Electrocardiographic Strain Pattern Research Articles

The Role of ECG Strain Pattern in Prognosis after TAVI: A Sub-Analysis of the DIRECT Trial.

The presence of an electrocardiographic (ECG) strain pattern-among other ECG features-has been shown to be predictive of adverse cardiovascular outcomes in asymptomatic patients with aortic stenosis. However, data evaluating its impact on symptomatic patients undergoing TAVI are scarce. Therefore, we tried to investigate the prognostic impact of baseline ECG strain pattern on clinical outcomes after TAVI. A sub-group of patients of the randomized DIRECT (Pre-dilatation in Transcatheter Aortic Valve Implantation Trial) trial with severe aortic stenosis who underwent TAVI with a self-expanding valve in one single center were consecutively enrolled. Patients were categorized into two groups according to the presence of ECG strain. Left ventricular strain was defined as the presence of ≥1 mm convex ST-segment depression with asymmetrical T-wave inversion in leads V5 to V6 on the baseline 12-lead ECG. Patients were excluded if they had paced rhythm or left bundle branch block at baseline. Multivariate Cox proportional hazard regression models were generated to assess the impact on outcomes. The primary clinical endpoint was all-cause mortality at 1 year after TAVI. Of the 119 patients screened, 5 patients were excluded due to left bundle branch block. Among the 114 included patients (mean age: 80.8 ± 7), 37 patients (32.5%) had strain pattern on pre-TAVI ECG, while 77 patients (67.5%) did not exhibit an ECG strain pattern. No differences in baseline characteristics were found between the two groups. At 1 year, seven patients reached the primary clinical endpoint, with patients in the strain group demonstrating significantly higher mortality in Kaplan-Meier plots compared to patients without left ventricular strain (five vs. two, log-rank p = 0.022). There was no difference between the strain and no strain group regarding the performance of pre-dilatation (21 vs. 33, chi-square p = 0.164). In the multivariate analysis, left ventricular strain was found to be an independent predictor of all-cause mortality after TAVI [Exp(B): 12.2, 95% Confidence Intervals (CI): 1.4-101.9]. Left ventricular ECG strain is an independent predictor of all-cause mortality after TAVI. Thus, baseline ECG characteristics may aid in risk-stratifying patients scheduled for TAVI.

Diagnostic value of left ventricle strain pattern of hypertensive patients in coronary and cerebrovascular diseases

Association of Electrocardiographic Left Ventricular Strain Pattern with Coronary Artery Disease and Cerebrovascular Accident in Hypertensive Patients
 Background: Patients diagnosed with hypertension and left ventricular hypertrophy could presented with electrocardiographic changes including criteria of left ventricular hypertrophy, and left ventricular strain pattern( fixed ST depression and T inversion in leads I, avL, V5&6)
 Objective: To study the impact of electrocardiographic left ventricular strain pattern in hypertensive patient as predictor for coronary artery disease and cerebrovascular accident development.
 Material and method: a cross sectional hospital based study was conducted during 2012-2017 at Iraqi center for heart diseases including hypertensive patients with normal ECG or LV strain pattern criteria, all patients underwent echocardiography and coronary angiography and the data were collected from patients’ files.
 Results: The records of 401 hypertensive patients [262(65.3%) males/139(34.7%) females] were included in this study. Their mean age was 60.07 ± 10.8 year.
 The relation between electrocardiographic left ventricular strain pattern and Coronary Angiography among patients was significant (P <0.001).
 There was a significant difference between electrocardiographic left ventricular strain pattern and cerebrovascular accident among studied group (P<0.001).
 Conclusions: electrocardiographic left ventricular strain in hypertensive patients is highly associated with coronary artery disease and cerebrovascular accident.
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Electrocardiographic left ventricular strain pattern, ST-segment depression and atrial fibrillation at the time of diagnosis of systemic light chain amyloidosis: Incidence and clinical significance

