Absolute Global Longitudinal Strain Research Articles

Liver stiffness as a prognostic parameter and tool for risk stratification in advanced cardiac transthyretin amyloidosis.

In light of increasing therapeutic options, risk stratification of advanced cardiac transthyretin amyloidosis (ATTR-CA) is gaining clinical importance to avoid ineffective treatments. Liver stiffness as a marker of hypervolemia and hepatic congestion might predict mortality in advanced ATTR-CA and allow to identify patients at highest risk. Proven ATTR-CA patients underwent repeated vibration-controlled transient elastography (VTCE) and standardized serial workup within the local amyloidosis cohort study AmyKoS. Spearman correlation analyses and Cox regressions were performed to evaluate the prognostic value. 41 patients with ATTR-CA were included with median age of 76.6 (55.1-89.1) years, of which 90.2% were male and > 92% wild-type ATTR-CA. In total, 85 VCTE examinations were performed. Median follow-up was 43.7 (2.4-75.6) months; 26.8% of the patients died. At the first clinical evaluation, median left ventricular (LV) absolute global longitudinal strain (GLS) was 11.4 (5.2-19.0) % and median liver stiffness was 6.3 (2.4-22.9) kPa, both significantly correlated with mortality. NT-proBNP possessed statistically significant predictive power in ATTR-CA with more preserved LV function (absolute GLS ≥ 10), whereas stiffness seemed to be more discriminative for ATTR-CA with absolute GLS < 10. The use of alternative congestion surrogates such as liver vein dilation and tricuspid regurgitation peak velocity (tr-vmax) showed congruent results. Liver stiffness shows prognostic value regarding all-cause mortality and allows risk stratification in advanced ATTR-CA, particularly in those with markedly impaired longitudinal LV function. These results are transferable to other congestion surrogates.

Cardiac troponin T associates with left ventricular function and synchrony assessed by CMR in the general population: results from the Akershus Cardiac Examination 1950 Study.

Cardiac troponin T (cTnT) is a blood biomarker of myocardial injury that is associated with future adverse cardiovascular events in the general population. Left ventricular (LV) global longitudinal strain (GLS) and mechanical dispersion (MD) are metrics of systolic function and synchrony that can be obtained from cardiac imaging. Studies suggest an association between cTnT and echocardiographically assessed GLS and MD, but it is unknown whether cTnT relates to these metrics when assessed by cardiac magnetic resonance (CMR). We hypothesized that cTnT associates with GLS and with MD assessed by CMR feature tracking (CMR-FT) in the general population. cTnT and CMR-FT measurements were performed in 186 community dwellers from the Akershus Cardiac Examination 1950 Study. The participants' age ranged from 68 to 70 years. Median cTnT concentration was 7.0 ng/L (interquartile interval 5.0-12.6 ng/L), median absolute value of GLS was 17.3% (interquartile interval 15.7-18.8%), and median MD was 80.7 milliseconds (interquartile interval 61.8-105.0 milliseconds). In multivariable linear regression models adjusted for common clinical risk factors of cardiovascular disease, with GLS and MD as outcome and cTnT as the predictor variable of interest, log10 transformed cTnT was significantly associated with both absolute GLS [β-coefficient -1.65, confidence interval (-2.84, -0.46)] and MD [β-coefficient 28.56, confidence interval (12.14, 44.92)]. In older adults from the general population, higher cTnT concentrations are associated with worse systolic function and synchrony assessed by CMR-FT LV GLS and MD, adding information about myocardial function to traditional risk factors.

Quantitative assessment of left ventricular myocardial work in patients with different types of atrial fibrillation by non-invasive pressure-strain loop technique.

This study aimed to analyze myocardial work in patients with atrial fibrillation (AF) using a noninvasive pressure strain loop (PSL) technique to provide a basis for the quantitative assessment of left ventricular (LV) systolic function. LV myocardial work of 107 AF patients (56 with paroxysmal atrial fibrillation and 51 with persistent atrial fibrillation) and 55 healthy individuals were assessed by the noninvasive PSL and then compared. Global longitudinal strain (GLS) in absolute values, global work index (GWI), global constructive work (GCW), and global work efficiency (GWE) were significantly lower in the AF group than control group, whereas peak strain dispersion (PSD) and global wasted work (GWW) were significantly higher (P<.05). Further subdivision according to the AF type revealed that, compared with the controls, GLS in absolute values and GWE decreased significantly; PSD and GWW increased significantly in the paroxysmal AF group (P<.05). Nevertheless, GWI and GCW were not significantly different between paroxysmal AF and control groups (P>.05). Compared to paroxysmal AF, persistent AF induced a further decrease in absolute GLS and GWE and a further increase in GWW (P<.05), but PSD did not increase further (P>.05). Multiple linear regression analysis showed that GWI and GCW were independently associated with systolic blood pressure. GWW was associated with types of AF and left atrial volume index (LAVI). GWE was correlated with age, types of AF, disease duration, and LAVI. Receiver operating characteristic curve analysis showed that the area under the curve predicting myocardial injury was higher for GWE and GWW than for GLS (area under the curve: .880, .846, and .821, respectively). Non-invasive PSL can quantitatively assess LV systolic function in patients with different kinds of AF and detect early subclinical myocardial injury in patients with paroxysmal AF. GWE and GWW outperform GLS and LV ejection fraction when assessing myocardial injury. Systolic blood pressure, type of AF, LVAI, disease duration, and age may be associated with myocardial injury in patients with AF.

