Subclinical Systolic Dysfunction Research Articles

Identification of cardiovascular abnormalities by multiparametric magnetic resonance imaging in end-stage renal disease patients with preserved left ventricular ejection fraction.

Our study aimed to evaluate myocardial strain and tissue characteristics by multiparametric cardiovascular magnetic resonance (CMR) imaging in end-stage renal disease (ESRD) patients on peritoneal dialysis with preserved left ventricular ejection fraction (LVEF). ESRD patients on peritoneal dialysis with echocardiographic LVEF > 50% and age- and sex-matched healthy volunteers underwent multiparametric CMR at 3 T. LV function, LV myocardial native T1 and T2, and biventricular strain were measured and compared between the patients and controls. Associations of LV myocardial mass index (LVMI) with tissue characterization and strain were evaluated by multiple linear regression. A total of 65 subjects (42 healthy volunteers and 23 ESRD patients) were enrolled. ESRD group demonstrated larger LVMI, higher native T1 and T2 (1301.9 ± 30.6 ms, 44.6 ± 2.6 ms) than those of the control group (1255.8 ± 45.2 ms, 40.5 ± 1.6 ms; both p < 0.001). Decreased LV strain and increased right ventricular circumferential strain were observed in the ESRD group. In ESRD patients with normal diastolic function on echocardiography, native T1 and T2 values were higher than those of the control group (p = 0.006, p = 0.001). Increased LVMI was associated with increased native T1 (p = 0.001) and T2 value (p < 0.001) after adjusting for age and sex. Increased myocardial native T1 value was associated with reduced LV strain after adjusting age, sex, and LVMI. ESRD patients on peritoneal dialysis with preserved LVEF demonstrated higher myocardial mass, higher native T1 and T2 values, decreased LV strain, and increased RVGCS compared with healthy controls. Increased myocardial T1 and T2 were found in ESRD even when no systolic or diastolic dysfunction was detected by routine echocardiography. • Even with preserved LVEF and no known cardiovascular diseases, ESRD patients on peritoneal dialysis demonstrated elevated myocardial T1 and T2 values and decreased left ventricular strain. • Subclinical changes in myocardial tissue composition may exist in ESRD patients on peritoneal dialysis even when no systolic or diastolic dysfunction was detected by routine echocardiography based on ejection fraction, left atrium size, and tissue Doppler. • Right ventricular free wall strain could be enhanced in response to subclinical LV systolic dysfunction in ESRD patients on peritoneal dialysis with preserved LVEF at an early stage.

Time to solve the puzzle of heart failure with preserved ejection fraction by biomarkers, echocardiography and cardiac magnetic resonance