BackgroundST/T abnormalities recognized as electrocardiographic (ECG) left ventricular (LV) strain pattern are known as a marker of myocyte death and reduced survival. The purpose of this study was to determine whether ECG LV strain pattern, its components and atrial fibrillation (AF) predict lower survival at the time of diagnosis of systemic light chain (AL) amyloidosis. Methods12‑lead surface electrocardiogram (ECG), standard two-dimensional echocardiography, laboratory analyses were retrospectively evaluated within 2 months of diagnosis in 87 patients with biopsy-proven systemic AL amyloidosis from 2009 to 2017 in a single center. ECG strain pattern was defined as coexistence of ST-segment horizontal or downward sloping depression ≥0.05 mV at its most horizontal section and negative asymmetrical T-wave deeper than 0.1 mV in at least 1 of leads I,aVL,V1-V6. Patients with QRS >120 ms (BBB or major IVCD) were excluded from the analysis. ResultsKaplan-Meier survival analysis revealed a 1.8-fold shorter overall survival (OS) at 2 years in the ECG strain (21% of participants) group (p = 0.0078), 2.0-fold shorter OS in the ST-segment depression (STd) (isolated and strain related as one group) (34% of participants) group (p < 0.0001), and 3.9-fold shorter OS in AF (23% of participants) group (p < 0.0001) compared with those without. Median survival of patients with STd and AF were and 13.0 (range 1–74) and 9.5 (range 1–74) months respectively. In univariate analysis STd and AF were stronger predictors of inferior OS than relative wall thickness, average E/e′ ratio, and LV ejection fraction, but weaker predictors of OS than B-type natriuretic peptide. In multivariate analysis STd and AF lost significance after adjustment for age, gender, number of organs involved and BNP. ConclusionsST-segment depression and AF were not significantly associated with reduced survival in AL amyloidosis at diagnosis.

Electrocardiographic Strain Pattern Is a Major Determinant of Rehospitalization for Heart Failure After Transcatheter Aortic Valve Replacement.

BackgroundElectrocardiographic strain pattern (ESP) has recently been associated with increased adverse outcome in aortic stenosis and after surgical aortic valve replacement. Our study sought to determine the impact and incremental value of ESP pattern in predicting adverse outcome after transcatheter aortic valve replacement.Methods and ResultsA total of 585 patients with severe aortic stenosis (mean age, 83±7 years; men, 39.8%) were enrolled for transcatheter aortic valve replacement from November 2012 to May 2018. ESP was defined as ≥1‐mm concave down‐sloping ST‐segment depression and asymmetrical T‐wave inversion in the lateral leads. The primary end points of the study were all‐cause mortality, rehospitalization for heart failure, myocardial infarction, and stroke. A total of 178 (30.4%) patients were excluded because of left bundle‐branch block (n=103) or right bundle‐branch block (n=75). Among the 407 remaining patients, 106 had ESP (26.04%). At a median follow‐up of 20.00 months (11.70–29.42 months), no impact of electric strain on overall and cardiac death could be established. By contrast, incidence of rehospitalization for heart failure was significantly higher (33/106 [31.1%] versus 33/301 [11%]; P<0.001) in patients with ESP. By multivariate analyses, ESP remained a strong predictor of rehospitalization for heart failure (hazard ratio, 2.75 [95% CI, 1.61–4.67]; P<0.001).ConclusionsIn patients with aortic stenosis who were eligible for transcatheter aortic valve replacement, ESP is frequent and associated with an increased risk of postinterventional heart failure regardless of preoperative left ventricular hypertrophy. ESP represents an easy, objective, reliable, and low‐cost tool to identify patients who may benefit from intensified postinterventional follow‐up.

Clinical significance of electrocardiographic markers of myocardial damage prior to aortic valve replacement

BackgroundPre-operative myocardial fibrosis and remodeling impact on outcomes after aortic valve replacement (AVR). We aimed at investigating the prognostic impact of preoperative electrocardiographic (ECG) markers of left ventricular (LV) myocardial damage, i.e. bundle branch block (BBB) and ECG strain pattern after (surgical or transcatheter) AVR for severe aortic stenosis (AS). MethodsBetween April 2008 and October 2017, we explored consecutive patients referred to our Heart Valve Clinic for first AVR for severe AS. Detailed pre-operative phenotyping and ECG analysis were performed. Patients were followed-up after AVR for major cardiac events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke. ResultsBBB and ECG strain were respectively observed in 13.5 and 21% of the 1122 patients included. These ECG markers identified a subgroup of older patients, with higher NYHA class and more advanced myocardial disease as detected by echocardiography, i.e. higher LV mass and lower LV ejection fraction, global longitudinal strain and integrated backscatter, than patients without ECG strain or BBB. ME occurred in 212 (18.6%) patients during a mean follow-up of 4.4 ± 1.5 years with higher incidence in case of ECG strain or BBB (HR 1.56, 95%CI 1.13–2.14, p = 0.006; HR 1.47, 95%CI 1.02–2.13, p = 0.04 respectively). The prognostic value of ECG strain remained significant after adjustment for age, diabetes and pre-operative LVEF. ConclusionsPre-operative ECG markers of myocardial damage identify a subgroup of AS patients at high risk of post-AVR cardiovascular complications irrespective of other prognostic factors and should help the multiparametric staging of cardiac damage to guide AVR.

