Early Systolic Lengthening Research Articles

Utilizing echocardiography and unsupervised machine learning for heart failure risk identification

BackgroundGlobal longitudinal strain (GLS) is recognized as a powerful predictor of heart failure (HF). However, the entire strain curve may entail important prognostic information regarding HF risk that might be undiscovered by only focusing on the peak strain value. ObjectiveThe hypothesis of the present study was, that analysis of the entire strain curve using unsupervised machine learning (uML) would reveal novel ventricular deformation patterns capable of predicting incident HF independently of GLS. MethodsLongitudinal strain curves from 3710 subjects from the general population without prevalent HF were analyzed using uML. ResultsMean age was 56 years and 43 % were male. During a median follow-up of 5.3 years, 92 subjects (2.5 %) developed HF. The uML algorithm generated a hierarchical clustering tree (HCT) resulting in 10 different clusters. Generally, the strain curves displayed reduced early diastolic strain to peak-strain ratio with an increasing incidence rate of HF. In multivariable Cox regressions, cluster 9 was significantly associated with increased risk of HF when compared to cluster 2–5, and 7–8 [For cluster 3: HR 8.95, 95 %CI: 2.08;38.48, P = 0.003] even though the subjects of cluster 9 were younger, displayed healthier clinical baseline characteristics, and only had slightly reduced GLS. The mean strain curve of cluster 9 displayed an early systolic lengthening followed by a late and reduced contraction specifically related to the basal lateral segment. ConclusionThe unsupervised machine learning algorithm identified unknown strain patterns beyond GLS presumably related to increased risk of HF.

A study to observe the association of left ventricular ejection fraction and wall motion score index with duration of early systolic lengthening in patients with non-ST-elevation acute coronary syndrome

Background: Management of non-ST elevation myocardial infarction acute coronary syndrome (NSTEMI ACS) patients is not well defined as that of ST elevation myocardial infarction. The accuracy of results of conventional echocardiography is significantly compromised when imaging is suboptimal, myocardial damage is in small areas, and compensatory hyperkinesias of healthy segment. Aims and Objectives: Duration of early systolic lengthening (DESL) may be employed to identify early myocardial ischemia and thus, may help to prepare treatment strategies for NSTEMI patients. Materials and Methods: A total of 57 patients with NSTEMI ACS attending the cardiology department were included in the study group. Results: More than 80% of patients of NSTEMI have normal or near normal ejection fraction and wall motion score index. In our study, the DESL is prolonged in a significant number of non-ST-elevation acute coronary syndrome patients. Conclusion: As DESL is afterload independent, it is superior to global longitudinal strain in assessing myocardial damage. Several studies including ourselves show that DESL of <50 ms may be the cutoff value to reveal minimal myocardial damage.

Myocardial motion in acute ischemia: revealing invisible deformation by echocardiography.

Echocardiography has been used clinically to assess regional myocardial wall motion for the diagnosis of acute myocardial ischemia or stress-induced ischemia, but it is often difficult to distinguish hypokinetic motion from normal motion. Myocardial wall motion is affected by loading conditions as well as intrinsic contractility, making it challenging to define a normal range of wall motion. Therefore, hypokinesis is usually diagnosed by comparing target areas with other areas of myocardium considered normal (relative hypokinesis). Myocardial strain analysis by tissue Doppler echocardiography and speckle-tracking echocardiography has enabled objective and quantitative evaluation of regional myocardial wall motion. Peak systolic strain decreases during acute ischemia, but subtle and invisible myocardial motion, such as early systolic lengthening (ESL) and postsystolic shortening (PSS), also occurs, and the analysis of these subtle motions can improve the diagnostic accuracy of ischemia. However, the diagnosis of ischemic myocardium by strain analysis is not widely performed in clinical practice at this time due to several limitations. This article reviews the features of myocardial motion during acute ischemia, the mechanisms of ESL and PSS, the diagnosis of ischemic myocardium using strain analysis, and current approaches and future challenges to overcome the limitations in the detection of relative hypokinesis. This article also explains the use of ESL and PSS to detect myocardial ischemic memory that remains after brief ischemia.

The association between myocardial early systolic lengthening and high risk angiographic territory involvement in patients with non-ST-segment elevation myocardial infarction.