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): HEART PRESERVED onbehalf HEART PRESERVED Background Heart failure with preserved ejection fraction (HFpEF) is now recognized as a major and growing public health problem worldwide. Clinical trials investigating different treatment strategies had disappointing results. Several biomarkers of inflammation, endothelial dysfunction, and myocardial fibrosis appeared to be promising in understanding HFpEF pathophysiology. Methods. We enrolled prospectively 94 patients with HFpEF in sinus rhythm (according to 2019 scoring system) (67 ± 9 yrs, 33 men). We evaluated them by 2D and speckle tracking echocardiography (STE). 80 patients had also a cardiac magnetic resonance (CMR) 1.5T evaluation. We measured LV ejection fraction (LVEF), mean E’ (E’m), E/E’ ratio, sPAP, left atrial volume indexed (LAVi), and global longitudinal stain by STE (GLS). By CMR we evaluated LVEFcmr, LV mass, T1 mapping with mean extracellular volume (ECVm), and pre-gadolinium mean times quantification (preGDT1m) as markers of myocardial fibrosis. All patients had NTproBNP and biomarkers for systemic inflammation (IL6, cystatin C, pentraxin-3, GDF15), endothelial dysfunction: soluble E -selectin, VCAM, von Willebrand factor (vWf), and myocardial fibrosis: Galectin-3. Results. LVEF was 60.5 ± 6 % and LVEFcmr 61 ± 6.6%. All parameters from the scoring system were as we expected: E’m = 7.6 ± 1.8 cm/s, E/E’ ratio = 11 ± 3.4, sPAP = 34 ± 8 mmHg, LAVi = 47 ± 11 ml/m2, GLS=-18.3 ± 2.9, and NTproBNP of 282 ± 294 pg/ml. NTproBNP significantly correlated with sPAP, LAVi, preGDT1m, ECVm, galectin-3, GDF15, and pentraxin-3 (all r &amp;gt; 0.4, p &amp;lt; 0.05). The best predictor for NTproBNP level was GDF15 (r = 0.4, r2 = 0.25, p = 0.001). LAVi significantly corelated with E/E’ ratio, sPAP, NTproBNP, galectin-3 (r &amp;gt; 0.4, p &amp;lt; 0.05). GLS correlated with LVEFcmr, LV mass, ECVm, preGDT1m, LAVi, E/E’ ratio, NTproBNP, GDF15, vWf, Eselectin, VCAM (all r = 0.4, p &amp;lt; 0.05). The best predictor model for GLS was LV mass, NTproBNP, E-selectine, and vWf (r = 0.67, r2 = 0.45, P &amp;lt; 0.001). sPAP was best predicted by a model composed by IL6, VCAM, LAVi (r = 0.5, r2 = 0.25, p &amp;lt; 0.001). E’m significantly correlated with vWf, GHD15, VCAM, LV mass, and preGDT1 (all r &amp;gt; 0.4, p &amp;lt; 0.05), but the best predictor model included only LV mass and GDF15 (r = 0.57, r2 = 0.32, P &amp;lt; 0.001). Galectin-3 significantly correlated with LAVi, preGDT1m, and NTproBNP, but the only predictor for galectin-3 level was preGDT1 (r = 0.4, r2 = 0.2, p = 0.007). Conclusions In HFpEF NTproBNP is significantly correlated with markers of inflammatory status, endothelial dysfunction, and fibrosis, but the level is mainly determined by inflammation (GDF15). Diastolic dysfunction parameters are mainly correlated with inflammatory and endothelial dysfunction biomarkers . Only LAVi was correlated with myocardial fibrosis. Sub-clinical systolic dysfunction is mainly determined by proinflamatory status and endothelial dysfunction, but not by fibrosis.

Circulating biomarkers of cardiac fibrosis: do they correlate with the echocardiographic parameters of the myocardial mechanics in systemic sclerosis?

Abstract Funding Acknowledgements Type of funding sources: None. Background In systemic sclerosis (SSc) myocardial fibrosis contributes to the impairment of the myocardial function resulting in manifest diastolic and subclinical systolic dysfunction of the left ventricle (LV) and impaired left atrial (LA) function. The pathophysiology of this connective tissue disease is still not fully elucidated. Recently, however, elevated serum levels of galectin-3 and soluble suppression of tumorigenicity 2 (sST2) have been reported in SSc patients suggesting that these fibrotic markers may participate in the fibrotic process in this disease. Thus we aimed to investigate the potential associations between galectin-3 and sST2 levels and the echocardiographic markers of the LV and LA function in SSc patients. Methods Forty patients (57.3 ± 13.7 years, 36 female) were enrolled into the study. In addition to the conventional echocardiography, tissue Doppler and speckle-tracking-derived strain techniques were used to estimate the LV systolic and diastolic function as well as the LA size and function. To assess the correlations between galectin-3 and sST2 levels and the echocardiographic variables, partial correlation method was used with age as correcting factor. Results In age adjusted analysis galectin-3 level showed significant correlation with LV global longitudinal strain (r = 0.460, p = 0.005); grade of LV diastolic dysfunction (r = 0.394, p = 0.013); septal e’ (r=-0.369, p = 0.021); septal E/e’ (r = 0.380, p = 0.017) and with the grade of mitral regurgitation (r = 0.323, p = 0.048) (Figure 1). No significant correlation was found between sST2 levels and the echocardiographic variables. Conclusions Galectin-3 levels, but not sST2 levels show significant correlation with the parameters of the LV diastolic function and with LV global longitudinal strain, a parameter reflecting the subclinical impairment of the LV systolic function. Galectin-3 may be a useful biomarker for identifying SSc patients with high risk for cardiac involvement. Abstract Figure 1