Electrocardiographic strain pattern is a major determinant of rehospitalization for heart failure after Transcatheter Aortic-Valve Replacement

Electrocardiographic (ECG) strain pattern (ESP) has recently been associated with increased adverse outcome in aortic stenosis (AS) and after surgical aortic-valve replacement (AVR). However, the relation linking ESP and cardiovascular MACE in patients with transcatheter aortic-valve replacement (TAVR) has not been yet described. Our study sought to determine the impact and incremental value of ESP pattern in predicting adverse outcome after TAVR. A total of 585 patients with severe AS (mean age: 83 ± 7 years; male 39.8%) were enrolled for TAVR from November 2012 to May 2018. ESP was defined as ≥ 1 mm concave down-sloping ST-segment depression and asymmetrical T-wave inversion in the lateral leads. Patients with baseline left bundle branch block (LBBB), right bundle branch block (RBBB) or ventricular paced rhythm were excluded. The primary endpoints of the study were the overall all-cause mortality after TAVR, rehospitalization for hearth failure (HF), myocardial infarction and stroke. 178 (30.4%) patients were excluded owing to LBBB ( n = 103) or RBBB ( n = 75). Among the 407 remaining patients, 106 had ESP (26.04%). Patients with ESP were younger, had lower BMI and more severe AS and significant lower LVEF. At a median follow-up of 608 days (356–895), no impact of electric strain on overall and cardiac death could be established. By contrast, incidence of rehospitalization for HF was significantly higher (33 (31.1%) vs. 33 (11%); P < 0.001) in ESP patients. By multivariate analyses, ESP remained a strong predictor of rehospitalization for hearth failure (HR 2.747 (95% CI 1.614–4.674); P < 0.001). In patients with AS eligible for TAVR, ESP is frequent and associated with an increased risk of post interventional heart failure regardless of preoperative LVH. ESP represents an easy, objective, reliable and low-cost tool to identify patients who may benefit from intensified post-interventional follow-up.

P6485Incremental prognostic value of electrocardiographic strain after transcatheter aortic valve replacement for aortic stenosis

Abstract Background Electrocardiographic (ECG) strain pattern has recently been associated with increased adverse outcome in aortic stenosis (AS) and after surgical aortic valve replacement (AVR). However, the relation linking ECG strain and cardiovascular MACE in patients with transcatheter aortic valve replacement (TAVR) has not been yet described. Objectives The aim of our study was to determine the impact and incremental value of ECG Strain pattern in predicting adverse outcome after TAVR. Methods 585 patients with severe AS (mean age: 83±7 male 39.8%) were enrolled from November 2012 to May 2018. ECG strain pattern was defined as ≥1 mm concave down-sloping ST-segment depression and asymmetrical T-wave inversion in the lateral leads. Patients with baseline left bundle branch block (LBBB), right bundle branch block (RBBB) or ventricular paced rhythm were excluded. All patients underwent transthoracic echocardiography (TTE) before TAVR and at 30 days follow up. The primary endpoints of the study were the overall all-cause mortality after TAVR, rehospitalization for Hearth failure (HF), myocardial infarction and stroke. Results 178 (30.4%) patients were excluded from analyses owing to the presence of either LBBB (n=103) or RBBB (n=75). Among the 407 remaining patients, 106 had ECG strain pattern (26.04%). Patients with ECG strain were significantly younger (81.6±8 years vs 83.5±6.8 years; p=0.022), had lower BMI (23±4.5 kg.m2 vs 27.9±6.8 kg.m2; p=0.02) more severe AS (mean gradient 52.3±15.2 mmHg vs 47.9±11.8 mmHg; p=0.003), significant lower LVEF (51.8±15% vs 58.4±10.7%; p&lt;0.001). Left ventricular hypertrophy (LVH) was more frequent in patients with ECG Strain (indexed left ventricular mass (135.9±33.4 g.m2 vs 123.6±31.9 g.m2; p=0.002)). Death from any cause (22 (20.8%) vs 61 (20.3%); p=0.508) did not differ significantly between groups. Major adverse cardiovascular events (MACE) including death, stroke and heart failure at 1 month showed similar incidence (7 (6.6%) vs 17 (5.6%), p=0.439). Rehospitalization for hearth failure (HF) was significantly higher (33 (31.1%) vs 33 (11%); p&lt;0.001) in patients with ECG strain pattern. In univariate model, ECG Strain was a strong predictor of rehospitalization for HF (HR 2.621 95% CI (1.607–4.277), p=0.001), independently of LVH assessed either by ECG criteria (HR 1.181 95% CI (0.698–1.997; p=0.536) or TTE (HR 1.557 95% (CI 0.701–3.458; p=0.277). ECG Strain remained associated with a higher risk of rehospitalization for hearth failure in multivariate analyses (HR 2.747 95% (CI 1.614- 4.674); p&lt;0.001) Conclusion In patients with AS eligible for TAVR, ECG Strain Pattern is frequent and associated with an increased risk of post interventional heart failure regardless of preoperative LVH. ECG Strain pattern represents an easy, objective, reliable and low-cost tool to identify patients who may benefit from an extend and intensified post-interventional follow-up.

