Impaired Global Longitudinal Strain Research Articles

Clinical application of echocardiographic-derived myocardial strain imaging in subclinical disease: a primer for cardiologists.

To highlight the evidence to support the measurement of left ventricular (LV) global longitudinal strain (GLS) in the risk assessment and management of patients with valvular heart disease. Subclinical myocardial dysfunction that is characterized by impaired LV GLS is often present in patients with valvular disease. The addition of GLS to the LV systolic function assessment refines disease classification and improves both prognosis and management of valvular disease. The measurement of global systolic function is essential in risk assessment and management of all patients with valvular heart disease. Although LV ejection fraction remains the main parameter of systolic function, strain measurement has emerged as a promising systolic function marker. Strain describes deformation of the myocardium that occurs during the cardiac cycle in the longitudinal, circumferential, and radial planes. Of all the regional strain deformation measurements, evidence gathered over the last decade has shown that GLS improves detection of systolic dysfunction beyond LV ejection fraction and provides additional prognostic information.

Global Longitudinal Strain as a Predictor of First and Subsequent Arrhythmic Events in Remotely Monitored ICD Patients With Structural Heart Disease

ObjectivesThis study sought to assess speckle-tracking–derived parameters as predictors of first and subsequent ventricular events in patients with structural heart disease and implantable cardioverter-defibrillators (ICD). BackgroundLeft ventricular ejection fraction (LVEF), the current primary parameter of risk stratification for ventricular arrhythmias (VAs) in structural heart diseases is burdened by many limitations. MethodsIn this retrospective, observational study, all consecutive patients with structural heart disease were admitted for ICD implantation. Patients not followed by a home-monitoring system were excluded. Two-dimensional (2D) speckle-tracking analysis was used to derive global longitudinal strain (GLS), mechanical dispersion (MD), and delta contraction duration (DCD) of all patients at enrollment. Home monitoring was checked weekly to detect all VAs and ICD therapies. A recurrent event statistical approach (Prentice, Williams, and Peterson model) was applied to evaluate subsequent events after the first ones. ResultsA total of 203 patients were consecutively enrolled and followed for a median of 2.2 years. Kaplan-Meier curves showed an increased risk of antitachycardia pacing or shock (log-rank p = 0.003) and VAs (log-rank p = 0.001) associated with lower quartiles of GLS. An impaired GLS was independently associated with an increased risk for the first ICD therapy (hazard ratio [HR]: 1.94; 95% confidence interval [CI]: 1.30 to 2.91; p = 0.001) and (HR: 1.42; 95% CI: 1.01 to 1.98; p = 0.04) for the first VA. GLS impairment was not significantly associated with an increased risk of recurrent ICD therapies or VAs. LVEF, MD, and DCD were not associated with an increased risk of first, second, and third ICD therapies or VA. ConclusionsImpaired GLS is associated with an increased risk of VAs and appropriate ICD therapies in a consecutive “real-world,” unselected population of remotely monitored patients with structural heart disease, although it does not seem reliable in predicting further arrhythmic events after the first one. MD and DCD do not predict first or subsequent arrhythmic events in ICD patients with structural heart disease.

Characterization of Left Ventricular Dysfunction by Myocardial Strain in Critical Pulmonary Stenosis and Pulmonary Atresia After Neonatal Pulmonary Valve Balloon Dilation

Transient left ventricular (LV) dysfunction occurs in some infants born with critical pulmonary stenosis (PS) or membranous pulmonary atresia with intact ventricular septum (PAIVS) after pulmonary valve (PV) balloon dilation (BD). The cause for this is not well understood. We sought to characterize this LV dysfunction by investigating regional differences in this cohort using myocardial strain imaging. Patients who underwent neonatal (<2 weeks age) PV BD for critical PS or PAIVS from Jan, 2007 to March, 2014 with echocardiographic images suitable for strain analysis were identified; infants with ≥moderate post-BD LV dysfunction (ejection fraction <40%, n = 8) were matched 1:1 with controls who underwent PV BD but did not develop LV dysfunction. Longitudinal and circumferential global and segmental strain were analyzed before and after PV BD. For the 8 LV dysfunction cases, LV global longitudinal strain worsened after PV BD (-16% pre- vs -8% post-PV BD, p = 0.008) with similar impairment in global LV circumferential strain (-17% vs -8%, p = 0.008); there was no significant change in RV global or segmental longitudinal strain pre- vs post-PVBD. No significant pre/post-BD differences in global or circumferential strain were found in control pts. Segmental analysis of longitudinal and circumferential LV strain before and after balloon dilation in cases demonstrated decreased strain in all segments, but more pronounced and statistically significant in septal segments as compared with the free wall. In conclusion, transient LV dysfunction post-PV BD for critical PS/PAIVS is characterized by impaired global longitudinal and circumferential LV strain, with the most significant reductions in strain at the interventricular septum; longitudinal RV strain remains unchanged. These findings suggest that the mechanism of LV dysfunction post-PV BD is adverse ventricular-ventricular interactions specifically involving the interventricular septum.