Non-ST-segment elevation myocardial infarction (NSTEMI) is more common than ST-segment elevation myocardial infarction (STEMI), consisting of 60-70% of myocardial infarctions. When left ventricular (LV) pressure increases during early systole, regionally ischaemic myocardium with a reduced active force exhibit stretching. The aim of this study was to evaluate the role of this parameter in determining high risk angiographic territory involvement in NSTEMI patients. This study was a descriptive correlational research that was conducted on 96 patients with NSTEMI and a left ventricular ejection fraction ≥ 50% who underwent coronary angiography (CAG). Patients were divided into two groups based on having or not having high risk angiographic territory involvement in CAG. All patients underwent a transthoracic echocardiography during the first day of hospitalization and early systolic lengthening (ESL), duration of ESL (DESL), left ventricular global longitudinal strain (LVGLS), pulsed-wave Doppler-derived transmitral early (E wave) and late (A wave) diastolic velocities, and tissue-Doppler-derived mitral annular early diastolic (e') and peak systolic (s') velocities were determined. The results of this study showed DESL, DESLLAD, and DESLLCX were longer in high risk angiographic territory group than other one (P value 0.016, 0.044, and 0.04, respectively). The logistic regression analysis showed among different variables, only age and ESLLAD had an independent association with high risk angiographic territory involvement (P = 0.01, odds ratio [OR] 1.09, 95% CI 1.021-1.164, and P = 0.024, odds ratio [OR] 1.243, 95% CI 1.029-1.50, respectively). Assessment of myocardial ESLLAD by speckle-tracking echocardiography may be helpful in predicting high risk angiographic territory involvement in patients with NSTEMI. Indeed, a higher value can be considered as a high risk parameter which may show benefit of an early invasive strategy versus a conservative approach.

Early Systolic Lengthening Is Associated with SYNTAX Score in Patients with Non-ST-Elevation Acute Coronary Syndrome.

Early systolic lengthening is a echocardiographic strain parameter previously used to determine the lesion severity in patients with stable coronary artery disease. In the present study, we aimed to evaluate the relationship between early systolic lengthening and anatomic SYNTAX score in troponin (-) and (+) groups among patients with non-ST-elevation acute coronary syndrome (ACS). A total of 95 patients diagnosed with non-ST-elevation ACS were included in the prospective, non-randomized, single-center study. The patients were categorized into 2 groups as troponin (+) and troponin (-). The patients were evaluated in terms of echocardiographic, clinical, and angiographic parameters. The baseline characteristics, including age (58 ± 13 vs. 60 ± 10 respectively, P =.340), a history of hypertension (67.1% vs. 64%, respectively, P =.479), diabetes (28.6% vs. 32%, respectively, P =.467), global longitudinal strain (-14.37 ± 5.11 vs. -16.42 ± 3.93, respectively, P =.095), left ventricular ejection fraction (58.71 ± 8.73 vs. 57.20 ± 8.70, respectively, P =.263), and E/e' (8.44 ± 2.13 vs. 8.33 ± 1.99, respectively, P =.785), were similar between troponin (+) and troponin (-) groups. Left ventricle end-systolic diameter (3.2 ± 0.78; 3.50 ± 0.74 vs. 3.2 ± 0.78, respectively, P =.031), left ventricle end-systolic volume (55.57 ± 32.17 vs. 38.28 ± 13.63, respectively, P =.013), left ventricle end-diastolic volume (115.31 ± 49.54 vs. 91.23 ± 20.57, respectively, P =.042), the rate of early systolic lengthening (65.7% vs. 28%, respectively, P =.001), the duration of early systolic lengthening (24.02 ± 31 ms vs. 15.56 ± 30.19 ms, respectively, P =.009), and the SYNTAX score (16 ± 11 vs. 10 ± 10, respectively, P =.023) were higher in the troponin (+) group. Furthermore, a significant correlation was found between early systolic lengthening and SYNTAX score (r = 0.43, P <.001). The rate and duration of early systolic lengthening were higher in patients in the troponin (+) group. Early systolic lengthening is related to SYNTAX score in patients with non-ST-elevation ACS.