Electrocardiographic Pattern of Left Ventricular Hypertrophy with Strain and Survival in Calcific Aortic Valve Disease

ABSTRACTBackground: The prevalence of electrocardiographic (ECG) patterns of left ventricular (LV) hypertrophy and strain in calcific aortic valve disease has not been extensively evaluated. We sought to evaluate the prevalence of ECG-defined LV hypertrophy and strain in a large cohort of patients with various grades of calcific aortic valve disease and to correlate these ECG patterns with survival.Methods: A total of 1,437 patients (mean age 66 ± 14 years, 62.6% men) with calcific aortic valve disease were evaluated. Demographic, clinical variables and presence of ECG patterns of LV hypertrophy and strain were collected and related to occurrence of all-cause mortality, correcting for aortic valve replacement during follow-up.Results: Aortic sclerosis was diagnosed in 29% of patients, mild aortic stenosis (AS) in 13%, moderate AS in 30% and severe AS in 28%. Seventy-six patients showed ECG pattern of LV hypertrophy without strain whereas 227 showed ECG pattern of LV hypertrophy with strain. Patients with LV hypertrophy with strain pattern showed more frequently severe AS. During a mean follow-up of 7.2 ± 4.8 years (10,258 patient-years), 545 (37.9%) patients died. Compared to ECG without hypertrophy pattern, ECG strain pattern was independently associated with all-cause mortality (HR 1.36, 95% CI 1.08–1.72; p = 0.009), whereas LV hypertrophy pattern on ECG was not (HR 1.38, 95% CI 0.94–2.24; p = 0.094).Conclusions: The ECG strain pattern reflects an advanced stage of the LV remodeling process in the natural history of calcific aortic valve disease and is independently associated with worse outcome.

ELECTROCARDIOGRAPHIC STRAIN PATTERN AND LONG-TERM MORTALITY AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT

Electrocardiographic (ECG) strain pattern has been linked to myocardial fibrosis, and cardiovascular morbidity and mortality in patients with hypertension. We aim to determine the differential impact of strain on baseline ECG on long-term mortality after transcatheter aortic valve replacement (TAVR

Electrocardiographic Strain Pattern Is Associated With Left Ventricular Concentric Remodeling, Scar, and Mortality Over 10Years: The Multi-Ethnic Study of Atherosclerosis.

BackgroundBoth ECG strain pattern and QRS measured left ventricular (LV) hypertrophy criteria are associated with LV hypertrophy and have been used for risk stratification. However, the independent predictive value of ECG strain in apparently healthy individuals in predicting mortality and adverse cardiovascular events is unclear.Methods and ResultsMESA (Multi‐Ethnic Study of Atherosclerosis) is a multicenter, prospective cohort of 6441 participants (mean age, 62 years; 54% women). In 2847 of these participants, cardiac magnetic resonance imaging was repeated ≈10 years later (Year‐10). At Year‐10, 1759 participants underwent cardiac magnetic resonance imaging with gadolinium to detect myocardial scar. During a median follow‐up of 11.7 years, ECG strain (n=168, 2.6%) was significantly associated with all‐cause death (adjusted hazard ratio, 1.33; 95% confidence interval, 1.01–1.77; P=0.045), heart failure (2.62; 1.73–3.97; P<0.001), myocardial infarction (1.86; 1.09–3.18; P=0.024), and incident cardiovascular disease (1.45; 1.06–2.00; P=0.022). ECG strain was also associated with an increase in LV mass (β=9.29 g; P<0.001) and LV mass‐to‐volume ratio (β=0.07 g/mL; P=0.007) and a decline in LV ejection fraction (β=−3.30%; P<0.001). Moreover, ECG strain either at baseline and Year‐10 was associated with LV scar (odds ratio, 4.93 and 5.22; P=0.002 and <0.001, respectively), whereas these associations were not observed in ECG LV hypertrophy.ConclusionsECG strain is independently associated with all‐cause mortality, adverse cardiovascular events, development of LV concentric remodeling and systolic dysfunction, and myocardial scar over 10 years in multiethnic participants without past cardiovascular disease. ECG strain may be an early marker of LV structural remodeling that contributes to development of adverse cardiovascular events.Clinical Trial RegistrationURL: https://www.clinicaltrials.gov/. Unique identifier: NCT00005487.