Clinical implications of subclinical left ventricular dysfunction in heart failure with preserved ejection fraction: The PARAGON-HF study.

Left ventricular (LV) subclinical impairment has been described in heart failure with preserved ejection fraction (HFpEF). We assessed the relationship between LV myocardial deformation by strain imaging and recurrent hospitalization for heart failure (HF) or cardiovascular death in a large international HFpEF population. We assessed two-dimensional speckle-tracking based global longitudinal strain (GLS) in 790 patients (mean age 74 ± 8 years, 54% female) with adequate image quality enrolled in the PARAGON-HF echocardiography study. We examined the relationship of GLS with total HF hospitalizations and cardiovascular death (the primary composite outcome) after accounting for clinical confounders. Approximately 47% of the population had evidence of LV subclinical dysfunction, defined as absolute GLS <16%. Impaired GLS was significantly associated with higher values of circulating baseline N-terminal pro-B-type-natriuretic peptide. After a median follow-up of 3.0 years, there were 407 total HF hospitalizations and cardiovascular deaths. After multivariable adjustment, worse GLS was associated with a greater risk for the primary composite outcome (adjusted hazard ratio per 1% decrease: 1.06; 95% confidence interval 1.02-1.11; p = 0.008). GLS did not modify the treatment effect of sacubitril/valsartan compared with valsartan for the composite outcome (p for interaction >0.1). In a large HFpEF population, impaired LV function was observed even among patients with preserved ejection fraction, and was associated with an increased risk of total HF hospitalizations or cardiovascular death, accounting for clinical confounders. These findings highlight the key role of subtle LV systolic impairment in the pathophysiology of HFpEF.

The Prognostic Role of Global Longitudinal Strain and NT-proBNP in Heart Failure Patients Receiving Cardiac Resynchronization Therapy.

We aimed to evaluate whether baseline GLS (global longitudinal strain), NT-proBNP, and changes in these after cardiac resynchronization therapy (CRT) can predict long-term clinical outcomes and the echocardiographic-based response to CRT (defined by 15% relative reduction in left ventricular end-systolic volume). We enrolled 143 patients with stable ischemic heart failure (HF) undergoing CRT-D implantation. NT-proBNP and echocardiography were obtained before and 6 months after. The patients were followed up (median: 58 months) for HF-related deaths and/or HF hospitalizations (primary endpoint) or HF-related deaths (secondary endpoint). A total of 84 patients achieved the primary and 53 the secondary endpoint, while 104 patients were considered CRT responders and 39 non-responders. At baseline, event-free patients had higher absolute GLS values (p < 0.001) and lower NT-proBNP serum levels (p < 0001) than those achieving the primary endpoint. A similar pattern was observed in favor of CRT responders vs. non-responders. On Cox regression analysis, baseline absolute GLS value (HR = 0.77; 95% CI, 0.51-1.91; p = 0.002) was beneficially associated with lower primary endpoint incidence, while baseline NT-proBNP levels (HR = 1.55; 95% CI, 1.43-2.01; p = 0.002) and diabetes presence (HR = 1.27; 95% CI, 1.12-1.98; p = 0.003) were related to higher primary endpoint incidence. In HF patients undergoing CRT-D, baseline GLS and NT-proBNP concentrations may serve as prognostic factors, while they may predict the echocardiographic-based response to CRT.

The Contemporary Role of Speckle Tracking Echocardiography in Cirrhotic Cardiomyopathy.

Cirrhotic cardiomyopathy (CCM) is characterized by elevated cardiac output at rest, an inability to further increase contractility under stress, and diastolic dysfunction. The diagnosis of CCM is crucial as it can lead to complications during liver transplantation. However, its recognition poses challenges with conventional echocardiography techniques. Speckle tracking echocardiography (STE), particularly global longitudinal strain (GLS), is a novel index that enhances the diagnostic efficacy of echocardiography for both ischemic and non-ischemic cardiomyopathies. GLS proves more sensitive in identifying early systolic dysfunction and is also influenced by advanced diastolic dysfunction. Consequently, there is an expanding scope for GLS utilization in cirrhotic cases, with newly updated diagnostic criteria for CCM incorporating GLS. Specifically, systolic dysfunction is now defined as either a left ventricular ejection fraction below 50% or an absolute GLS below 18%. However, conflicting data on GLS alterations in liver cirrhosis patients persist, as many individuals with advanced disease and a poor prognosis exhibit a hyperdynamic state with preserved or increased GLS. Consequently, the presence of CCM, according to the updated criteria, does not exhibit a significant association-in the majority of studies-with the severity of liver disease and prognosis. Furthermore, information on other indices measured with STE, such as left atrial and right ventricular strain, is promising but currently limited. This review aims to offer a critical assessment of the existing evidence concerning the application of STE in patients with liver cirrhosis.