Successful radiofrequency catheter ablation of atrial fibrillation is associated with improvement in left ventricular energy loss and mechanics abnormalities.

Dissipative energy loss (EL), an index of inefficient blood flow, has not been studied in patients with atrial fibrillation (AF). We therefore assessed the effect of AF and of successful catheter ablation on left ventricular (LV) EL and global longitudinal strain (GLS) to explore the effect of inefficient blood flow on LV remodeling. In 53 patients undergoing catheter ablation for AF (AF group), LV EL (in mW/m) was evaluated by vector flow mapping (VFM) during systole (ELsys), early diastole (ELed) and atrial contraction phase (ELac), and GLS was calculated by two-dimensional tissue tracking (2DTT). Of the 53 patients, 37 patients who sustained sinus rhythm and completed echocardiographic evaluation at baseline and at 3 and 6months follow-up were examined for change in EL and GLS. The latter parameters also were assessed in 44 age- and sex-matched controls. At baseline in AF group, ELsys and ELed were significantly higher (3.97 ± 2.29 vs. 3.14 ± 1.01; and 9.22 ± 5.01 vs. 3.89 ± 1.51; both P < 0.05, respectively), and GLS was lower (- 16.66 ± 3.50 vs. - 19.95 ± 2.40, P < 0.05) than in controls. During follow-up after catheter ablation, ELsys and ELed significantly improved at 3months, and almost normalized at 6months (both P < 0.05); GLS also improved significantly (P < 0.05). In multivariate logistic regression analysis, ELed was the only independent predictor for maintenance of sinus rhythm at 1-year follow-up (hazard ratio, 1.254; 95% confidence interval 1.073-1.467). VFM and 2DTT revealed impaired LV EL and GLS in patients with AF. Successful catheter ablation appeared to ameliorate impairment in intraventricular flow and mechanics.

Left atrial function in obese and non-obese patients undergoing percutaneous pulmonary vein isolation

Obesity constitutes a risk factor for atrial fibrillation (AF) and modifies the efficacy of invasive AF treatment. Left atrial (LA) global longitudinal strain (GLS), which is measured using speckle-tracking echocardiography (STE), is one of the new methods that are helpful in evaluating the function of LA. The aim of the study was to evaluate LA function in obese and non-obese patients that were undergoing percutaneous pulmonary vein isolation (PVI) before and 6 months after the procedure. 89 patients (F/M: 31/58; mean age: 55.8 ± 9.8 years) with paroxysmal or persistent symptomatic AF that had been qualified for percutaneous PVI were prospectively enrolled in the study. Body mass index (BMI) constituted as a discriminating factor for the study groups: obese group: BMI ≥ 30 kg/m2 (29 patients, F/M: 13/16, mean age: 55.13 ± 10.1 years) and non-obese group BMI < 30 kg/m2 (60 patients, F/M: 18/42, mean age: 57.17 ± 9.0 years). Transthoracic echocardiography (TTE) with LA GLS and segmental longitudinal strain were analysed 1 day before and 6 months after PVI. PVI efficacy was evaluated 6 months after PVI via a seven-day Holter monitoring. Baseline analysis revealed significantly lower two-chamber (2-Ch) LA GLS in the obese patients compared to the non-obese subjects (− 10.55 ± 3.7 vs − 13.11 ± 5.1, p = 0.004). Segmental strain analysis showed no significant differences between the groups. The data that was obtained 6 months after PVI showed a significantly lower 4-Ch LA GLS in the obese patients compared to the non-obese subjects (− 11.04 ± 5.0 vs − 13.91 ± 4.2, p = 0.02), which was accompanied by a significantly lower segmental 4-Ch LA function in the obese patients (med-sept: − 11.66 ± 11.2 vs − 15.97 ± 5.3, p = 0.04; api-sept: − 9.04 ± 6.3 vs − 13.62 ± 6.5, p < 0.001; api-lat: − 7.62 ± 4.0 vs − 13.62 ± 6.5, p < 0.001; med-lat: −9.31 + − 7.9 vs − 15.04 + − 6.3, p = 0.003, global: − 11.04 + − 5.0 vs − 13.91 + − 4.2, p = 0.02). PVI efficacy was confirmed in 52 (58.4%) patients and was similar in both groups. Comparison of the baseline and 6-month strain revealed no differences in LA GLS in either group. Differences in LA GLS before and after the procedure (delta LA GLS) were not obesity dependent. Apical-septal and apical-lateral strain in the obese group, which were measured in 4-Ch view, were significantly lower after the procedure compared to the baseline (p < 0.001). Obese patients with paroxysmal AF were characterised by impaired LA GLS, which is persistent and was accompanied by segmental dysfunction after PVI at the 6-month follow-up. PVI efficacy was comparable between the obese and non-obese patients.