OP.7B.06] RELATIONSHIP OF INCIDENT ATRIAL FIBRILLATION TO THE ELECTROCARDIOGRAPHIC STRAIN PATTERN IN HYPERTENSIVE PATIENTS WITH ELECTROCARDIOGRAPHIC LEFT VENTRICULAR HYPERTROPHY

Objective: Atrial fibrillation (AF) is strongly related to hypertension and to left ventricular hypertrophy (LVH), and both regression of ECG-LVH and achievement of lower systolic blood pressure (SBP) are associated with lower incidence of AF. The ECG strain pattern of lateral ST depression and T-wave inversion has been associated with more severe LVH, decreased LV systolic function and an increased risk of cardiovascular morbidity and mortality, including new heart failure (HF). However, whether ECG strain is associated with an increased risk of new AF is unclear. Design and method: Risk of new-onset AF was examined in relation to the presence of the strain pattern on baseline ECG in 7921 hypertensive patients with ECG-LVH with no history of AF, who were in sinus rhythm on their baseline ECG, had baseline strain determination and were randomized to losartan- vs. atenolol-based treatment. Results: During 4.7 ± 1.1 yrs. of follow-up, new-onset AF was diagnosed in 621 patients (7.8%). Baseline ECG strain was present in 882 patients (11.1%) and was associated with a significantly higher 5-yr. incidence of AF in Kaplan-Meier estimates (12.2 vs 7.4%, p < 0.001) and with a 66% greater risk of new AF in a univariate Cox model (HR 1.66, 95% CI 1.34–2.06, p < 0.001), compared with the absence of ECG strain. After adjusting for other univariate predictors of new AF in this population, including age, sex, race, prior anti-hypertensive treatment, randomized treatment allocation, prevalent diabetes, history of ischemic heart disease, prior myocardial infarction, stroke or HF, baseline serum cholesterol and urine albumin/creatinine ratio entered as standard covariates and incident HF and on-treatment diastolic BP, SBP, heart rate and Cornell product LVH entered as time-varying covariates, ECG strain remained associated with a 39% greater risk of new-onset AF (HR 1.39, 95% CI 1.09–1.76, p = 0.008). Conclusions: The presence of baseline ECG strain is strongly associated with an increased risk of developing new-onset AF in hypertensive patients with ECG-LVH, independent of other AF risk factors and the effects of incident HF, LVH regression and SBP reduction. These findings suggest that hypertensive patients with ECG strain should be followed for development of new AF.

128 Genomic insights of ecg strain patten in aortic stenosis: t wave inversion and st-segment depression are underlined by different molecular pathways

BackgroundECG strain pattern is frequently presented in AS patients as a marker of LV hypertrophy and is emerging as one of the predictors for AVR. Our previous study had demonstrated...

Abstract 11359: Relationship of Incident Atrial Fibrillation to the Electrocardiographic Strain Pattern in Hypertensive Patients With Electrocardiographic Left Ventricular Hypertrophy

