Regional Strain Score as Prognostic Marker of Cardiovascular Events From the Multi-Ethnic Study of Atherosclerosis (MESA)

Left Ventricular Injury Detected by Cardiac MRI and Incident Ischemic Stroke and Dementia Risk: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND OBJECTIVES

Left ventricular injury (LVI) can be detected by cardiac magnetic resonance (CMR) imaging with high sensitivity; however, the implication of these findings on brain health longitudinally is uncertain. We aimed to evaluate the association between LVI biomarkers detected by CMR and the risk of developing ischemic stroke and dementia.

METHODS

We analyzed the prospective, observational cohort of participants in the Multi-Ethnic Study of Atherosclerosis (MESA) study (median follow-up of 8.7 years). MESA is a population-based cohort recruited from 6 communities. The complete case analysis (CCA) sample included stroke-free participants who underwent CMR at Exam 5 (2010-2012). The multiple imputation (MI) sample consisted of stroke-free participants at Exam 5, irrespective of CMR collection. Missing CMR variables were imputed because of the nonrandom missingness of CMR data. The primary exposure was LVI defined by LV ejection fraction < 50% or circumferential strain ≥ -10 in any LV apical wall. Secondary exposures were left ventricular ejection fraction (LVEF) and strain as continuous measures. Primary outcomes were (1) incident ischemic stroke and (2) newly diagnosed all-cause dementia. Cox proportional hazard models were adjusted for demographic and clinical covariates.

RESULTS

There were 2,584 (11.7% with LVI [mean age 71, 65% male], 88.3% without LVI [mean age 69, 44% male]) and 4,594 participants in the CCA and MI cohorts, respectively. Incident ischemic stroke occurred in 18 (6%) participants with and 65 (3%) without LVI in the CCA sample (302 or 12% with and 18 or 6% without LVI in the MI sample). Both groups had similar rates of cardiovascular disease (6% vs 4%, p = 0.143). LVI was significantly associated with incident ischemic stroke in the MI cohort (adjusted hazard ratio [HR] 1.82, 95% CI 1.08-3.09), but not in the CCA cohort. LV apical peak strain was significantly associated with newly diagnosed dementia only in the MI cohort (adjusted HR 1.06, 95% CI 1.01-1.12). LVEF per 10% was significantly associated with newly diagnosed dementia in both cohorts (adjusted HR in MI cohort 0.73, 95% 0.59-0.90).

DISCUSSION

CMR-detected LVI is associated with incident ischemic stroke and newly diagnosed dementia. Further studies are needed to validate CMR biomarkers of brain injury risk.

Speckle-tracking and conventional echocardiography in MIS-C: tracking cardiac involvement and recovery

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C), a complication of COVID-19, is frequently associated with cardiac involvement. Although most affected children recover, the extent and duration of myocardial abnormalities remain uncertain. This study evaluates mid-term cardiac function in MIS-C patients, with and without cardiac involvement, using transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE).

METHODS

This case-control study (2022-2023) included 90 children: 30 with MIS-C and cardiac involvement, 30 with MIS-C without cardiac involvement, and 30 healthy controls. TTE and STE were used to assess left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) at diagnosis and at three months, comparing outcomes across groups.

RESULTS

The cardiac involvement group exhibited significantly elevated ferritin and C-reactive protein levels (P = 0.006 and P = 0.017, respectively) and a higher prevalence of troponin positivity (56.67% vs. 20%, P = 0.009). At baseline, these patients had markedly reduced LVEF (56.5 ± 4.3) and GLS (-21.6 ± 3.21) compared to healthy controls (LVEF: 68.2 ± 5.21; GLS: -24.8 ± 1.48; both P < 0.001). Notably, the basal segment showed significant longitudinal strain reduction (-18.75 ± 3.89 vs. -23.58 ± 0.27, P = 0.027), while differences in the apical and mid segments were not significant. By three months, LVEF (69 ± 4.21, P = 0.53) and GLS (-24.13 ± 2.39, P = 0.17) normalized. Heart failure and coronary artery brightness resolved in all affected patients, and most structural abnormalities improved; only two cases exhibited persistent mild left ventricular dilation. Regional strain analysis at follow-up revealed values comparable to those of healthy controls across all segments.