Evaluation of left and right ventricular functions with three-dimensional speckle tracking in patients with mitral stenosis.

The function of both ventricles has been suggested to be affected in patients with mitral stenosis. In this study, it was aimed to investigate deformation properties of right (RV) and left ventricle (LV) in rheumatic mitral stenosis (MS) patients with three-dimensional speckle tracking echocardiography (3D-STE). A total of 60 patients were included in the study (20 patients with mild MS diagnosis, 20 patients with moderate MS diagnosis, and 20 healthy volunteers). Three-dimensional echocardiography datasets were obtained for both ventricles in all patients. LV global longitudinal strain (GLS), LV torsion, RV free wall (FW) LS, and interventricular septal (IVS) LS measurements were analyzed. The LV ejection fraction (EF), RV fractional area change, peak systolic velocity of the tricuspit annulus, isovolumic acceleration, and tricuspid annular plane systolic excursion values were statistically similar and in the normal range. The LV GLS measurements were significantly different among the groups by being highest in the control group and least in the moderate stenosis group. Patients with MS showed higher torsional values, correlated with MS severity. IVS LS, RVFW LS values obtained by RV analysis also differed significantly among groups. The RVFW-GLS values only showed significant difference between the control group and moderate MS group. Patients with MS showed lower LV-GLS and higher LV torsion values. RV deformation indices showed significant decrease in correlation with the severity of the mitral stenosis. In conclusion, our data suggest that subclinical LV and RV systolic dysfunction is present in mild-moderate MS patients and this dysfunction can be detected by 3D-STE.

Assessment of subclinical diabetic cardiomyopathy by speckle-tracking imaging.

Diastolic dysfunction is traditionally believed to be the first subclinical manifestation of diabetic cardiomyopathy (DCM), leading to systolic dysfunction and then overt heart failure. However, in the last few years, several studies suggested that systolic subclinical dysfunction measured by speckle-tracking echocardiography (STE) may appear ahead of diastolic dysfunction. In this review, the main endpoint is to show whether subclinical myocardial systolic dysfunction appears ahead of diastolic dysfunction and the implication this may have on the evolution and management of DCM. We performed a search in PubMed for all relevant publications on the assessment of DCM by STE from 1 June 2015 to 1 June 2020. The results illustrate that subclinical systolic dysfunction assessed by STE is present in early DCM stages, with or without the association of diastolic dysfunction. This could be a promising perspective for the early management of patients with DCM leading to the prevention of the overt form of disease.

A Subtle Decline in Cardiac Mechanics is correlated with Albuminuria in Asymptomatic Normotensive Patients with Type 2 Diabetes Mellitus: A Two Dimensional Strain Echocardiography Study.