Background: Atrial fibrillation (AF) is strongly related to hypertension and to left ventricular hypertrophy (LVH) and both regression of ECG LVH and achievement of lower systolic blood pressure (SBP) are associated with lower incidence of AF. The ECG strain pattern of lateral ST depression and T-wave inversion has been associated with more severe LVH, decreased LV systolic function and an increased risk of cardiovascular mortality and morbidity, including new heart failure (HF). However, whether ECG strain is associated with an increased risk of new AF is unclear. Methods: Risk of new-onset AF was examined in relation to the presence of the strain pattern on baseline ECG in 7921 hypertensive patients with ECG LVH with no history of AF, who were in sinus rhythm on their baseline ECG, had baseline strain determination and were randomized to losartan- vs atenolol-based treatment. Results: During 4.7±1.1 years follow-up, new-onset AF was diagnosed in 621 patients (7.8%). Baseline ECG strain was present in 882 patients (11.1%) and was associated with a significantly higher 5-year incidence of AF in Kaplan-Meier estimates (12.2 vs 7.4%, p&lt;0.001) and with a 66% greater risk of new AF in a univariate Cox model (HR 1.66, 95% CI 1.34-2.06, p&lt;0.001), compared with the absence of ECG strain. After adjusting for other univariate predictors of new AF in this population, including age, sex, race, prior anti-hypertensive treatment, randomized treatment allocation, prevalent diabetes, history of ischemic heart disease, prior myocardial infarction, stroke or HF, baseline serum cholesterol and urine albumin/creatinine ratio entered as standard covariates and incident HF and on-treatment diastolic BP, SBP, heart rate and Cornell product LVH entered as time-varying covariates, ECG strain remained associated with a 39% greater risk of new-onset AF (HR 1.39, 95% CI 1.09-1.76, p=0.008). Conclusions: The presence of strain on a baseline ECG is strongly associated with an increased risk of developing new-onset AF in hypertensive patients with ECG LVH, independent of other AF risk factors and the effects of incident HF, LVH regression and SBP reduction. These findings suggest that hypertensive patients with ECG strain should be followed closely for development of new AF.

Value of the electrocardiographic strain pattern in children and adolescents with end stage renal disease

BackgroundAmong several electrocardiographic LVH criteria, LVH strain pattern was implicated as the strongest marker of cardiovascular adverse outcomes in general population and hypertensives. ObjectiveThe aim of this work is to detect the prevalence, clinical relevance and determinants of ECG strain pattern presence in children and adolescents with ESRD. MethodsThe study was performed at Zagazig University Hospital during the year 2012–2013. The studied patients with ESRD undergoing hemodialysis (24 males and 26 females) were categorized into three groups according to ECG. All patients were subjected to laboratory investigations (albumin, fasting lipids, renal function, serum creatinine, K+ serum, Ca2+ serum, phosphorus serum, alkaline phosphatase [ALP] serum, hemoglobin, pro BNP and parathormone), standard 12 leads surface ECG, and echocardiography (ECHO). ResultsECG strain was the most prevalent electrocardiographic pattern among the studied patients (42% versus 26% normal ECG and 32% ECG LVH without strain) who clinically have more ischemic chest pain (81% in group III versus 23.1% in group I and 43.8% in group III, p=0.003) and systolic hypertension (p=0.006). The prolonged disease duration (p=0.005), increased LVM (p=0.007), higher TC (p<0.01), lower Hb (p=0.02) and increased internal carotid velocity (p=0.05) were the independent variables associated with the ECG strain pattern. ConclusionIdentification of ECG strain pattern is correlated with myocardial ischemia risk, so it could be helpful in risk stratification of children and adolescents with ESRD. Factors determining ECG strain are prolonged disease duration, increased LVM, higher TC, lower Hb and increased internal carotid velocity could become an important part of management of ESRD patients.

Abstract 13080: Electrocardiographic Strain Pattern as a Predictor for New-Onset Heart Failure, Concentric Hypertrophy, Reduced Function, and Scar: MESA (Multi-Ethnic Study of Atherosclerosis)

Introduction: Left ventricular hypertrophy (LVH) is associated with incident heart failure (HF), and ECG strain is a marker of LVH. This study sought to evaluate the relationship of baseline ECG strain to the incidence of HF, longitudinal change of left ventricular (LV) geometry and function by cardiac magnetic resonance imaging (CMR). Methods: A total of 4,732 participants (mean age 61 years, 54% women) free of cardiovascular disease (CVD) underwent ECG and CMR. We used univariable and multivariable Cox proportional hazards to evaluate the association of ECG strain with incident HF (n=137). We also examined the association of baseline ECG strain with changes of LV geometry and function in 2,846 participants imaged at baseline and 10 years later using multiple linear regression models. Finally, we evaluated the association between the presence of ECG strain and LV scar defined by late Gadolinium enhancement at year 10 (n=1,650). Results: The presence of ECG strain was significantly associated with incident HF (hazard ratio: 2.53; 95% CI: 1.40 to 4.57; p=0.021) during follow-up (median 11.2 years). Longitudinal analysis revealed that the presence of ECG strain at baseline was significantly associated with an increase in the LV mass index (β=5.54g/m2, p&lt;0.001), LV mass-to-volume ratio (β=0.07g/mL, p=0.009), and a decrease in LV ejection fraction (EF) (β=-2.35%, p=0.015), even when coronary heart disease events were excluded. Moreover, ECG strain was independently associated with LV scar (p=0.004). Conclusions: In a cohort of middle-aged participants without prior CVD, ECG strain was an independent predictor of new-onset HF. In addition, ECG strain was related to development of LV concentric hypertrophy and decline in EF as well as LV scar.