CONCLUSION

Cardiac dysfunction in MIS-C largely resolves within three months, with LVEF and GLS returning to normal. However, persistent myocardial abnormalities in a few cases highlight the need for long-term cardiac monitoring to detect and manage potential sequelae.

Prognostic impact of late gadolinium enhancement granularity in non-ischemic dilated cardiomyopathy

OBJECTIVES

We aimed to assess the additional prognostic value of the concept of "late gadolinium enhancement (LGE) granularity" in non-ischemic dilated cardiomyopathy (DCM) patients to predict all-cause death.

METHODS

Between 2008 and 2021, we conducted a bicentric retrospective study including all consecutive DCM patients referred for Cardiovascular Magnetic Resonance (CMR). The primary outcome was all-cause death. Cox regressions were performed to determine the prognostic value of LGE findings.

RESULTS

Of 1668 DCM patients recruited (age 52 ± 8 years, 54% male), 268 (16%) died after a median (interquartile range) follow-up of 9 (7-12) years. In DCM patients with LGE (N = 472), the LGE extent, the septal location, and its presence in multiple areas were independently associated with death after adjustment for all prognostic variables (adjusted hazard ratio (HR): 4.27, 95% CI: 2.22-8.22; HR: 5.74, 95% CI: 3.35-9.85; and HR: 4.38, 95% CI: 2.08-9.22 respectively; all p < 0.001). The LGE granularity model combining all these LGE features showed the best improvement in model discrimination and reclassification over traditional prognostic variables, including the left ventricular ejection fraction (LVEF) value (C-statistic improvement: 0.14; net reclassification improvement = 64.3%; integrative discrimination index = 29.0%; all p < 0.05).

CONCLUSION

In a large cohort of DCM patients, a LGE granularity model combining LGE extent, location and multiple areas had additional prognostic value above traditional prognostic variables including the LVEF value to predict all-cause death.

KEY POINTS

Question Assessment of late gadolinium enhancement (LGE) is recommended in non-ischemic dilated. cardiomyopathy (DCM) patients to stratify the risk of death, but other LGE characteristics are not currently considered. Findings The concept of "LGE granularity," including the extent, location, and number of areas, provides additional prognostic value, especially in predicting all-cause mortality. Clinical relevance "LGE granularity" could play a crucial role not only in guiding the decision to implant a defibrillator in DCM patients but also in providing more personalized management, such as enhanced cardioprotective treatments, for those with high-risk LGE characteristics.

Absence of cardiac impairment in patients after severe acute respiratory syndrome coronavirus type 2 infection: A long-term follow-up study

BACKGROUND

Concerns exist that long-term cardiac alterations occur after severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection, particularly in patients who were hospitalized in the acute phase or who remain symptomatic. This study investigates potential long-term functional and morphological alterations after SARS-CoV-2 infection.

METHODS

The authors of this study investigated patients after SARS-CoV-2 infection by using a mobile 1.5T clinical magnetic resonance scanner for cardiac alterations. Cardiac function and dimensions were assessed using a highly efficient cardiac magnetic resonance protocol, which included cine sequences, global longitudinal and circumferential strain assessed by fast-Strain-ENCoded imaging, and T1 and T2 mapping. We assessed symptoms through a questionnaire. Patients were compared with a control group matched for age, gender, body mass index, and body surface area.

RESULTS

Median follow-up time was 395 (192-408) days. The final population included 183 participants (age 48.4 ± 14.3 years, 48.1% male (88/183)). During the acute phase of SARS-CoV-2 infection, 27 patients were hospital-admitted. Forty-two patients reported persistent symptoms (shortness of breath, chest pain, palpitations, or leg edema), and 63 reported impaired exercise tolerance. Left ventricular (LV) functional and morphological parameters were within the normal range. T1- and T2-relaxation times were also within the normal range, indicating that the presence of myocardial edema or fibrosis was unlikely. Persistently symptomatic patients showed a slightly reduced indexed LV stroke volume. Functional parameters remained normal in patients who were hospitalized for SARS-CoV-2, persistently symptomatic, or with ongoing impaired exercise tolerance.

