The predictive value of regional 2D longitudinal strain in determining the localization of coronary artery stenosis in NSTE-ACS patients

Background and purpose

Previous studies have shown that the role of global longitudinal 2DS in diagnosing and detecting coronary artery disease is modest. However, data on the sensitivity of the regional 2DS assessment is lacking (1–6). The aim of this study was to determine whether in echocardiographic evaluation of myocardial ischemia, regional 2D strain (2DS) assessment is more sensitive and specific in detecting ischemia due to critical stenosis of one or more coronary arteries in comparison with current standard of visual assessment of regional wall motion abnormalities (RWMA).

Material and methods

This retrospective study included 123 patients admitted through the Emergency Department across 36 months with the diagnosis of NSTE-ACS without previously known CAD or LBBB who underwent coronary angiography within the first 24 hours and had an echocardiogram with RWMA analysis done prior to procedure. 2DS analysis of regional longitudinal peak systolic strain (LPSS) according to the 18-segment model was performed by four clinicians, blinded to patient's clinical data.

Results

A significant correlation was found between individual parameters of LPSS and significant stenosis of all three major coronary vessels (>70% narrowing on coronary angiography, Table 1). Lower regional LPSS correlated well anatomically with the supplying arteries; for example, patients with LAD stenosis had significantly lower regional LPSS in all apical segments, lateral, anteroseptal and anterior mid segments and anterior basal segment. Similar patterns were seen in the LCx and RCA regions. Three graphs show the sensitivity and specificity of the most sensitive segments for each artery. The diagnostic accuracy of endocardial and epicardial regional LPSS was similar to the average regional LPSS.

Conclusion

We have shown that regional 2DS could be a good predictor of the presence and localization of coronary stenosis for each of the three main coronary arteries but further studies are needed to confirm this assumption.

Funding Acknowledgement

Type of funding sources: None.

Oral estramustine therapy in serum chromogranin A-positive stage D3 prostate cancer patients

Neuroendocrine (NE) differentiation in prostate cancer (PC) has attracted much attention since it has been shown to be associated with androgen independence and bad prognoses. In this study 34 patients with hormone refractory prostate cancer and elevated Chromogranin A (CgA) serum values were treated with estramustine for 15 months. The results were evaluated by analyzing clinical data and the serially measured total PSA and Chromogranin A serotest concentration, as well as bone scan recordings. In responders to therapy a sharp decline in CgA level was recorded as well as a slight decrease in the number of metastatic lesions in the bone. However, in 6- and 12-month nonresponders, supranormal serum CgA concentrations were measured (mean 305 +/- 122 ng/ml/ and 284 +/- 101 ng/ml, respectively). Statistical significance was found between neither of these groups (p > 0.05). Mean bone lesions data were practically identical in nonresponding groups (9.6 and 9.5) but were much lower in the respective responders (4.9 and 4.1). Twelve patients were found to be nonresponders 3 months after therapy initiation (12 out of 34, 35.3%). From the remaining 22 studied subjects a positive response patients continued in 17 patients during the next 3 months or overall in a six-month period (17 out of 34, 50%, or 17 out of 22, 77.3% from 3-month responders). After 9 months of therapy, 15 responding, patients were found (15 out of 34, 44.1%, or 15 out of 17, 88.2% from 6-month responders) while, after a full year of estramustine administration, 8 patients responded to therapy (8 out of 34, 23.5%, or 8 out of 15, 53.3% from responders after 9 months of treatment). Finally, after 15 months of treatment, only 3 responding patients found (3 out of 34, 8.8% or 3 out of 8, 37.5% from responders after 12 months of treatment). Mean response periods after 12 and 15 months of estramustine treatment were 5.5 and 5.7 months, respectively. In conclusion, the reported results indicate a 12-15 month responding period for estramustine therapy in patients with a slight initial elevation in CgA serotest (up to 150 ng/ml) and less than 10 metastatic osseous lesions. Thus, serum CgA assessment has definitely found a role in monitoring PC patients with NE positive stage D3 disease. This specially holds true as the population of aged men is rapidly increasing, posing a great challenge to urologists and oncologists in treating difficult-to-manage hormone-independent prostatic carcinoma.

Cross-correlation of serum chromogranin A, %-F-PSA and bone scans in prostate cancer diagnosis

Circulating Chromogranin A (CgA), total PSA (TPSA) and F-PSA concentrations were measured in 211 patients (pt) with newly diagnosed prostate cancer (PC) and in 25 controls with benign prostatic hypertrophy (BPH). TPSA values ranging 3.5-5.5 ng/ml were found in 14 PC pt (6.6%), 5.5-9.9 ng/ml in 29 pt (13.7%), 10-19.9 ng/ml in 75 pt (35.6%), 20-50 ng/ml in 64 pt (30.3%) and > 50 ng/ml in 29 pt (13.7%). In those groups of PC pt false negative % F-PSA level > 18 was respectively measured in 0 out of 14, 2 out of 29 (6.9%) 6 out of 75 (8.0%), 61 out of 4 (9.4%) and 6 out of 29 (20.7%) pt, or totally in 20 out of 211 (9.5%) pt. Among 20 PC pt with false negative %F-PSA data elevated CgA level (> 80 ng/ml) was found in 18 subjects (18 out of 20 90%) or respectively in 0, 1/2 (50%), 516 (83%), 6 out of 6 (100%) and 6 out of 6 (100%) patients. Bone scintigraphy was performed in all pt with TPSA concentration > 10 ng/ml at the time of diagnosis. Bone lesions were respectively found in 4 out of 75 (5.3%) pt with TPSA 10-20 ng/ml, 12 out of 64 (14%) pt with TPSA level from 20-50 mg/ml and in 25k9 (75.9%) pt with. TPSA above 50 ng/ml. Overall osseous metastases were recorded in 41 out of 211 pt (19.4%) with newly diagnosed PC and in 18 of these Stage D2 pt (43.9%) elevated CgA concentration were measured Among them elevated CgA level and tumor dissemination matched with false negative %F-PSA parameter (> 18%) in 4 out of 18 (22.2%) pt as well as in 37 out of 191 (19.4%) pt with %F-PSA < 18% (p > > 0.05). In parallel, a positive CgA level in newly presented PC pt was closely associated with %F-PSA false negativity (18 out of 20, 90%). A negative correlation between TPSA elevation and the magnitude of CgA serotest level indicate differences in their biological origin and activities. According to the data reported herein we advocate the assessment of serum Chromogranin A concentration in first presented patients with clinically proven PC, elevated T-PSA level and %F-PSA parameter > 18%. Neuroendocrine structures are resistant toward hormonal treatment and hence CgA measurement is strongly suggested in all candidates for a systemic hormone therapy.

I-131 MIBG and bone scintigraphy in a patient with MEN

The case of a patient with MEN is described. Emphasis is placed on the role of I-131 MIBG and bone scintigraphy as a part of the diagnostic and follow-up procedures.