Diagnostic potential of myocardial early systolic lengthening for patients with suspected non-ST-segment elevation acute coronary syndrome

BackgroundDuring early systole, ischemic myocardium with reduced active force experiences early systolic lengthening (ESL). This study aimed to explore the diagnostic potential of myocardial ESL in suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with normal wall motion and left ventricular ejection fraction (LVEF).MethodsOverall, 195 suspected NSTE-ACS patients with normal wall motion and LVEF, who underwent speckle tracking echocardiography (STE) before coronary angiography, were included in this study. Patients were stratified into the coronary artery disease (CAD) group when there was ≥ 50% stenosis in at least one major coronary artery. The CAD patients were further stratified into the significant (≥ 70% reduction of vessel diameter) stenosis group or the nonsignificant stenosis group. Myocardial strain parameters, including global longitudinal strain (GLS), duration of early systolic lengthening (DESL), early systolic index (ESI), and post-systolic index (PSI), were analyzed using STE and compared between groups. Receiver operating characteristic curve (ROC) analysis was performed to determine the diagnostic accuracy. Logistic regression analysis was conducted to establish the independent and incremental determinants for the presence of significant coronary stenosis.ResultsThe DESL and ESI values were higher in patients with CAD than those without CAD. In addition, CAD patients with significant coronary stenosis had higher DESL and ESI than those without significant coronary stenosis. The ROC analysis revealed that ESI was superior to PSI for identifying patients with CAD, and further superior to GLS and PSI for predicting significant coronary stenosis. Moreover, ESI could independently and incrementally predict significant coronary stenosis in patients with CAD.ConclusionsThe myocardial ESI is of great value for the diagnosis and risk stratification of clinically suspected NSTE-ACS patients with normal LVEF and wall motion.

Abstract 14179: Unsupervised Machine Learning on Myocardial Deformation Curves Identifies Specific Clusters of People at Risk of Heart Failure - The Copenhagen City Heart Study

Background Peak global longitudinal strain is recognized as a powerful predictor of heart failure (HF). However, whether the entire strain curve add important prognostic information regarding risk of HF remains unknown. We aimed to investigate whether patterns of myocardial deformation identified through unsupervised machine learning (uML) entailed additional information regarding risk of HF. Methods Longitudinal strain curves from 3,710 subjects from the general population without prevalent HF were clustered by similarity using uML based on strain curves alone. The grouped clusters were then compared by incidence rate of HF and in multivariable COX models. Results Mean age was 56 years and 43% were male. During a median follow-up of 5.3 years, 92 subjects (2.5%) developed HF. The uML algorithm generated a hierarchical clustering tree (Figure 1) and 10 different clusters. Generally, with increasing incidence of HF, strain curves displayed a smaller reduction of strain from peak-GLS to the maximal curvature during the early filling relative to the size of their peak-GLS (Figure 1 and 2): We called this value early diastolic strain to peak-GLS (EDS to peak-GLS). One exception was cluster 9. In multivariable Cox regression, cluster 9 was significantly associated with increased incidence of HF when compared to cluster 3,4 and 5 [For cluster 3: HR 6.6, 95%CI: 1.5;29.0, p = 0.013] even though the subjects of cluster 9 were younger (40 years), displayed healthier clinical baseline characteristics, and only had slightly reduced Peak-GLS. The mean strain curve of the lateral basal segment of cluster 9 displayed an early systolic lengthening followed by a late and reduced contraction specifically related to the basal lateral segment (Figure 3). Conclusion uML could identify clusters with high incidence of HF based on strain curves alone. The algorithm identified unknown strain patterns beyond peak-GLS presumably related to increased risk of HF.

Postsystolic shortening and early systolic lengthening for early detection of myocardial involvement in patients with systemic lupus erythematosus.

Cardiac involvement predicts a poor prognosis in patients with systemic lupus erythematosus (SLE). Two-dimensional speckle-tracking echocardiography (2D-STE) are used to identify subclinical myocardial involvement in various diseases. This study objected to evaluate postsystolic shortening (PSS) and early systolic lengthening (ESL) by 2D-STE for early detection of myocardial involvement in patients with SLE. A total of 121 patients with preserved left ventricular ejection fraction (LVEF) in SLE and 30 healthy controls underwent standard 2D-STE in our study. According to SLE disease activity index (SLEDAI), we divided SLE patients into two groups: the group of inactive disease (SLEDAI ≤ 4) and active disease (SLEDAI ≥ 5). The maximum of postsystolic strain index (PSImax ) and early systolic strain index (ESImax ) were acquired from 17 segments of left ventricular (LV). We also compared the PSImax and ESImax of basal, medial, and apical segments between SLE patients and controls. Compared with healthy controls and the group of SLEDAI ≤ 4, the group of SLEDAI ≥ 5 had higher PSImax and ESImax value of global LV and basal segments. The absolute value of global longitudinal strain (GLS) had no difference between the group of active disease and inactive disease. Multivariate analysis demonstrated that PSS was independently associated with SLEDAI and diabetes mellitus. Detection of PSS and ESL enable to identify LV systolic impairment in SLE patients at an early stage.