Incremental prognostic utility of left ventricular and left atrial strains in coronary artery disease patients with reduced systolic function.

This study aimed to investigate the predictive value of left ventricular global longitudinal strain (GLS) and left atrial reservoir strain (LARS) on adverse events in chronic coronary artery disease (CAD) patients with reduced systolic function. A total of 192 consecutive patients clinically diagnosed with chronic CAD and left ventricular ejection fraction (LVEF)≤50% were finally included. Multiple strain parameters were analyzed with speckle tracking echocardiography. The composite endpoint included all-cause mortality, rehospitalization due to heart failure, myocardial infarction, and stroke. Patients experiencing the endpoint showed lower LVEF, lower absolute GLS and LARS than those without events. Both GLS (AUC=0.82 [GLS] vs. 0.58 [LVEF], p < 0.001) and LARS (AUC=0.71 [LARS] vs. 0.58 [LVEF], p=0.033) were superior to LVEF in predicting adverse events. Multivariate cox regression analysis showed that both GLS (hazard ratio, 0.71; 95% CI, 0.63-0.79; p < 0.001) and LARS (hazard ratio, 0.96; 95% CI, 0.93-0.98; p < 0.001) were independent predictors for the endpoint. The addition of LARS (global chi-squared, 35.7vs. 17.4; p < 0.05), GLS (global chi-squared, 58.6vs. 17.4; p < 0.05) or both LARS and GLS (global chi-squared, 79.6vs. 17.4; p < 0.05) to LVEF in the prediction model significantly improved its performance. The same significant improvement was also shown in the subgroups of mild (30%<LVEF≤50%) and severe (LVEF≤30%) reduced systolic function. Regarding CAD patients with reduced LVEF, both GLS and LARS are superior to LVEF in predicting adverse events, providing significant incremental value to LVEF.

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

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. 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. 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. 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.

Echocardiographic characterization of patients with supranormal ejection fraction: pooled core laboratory analysis of the TOPCAT and PARAGON-HF trials

Abstract Background Patients with heart failure and supranormal ejection fraction (HFsnEF) may be phenotypically distinct from those with normal or below normal left ventricular ejection fraction (LVEF), and may demonstrate different prognostic trajectories or treatment responses. Purpose To characterize clinical features, cardiac structure and function among patients with HF with preserved EF (defined as 45% ≤ LVEF ≤ 65%) and supranormal EF (defined as LVEF&amp;gt;65%). Methods Baseline clinical characteristics and key echocardiographic parameters from patients enrolled in the echocardiographic substudies of TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist)-Americas and PARAGON-HF (Prospective Comparison of ARNI [angiotensin receptor–neprilysin inhibitor] with ARB [angiotensin-receptor blocker] Global Outcomes in Heart Failure with Preserved Ejection Fraction) were compared between patients with and without HFsnEF. Results Among 1,751 participants (mean age 73 years old, 51% women) in this pooled core laboratory analysis, 265 (15%) had HFsnEF. Participants in HFsnEF group were more likely to be women, and less likely to have prior myocardial infarction and atrial fibrillation (Table 1). Compared with those with LVEF ≤ 65%, those with LVEF &amp;gt; 65% had lower LV end-diastolic and end-systolic volume indices, lower LV mass index, higher LV relative wall thickness, and higher right ventricular fractional area change. LV geometry and measures of LV diastolic function were similar in both groups (Table 1). Global longitudinal strain (GLS) was abnormal (absolute GLS &amp;lt;16%) in 28% in those with HFsnEF compared with 53% in those with LVEF ≤ 65%. After adjusting for baseline LV ejection fraction and sex, and stratified by trial, abnormal GLS was associated with a higher risk of composite of first heart failure hospitalization or cardiovascular death (overall hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.23 – 1.98, P &amp;lt; 0.001), cardiovascular death (overall HR 2.06, 95% CI 1.35 – 3.13, P = 0.001), and heart failure hospitalization (overall HR 1.49, 95% CI 1.15 – 1.93, P = 0.003) in both HFsnEF and non-HFsnEF groups (P-interaction &amp;gt; 0.05 for all, Figure 1). Conclusions Among participants in the TOPCAT-Americas and PARAGON-HF trials, those with LVEF &amp;gt; 65% were predominantly women, had less LV remodeling, and had better RV function based on echocardiographic measures. Nevertheless, despite supranormal LVEF, GLS was abnormal in over a quarter of patients and remained an important predictor of adverse clinical outcomes in this cohort.Table 1Figure 1

Longitudinal myocardial deformation and its improvement after treatment has an additive prognostic value to SCORE2 in psoriasis: a 4-year follow-up study