A clinical risk score of myocardial fibrosis predicts adverse outcomes in aortic stenosis.

AimsMidwall myocardial fibrosis on cardiovascular magnetic resonance (CMR) is a marker of early ventricular decompensation and adverse outcomes in aortic stenosis (AS). We aimed to develop and validate a novel clinical score using variables associated with midwall fibrosis.Methods and resultsOne hundred forty-seven patients (peak aortic velocity (Vmax) 3.9 [3.2,4.4] m/s) underwent CMR to determine midwall fibrosis (CMR cohort). Routine clinical variables that demonstrated significant association with midwall fibrosis were included in a multivariate logistic score. We validated the prognostic value of the score in two separate outcome cohorts of asymptomatic patients (internal: n = 127, follow-up 10.3 [5.7,11.2] years; external: n = 289, follow-up 2.6 [1.6,4.5] years). Primary outcome was a composite of AS-related events (cardiovascular death, heart failure, and new angina, dyspnoea, or syncope). The final score consisted of age, sex, Vmax, high-sensitivity troponin I concentration, and electrocardiographic strain pattern [c-statistic 0.85 (95% confidence interval 0.78–0.91), P < 0.001; Hosmer–Lemeshow χ2 = 7.33, P = 0.50]. Patients in the outcome cohorts were classified according to the sensitivity and specificity of this score (both at 98%): low risk (probability score <7%), intermediate risk (7–57%), and high risk (>57%). In the internal outcome cohort, AS-related event rates were >10-fold higher in high-risk patients compared with those at low risk (23.9 vs. 2.1 events/100 patient-years, respectively; log rank P < 0.001). Similar findings were observed in the external outcome cohort (31.6 vs. 4.6 events/100 patient-years, respectively; log rank P < 0.001).ConclusionWe propose a clinical score that predicts adverse outcomes in asymptomatic AS patients and potentially identifies high-risk patients who may benefit from early valve replacement.

Clinical determinants and prognostic significance of the electrocardiographic strain pattern in chronic kidney disease patients

The electrocardiographic (ECG) strain pattern (Strain) is a marker of left ventricular hypertrophy (LVH) severity that provides additional prognostic information beyond echocardiography (ECHO) in the community level. We sought to evaluate its clinical determinants and prognostic usefulness in chronic kidney disease (CKD) patients. We evaluated 284 non-dialysis-dependent patients with CKD stages 3 to 5 (mean age, 61 years [interquartile range, 53–67 years]; 62% men). Patients were followed for 23 months (range, 13–32 months) for cardiovascular (CV) events and/or death. Strain patients (n = 37; 13%) were using more antihypertensive drugs, had higher prevalence of peripheral vascular disease and smoking, and higher levels of C-reactive protein, cardiac troponin, and brain natriuretic peptide (BNP). The independent predictors of Strain were: left ventricular mass index (LVMI), BNP, and smoking. During follow-up, there were 44 cardiovascular events (fatal and non-fatal) and 22 non-CV deaths; and Strain was associated with a worse prognosis independently of LVMI. Adding Strain to a prognostic model of LVMI improved in 15% the risk discrimination for the composite endpoint and in 12% for the CV events. Strain associates with CV risk factors and adds prognostic information over and above that of ECHO-assessed LVMI. Its routine screening may allow early identification of high risk CKD patients.