Early systolic lengthening in patients with ST-elevation myocardial infarction: a novel tool for risk stratification

Abstract Funding Acknowledgements Type of funding sources: None. Background After an ST-elevation myocardial infarction (STEMI), the risk of subsequent cardiovascular events is high. Risk stratification at index hospitalization remains a core challenge, especially in patients with subtle changes in LV function. Early systolic lengthening (ESL) may occur in ischemic myocardial segments with reduced contractile force and it has been correlated with infarct size and prognosis in STEMI patients with mildly impaired LV function. In this study, we aimed to evaluate the correlation of ESL with common echocardiographic parameters and its prognostic value in STEMI patients with preserved LV function. Methods We retrospectively included all the patients admitted to an intensive care unit with STEMI and a left ventricle ejection fraction ≥55% from January to June of 2016. Patients with inadequate image quality for speckle tracking echocardiographic examination were excluded (n = 14). We evaluated the ESL index, defined as follows: [−100×(peak positive systolic strain/peak negative strain in cardiac cycle)], and ESL duration. Results A total of 37 patients were included in the study. Mean age was 63 ± 12 years with a male preponderance (81%). All patients were submitted to complete revascularization. Median values of the ESL index and ESL duration were 7% (IQR, 4%–10%) and 37 msec (IQR, 21–55 msec), respectively. No significant differences were found between ESL index and ESL duration groups, except for a higher prevalence of heart failure at hospitalization in both highest groups, and women were more prevalent in the ESL index higher group (Tables 1 and 2). ESL index was correlated with post-systolic index (PSI) (r2 = 0.34, p = 0.04) and showed a weak correlation with E/A ratio (r2=-0.37, p = 0.02). ESL duration was correlated with ESL index (r2 = 0.76, p &amp;lt; 0.001) and PSI (r2 = 0.43, p = 0.008). During a median follow-up of 3.2 years (interquartile range, 2.9–3.4 years), 7 (18.9%) patients experienced major adverse cardiovascular events (MACE), a composite of heart failure admission, myocardial infarction, and all-cause mortality Both ESL index (HR 2.5; 95%CI 1.2–5.3; P = 0.02) and ESL duration (HR 1.7; 95%CI 1.1–2.7; P = 0.02) were independent predictors of MACE. Both associations remained significant after adjusting for clinical confounders. Conclusions In our cohort of STEMI patients with preserved LV function, assessment of ESL yielded important and significant prognostic information on MACE. ESL may be a useful tool to enhance routine risk stratification in this population. Abstract TABLE 1 Abstract TABLE 2

Myocardial early systolic lengthening predicts mid-term outcomes in patients with hypertrophic cardiomyopathy.

In this study, we investigated whether early systolic lengthening (ESL) which reflects subclinical ischemia and other echocardiographic and clinic parameters predict primary outcome [appropriate ICD shock, cardiovascular mortality and ventricular tachycardia (VT) or fibrillation] in patients with hypertrophic cardiomyopathy (HCM). 202 Patients with HCM (68% male, mean age 48 ± 13.9years) were included in the study. Patients' clinical, electrocardiographic, 2D classic and speckle tracking echocardiography (STE) data were collected. ESL was defined as time from onset of the Q wave on ECG (onset of the R wave if the Q wave was absent) to maximum myocardial systolic lengthening. Patients were divided into two groups as occurrence or absence of primary outcome during 5years follow up. During the follow-up period of 5years (mean follow-up duration, 45.9 ± 10.8months), 31 patients (15%) developed primary outcome [appropriate ICD shock 22 (11%), cardiovascular death 6 (3%), VT/VF 3(1.5%)]. Higher HCM Risk SCD score, longer ESL, and decreased global longitudinal peak strain (GLPS) were observed in patients with primary outcome. A Cox regression analysis, ESL, GLPS and HCM Risk SCD score were found to be independent predictors of occurrence of primary outcome. In ROC curve analysis, ESL > 53.5 msn could discriminate between groups with and without a primary outcome (AUC 0.768, 80% sensitivity and 60% specificity, CI 95% 0.666-0.871). ESL were found to be predictive for primary outcome in patients with HCM. Readily measurable ESL could be helpful to distinguish patients at high risk who could optimally benefit from ICD therapy.