Abstract Background/Introduction Psoriasis has been associated with increased cardiovascular risk. Purpose We investigated whether markers of cardiovascular function and their change after treatment have a prognostic value for adverse outcomes. Methods In a prospective study, at baseline and after 6 months of treatment with biological agents, we assessed in 298 psoriasis patients a) left ventricular (LV) global longitudinal strain (GLS) and b) carotid-femoral pulse wave velocity (PWV), to evaluate their prognostic value for the composite endpoint of major adverse cardiovascular events (MACE), including coronary artery disease, stroke, hospitalization for heart failure and all-cause death over a 4 year follow-up period. Results During follow-up, 26 (8.7%) MACE were recorded. By univariate analysis, decreasing absolute GLS values (hazard ratio [HR]: 0.73, p&amp;lt;0.001), decreasing GLS change after treatment (HR: 0.53, p=0.008) and increasing PWV values (HR: 1.16 p=0.049) were associated with adverse outcomes. Baseline GLS and its change post-treatment remained independent predictors of adverse events after adjusting for several confounders (p&amp;lt;0.05). The addition of baseline GLS and its absolute change post-treatment to SCORE2, increased Harrell’s C from 0.882 to 0.941. By multivariable analysis, for each 1% increase in absolute baseline GLS values, the risk of MACE decreased by 33% and for each 1% absolute increase of GLS post treatment compared to the baseline value, the risk of MACE decreased by 58%. Conclusion Global longitudinal strain has an independent and additive prognostic value to SCORE2 for adverse cardiovascular events in psoriasis, providing timely decision-making for intensive anti-inflammatory treatment and aggressive modification of risk factors to reduce cardiovascular risk.

Echocardiography-based risk score predicts cardiovascular outcomes in ischemic heart failure patients with reduced ejection fraction

Abstract Background Ischemic heart disease (IHD) is the most common cause of heart failure (HF) and serves as an important prognostic factor across the whole HF spectrum. Prognostic assessment is important for optimal patient care, and a number of prediction models or prognostic scores have been developed in the past years for risk stratification of HF patients. Purpose Present study aimed to develop a comprehensive echocardiography-based score algorism for risk assessment of ischemic heart failure (IHF) patients with reduced left ventricular ejection fraction (&amp;lt;50%). Methods This study included 1355 IHF patients with ejection fraction &amp;lt;50%, the median clinical follow-up was 25 months. Multivariable Cox hazard models were used to assess the associations between echocardiography variables [including 13 standard parameters and global longitudinal strain (GLS)] and major adverse outcomes [including all-cause mortality, cardiovascular (CV) death, and CV related hospitalization]. Results Rates of all-cause mortality, CV mortality, and combined CV events including death and hospitalization, were 29.2%, 18.2%, 41.1%, respectively. Right ventricular mid-cavity diameter (RVD)&amp;gt;38mm, mitral annular plane systolic excursion (MAPSE)&amp;lt;8mm, tricuspid annular plane systolic excursion (TAPSE)&amp;lt;12mm, transmitral early flow velocity to mitral annular velocity ratio (E/E´)&amp;gt;14.5, systolic pulmonary artery pressure (sPAP)&amp;gt;38mmHg, and absolute GLS&amp;lt;8% were identified as independent echocardiographic indexes for worse clinical outcome in the multivariable Cox models. An echocardiography-based risk score (Echo Risk Score, ranged from 0 to 6 points) was established based on these markers and patients were classified into 3 risk groups: a score of 0 to 1 as low-risk, 2 to 3 as intermediate-risk, and 4-6 as high-risk. After adjustment for all clinical covariates, high-risk patients faced 2 to 3-fold increased risk of all-cause mortality (HR 2.42, 95% CI 1.81-3.24), CV mortality (HR 2.75, 95% CI 1.88-4.02), and combined CV events (HR 1.84, 95% CI 1.43-2.36) compared with low-risk patients. Incremental predicting efficacy was evidenced after the addition of Echo Risk Score either to the model including clinical risk factors or to the model including clinical risk factors and N-terminal prohormone of brain natriuretic peptide (all P&amp;lt;0.001, Figure 1). Conclusions This new echocardiography-based risk score is significantly and independently associated with all-cause mortality and CV mortality or hospitalization in ischemic heart failure patients with reduced ejection fraction. Future studies are warranted to validate the predicting efficacy of this echocardiography-based risk score in ischemic heart failure patients with reduced ejection fraction.Figure 1

Impact of atrial fibrillation burden on longitudinal changes in left ventricular structure and function: a post-hoc analysis of a randomized clinical trial