Background:Type 2 diabetes mellitus (T2DM) insidiously affects the myocardium with subsequent cardiomyopathy and induces microvascular damage in the kidneys reflected by albuminuria. We aimed to investigate the relationship between albuminuria and subclinical left ventricular (LV) systolic dysfunction in asymptomatic normotensive patients with T2DM assessed by two-dimensional speckle-tracking echocardiography.Materials and Methods and Results:Sixty normotensive patients with T2DM were included and subdivided into two subgroups, each including thirty patients according to the presence of albuminuria, together with thirty control subjects. All underwent echocardiographic examination, including LV regional and global longitudinal strain (GLS) measurements. Laboratory tests were withdrawn, including serum glycated hemoglobin (HbA1C) and albumin–creatinine ratio (ACR). When compared to the control group, patients with T2DM had a significantly lower average peak systolic LV GLS (−16.18% ± 2.78% vs. −18.13% ± 2.86%, P < 0.001), however, there was no significant difference in average peak systolic LV GLS between both diabetic subgroups (−15.57% ± 2.77% in the albuminuric subgroup vs. −16.79% ± 2.70% in the nonalbuminuric subgroup, P = 0.077). Moreover, there was a significant correlation between ACR and reduction of GLS in patients with T2DM and albuminuria (r = 0.55, P = 0.002). However, this correlation was absent in patients with T2DM without albuminuria (r = 0.107, P = 0.573).Conclusions:Patients with T2DM have subclinical LV systolic dysfunction with a reduction of average LV GLS that correlates with ACR in patients with T2DM and albuminuria.

Epicardial fat tissue can predict subclinical left ventricular dysfunction in patients with erectile dysfunction

Background Erectile dysfunction (ED) is an early form of atherosclerosis and subclinical myocardial dysfunction. Epicardial fat tissue (EFT) is associated with impaired left ventricular (LV) function, even in the absence of cardiovascular disease. The aim of this study was to investigate the association between EFT and LV systolic function in patients with erectile ED by speckle tracking echocardiography (2D-STE) method. Methods A total of 129 consecutive patients with ED were compared with 145 age- and sex-matched control subjects. ED was evaluated using the International Index of Erectile Function questionnaire. Thickness of EFT was measured by TTE. Global LV longitudinal strain (LV-GLS) and global LV circumferential strain (LV-GCS) were measured by 2D-STE method. Results The EFT thickness was significantly higher in the patients with ED (p <.01). LV-GLS and LV-GCS were revealed to be more deterioration in the ED group compared to controls (−18.2 ± 2.7 vs. (−21.1 ± 3.9, p<.001; −19.5 ± 4.1 vs. −21.9 ± 3.9, p<.001, respectively). It has been shown that EFT thickness is an independent predictor of LV dysfunction. Conclusions These results indicate that EFT thickness is associated with subclinical LV systolic dysfunction in patients with ED.

Echocardiographic Prevalence and Risk Predictors of Ventricular Dysfunction in Connective Tissue Disorders: Tertiary Care Hospital-Based Prospective Case-Control Study

Background: There is a paucity of contemporary Indian data about the prevalence of cardiac abnormalities in patients of connective tissue disorders (CTD) and their risk determinants. Methods: We prospectively recorded data from 35 consecutive CTD patients who presented to our out-patient department and had no significant cardiovascular risk factors at baseline. We also recorded data from their age- and sex-matched controls. All cases and controls were subjected to 12 lead electrocardiogram and echocardiography after routine investigations. Results: The CTD group comprised 19 (54.3%) patients of systemic lupus erythematosus, 12 (34.3%) patients of systemic sclerosis, 2 (5.7%) patients of mixed CTD, and 1 (2.9%) patient each of overlap syndrome and dermatomyositis. Cardiovascular involvement on echocardiography was documented in 71.4% of CTD patients despite majority of them having no cardiac symptom. Overt left ventricular (LV) systolic dysfunction was observed in 3 (8.6%) CTD patients, while subclinical LV systolic dysfunction was recorded in 13 (37.1%) patients. LV diastolic dysfunction was observed in 11.4% (n = 4) patients. RV systolic dysfunction was prevalent in 20% (n = 7) patients. Pulmonary hypertension was observed in 40% (n = 14) of CTD patients. Conclusion: The present study evaluated subclinical LV systolic dysfunction and pulmonary hypertension in about one third of CTD patients. It is imperative to screen for these abnormalities in CTD to ensure timely diagnosis and treatment.