Incremental value of early systolic lengthening and postsystolic shortening in detecting left anterior descending artery stenosis using nonstress speckle-tracking echocardiography

The diagnosis of coronary artery disease (CAD) with nonstress echocardiography remains challenging. Although the assessment of either early systolic lengthening (ESL) or postsystolic shortening (PSS) allows the sensitive detection of CAD, it is unclear whether the integrated analysis of ESL and PSS in addition to the peak systolic strain can improve the diagnostic accuracy. We investigated the incremental value of ESL and PSS in detecting left anterior descending artery (LAD) stenosis using nonstress speckle-tracking echocardiography. Fifty-nine patients with significant LAD stenosis but without visual wall motion abnormalities on echocardiography at rest (30 single-vessel stenosis, 29 multivessel stenosis) and 43 patients without significant stenosis of any vessel were enrolled. The peak systolic strain, the time to ESL (TESL), and the time to PSS (TPSS) were analyzed in all LAD segments, and the incremental values of the TESL and TPSS in detecting LAD stenosis and the diagnostic accuracy were evaluated. In the apical anterior segment, the peak systolic strain was significantly lower and TESL and TPSS were significantly longer in the single-vessel group than in the no stenosis group. In the single-vessel group, the addition of TESL and TPSS to the peak systolic strain significantly increased the model power in detecting stenosis, and the integrated analysis improved diagnostic accuracy compared with the peak systolic strain alone. In contrast, this incremental value was not demonstrated in the multivessel group. The integrated analysis of the peak systolic strain, ESL, and PSS may allow better screening of single-vessel LAD stenosis using nonstress speckle-tracking echocardiography.

Myocardial Postsystolic Shortening and Early Systolic Lengthening: Current Status and Future Directions.

The concept of paradoxical myocardial deformation, commonly referred to as postsystolic shortening and early systolic lengthening, was originally described in the 1970s when assessed by invasive cardiac methods, such as ventriculograms, in patients with ischemia and animal experimental models. Today, novel tissue-based imaging technology has revealed that these phenomena occur far more frequently than first described. This article defines these deformational patterns, summarizes current knowledge about their existence and highlights the clinical potential associated with their understanding.

Оцінка повздовжньої деформації лівого шлуночка і її зміни при інфаркті міокарда та ішемічній хворобі серця з обструктивним ураженням коронарних артерій

The review provides data on a new method of ultrasound diagnostics – speckle tracking echocardiography in the diagnosis of myocardial infarction and coronary heart disease with obstructive coronary artery lesions, the advantages of the global longitudinal strain (GLS) compared to the existing echocardiographic indicators of global systolic and segmental systolic function. The value of measuring GLS in coronary heart disease is the quantitative detection of wall motion abnormalities, when left ventricular ejection fraction is within normal values and visual assessment does not detect violations of regional contractility. In patients with myocardial infarction without ST-segment elevation, GLS measurement may assist in the selection of patients who need urgent reperfusion therapy. In coronary heart disease, GLS can complement the conventional assessment of wall movement; replace the need for additional non-invasive testing for some patients with suboptimal stress tests. The normal limits of the GLS for various manufacturers of ultrasound scanners and technical characteristics for the correct studying of the GLS are described. The value of the GLS gradually decreases in mild, moderate and severe forms of coronary heart disease, and is the lowest in patients with myocardial infarction with ST segment elevation. The possibilities of detecting infarct-related coronary artery using the amplitude of the segmental strain and the «bull’s eye» diagram in isolated lesions of one of the coronary arteries are described. The analysis of the strain curves is carried out, the characteristics of the strain curve in normal conditions and in ischemia are presented. The probable signs of ischemia are the phenomena of early systolic lengthening and postsystolic shortening on the curves of longitudinal deformation. The conditions when the postsystolic contraction on the strain curve is pathological are described. Key words: global longitudinal strain, myocardial infarction, ischemic heart disease, «bull’s eye», early systolic lengthening, postsystolic shortening.