Cardiac systolic dysfunction in past illicit users of anabolic androgenic steroids

BackgroundIllicit use of anabolic androgenic steroids (AAS) is associated with left ventricle (LV) systolic dysfunction and increased LV mass (LVM), but whether these findings persist in former AAS users has yet to be elucidated. The objective was to assess LV systolic function, LVM and myocardial fibrosis in current and former illicit AAS users compared with non-users. MethodsCommunity-based cross-sectional study among men, aged 18–50 years, involved in recreational resistance training. We included 37 current and 33 former illicit AAS users, geometric mean (95%CI), 30 (21; 44) months since AAS cessation, and 30 non-users as controls. We assessed myocardial function and structure using advanced echocardiography and cardiac MRI with late-gadolinium enhancement. ResultsMean (SE) LV global longitudinal strain (GLS) was impaired in former AAS users compared with non-users, −16.7 (0.5) versus −18.2 (0.4) %, P < .05. Mean (SE) LV ejection fraction (EF) was decreased, 51 (1) versus 58 (1) %, P < .001 and LV GLS impaired, −14.5 (0.4)%, P < .001, in current AAS users compared with non-users. Measures of LVM were increased in current AAS users compared with the other two groups, P < .001. Plasma total testosterone was independently associated with reduced LVEF (P = .049) and increased LVM/body surface area (P = .005) in multivariate linear regressions. Focal myocardial fibrosis was not detected in any participants and diffuse myocardial fibrosis, assessed using post-contrast T1-mapping time, did not differ among the three groups. ConclusionsPast illicit AAS use is associated with impaired LV GLS, suggesting subclinical cardiac systolic dysfunction years after AAS cessation.

High prevalence of occult heart disease in normotensive patients with rheumatoid arthritis.

Due to chronic inflammatory status, rheumatoid arthritis (RA) patients are exposed to changes in left ventricular (LV) geometry and function. We assessed prevalence, factors associated with, and prognostic role of concentric LV geometry and systolic dysfunction (LVSD) detected by echocardiography in a large cohort of patients with RA and normal blood pressure. Changes in LV geometry and function are widely detectable in normotensive patients with RA analyzed in primary prevention. We prospectively analyzed 194 normotensive RA patients without overt cardiac disease recruited between March 2014 and May 2016, compared with 194 non-RA matched controls. Relative wall thickness >0.43 defined concentric LV geometry. LVSD was defined as impaired global longitudinal strain (GLS). The prespecified study endpoints were all-cause hospitalization and hospitalization for cardiovascular cause. The 194 normotensive subjects (mean age, 54 years; 63% female; RA duration 13 years) had a prevalence of LV concentric geometry 5-fold higher and LVSD 5-fold higher than non-RA matched controls. Body mass index, LVSD, and diastolic dysfunction were associated with concentric LV geometry, while worsening renal function and older age were associated with LVSD. LVSD was independently related to the study endpoints (HR 2.37 [1.24-4.53], p = 0.009, for all-causes hospitalization and HR 6.60 [1.47-29.72], p = 0.01 for cardiovascular hospitalization). Despite normotensive status, a consistent proportion of RA patients analyzed in primary prevention have cardiac abnormalities detectable by echocardiography. LVSD is a strong prognosticator of adverse outcome at midterm period in these patients.

Diagnosis of Nonischemic Stage B Heart Failure in Type 2 Diabetes Mellitus: Optimal Parameters for Prediction of Heart Failure

ObjectivesThis study sought to identify whether impaired global longitudinal strain (GLS), diastolic dysfunction (DD), or left atrial enlargement (LAE) should be added to stage B heart failure (SBHF) criteria in asymptomatic patients with type 2 diabetes mellitus. BackgroundSBHF is a precursor to clinical heart failure (HF), and its recognition justifies initiation of cardioprotective therapy. However, original definitions of SBHF were based on LV hypertrophy and impaired ejection fraction. MethodsPatients with asymptomatic type 2 diabetes mellitus ≥65 years of age (age 71 ± 4 years; 55% men) with preserved ejection fraction and no ischemic heart disease were recruited from a community-based population. All underwent a standard clinical evaluation, and a comprehensive echocardiogram, including assessment of left ventricular hypertrophy (LVH), LAE, DD (abnormal E/e′), and GLS (<16%). Over a median follow-up of 1.5 years (range 0.5 to 3), 20 patients were lost to follow-up, and 290 individuals were entered into the final analyses. ResultsIn this asymptomatic group, LV dysfunction was identified in 30 (10%) by DD, 68 (23%) by LVH, 102 (35%) by LAE, and 68 (23%) by impaired GLS. New-onset HF developed in 45 patients and 4 died, giving an event rate of 112/1,000 person-years. Survival free of the composite endpoint (HF and death) was about 1.5-fold higher in patients without a normal, compared with an abnormal echocardiogram. LVH, LAE, and GLS <16% were associated with increased risk of the composite endpoint, independent of ARIC risk score and glycosylated hemoglobin, but abnormal E/e′ was not. The addition of left atrial volume and GLS provided incremental value to the current standard of clinical risk (ARIC score) and LVH. In a competing-risks regression analysis, LVH (hazard ratio: 2.90; p < 0.001) and GLS <16% (hazard ratio: 2.26; p = 0.008), but not DD and LAE were associated with incident HF. ConclusionsSubclinical left ventricular systolic dysfunction is prevalent in asymptomatic elderly patients with type 2 diabetes mellitus, and impaired GLS is independent and incremental to LVH in the prediction of incident HF.