Value of speckle tracking echocardiography in detection of clinically silent left ventricular systolic dysfunction in diabetic patients

Background and Aims: Diabetic patients with normal left ventricular ejection fraction are frequently associated with diastolic dysfunction .Speckle tracking is more sensitive than LVEF in detection subclinical LV systolic dysfunction However, it is not clear whether there is any difference in early LV systolic dysfunction between DM patients if they have controlled or uncontrolled blood glucose Aim:detection of silent clinically left ventricular systolic dysfunction even in normal 2D echocardiography

Clinical outcomes of chemotherapy-induced subclinical left ventricular systolic dysfunction among breast cancer patients detected using echocardiographic global longitudinal strain

Abstract Background Echocardiographic global longitudinal strain (GLS) detects early subclinical left ventricular (LV) systolic dysfunction, before the occurrence of a decreased LV ejection fraction. However, our local data is lacking to determine its impact to clinical outcomes. Purpose The study aimed to determine the clinical outcomes of breast cancer patients who developed subclinical LV systolic dysfunction as determined by an abnormal GLS post-chemotherapy. Methods This retrospective cohort study included 99 breast cancer patients who underwent anthracycline and/or HER-2 receptor inhibitor chemotherapy from January 1, 2016 to December 31, 2018 in a single tertiary hospital. Clinical outcomes of all-cause mortality and overt heart failure were compared between those with normal and abnormal GLS post-chemotherapy. Results The prevalence of subclinical LV systolic dysfunction was 18%, wherein 28% of them had subsequent overt heart failure, and 33% expired. Abnormal GLS occurred at a mean 3.5 months (range 1–8 months) after initiation of chemotherapy and at 8 months (range 6–10 months) after the entire chemotherapy sessions. Development into heart failure was observed at a mean of 6.7 months (range 4–12 months) after occurrence of abnormal GLS. Hypertension and age &amp;gt;56 years were determined to be risk factors. Beta-blockers, ACE inhibitors and statins seemed to be non-protective in our cohort. Abnormalities in GLS were observed at a mean dose of 260 mg/m2 of epirubicin, lower than the dose described as high risk in the literature (600 mg/m2 for epirubicin). In trastuzumab, abnormal GLS occurred as early as 1 month after initiation. LVEF had no significant change within 2 months (p=0.56), but was significantly lower within 12 months post-chemotherapy (p=0.005). All-cause mortality was 3-fold higher (RR=3.00; p=0.02), and the risk to develop heart failure was 4 times higher (RR=4.74; p=0.008) in those with abnormal GLS. Conclusion The development of abnormal GLS post-chemotherapy was associated with subsequent development of overt heart failure and increased all-cause mortality. Abnormal GLS occurred at lower doses of epirubicin and as early as 1 month after initiating trastuzumab. We recommend echo surveillance with GLS monitoring beginning &amp;gt;250 mg/m2 with anthracycline (and after 1–2 months of Trastuzumab), and to repeat at 1–2 months and 9–12 months post-chemotherapy. Funding Acknowledgement Type of funding source: None

Subclinical left atrial dysfunction profiles for prediction of cardiac outcome in the general population