Early systolic lengthening by speckle tracking echocardiography predicts outcome after coronary artery bypass surgery.

Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, has been linked to loss of myocardial viability and contractile dysfunction. We assessed the long-term prognostic potential of ESL in coronary artery bypass graft (CABG) patients. We retrospectively included patients (n=709; mean age 68years; 85% men) who underwent speckle tracking echocardiography (median 15days) prior to CABG. Endpoints were cardiovascular death (CVD) and all-cause mortality. We assessed amplitude of ESL (%), defined as peak positive strain, and duration of ESL (ms), determined as time from Q-wave on the ECG to peak positive strain. We applied Cox models adjusted for clinical risk assessed as EuroSCORE II. During median follow-up of 3.8years [IQR 2.7-4.9years], 45 (6%) experienced CVD and 80 (11%) died. In survival analyses adjusted for EuroSCORE II, each 1% increase in amplitude of ESL was associated with CVD (HR 1.35 [95%CI 1.09-1.68], P=0.006) and all-cause mortality (HR 1.29 [95%CI 1.08-1.54], P=0.004). Similar findings applied to duration of ESL (per 10ms increase) and CVD (HR 1.12 [95%CI 1.02-1.23], P=0.016) and all-cause mortality (HR 1.09 [95%CI 1.01--1.17], P=0.031). The prognostic value of ESL amplitude was modified by sex (P interaction<0.05), such that the prognostic value was greater in women for both endpoints. When adding ESL duration to EuroSCORE II, the net reclassification index improved significantly for both CVD and all-cause mortality. Assessment of ESL provides independent and incremental prognostic information in addition to the EuroSCORE II for CVD and all-cause mortality in CABG patients.

The prognostic value of myocardial deformational patterns on all-cause mortality is modified by ischemic cardiomyopathy in patients with heart failure.

Early systolic lengthening and postsystolic shortening may yield prognostic information in cardiovascular high-risk groups. We aimed to investigate the prognostic potential of these patterns in patients with heart failure with reduced ejection fraction (HFrEF), and specifically if the value was greater in patients with ischemic etiology. A total of 884 patients with HFrEF (66 ± 12years, male 73%, mean EF 28 ± 9%) underwent speckle tracking echocardiography. Of these, 61% suffered from ischemic cardiomyopathy (ICM). Patients were followed for all-cause mortality. We assessed myocardial lengthening during early systole, defined by the early systolic strain index (ESI): [-100x (peak positive strain/maximal strain)] and myocardial shortening after aortic valve closure, defined by the postsystolic strain index (PSI): [100x (postsystolic strain-peak systolic strain)/maximal strain]. During median follow-up of 3.4 [interquartile range 1.9 to 4.8] years, 132 patients (15%) died. ICM modified the relationship between ESI and all-cause mortality (P interaction = 0.008), but not for PSI (P interaction = 0.13). When assessing patients with ICM by Cox proportional hazards models, per 1% increase in ESI (HR 1.09 [1.04 to 1.15], P < 0.001) and PSI (HR 1.02 [1.01 to 1.03], P = 0.002) were associated with all-cause mortality. However, in multivariable models adjusted for clinical, invasive and echocardiographic information, only ESI was a predictor of the endpoint (HR 1.07 [1.00 to 1.13], P = 0.023). In patients with no ICM, neither ESI (HR 0.99 per 1% increase [0.90 to 1.09], P = 0.86) nor PSI (HR 1.00 per 1% increase [0.99 to 1.02], P = 0.88) were associated with all-cause mortality. Our results indicate that in HFrEF patients with ischemic etiology, the ESI may provide some information on prognosis, whereas the prognostic value of PSI is reduced. In patients with HFrEF and no prior exposure to ischemia, the prognostic value of both deformational patterns is reduced.