Myocardial Strain in Prediction of Outcomes After Surgery for Severe Mitral Regurgitation

ObjectivesWe investigated whether global longitudinal strain (GLS) is a better predictor of clinical events after surgery for mitral regurgitation (MR) than conventional parameters. BackgroundThe optimal timing for surgery is guided by left ventricular (LV) dimension or left ventricular ejection fraction (LVEF), even though normal LVEF can mask depressed LV systolic function in severe mitral MR. MethodsFrom 2006 to 2016, 506 patients (age 58.5 ± 13.7 years, 54.3% male) with severe primary MR who underwent mitral valve surgery were included. We measured GLS and global circumferential strain. Cardiac events included admission for worsening heart failure (HF), reoperation for failure of MV surgery, and cardiac death. ResultsDuring a median follow-up period of 3.5 years, 56 (11.1%) patients died, 41 (8.1%) were hospitalized for HF, and 10 (2.0%) underwent reoperation. In univariate analysis, LVEF, atrial fibrillation, left atrial dimension, age, previous ischemia, concomitant coronary artery bypass graft, and both GLS and global circumferential strain were predictive of cardiac events. On multivariate Cox models, age (hazard ratio [HR]: 1.429, 95% confidence interval [CI]: 1.116 to 1.831; p = 0.005), left atrial dimension (HR: 1.034, 95% CI: 1.006 to 1.063; p = 0.019) and GLS (HR: 1.229, 95% CI: 1.135 to 1.331; p < 0.001) were independent predictors of cardiac events. In subgroup analysis, LV GLS was a significant predictor of cardiac outcome, regardless of the presence of LV dysfunction, the presence of atrial fibrillation, and the type of surgery. Impaired GLS was associated with all-cause mortality (HR: 1.068, 95% CI: 1.003 to 1.136; p = 0.040). ConclusionsGLS appears to be a better predictor of cardiac events all-cause death than conventional parameters. Measuring preoperative GLS is helpful to predict post-operative outcome and determine optimal timing for surgery in patients with severe primary MR.

Epicardial Adipose Tissue Is Associated With Left Atrial Dysfunction in People Without Obstructive Coronary Artery Disease or Atrial Fibrillation

BackgroundEpicardial adipose tissue (EAT) is a metabolically active visceral fat depot. Although EAT volume is associated with the incidence and burden of atrial fibrillation (AF), its role in subclinical left atrial (LA) dysfunction is unclear. This study aims to evaluate the relationships between EAT volumes, LA function, and LA global longitudinal strain. MethodsOne hundred and thirty people without obstructive coronary artery disease or AF were prospectively recruited into the study in Australia and underwent cardiac computed tomography and echocardiography. EAT volume was quantified from cardiac computed tomography. Echocardiographic 3-dimensional (3D) volumetric measurements and 2D speckle-tracking analysis were performed. ResultsUsing the overall median body surface area–indexed total EAT volume (EATi), the study cohort was divided into 2 groups of larger and smaller EATi volume. Subjects with larger EATi volume had significantly impaired LA reservoir function (3D LA ejection fraction, 46.1% ± 8.9% vs 49.0% ± 7.0%, P = 0.044) and reduced LA global longitudinal strain (37.6% ± 10.2% vs 44.1% ± 10.7%, P < 0.001). Total EATi volume was a predictor of impaired 2D LA global longitudinal strain (standardized β = −0.204, P = 0.034), reduced 3D LA ejection fraction (standardized β = −0.208, P = 0.036), and reduced 3D active LA ejection fraction (standardized β = −0.211, P = 0.017). Total EATi volume, rather than LA EATi volume, was the more important predictor of LA dysfunction. ConclusionsIndexed EAT volume is independently associated with subclinical LA dysfunction and impaired global longitudinal strain in people without obstructive coronary artery disease or a history of AF.