Abstract Background Atrial fibrillation (AF) is a well-established risk factor for heart failure (HF), stroke, and left ventricular (LV) dysfunction. However, only limited longitudinal data exist regarding the impact of AF burden on left ventricular (LV) structure and function. Purpose The aim of this study was to investigate the association between AF burden and longitudinal changes in LV structure and function in an older patient population with cardiac risk factors. Methods This study was a post-hoc analysis of a randomized clinical trial, which investigated whether AF screening with implantable loop recorders (ILRs) and subsequent initiation of anticoagulation could prevent stroke in high-risk individuals. As a substudy, a group of participants had extensive transthoracic echocardiography performed at baseline and a re-examination after ILR end-of-life. We included participants with available ILR data and echocardiographic data from both baseline and follow-up. We excluded participants with ongoing AF during the baseline echocardiogram. AF episodes were adjudicated by two cardiologists and AF burden was calculated as the percentage of time spent in AF during the total ILR monitoring period. Univariable and multivariable linear regression models were used to investigate the association between AF burden and changes in echocardiographic measures. The multivariable model was adjusted for age, sex, systolic blood pressure, diabetes, smoking status, previously acute myocardial infarction, previous coronary artery bypass grafting, prevalent HF, body mass index, estimated glomerular filtration rate, number of days monitored by ILR, and the number of days between the two echocardiographic examinations. Both models included adjustment for the baseline value of the echocardiographic measure. Results The study population consisted of 640 participants with available baseline and follow-up echocardiograms. Mean age was 73.6 years (±3.4 years) and 278 (43.4%) were women. AF was documented in 188 (29.4%) participants during a median ILR monitoring period of 3.2 years (IQR 2.9-3.4 years). The mean timespan between the echocardiographic examinations was median 5.0 (IQR 4.6-5.2) years. Among participants with AF, the median AF burden was 0.098% (IQR 0.026-0.758%). Over the course of echocardiographic follow-up, mean ∆GLS was -0.59% (±3.49%), mean ∆LVEF was -1.44% (±8.5%), and mean ∆E/e’ was -1.12(±3.23) in those with AF. Increasing AF burden was significantly associated with an accelerated decline in absolute global longitudinal strain in both univariable (ß= -0.12, p=0.002) and multivariable (ß= -0.11, p=0.003) models (Table 1/Figure 1). Conclusions In an older at-risk population, AF was frequent, and increasing AF burden was found to be independently associated with an accelerated decline in LV function. These findings support AF as an independent risk factor in the development of HF.

The prognostic power of two-dimensional strain-derived left ventricular myocardial work for all-cause mortality in pancreatic ductal adenocarcinoma patients receiving cancer therapy

Abstract Background Left ventricular (LV) myocardial work (MW) is a relatively novel parameter derived from the integration of LV global longitudinal strain (GLS) and LV pressure. MW may provide additive information beyond LV ejection fraction (EF) and GLS. However, the clinical implication of MW in pancreatic ductal adenocarcinoma (PDAC) patients receiving cancer therapy is still unclear. Purpose We conducted this prospective cohort study to investigate the clinical implication and the prognostic valve of LV MW in PDAC patients receiving cancer therapy. Methods We prospectively enrolled a total of 234 newly diagnosed PDAC patients (65.1±11.1 years old, 51% male). We did echocardiographic study at the following timepoints: before chemotherapy and 3 months after cancer therapy. MW parameters, including global work index (GWI), global constructive work (GCW), global waste work (GWW) and global work efficiency (GWE), would be determined from the pressure-strain loop. A ≥15% reduction in absolute GLS value from baseline was defined as signifying cancer therapy–related cardiac dysfunction (CTRCD). The primary outcome was defined as all-cause mortality. Results A total of 185 patients (64.7±11.3 years old, 49% male) were included for analysis. We excluded 49 cancer patients who did not have echocardiographic studies at 3 months after cancer therapy. Over a median follow-up of 8 months, twenty-six (14.1%) patients had CTRCD and sixty (32.4%) patients were dead. There was no significant difference of baseline demographic and echocardiographic parameters between the survivors and the mortality patients. At 3 months after cancer therapy, compared to the survivors, the mortality patients had lower LV EF (survivor vs. death: 68.6±6.5% vs. 63.5±11.3%, p=0.002) and lower GLS (survivor vs. death: -18.8±2.2% vs. -17.3±3.4%, p=0.003). Moreover, the mortality group had lower GWI (survivor vs. death: 1984.2±376.0 mmHg% vs. 1746.8±495.1 mmHg%, p=0.002) and GCW (survivor vs. death: 2307.0±405.6 mmHg% vs. 2125.1±493.9 mmHg%, p=0.02). After adjusting for age, gender, LVEF (at 3-month), GLS and CTRCD, GWI &amp;lt;1700 mmHg% was independently associated with all-cause mortality (hazard ratio 2.35, 95% confidence interval 1.37–4.03, p&amp;lt;0.001; Figure). Conclusion Approximate 14% of PDCA patients receiving cancer therapy had CTRCD. Lower values of LV GWI (&amp;lt;1700 mmHg%) was independently associated with increased all-cause mortality at a median follow-up of 8 months. LV GWI showed the better performance for mortality prognostic power compared to LVEF and LV GLS in PDCA patients receiving cancer therapy.