Prognostic utility of early systolic lengthening by speckle tracking in patients undergoing coronary artery bypass graft

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Independent Research Fund Denmark Background Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, has been linked to myocardial viability and contractile dysfunction. We assessed the long-term prognostic potential of ESL in coronary artery bypass graft (CABG) patients. Methods We retrospectively included patients (n = 709; mean age 68 years; 85% men) who underwent speckle tracking echocardiography (median 15 days) prior to CABG. Endpoints were cardiovascular death (CVD) and all-cause mortality. We assessed amplitude of ESL (%), defined as peak positive strain, and duration of ESL (ms), determined as time from Q-wave on the ECG to peak positive strain. We applied Cox proportional hazards models adjusted for the clinical risk tool, EuroSCORE II. Results During median follow-up of 3.8 years [IQR 2.7 to 4.9 years], 45 (6%) experienced CVD and 80 (11%) died. In survival analyses adjusted for EuroSCORE II, amplitude of ESL was associated with CVD (HR 1.37 [95%CI 1.13 to 1.66], P = 0.001) and all-cause mortality (HR 1.31 [95%CI 1.13 to 1.54], P = 0.001). Similar findings applied to duration of ESL and CVD (HR 1.17 [95%CI 1.08 to 1.26], P &amp;lt; 0.001) and all-cause mortality (HR 1.14 [95%CI 1.07 to 1.21], P &amp;lt; 0.001). The prognostic value of ESL amplitude was modified by sex (P interaction &amp;lt; 0.05), such that it was greater in women for both endpoints (Figure 1A-B). When adding ESL duration to EuroSCORE II, the net reclassification index improved significantly for both CVD and all-cause mortality. Conclusions Assessment of ESL provides independent and incremental prognostic information in addition to the EuroSCORE II for CVD and all-cause mortality in CABG patients. The prognostic value was greater in women. Abstract Figure. Prognostic value of ESL amplitude by sex

Prognostic utility of early systolic lengthening by speckle tracking echocardiography in patients with type 2 diabetes

Abstract Background Early systolic lengthening (ESL) has recently recognized as a predictor of cardiovascular events in patients with myocardial ischemia. Our aim was to evaluate the prognostic value of ESL in patients with type 2 diabetes. Methods In this prospective study we conducted speckle tracking examinations in 743 patients with type 2 diabetes (62% male; age 63±10 years; diabetes duration 11 [5, 17] years). Patients were free from interventricular conduction disturbances, atrial fibrillation, heart failure and ischemic heart disease at study inclusion. We assessed the ESL index, defined as: (−100 x [peak positive systolic strain / global longitudinal strain (GLS)]), and duration of ESL, defined as time from onset of QRS complex on the electrocardiogram to time of peak positive systolic strain. Measurements were averaged from 18 myocardial segments. Results During the median follow-up time of 4.8 years [IQR 4, 5.3 years], 93 (13%) patients experienced major adverse cardiovascular events (MACE), a composite of incident heart failure, myocardial infarction and cardiovascular death. Because GLS modified the association with MACE (P interaction &amp;lt;0.05), the population was stratified by the median GLS value (low &amp;gt;−15% and high ≤−15%). In patients with low GLS, the ESL index (HR 1.47 per 1% increase [1.12 to 1.93], P=0.005) and ESL duration (HR 1.73 per 1ms increase [1.10 to 2.72], P=0.017) were associated with MACE. Both associations remained significant in multivariable models adjusted for clinical, echocardiographic and speckle tracking measurements (Figure). No associations were found in patients with high GLS (Figure). Conclusion Assessment of ESL yields novel and independent prognostic information on major adverse cardiovascular events in patients with diabetes type 2 and reduced longitudinal strain. Forest plot: ESL and risk of MACE by GLS Funding Acknowledgement Type of funding source: None

Prognostic Value of Early Systolic Lengthening by Strain Imaging in Type 2 Diabetes

Patients with type 2 diabetes (T2D) have increased risk for subclinical myocardial disease. Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, is a sensitive marker of myocardial dysfunction. The aims of this study were to investigate the prognostic value of ESL in patients with T2D and to determine if global longitudinal strain (GLS) modifies this relationship. In this prospective study, speckle-tracking echocardiography was conducted in 703 patients with T2D (62% men; mean age, 63±10years; median diabetes duration, 11years; interquartile range, 6-17years). Patients had no histories of significant heart disease. ESL index was assessed as [-100×(peak positive systolic strain/maximal strain)] and ESL duration as time from QRS complex on the electrocardiogram to time of peak positive systolic strain. P values≤.004 were considered to indicate statistical significance. During a median follow-up time of 4.8years (interquartile range, 4.1-5.3years), 86 patients (12%) experienced major adverse cardiovascular events (MACE), a composite of incident heart failure, myocardial infarction, and cardiovascular death. In multivariate models, only the ESL index (hazard ratio [HR], 1.06 per 1% increase; 95% CI, 1.01-1.010; P=.004) but not ESL duration (HR, 1.02 per 1-ms increase; 95% CI, 1.00-1.03; P=.036) were associated with MACE. GLS modified this relationship (P for interaction<.05) such that in patients with low GLS (>-18%), ESL index (HR, 1.06 per 1% increase; 95% CI, 1.02-1.10; P=.003) was associated with MACE, but ESL duration was not (HR, 1.02 per 1-ms increase; 95% CI, 1.00-1.04; P=.005). No associations were found for high GLS (<-18%). In patients with T2D and no histories of heart disease, ESL provides prognostic information on MACE and may potentially aid in cardiovascular risk stratification.