Prognostic value of global longitudinal strain in heart failure patients treated with cardiac resynchronization therapy

Myocardial fibrosis (macroscopic scar or diffuse reactive fibrosis) is one of the determinants of impaired left ventricular (LV) global longitudinal strain (GLS) in heart failure (HF) patients. The purpose of this study was to evaluate the prognostic value of LV GLS in HF patients treated with cardiac resynchronization therapy (CRT). The study included 829 HF patients (mean age 64.6 ± 10.4 years; 72% men) treated with CRT. Before CRT implantation, LV GLS was assessed using 2-dimensional speckle tracking echocardiography. The primary endpoint was the combination of all-cause mortality, heart transplantation, and LV assist device implantation. The secondary endpoint was the occurrence of ventricular arrhythmias or appropriate implantable defibrillator device therapies. During follow-up, 332 patients reached the primary endpoint, and 233 presented with the secondary endpoint. Patients were divided according to LV GLS quartiles. Patients with the most impaired LV GLS quartile had a 2-fold higher risk of reaching the combined endpoint compared with patients in the best LV GLS quartile (hazard ratio [HR] 2.088; 95% confidence interval [CI] 1.555-2.804; P <.001). LV GLS was significantly associated with the combined endpoint (HR 1.075; 95% CI 1.020-1.133; P = .007) after adjusting for clinical, electrocardiographic, and echocardiographic characteristics. Although patients in the most impaired LV GLS quartile showed higher event rates for the secondary endpoint compared with the other groups, LV GLS was not independently associated with the secondary endpoint (HR 1.047; 95% CI 0.989-1.107; P = .115). In this large cohort of CRT patients, baseline LV GLS was independently associated with the combined endpoint.

Left ventricular global longitudinal strain across the spectrum of heart failure stages and its prevalence, correlates and prognostic relevance in heart failure with preserved ejection fraction

LV global longitudinal strain (GLS) is significantly altered in HFpEF and is a powerful predictor of outcome according to a recent meta-analysis. We sought to determine the evolution of GLS across the spectrum of AHA HF stages and to analyze the correlation of GLS with other clinical, biological and imaging variables and its prognostic value in HFpEF. GLS was assessed by 2D speckle-tracking echocardiography in 172 patients with HFpEF stage C (78 ± 10 yrs, 38%men), 22 stage B (73 ± 10 yrs, 32%men), 56 stage A (63 ± 16 yrs, 52% men) and 20 healthy volunteers (38 ± 12 yrs, 55% men). Impaired GLS was defined as −16.6%, corresponding to 2 SD below the mean value of age and sex matched controls. All patients underwent 2D echo and cMR. Patients were followed up for a composite outcome of mortality and first HF hospitalization. Mean GLS was −20.1 ± 1.0%, −19.8 ± 1.6%, −19.1 ± 2.6% and −16.6 ± 3.0% in volunteers, stage A, stage B and stage C respectively ( P for trend < 0.001), showing the worsening of GLS across the stages ( Fig. 1 ). In HFpEF stage C, 86 patients (50%) had an impaired GLS. They had higher NTproBNP ( P = 0.002), higher sST2 ( P = 0.023), higher incidence of AF (55% vs. 36%, P = 0.014), lower LVEF ( P < 0.001), higher indexed RA volume ( P = 0.041) and impaired RV systolic function (lower FAC, P = 0.002; lower TAPSE, P < 0.001 and lower cMR RVEF, P < 0.001). In multivariate logistic analysis, only RVEF (OR 0.94 [0.89–0.98], P = 0.005) and NTproBNP (OR 1.91 [1.26–2.88], P = 0.003) were associated with impaired GLS in HFpEF stage C, even after adjustment for other variables. During a mean follow up of 19 ± 9months, 85 patients (49%) reached the combined endpoint. In univariate Cox analysis, GLS was not associated with outcome. There is a continuum in GLS impairment across the spectrum of AHA HF stages confirming the role of a subclinical myocardial dysfunction in HFpEF. Impaired GLS was associated with RV dysfunction and NTproBNP but not with clinical outcomes in HFpEF.

Left ventricular global longitudinal strain and long-term prognosis in patients with chronic obstructive pulmonary disease after acute myocardial infarction