CONCLUSION

Irrespective of ongoing symptoms or severity of prior illness, patients who have recovered from SARS-CoV-2 infection demonstrate normal functional and morphological cardiac parameters. Long-term cardiac changes due to SARS-CoV-2 infection appear to be rare.

Association of global longitudinal strain by feature tracking cardiac magnetic resonance imaging with adverse outcomes among community-dwelling adults without cardiovascular disease: The Dallas Heart Study

AIM

Left ventricular (LV) global longitudinal strain (GLS) may detect subtle abnormalities in myocardial contractility among individuals with normal LV ejection fraction (LVEF). However, the prognostic implications of GLS among healthy, community-dwelling adults is not well-established.

METHODS AND RESULTS

Overall, 2234 community-dwelling adults (56% women, 47% Black) with LVEF ≥50% without a history of cardiovascular disease (CVD) from the Dallas Heart Study who underwent cardiac magnetic resonance (CMR) with GLS assessed by feature tracking CMR (FT-CMR) were included. The association of GLS with the risk of incident major adverse cardiovascular events (MACE; composite of incident myocardial infarction, incident heart failure [HF], hospitalization for atrial fibrillation, coronary revascularization, and all-cause death), and incident HF or death were assessed with adjusted Cox proportional hazards models. A total of 309 participants (13.8%) had MACE during a median follow-up duration of 17 years. Participants with the worst GLS (Q4) were more likely male and of the Black race with a history of tobacco use and diabetes with lower LVEF, higher LV end-diastolic volume, and higher LV mass index. Cumulative incidence of MACE was higher among participants with worse (Q4 vs. Q1) GLS (20.4% vs. 9.0%). In multivariable-adjusted Cox models that included clinical characteristics, cardiac biomarkers and baseline LVEF, worse GLS (Q4 vs. Q1) was associated with a significantly higher risk of MACE (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.07-2.24, p = 0.02) and incident HF or death (HR 1.57, 95% CI 1.03-2.38, p = 0.04).

CONCLUSIONS

Impaired LV GLS assessed by FT-CMR among adults free of cardiovascular disease is associated with a higher risk of incident MACE and incident HF or death independent of cardiovascular risk factors, cardiac biomarkers and LVEF.

Layer-specific fast strain-encoded cardiac magnetic resonance imaging aids in the identification and discrimination of acute myocardial injury: a prospective proof-of-concept study

BACKGROUND

Acute myocardial injury is a common diagnosis in the emergency department and differential diagnoses are numerous. Cardiac magnetic resonance (CMR) strain sequences, such as fast strain ENCoded (fSENC), are early predictors of myocardial function loss. This study assessed the potential diagnostic and prognostic benefits of a layer-specific approach.

METHODS

For this prospective study, patients in the emergency department fulfilling rule-in criteria for non-ST-elevation myocardial infarction (NSTEMI) received an ultra-fast fSENC CMR. Volunteers without cardiac diseases (controls) were recruited for comparison. Measurements were performed in a single heartbeat acquisition to measure global longitudinal strain (GLS) and segmental longitudinal strain and dysfunctional segments. The GLS was measured in two layers and a difference (GLSdifference = GLSepicardial - GLSendocardial) was calculated. The performance of those strain features was compared to standard care (physical examination, cardiac biomarkers, electrocardiogram). According to the final diagnosis after discharge, patients were divided into groups and followed up for 2 years.

RESULTS

A total of 114 participants, including 50 controls, were included. The 64 patients (51 male) were divided into a NSTEMI (25), myocarditis (16), and other myocardial injury group (23). GLS served as a potent predictor of myocardial injury (area under the curve (AUC) 91.8%). The GLSdifference provided an excellent diagnostic performance to identify a NSTEMI (AUC 83.2%), further improved by including dysfunctional segments (AUC 87.5%, p = 0.01). An optimal test was achieved by adding fSENC to standard care (AUC 95.5%, sensitivity 96.0%, specificity 86.5%, p = 0.03). No death occurred in 2 years for patients with normal GLS and ≤5 dysfunctional segments, while three patients died that showed abnormal GLS or >5 dysfunctional segments.