Ventriculoarterial coupling as estimated by the PWV/GLS ratio correlates with disease severity in liver cirrhosis patients

Abstract Introduction Liver cirrhosis is characterized by vasodilation, reduced peripheral resistances and increased cardiac output. Recently, a novel parameter based on the ratio of carotid-femoral pulse wave velocity (PWV) to the absolute value of global longitudinal strain (GLS), has been proposed to estimate the relationship between left ventricle and aortic function (ventriculoarterial coupling- VAC). Purpose This study aimed to investigate the potential correlation between VAC, as estimated by the PWV/GLS ratio, and disease severity in patients with liver cirrhosis. Methods A total of 65 cirrhotic patients (mean age 59.1±8.3 years, 48 (73.8%) males) without cardiovascular disease were included in this study. PWV was calculated by dividing the estimated distance difference between the femoral and carotid arteries by the pulse transit time measured with a validated noninvasive device (simultaneous measurement with two transducers). Echocardiography was performed to determine GLS, which was calculated semi-automatically using dedicated software. Disease severity was assessed using the Model for End-Stage Liver Disease (MELD) score. Results The mean PWV was 7.8 ± 1.6 m/s, mean GLS was 21.1 ± 2.7%, and mean PWV/GLS ratio was 0.38 ± 0.11. Spearman’s correlation analysis showed that both PWV and GLS were significantly correlated with MELD score (rho=-0.330, p=0.007 and rho=0.276, p=0.026, respectively), indicating that patients with higher disease severity had lower PWV and higher absolute GLS values. There was also a negative correlation between PWV and GLS (rho=-0.377, p=0.002). PWV/GLS ratio was negatively correlated with MELD score (rho=-0.354, p=0.004). In addition to MELD score, PWV/GLS ratio was significantly associated with age (rho=0.281, p=0.023) and systolic blood pressure (SBP) (rho=0.445, p&amp;lt;0.001). A non-significant association with stroke volume (SV) was also observed (rho=-0.207, p=0.099), suggesting that cirrhotic patients with reduced afterload and increased cardiac output had lower values of the ventriculoarterial coupling index. Multivariate linear models confirmed the robustness of the association between PWV/GLS ratio and disease severity even after accounting for age, SBP, and SV (p=0.047). Conclusions Our findings suggest that the PWV/GLS ratio is reduced in cirrhotic patients with more severe disease. This association remains significant even after controlling for age, systolic blood pressure, and stroke volume, indicating that PWV/GLS ratio may serve as an early marker of cardiovascular dysfunction in patients with liver cirrhosis.Figure 1Table 1

Effect of diabetes duration on subclinical target organ damage in young diabetic adults with type 1 diabetes mellitus

Abstract Objective and aim Cardiovascular disease is a key cause of premature mortality in type 1 diabetes mellitus (DMt1). According to ESC guidelines, 10-year risk of death from cardiovascular disease in 35-year-old patients with diabetes lasting ≤10 years is estimated as moderate, however studies based on the young adult patients with DMt1 are limited. The aim of this study is to identify the relationship between the duration of DMt1 and occurrence of subclinical cardiovascular target organ damage among adult patients before the age of thirty. Material and methods We included patients aged from 18 to 30 years old with childhood- or juvenile-onset diabetes mellitus type 1. In all patients 24-hour blood pressure measurement was performed and a daily pressure profile (dipper or non-dipper) was defined. Non-invasive diagnostics of subclinical cardiovascular damage included: • 2-dimensional echocardiographic examination with the assessment of global longitudinal strain (GLS), • ultrasound of the carotid arteries with the assessment of intima media thickness (IMT), • assessment of the pulse wave velocity (PWV), • assessment of flow-dependent brachial artery vasodilation (FMD), • assessment of the ankle-brachial index (ABI). Results Obtained from non-invasive examination were compared between two groups depending on duration of DMt1: group 1 ( DMt1 lasting ≤10 years) vs group 2 (DMt1 lasting &amp;gt;10 years). Results The study population consist of 56 patients (48% male). Group consist of 25 patients and group 2 consist of 31 patients. Statistical analysis showed that received values of GLS (P=0.04) and PWV (P=0.01) differ significantly between group 1 and group 2. Interestingly the GLS, but not PWV, showed a significant negative linear correlation with the duration of diabetes (r=0.28; P=0.03). A post-hoc analysis showed that among patients with a DMt1 duration of ≤10 years absolute GLS values were significantly lower in patients with non-dipper profile than those with a dipper profile (P=0.04) (Fig. 1). Also a post-hoc analysis demonstrated significant difference in IMT thickness among non-dipping patients according to time of DMt1 duration (P=0.01) (Fig. 1). Conclusions Subclinical target organ damage can be detected even in young adults with DMt1 (aged 18-30 years). Patients with DMt1 lasting &amp;gt;10 years had a significantly lower absolute GLS value and GLS value correlate with the duration of diabetes. Patients with DMt1 lasting &amp;gt;10 years had a significantly higher PWV value.Fig 1. Post-hoc analysis of GLS and IMT

Association of GDF15, NTpoBNP and PLGF with subclinical cardiac dysfunction in type 2 diabetes: effects of novel antidiabetic treatment