Left ventricular (LV) systolic function is a known prognostic factor after ST-segment elevation myocardial infarction (STEMI). We evaluated the prognostic value of LV global longitudinal strain (GLS) in patients with chronic obstructive pulmonary disease (COPD) after STEMI. One hundred and forty-three STEMI patients with COPD (mean age 70 ± 11 years, 71% male), were retrospectively analysed. Left ventricular ejection fraction (LVEF) and LV GLS were measured on transthoracic echocardiography within 48 h of admission. Patients were followed for the occurrence of all-cause mortality and the combined endpoint of all-cause mortality and heart failure hospitalization. After a median follow-up of 68 (interquartile range 38.5-99) months, 66 (46%) patients died and 70 (49%) patients reached the combined endpoint. The median LV GLS was -14.4%. Patients with LV GLS >-14.4% (more impaired) showed higher cumulative event rates of all-cause mortality (19%, 26%, and 44% vs. 7%, 8%, and 18% at 1, 2, and 5 years follow-up; log-rank P = 0.004) and the combined endpoint (26%, 34%, and 50% vs. 8%, 10%, and 20% at 1, 2, and 5 years follow-up; log-rank P = 0.001) as compared to patients with LV GLS ≤-14.4%. In multivariate analysis, LV GLS >-14.4% was independently associated with increased all-cause mortality and the combined endpoint [hazard ratio (HR) 2.07; P = 0.02 and HR 2.20; P = 0.01, respectively] and had incremental prognostic value over LVEF demonstrated by a significant increase in χ2 (P = 0.023 and P = 0.011, respectively). Impaired LV GLS is independently associated with worse long-term survival in STEMI patients with COPD and has incremental prognostic value over LVEF.

La obesidad central es el componente clave en la asociación del síndrome metabólico con el deterioro del strain longitudinal global del ventrículo izquierdo

Introduction and objectivesSubclinical systolic dysfunction is one of the proposed mechanisms for increased cardiovascular risk associated with metabolic syndrome (MS). This study investigated the association between MS and impaired left ventricular global longitudinal strain (GLS) and the role of each MS criteria in this association. MethodsWe analyzed a random sample of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) after excluding participants with prevalent heart disease. ResultsAmong the 1055 participants fulfilling the inclusion criteria (53% women; 52±9 years), 444 (42%) had MS. Those with MS had worse GLS (–18.0%±2.5%) than those without (–19.0%±2.4%; P<.0001). In multiple linear regression models, MS was associated with worse GLS after adjustment for various risk factors (GLS difference=0.86%; P <.0001), even after inclusion of body mass index. Adjusted PR for impaired GLS as assessed by 3 cutoffs (1, 1.5, and 2 standard deviations) were higher among participants with than without MS: GLS –16.1% (PR, 1.76; 95%CI, 1.30-2.39); GLS –14.8% (PR, 2.35; 95%CI, 1.45-3.81); and GLS –13.5% (PR, 2.07; 95%CI, 0.97-4.41). After inclusion of body mass index in the models, these associations were attenuated, suggesting that they may, at least in part, be mediated by obesity. In quantile regression analyses, elevated waist circumference was the only MS component found to be independently associated with GLS across the whole range of values. ConclusionsMetabolic syndrome is independently associated with impaired GLS. Among the MS criteria, central obesity best depicted the link between metabolic derangement and cardiac function.Full English text available from: www.revespcardiol.org/en

Variations in subclinical left ventricular dysfunction, functional capacity, and clinical outcomes in different heart failure aetiologies.

AimsPatients with heart failure (HF) risk factors are described as being in Stage A of this condition (SAHF). Management is directed towards prevention of HF progression, but to date, no evidence has been described to align the intensity of this intervention to HF risk. We sought to what extent SAHF of Type 2 diabetes mellitus (T2DM) and other HF risks showed differences in subclinical left ventricular function, exercise capacity, and prognosis.Methods and resultsWe recruited 551 elder asymptomatic SAHF patients (age 71 ± 5 years, 49% men, 290 T2DM) with at least one risk factor from a community‐based population with preserved ejection fraction. All underwent a comprehensive echocardiogram including global longitudinal strain (GLS) and a 6 min walk test and were followed for 2 years. The primary endpoints were new‐onset HF and all‐cause mortality. The T2DM group was associated with reduced 6 min walk test distance (451 ± 111 vs. 493 ± 87 m, P < 0.001), worse diastolic function (E/e′ 9.2 ± 2.7 vs. 8.7 ± 2.4, P = 0.028), and impaired GLS (−17.7 ± 2.6% vs. −19.0 ± 2.6%, P < 0.001). Over a median follow‐up of 1.6 years, 49 T2DM‐SAHF and 27 other‐SAHF met the primary endpoint. T2DM‐SAHF had significantly worse outcome than other‐SAHF (P = 0.021). In Cox models, obesity [hazard ratio (HR) = 2.46; P = 0.007], atrial fibrillation (HR = 2.39; P = 0.028), 6 min walk distance (HR = 0.99; P = 0.034), and GLS (HR = 1.14; P = 0.033) were independently associated with the primary endpoint in T2DM‐SAHF, independent of age and glycaemic control.ConclusionsThe T2DM‐SAHF has worse subclinical left ventricular function, exercise capacity, and prognosis than other‐SAHF. Impaired GLS, atrial fibrillation, exercise capacity, and obesity are associated with a worse prognosis in T2DM‐SAHF but not in other‐SAHF.

