have suggested the fibrosis of papillary muscles and inferobasal left ventricular wall as the malignant hallmark. Cardiac magnetic resonance, while of limited availability, allows the identification of this arrhythmogenic substrate. Therefore, speckle-tracking echocardiography may be a gateway to prompt referring patients to further advanced imaging investigation. Our review aims to summarize the phenotypic features linked to the arrhythmic risk and to propose an image-based algorithm intended to help stratifying asymptomatic MVP patients.

Prevalence of subclinical systolic dysfunction in Takayasu's arteritis and its association with disease activity: a cross-sectional study

BACKGROUND

Takayasu's arteritis (TA) is a vasculitis that affects the aorta and its branches and causes stenosis, occlusion, and aneurysms. Up to 60% of TA patients are associated with cardiac involvement which confers a poor prognosis. Global longitudinal strain (GLS) analysis is an echocardiographic technique that can detect the presence of subclinical systolic dysfunction. Hence, this study aimed to describe the prevalence of subclinical systolic dysfunction in patients with TA using the GLS method and to correlate this finding with disease activity using the ITAS-2010 (Indian Takayasu Activity Score).

METHODS

Thirty patients over 18 years of age who met the American College of Rheumatology (ACR) 1990 criteria for TA were included. The sample was submitted for medical record review, clinical and echocardiographic evaluation, and application of ITAS-2010. The cutoff for systolic dysfunction was GLS > - 20%.

RESULTS

Of the 30 patients analyzed, 25 (83.3%) were female, and the mean age was 42.6 years (± 13.2). The median time since diagnosis was 7.5 years [range, 3-16.6 years], and the type V angiographic classification was the most prevalent (56.7%). Regarding echocardiographic findings, the median ejection fraction (EF) was 66% [61-71%] and the GLS was - 19.5% [-21.3 to -15.8%]. Although half of the participants had reduced GLS, only two had reduced EF. Eleven patients (33.%) met the criteria for activity. An association was found between disease activity and reduced GLS in eight patients (P = 0.02) using the chi-square test.

CONCLUSION

GLS seems to be an instrument capable of the early detection of systolic dysfunction in TA. The association between GLS and disease activity in this study should be confirmed in a study with a larger sample size.

Predictive value of cardiac magnetic resonance mechanical parameters for myocardial fibrosis in hypertrophic cardiomyopathy with preserved left ventricular ejection fraction

Objective

Myocardial fibrosis leads to systolic dysfunction in hypertrophic cardiomyopathy (HCM) patients. This study aims to investigate the relationship between cardiac magnetic resonance mechanical parameters for evaluating the left ventricular function in HCM with preserved left ventricular ejection fraction (LVEF ≥50%) and the association between myocardial fibrosis defined by late gadolinium enhancement (LGE).

Methods

This study was a retrospective analysis of CMR images of 93 patients with HCM with preserved ejection fraction (HCMpEF) and 96 controls diagnosed by cardiac magnetic resonance (CMR) at our hospital from July 2019 to January 2022. The myocardial contraction fraction (MCF) was calculated, and myocardial mechanical parameters, including global myocardial longitudinal strain (GLS), circumferential strain (GLS), and myocardial strain (GLS), were obtained by tissue tracking and LGE quantitative modules of dedicated software, respectively. The correlation between myocardial strain and LGE was analyzed, and a multivariate logistic regression model was developed to discuss the risk predictors of LGE.

Results

Compared to the control group, the left ventricular mechanical parameters GLS (-13.90 ± 3.80% versus -18.20 ± 2.10%, p < 0.001), GCS (-16.62 ± 3.50% versus -18.4 ± 2.69%, p < 0.001), GRS (28.99 ± 10.38% versus 33.02 ± 6.25%, p < 0.01), and MCF (64 ± 16% versus 99 ± 18%, p < 0.001) were found significantly lower in HCM group. Moreover, even in LGE-negative HCM patients, GLS (-16.3 ± 3.9%) and MCF (78 ± 19%) were significantly lower compared to the control group. Left ventricular GLS [OR = 1.61, (1.29, 2.02), p = 0.001] and MCF [OR = 0.90, (0.86, 0.94), p = 0.001] independently predicted myocardial late gadolinium enhancement (LGE).

Conclusion

In participants of HCM with preserved ejection fraction, the early onset of reduced left ventricular GLS and MCF in patients with HCMpEF may provide new evidence for evaluating impaired myocardial systolic function. The reduction of myocardial mechanical indexes may reflect the presence and extent of myocardial fibrosis, and the more significant the reduction, the more severe the myocardial fibrosis; GLS and MCF may be ideal predictors for LGE.

Detection of myocardial fibrosis: Where we stand

Myocardial fibrosis, resulting from the disturbance of extracellular matrix homeostasis in response to different insults, is a common and important pathological remodeling process that is associated with adverse clinical outcomes, including arrhythmia, heart failure, or even sudden cardiac death. Over the past decades, multiple non-invasive detection methods have been developed. Laboratory biomarkers can aid in both detection and risk stratification by reflecting cellular and even molecular changes in fibrotic processes, yet more evidence that validates their detection accuracy is still warranted. Different non-invasive imaging techniques have been demonstrated to not only detect myocardial fibrosis but also provide information on prognosis and management. Cardiovascular magnetic resonance (CMR) is considered as the gold standard imaging technique to non-invasively identify and quantify myocardial fibrosis with its natural ability for tissue characterization. This review summarizes the current understanding of the non-invasive detection methods of myocardial fibrosis, with the focus on different techniques and clinical applications of CMR.