Impaired Endocardial Radial Strain in Hypertensive Patients with Electrocardiographic Strain Pattern on Twodimensional Speckle-Tracking Echocardiography

Background: Strain ST-T changes on Electrocardiography (ECG) is a well-recognized marker of the presence and severity of Left Ventricular (LV) hypertrophy, which is usually associated with subendocardial dysfunction. However, the relationship between ST-T change and subendocardial dysfunction in hypertensive patients is unknown. Recently, two-dimensional speckle-tracking echocardiography has been used to define myocardial deformation parameters of the LV segment. Herein, we assessed subendocardial dysfunction patients with strain ST-T changes on electrocardiogram using two-dimensional speckle-tracking echocardiography. Methods: Parasternal short-axis and apical long-axis views of the LV were acquired in 42 controls and 69 essential hypertensive patients. Patients were divided into two groups according to presence (n = 29) or absence (n = 40) of strain ST-T changes. Radial, circumferential and longitudinal strain in subendocardial and subepicardial layers were calculated. Results: No significant intergroup differences in circumferential strain in the subendocardial and subepicardial layers were observed. Longitudinal strain was decreased in hypertensive patients with strain ST-T changes versus patients without strain ST-T changes or control subjects (antero-septal: p < 0.0001; posterior: p < 0.005). Although epicardial radial strain was similar between patients with and without strain ST-T changes, endocardial radial strain was reduced in strain ST-T change group versus the no ST-T change group (antero-septal : 19.3 ± 14.5 vs. 31.9 ± 15.8, p < 0.01; posterior : 25.4 ± 14.9 vs. 34.5 ± 11.4, p < 0.05). Conclusions: Hypertensive patients with strain ST-T changes exhibit impaired longitudinal strain and endocardial radial strain, with preserved circumferential strain and epicardial radial strain. The impairment of endocardial radial strain in hypertensive patients with strain ST-T changes suggests a possible link between strain ST-T changes and subendocardial dysfunction.

Relation of Thoracic Aortic Distensibility to Left Ventricular Area (from the Multi-Ethnic Study of Atherosclerosis [MESA

Decreased arterial compliance is an early manifestation of adverse structural and functional changes within the vessel wall. Its correlation with left ventricular (LV) area on computed tomography, a marker of LV remodeling, has not been well demonstrated. The aim of this study was to test the hypothesis that decreasing aortic compliance and increasing arterial stiffness are independently associated with increased LV area. The study population consisted of 3,540 patients (mean age 61 ± 10 years, 46% men) from the Multi-Ethnic Study of Atherosclerosis (MESA) who underwent aortic distensibility (AD) assessment on magnetic resonance imaging and LV area measurement on computed tomography (adjusted to body surface area). Multivariate logistic regression was performed to assess the association between body surface area-normalized LV area >75th percentile and AD after adjusting for baseline clinical, historical, and imaging covariates. Mean LV area index was 2,153 cm(2), and mean AD was 1.84 × 10(3) mm Hg(-1). Subjects in the lowest AD quartile were older, with higher prevalence rates of hypertension, diabetes, and hypercholesterolemia (p <0.05 for all comparisons). Using multivariate linear regression adjusting for demographics, traditional risk factors, coronary artery calcium, and C-reactive protein, each SD decrease was associated with an 18-cm(2) increase in LV area. In addition, decreasing AD quartiles were independently associated with increasing LV area index, defined as >75th percentile. In conclusion, in this multiethnic cohort, reduced AD was associated with increased LV area. Longitudinal studies are needed to determine if decreased distensibility precedes and directly influences increased LV area.

The strain pattern, and not Sokolow–Lyon electrocardiographic voltage criteria, is independently associated with anatomic left ventricular hypertrophy

Although obesity and chest-wall thickness influence the Sokolow-Lyon electrocardiographic (ECG) voltage criteria and strain pattern, these factors have not been taken into account in previous studies that evaluate the relationship between the ECG criteria and anatomic left ventricular hypertrophy (LVH). The introduction of multislice computed tomography (MSCT) has enabled assessment of not only coronary artery stenoses but also left ventricular volume and mass, left atrial volume, and chest-wall thickness. We hypothesized that evaluating the relation between the ECG voltage criteria or strain pattern and the aforementioned factors using MSCT would be highly valuable. The study population consisted of 93 patients who required MSCT angiography. The Sokolow-Lyon voltage and strain patterns were determined to detect anatomic LVH, which was defined as increased left ventricular mass. The Sokolow-Lyon voltage criteria, as an indicator of anatomic LVH, had a sensitivity of 57 %, specificity of 67 %, positive predictive value of 36 %, and negative predictive value of 82 %. By contrast, the strain pattern had a sensitivity of 65 %, specificity of 87 %, positive predictive value of 63 %, and negative predictive value of 88 %. Multivariate analysis revealed that the strain pattern was associated with the presence of anatomic LVH, whereas the Sokolow-Lyon voltage was not. This MSCT study demonstrated that even after removing the effects of various factors, the strain pattern remained associated with the presence of anatomic LVH, in contrast to the Sokolow-Lyon voltage.