Left ventricular function and contractile reserve in patients with hypertension.

An impaired contractile reserve (CR) may be an early manifestation of left ventricular (LV) systolic dysfunction in hypertensive patients. Using normotensive patients as controls, we examined LV CR and its correlates in hypertensive patients. One hundred and twenty-nine (68 men, aged 58.6 ± 9.5 years, 73 had hypertension) patients underwent dobutamine echocardiography. Patients with significant coronary or valvular disease, previous myocardial infarction or revascularization, and diabetes were excluded. LV ejection fraction (LVEF), global longitudinal strain (GLS), circumferential, and radial strain were measured at rest and at low-dose dobutamine. Absolute CR was calculated as the difference in LVEF and multi-directional strain between low-dose dobutamine and their corresponding resting values. Relative CR is the ratio of absolute CR to their corresponding resting values. Hypertensive patients, compared with controls, have significantly impaired GLS at rest (-16.8 ± 2.2% vs. -19.6 ± 1.5%, P < 0.0001) and at low-dose dobutamine (-17.9 ± 2.7% vs. -22.8 ± 2.6%, P < 0.0001). Absolute and relative GLS CR were significantly lower in hypertensive patients (-1.1 ± 2.1% vs. -3.2 ± 2.2% and 7.4 ± 13.9% vs. 16.4 ± 11.7%, respectively, both P < 0.001). Circumferential strain was preserved at rest but impaired at low-dose dobutamine in hypertensive patients (-23.0 ± 4.1% vs. -25.2 ± 3.4%, P = 0.002). There were no differences in LVEF or radial strain between the groups. LV wall thickness and systolic blood pressure correlated significantly with GLS at rest and at low-dose dobutamine. LV wall thickness is the only independent correlates of absolute CR. Compared with controls, hypertensive patients have impaired LV GLS at rest and impaired CR despite normal LVEF. Impaired CR correlated with LV wall thickness but independent of prevailing blood pressure.

Cardiac remodelling after valvular replacement in patients with aortic stenosis: A substudy from Translink

Reverse cardiac remodelling is a major goal of aortic valve replacement (AVR). Global longitudinal strain (GLS) currently allows a more sensitive evaluation of systolic function than left ventricle ejection fraction (LVEF). The European Translink FP7 project prospectively included patients with aortic stenosis scheduled for surgical or percutaneous AVR. The present substudy included patients enrolled in Nantes University Hospital. Patients were separated in two groups according to baseline left ventricle (LV) GLS value (normal ≤ or altered > −16%). Changes in LV GLS and cardiac morphology were evaluated 6 months after AVR. Two hundred patients (64% men, mean age 74 ± 9 years) were included and the follow up at 6 months was completed in 127. LVEF at baseline was 62 ± 10% and GLS −16.1 ± 3.7%. Patients with impaired GLS at baseline ( n = 85, 43%) were more often diabetics and obese, and had higher NT-proBNP levels. Cardiac cavities remodelling was more pronounced, LVEF was moderately decreased (57.1 ± 10.9% vs. 65.9 ± 7.3%; P < 0.001), and valvulo-arterial impedance was higher. These patients experienced a significant improvement in GLS at 6 months (−15.3 ± 3.8% vs. −12.9 ± 2.3%; P < 0.001), in contrast with patients with normal GLS at baseline (-18.7 ± 1.6% vs. −18.1 ± 2.6%; P = 0.07). Baseline LVEF and septal E/Ea were significantly associated with GLS value at 6 months in multivariate analysis. There was no significant change in left atrium size but a decrease in E/Ea at 6 months. Despite a significant decrease in pulmonary artery pressure, there was a significant alteration of right ventricle strain at 6 months (−20.7 ± 4.7% vs. −23.2 ± 5.8%; P < 0.001), in correlation with tricuspid annulus dilatation ( Fig. 1 ). Left ventricle presented a significant reverse remodelling after surgical or percutaneous AVR, especially in patients with altered GLS before procedure. This favourable LV remodelling contrast with unfavourable right cavities remodelling.