Early Systolic Lengthening in Patients With ST-Segment-Elevation Myocardial Infarction: A Novel Predictor of Cardiovascular Events.

BackgroundEarly systolic lengthening (ESL) may occur in ischemic myocardial segments with reduced contractile force. We sought to evaluate the prognostic potential of ESL in patients with ST‐segment–elevation myocardial infarction treated with primary percutaneous coronary intervention.Methods and ResultsWe prospectively enrolled 373 patients with ST‐segment–elevation myocardial infarction treated with primary percutaneous coronary intervention. All patients underwent a speckle tracking echocardiographic examination a median of 2 days (interquartile range, 1–3 days) after the percutaneous coronary intervention. We assessed a novel viability index, the ESL index, defined as follows: [−100×(peak positive systolic strain/peak negative strain in cardiac cycle)]. We also calculated ESL duration, defined as time from onset of QRS complex on the ECG to time of peak positive systolic strain. Both parameters were averaged from 18 myocardial segments. During a median follow‐up of 5.3 years (interquartile range, 2.5–6.0 years), 145 (39%) experienced major adverse cardiovascular events, a composite of incident heart failure, new myocardial infarction, and all‐cause mortality. The ESL index and ESL duration were significantly increased in culprit lesion areas (6.7±6.2% versus 5.0±4.1% and 43±33 ms versus 33±24 ms, respectively; P<0.001 for both). In Cox proportional hazard models, the ESL index (hazard ratio, 1.27 per 1% increase; 95% CI, 1.13–1.43; P<0.001) and ESL duration (hazard ratio, 1.49 per 1‐ms increase; 95% CI, 1.15–1.92; P=0.002) yielded prognostic information on major adverse cardiovascular events. Both associations remained significant after adjusting for clinical, echocardiographic, and invasive confounders.ConclusionsAssessment of ESL after primary percutaneous coronary intervention in patients with ST‐segment–elevation myocardial infarction yields independent and significant prognostic information on the future risk of cardiovascular events.

Duration of early systolic lengthening: prognostic potential in the general population.

When the left ventricle pressure rises during early systole, myocardial fibres with reduced contractility tend to stretch instead of shortening. This interval is known as duration of early systolic lengthening (DESL). We sought to investigate if DESL provides prognostic information on cardiovascular events. In this prospective study we included 1210 participants from a low-risk general population who underwent speckle tracking echocardiography (men 41%, mean age 56 years, SD 16). Primary endpoints were incident heart failure (HF), myocardial infarction (MI), and cardiovascular death (CVD). We defined DESL as time from onset of Q-wave on the electrocardiogram to peak positive systolic strain. In addition, we assessed the ratio between DESL and duration of cardiac systole, DESLsystole.During median follow-up of 16 years, 90 (7%) developed HF, 50 (4%) MI, and 70 (6%) experienced CVD. Both DESL [hazard ratio (HR) 1.58 95%CI 1.16-2.15, P = 0.004 per 10 ms increase] and DESLsystole (HR 1.74 95%CI 1.24-2.47, P = 0.001 per 1% increase) were predictors of HF. Similarly, DESL (HR 1.40 95%CI 1.09-1.78, P = 0.007 per 10 ms increase) and DESLsystole (HR 1.58 95%CI 1.01-2.49, P = 0.047 per 1% increase) were predictors of MI. No associations were found with CVD. After adjusting for clinical and echocardiographic parameters, the associations remained significant. DESLsystole was superior to systolic echocardiographic parameters for predicting HF (P = 0.012). DESL and the novel index of DESLsystole provide independent and novel prognostic information on the risk of HF and MI in the general population. Evaluation of DESL should be explored in future echocardiographic studies.