Abstract Background In type 2 diabetics, we investigated the effects of insulin, GLP-1Ra, SGLT-2i and their combination on blood biomarkers of cardiac function and their association with left ventricular and atrial function. Patients and methods A total of 200 diabetics (60.3±10.3-year-old) treated with metformin were randomized to insulin (n= 50), liraglutide (n=50), empagliflozin (n=50) or their combination (GLP-1RA+SGLT-2i) (n= 50) . We measured at baseline and 6 months post-treatment: (a) perfused boundary region of the sublingual arterial microvessels (marker of endothelial glycocalyx thickness), (b) pulse wave velocity (PWV), (c) Left Ventricular (LV) Global Longitudinal Strain (GLS) and Torsion, (d) LV Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW), Global Work Efficiency (GWE), (e) Left atrial reservoir strain (LASr) and (f) Growth/Differentiation Factor-15 (GDF-15), NTproBNP, Placental Growth Factor (PLGF) as markers of cardiac dysfunction. Results Increasing GGDF-15 levels at baseline were related with increasing PWV (r=0.357, p&amp;lt;0.001). Moreover, increasing GDF-15 was related with reduced absolute GLS values (r=-0.425, p=0.005), increased LV Torsion (r=0.309, p=0.035), Twisting Velocity (r=0.345, p=0.018) and E/E’ (r=0.307, p=0.041) as well as reduced Untwisting velocity (r=-0.383, p=0.008) and LASr (r=-0,388, p=0.005). Increasing NTproBNP concentration at baseline was related with increasing PWV (r=0.445, p=0.001 and PBR5-25 (r=0.222, p=0.04) . Also, increasing NTroBNP was related with reduced absolute GLS (r=-0.454, p=0.002), LV GL strain rate (r=-0.360, p=0.008) , increased LV Torsion (r=0.329, p=0.029) and E/E’ (r=0.365, p=0.021). Increasing NTproBNP was also related with decreasing GWI (r=-0.471, p&amp;lt;0.001), GWE (r=-0.555, p&amp;lt;0.001), Untwisting velocity (r=-0.383, p=0.008) and LASr (r=-0,424, p=0.002). PLGF concentration at baseline was related with reduced absolute GLS (r=-0.341, p=0.012), LV GL strain rate (r=-0.302, p=0.008) and LASr (r=-0.321, p=0.036). At 6 months, the reduction of GDF-15 and NTproBNP levels was related with the respective reduction of PWV (p=0.022 and p=0.34) Furthermore, the reduction of NTproBNP at 6 months was related with an increase of GWI and GWE (r=0.455, p=0.006/ r=0.631, p=0.001,respectively). In patients treated with GLP-1RA, SGLT-2i and their combination, there was greater improvement of GLS, Torsion, Myocardial Work, LASr, NTproBNP, GDF-15 PLGF compared to patients treated with insulin (p&amp;lt;0.05) post-treatment. In patients treated with insulin, NTproBNP, GDF-15 and PLGF changes post-treatment were not related with the respective changes of the examined cardiac and vascular markers. Conclusion Elevated levels of GDF15, PLGF and NTproBNP are associated with cardiac and vascular dysfunction in patients with type 2 diabetics and their improvement after 6 months of treatment with GLP-1RA and /or SGLT2i is associated with improved cardiovascular function.

Abstract 13403: Age-Related Echocardiographic Characteristics in Patients With Heart Failure With Preserved Ejection Fraction in PARAGON-HF

Introduction: Heart failure with preserved ejection fraction (HFpEF) may have different characteristics by age groups. Aim Compare clinical and echocardiographic characteristics in patients with HFpEF enrolled in the PARAGON-HF echocardiography substudy by age groups. Methods: Echocardiography was performed in 1097 patients in PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction), where patients with left ventricular ejection fraction (LVEF) &gt;=45% were enrolled. Clinical and echocardiographic characteristics were compared in patients who were &lt;65, 65-74, and &gt;75 years of age. Results: Younger patients were more likely to be male, obese, have prior myocardial infarction (MI) and diabetes, but less likely to have atrial fibrillation (AF, Table 1). Older patients had smaller left ventricular (LV) dimension indices, more likely to have concentric hypertrophy or remodeling, higher LVEF and better global longitudinal strain, and more likely to have left atrial enlargement and echocardiographic evidence of higher LV filling pressure (Table 1). Echocardiographic measures of pulmonary pressure and right ventricular function were similar across age groups. After adjusting for sex, race, region, history of MI, diabetes, AF, and body mass index, every 10 years of increase in age was associated with 5.1 mL/m 2 decrease in LV end-diastolic volume index (95% confidence interval [CI] 3.9 - 6.5, p &lt; 0.001), 0.4% increase in absolute global longitudinal strain (95% CI 0.1% - 0.7%, p = 0.017), and 1.07 increase in E/e’ septal ratio (95% CI 0.42 - 1.73, p = 0.001). Conclusions: Compared with younger patients, older patients with HFpEF were more likely to be female with AF, have better systolic function and higher LV filling pressure. These findings demonstrated the heterogeneity in cardiac structure and function in HFpEF by age and may have implications for treatment and future clinical trial recruitment.

Evaluation of left atrial and ventricular remodeling in atrial fibrillation subtype by using speckle tracking echocardiography.