Prognostic value of collagen biomarkers on left atrial remodeling and arrhythmia on hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a disease characterized by cell disorganization with a matrix remodeling leading to fibrosis. To investigate biological markers which are the amino terminal propeptide of type III collagen (PIIINP), a synthetic indicator which may reflect the rate of myocardial fibrosis, a metalloproteinase (MMP3) involved in the regulation of collagen and its specific tissue inhibitor TIPM2. We included 107 patients and 175 controls who benefited of a clinical study. The serum level of the PIIINP, MMP3 and TIMP2 activities were determined in the peripheral vein by ELISA technique. We studied the association of serum levels of these markers with clinical, echocardiographic and atrial fibrillation onset. The mean age was 49 years, 60 were male, the rate of PIIINP was significantly higher inpatients compared with controls (361.92 ± 41.6 pg/mL vs 242.80 ± 46.7 ng/mL; P = 0.036). Same for the MMP3 and TIMP2 levels (12.16 ± 4,33 pg/mL vs 10.4 ± 3.78 pg/mL and 63.4 ± 23.5 pg/mL vs 57.50 ± 21.43 pg/mL, respectively, P = 0.03). MMP3/TIMP2 ratio is correlated to left ventricular (LV) mass and the left atrium volume (r = 0.560, P = 0.002 and r = 0.633, P = 0.001 respectively), the PIIINP is correlates to the maximum thickness of the LV (r = 0.466, P = 0.002), to the LV global longitudinal Strain (GLS) (r = −0.578, r = 0.001, after a median follow up of 62 ± 12 months, 26 patients presented sustained atrial fibrillation symptomatic or detected by ECG monitoring. They were older and had a higher rate of PIIINP (432.5 ± 34.6 pg/mL vs 320.44 ± 32.8 pg/mL, P = 0.002) and impaired LV GLS(−14.7 ± 2.6% vs 16.7 ± 3.2%, P = 0.0034). HMC is characterized by atrial remodeling and fibrosis with a high risk of atrial arrhythmia and morbidity, related to the collagen accumulation that is reflected by MMP3/TIMP2 ratio serum and the PIIINP concentration. These parameters may represent new risk factors for AF.

Prevalence of left ventricular systolic dysfunction in pre-dialysis and dialysis patients with preserved left ventricular ejection fraction.

Patients with chronic kidney disease (CKD) have an excess of cardiovascular morbidity and mortality, with heart failure (HF) being particularly frequent. Reduced left ventricular ejection fraction (LVEF) defines left ventricular (LV) systolic dysfunction and is associated with poor prognosis. However, CKD patients may have HF symptoms with preserved LVEF. In this subgroup of patients, two-dimensional speckle tracking echocardiography can detect LV systolic dysfunction by analysing LV myocardial deformation. The present study evaluated the prevalence of impaired LV global longitudinal strain (GLS) in CKD patients with preserved LVEF and its prognostic consequences. Overall, 200 pre-dialysis and dialysis patients (65% men, mean age 60 ± 14 years) with CKD stage 3b-5 and preserved LVEF (≥50%) were evaluated. Left ventricular systolic dysfunction despite preserved LVEF was defined by LV GLS ≤15.2% (cut-off value derived from two standard deviations below the mean value of individuals without structural heart disease). Impaired LV GLS (≤15.2%) despite preserved LVEF was observed in 32% of patients. During a median follow-up of 33 months (interquartile range 17-62 months), 47% of patients underwent renal transplantation, 9% were admitted with HF, and 28% died. Patients with LV GLS ≤15.2% showed significantly worse cumulative event-free survival rates of the combined endpoint of HF hospitalization and all-cause mortality compared to patients with LV GLS >15.2% (log-rank P = 0.018). The prevalence of impaired LV GLS despite preserved LVEF in pre-dialysis and dialysis patients is relatively high. Patients with preserved LVEF but impaired LV GLS have an increased risk of HF hospitalization and all-cause mortality.

Central Obesity is the Key Component in the Association of Metabolic Syndrome With Left Ventricular Global Longitudinal Strain Impairment

Introduction and objectivesSubclinical systolic dysfunction is one of the proposed mechanisms for increased cardiovascular risk associated with metabolic syndrome (MS). This study investigated the association between MS and impaired left ventricular global longitudinal strain (GLS) and the role of each MS criteria in this association. MethodsWe analyzed a random sample of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) after excluding participants with prevalent heart disease. ResultsAmong the 1055 participants fulfilling the inclusion criteria (53% women; 52±9 years), 444 (42%) had MS. Those with MS had worse GLS (–18.0%±2.5%) than those without (–19.0%±2.4%; P<.0001). In multiple linear regression models, MS was associated with worse GLS after adjustment for various risk factors (GLS difference=0.86%; P <.0001), even after inclusion of body mass index. Adjusted PR for impaired GLS as assessed by 3 cutoffs (1, 1.5, and 2 standard deviations) were higher among participants with than without MS: GLS –16.1% (PR, 1.76; 95%CI, 1.30-2.39); GLS –14.8% (PR, 2.35; 95%CI, 1.45-3.81); and GLS –13.5% (PR, 2.07; 95%CI, 0.97-4.41). After inclusion of body mass index in the models, these associations were attenuated, suggesting that they may, at least in part, be mediated by obesity. In quantile regression analyses, elevated waist circumference was the only MS component found to be independently associated with GLS across the whole range of values. ConclusionsMetabolic syndrome is independently associated with impaired GLS. Among the MS criteria, central obesity best depicted the link between metabolic derangement and cardiac function.