CONCLUSIONS

Layer-specific strain is a potential new marker with high diagnostic performance in the identification and differentiation of acute myocardial injuries.

Systematic review and meta-analysis for the value of cardiac magnetic resonance strain to predict cardiac outcomes

Cardiac magnetic resonance (CMR) is the gold standard for the diagnostic classification and risk stratification in most patients with cardiac disorders. The aim of the present study was to investigate the ability of Strain-encoded MR (SENC) for the prediction of major adverse cardiovascular events (MACE). A systematic review and meta-analysis was performed according to the PRISMA Guidelines, including patients with or without cardiovascular disease and asymptomatic individuals. Myocardial strain by HARP were used as pulse sequences in 1.5 T scanners. Published literature in MEDLINE (PubMed) and Cochrane's databases were explored before February 2023 for studies assessing the clinical utility of myocardial strain by Harmonic Phase Magnetic Resonance Imaging (HARP), Strain-encoded MR (SENC) or fast-SENC. In total, 8 clinical trials (4 studies conducted in asymptomatic individuals and 4 in patients with suspected or known cardiac disease) were included in this systematic review, while 3 studies were used for our meta-analysis, based on individual patient level data. Kaplan-Meier analysis and Cox proportional hazard models were used, testing the ability of myocardial strain by HARP and SENC/fast-SENC for the prediction of MACE. Strain enabled risk stratification in asymptomatic individuals, predicting MACE and the development of incident heart failure. Of 1332 patients who underwent clinically indicated CMR, including SENC or fast-SENC acquisitions, 19 patients died, 28 experienced non-fatal infarctions, 52 underwent coronary revascularization and 86 were hospitalized due to heart failure during median 22.4 (17.2-28.5) months of follow-up. SENC/fast-SENC, predicted both all-cause mortality and MACE with high accuracy (HR = 3.0, 95% CI = 1.2-7.6, p = 0.02 and HR = 4.1, 95% CI = 3.0-5.5, respectively, p < 0.001). Using hierarchical Cox-proportional hazard regression models, SENC/fast-SENC exhibited incremental value to clinical data and conventional CMR parameters. Reduced myocardial strain predicts of all-cause mortality and cardiac outcomes in symptomatic patients with a wide range of ischemic or non-ischemic cardiac diseases, whereas in asymptomatic individuals, reduced strain was a precursor of incident heart failure.

Prognostic impact of artificial intelligence-based fully automated global circumferential strain in patients undergoing stress CMR

AIMS

To determine whether fully automated artificial intelligence-based global circumferential strain (GCS) assessed during vasodilator stress cardiovascular (CV) magnetic resonance (CMR) can provide incremental prognostic value.

METHODS AND RESULTS

Between 2016 and 2018, a longitudinal study included all consecutive patients with abnormal stress CMR defined by the presence of inducible ischaemia and/or late gadolinium enhancement. Control subjects with normal stress CMR were selected using a propensity score-matching. Stress-GCS was assessed using a fully automatic machine-learning algorithm based on featured-tracking imaging from short-axis cine images. The primary outcome was the occurrence of major adverse clinical events (MACE) defined as CV mortality or nonfatal myocardial infarction. Cox regressions evaluated the association between stress-GCS and the primary outcome after adjustment for traditional prognosticators. In 2152 patients [66 ± 12 years, 77% men, 1:1 matched patients (1076 with normal and 1076 with abnormal CMR)], stress-GCS was associated with MACE [median follow-up 5.2 (4.8-5.5) years] after adjustment for risk factors in the propensity-matched population [adjusted hazard ratio (HR), 1.12 (95% CI, 1.06-1.18)], and patients with normal CMR [adjusted HR, 1.35 (95% CI, 1.19-1.53), both P < 0.001], but not in patients with abnormal CMR (P = 0.058). In patients with normal CMR, an increased stress-GCS showed the best improvement in model discrimination and reclassification above traditional and stress CMR findings (C-statistic improvement: 0.14; NRI = 0.430; IDI = 0.089, all P < 0.001; LR-test P < 0.001).

CONCLUSION

Stress-GCS is not a predictor of MACE in patients with ischaemia, but has an incremental prognostic value in those with a normal CMR although the absolute event rate remains low.