Atrial fibrillation (AF) is associated with cardiac structural and functional remodeling. We investigated the left atrial (LA) and left ventricular (LV) changes in AF subtypes by using two-dimensional echocardiography strain techniques. The study population consisted of 102 subjects with sinus rhythm (control group) and 463 patients with AF, among which 284 patients had paroxysmal AF (PAF) and 179 patients had persistent AF (PerAF). A speckle tracking automatic functional imaging software was used to perform the strain analysis. Patients with AF had dilated LA maximum and minimum volume, decreased LA reservoir strain, lower LV ejection fraction (LVEF), and impaired global longitudinal strain (GLS) compared to those of the sinus rhythm control group. In patients with PerAF, the LA maximum and minimum volumes were larger, and the LA reservoir strain [PAF vs. PerAF, 28% (21,33) vs. 19% (14, 28), P < 0.05], LVEF, and absolute GLS value (PAF vs. PerAF, -16.9 ± 3.3 vs. -14.1 ± 3.5%) were lower than those in patients with PAF. Patients with AF regardless of LA enlargement had decreased LA reservoir strain and lower LVEF and absolute GLS value than those in the sinus rhythm control group. Compared with those with normal sinus rhythm, patients with AF had dilated LA volume and impaired LA function, which were further worsened in patients with PerAF than those in patients with PAF. LA functional impairment occurred before LA enlargement. Left atrioventricular remodeling happened across different stages of AF development.

Endocardial versus whole-myocardial tracking global longitudinal strain analysis in patients with hypertrophic cardiomyopathy: A preliminary comparative study.

We investigated whether the feasibility of left ventricular (LV) global longitudinal strain (GLS) in hypertrophic cardiomyopathy (HCM) varies according to the methodology (e.g. endocardial vs. whole myocardial tracking techniques). We retrospectively analyzed 111 consecutive patients with HCM (median age, 58 years; male, 68.5%) who underwent both transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (apical 29.7%, septal 33.3%, and diffuse or mixed 37.0%). TTE-whole myocardial and TTE-endocardial GLS were measured and compared in terms of association with late gadolinium enhancement (LGE) extent and discrimination performance for extensive LGE (>15% of the LV myocardium). Although TTE-whole myocardial and TTE-endocardial GLS were significantly correlated, absolute TTE-endocardial GLS values (19.3 [16.2-21.9] %) were higher than TTE-whole myocardial GLS values (13.3[10.9-15.6] %, p<0.001). Both TTE-derived GLS parameters were significantly correlated with the LGE extent and independently associated with extensive LGE (odds ratio [OR] 1.30, p = 0.022; and OR 1.24, p = 0.013, respectively). Discrimination performance for extensive LGE was comparable between TTE-whole myocardial and TTE-endocardial GLS (area under the curve [AUC], 0.747 and 0.754, respectively, pdifference = 0.610). However, among patients with higher LV mass index (>70 g/m2), only TTE-whole myocardial GLS correlated with LGE extent and was independently associated with extensive LGE (OR 1.35, p = 0.042), while TTE-endocardial GLS did not. Additionally, TTE-whole myocardial GLS had better discrimination performance for extensive LGE than TTE-endocardial GLS (AUC, 0.705 and 0.668, respectively, pdifference = 0.006). TTE-derived GLS using either the endocardial or whole myocardial tracking technique is feasible in patients with HCM. However, in those with severe hypertrophy, TTE-whole myocardial GLS is better than TTE-endocardial GLS.

Pre–Heart Failure Longitudinal Change in a Hispanic/Latino Population-Based Study: Insights From the Echocardiographic Study of Latinos

BackgroundPre–heart failure (pre-HF) is an entity known to progress to symptomatic heart failure (HF). ObjectivesThis study aimed to characterize pre-HF prevalence and incidence among Hispanics/Latinos. MethodsThe Echo-SOL (Echocardiographic Study of Latinos) assessed cardiac parameters on 1,643 Hispanics/Latinos at baseline and 4.3 years later. Prevalent pre-HF was defined as the presence of any abnormal cardiac parameter (left ventricular [LV] ejection fraction <50%; absolute global longitudinal strain <15%; grade 1 or more diastolic dysfunction; LV mass index >115 g/m2 for men, >95 g/m2 for women; or relative wall thickness >0.42). Incident pre-HF was defined among those without pre-HF at baseline. Sampling weights and survey statistics were used. ResultsAmong this study population (mean age: 56.4 years; 56% female), HF risk factors, including prevalence of hypertension and diabetes, worsened during follow-up. Significant worsening of all cardiac parameters (except LV ejection fraction) was evidenced from baseline to follow-up (all P < 0.01). Overall, the prevalence of pre-HF was 66.7% at baseline and the incidence of pre-HF during follow-up was 66.3%. Prevalent and incident pre-HF were seen more with increasing baseline HF risk factor burden as well as with older age. In addition, increasing the number of HF risk factors increased the risk of prevalence of pre-HF and incidence of pre-HF (adjusted OR: 1.36 [95% CI: 1.16-1.58], and adjusted OR: 1.29 [95% CI: 1.00-1.68], respectively). Prevalent pre-HF was associated with incident clinical HF (HR: 10.9 [95% CI: 2.1-56.3]). ConclusionsHispanics/Latinos exhibited significant worsening of pre-HF characteristics over time. Prevalence and incidence of pre-HF are high and are associated with increasing HF risk factor burden and with incidence of cardiac events.