Abstract Background Echocardiographic screening for subclinical left atrial (LA) dysfunction might enhance the prediction of cardiac diseases such as atrial fibrillation (AFib) in the community. To date, however, outcome-driven definitions of early-stage LA dysfunction remain scarce. Purpose In a large population sample, we sought to extract outcome-driven thresholds for echocardiographic indexes of LA function to define subclinical left atrial (LA) dysfunction and assess the prognostic value of these echocardiographic criteria for prediction of cardiac events. Methods In 1306 community-dwelling individuals (mean age, 50.7 years; 51.6% women), we assessed LA function and left ventricular (LV) global longitudinal strain (LS) by echocardiography. Using receiver-operating curve threshold analysis, we derived outcome-driven cut-offs for LA emptying fraction (LAEF) and LA reservoir strain (LARS) that best balanced the cardiac event prediction (i.e. cut-offs yielding the highest Youden index (=sensitivity+specificity-1)). Next, we constructed LA dysfunction profiles and integrative LA/LV strain profiles based on the extracted cut-offs for LAEF and LARS and a validated definition of impaired LV global LS. We assessed the prognostic performance of these profiles in predicting the incidence of cardiac events and AFib (mean follow-up, 8.5 years). Results During follow-up, 93 participants experienced a cardiac event (8.3 events/1000 person-years) and 27 developed AFib (2.3 events/1000 person-years). LAEF&amp;lt;55% and LARS&amp;lt;23% yielded the highest Youden indexes and thus provided the most balanced prediction of incident AFib. When applying these cut-offs, abnormal LAEF and LARS were respectively present in 27.0% and 18.1% of the cohort. Abnormal LARS was independently associated with higher risk for cardiac events (hazard ratio (HR) versus normal LA phenotype: 2.11, P=0.0021). Both abnormal LAEF (HR: 2.57) and abnormal LARS (HR: 3.28) predicted incident AFib (P≤0.029). As compared to subjects free from any LA dysfunction, those with both LAEF&amp;lt;55% and LARS&amp;lt;23% had a significantly higher risk to develop cardiac events (HR: 2.10; P=0.014) and AFib (HR: 6.45; P=0.0036). Of the integrative LA/LV strain profiles, the concomitant presence of an impaired LARS and LV global LS independently elevated the risk for cardiac events (HR: 2.81; P=0.0012) and AFib (HR: 4.36, P=0.0071) as compared to normal counterparts. Both the degree of LA dysfunction and the integrative LA/LV strain profiles improved the prognostic accuracy beyond clinical risk models and risk scores. Conclusions We validated population-based and outcome-driven definitions of subclinical LA dysfunction predicting cardiac events independent of conventional risk factors. Echocardiographic screening for subclinical LA and LV systolic dysfunction might enhance the prediction of cardiac diseases such as AFib in the community, empowering clinicians to timely intervene with the disease development. Prediction of cardiac events Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders, Internal Funds KU Leuven

Prominent involvement of basal left ventricular longitudinal strain in patients with monoclonal gammopathy of undetermined significance

Abstract Background In cardiac amyloidosis the application of Speckle Tracking Echocardiography allows to identify a specific left ventricular (LV) longitudinal strain (LS) pattern characterized by “apical sparing”, with a prominent involvement of basal and middle segments and normal LS of apical cap. The pattern of regional LS has been never investigated in monoclonal gammopathy of undetermined significance (MGUS), a condition which can predispose to cardiac amyloidosis. Purpose To compare LV regional LS patterns and LS base-to-apex behaviour of patients affected by MGUS in comparison with healthy subjects. Methods We enrolled 40 patients affected by MGUS (M/F=20/20; age 62.6±13.8 years), asymptomatic for cardiac symptoms, and a control group of 40 healthy subjects, matched for sex and age. Nineteen (47%) MGUS patients showed prevalent free K light chain and 21 (53%) had prevalent free λ light chain. Participants underwent standard echo-Doppler exam, including Speckle Tracking of the three apical views. Global longitudinal strain (GLS), the average LS of six basal (BLS), six middle (MLS), and six apical (ALS) segments (considered in absolute values) and relative regional strain ratio RRSR [=ALS/(BLS+MLS)] were computed. Exclusion criteria were overt heart failure, LV ejection fraction &amp;lt;53%, coronary artery and congenital heart disease, moderate to severe valvular disease, primary cardiomyopathies, atrial fibrillation and inadequate echo imaging. Results The two groups were comparable for body mass index, blood pressure and heart rate. LV mass index, relative wall thickness, left atrial volume index and Doppler-derived LV diastolic parameters did not differ significantly between the two groups. LV ejection fraction was also similar in MGUS and healthy controls. GLS resulted significantly lower in MGUS group than in controls (20.5±3.0 vs. 22.4±2.0%, p&amp;lt;0.02). BLS (17.1±3.7 vs. 19.2±2.2%, p=0.004), MLS (24.9±3.8 vs. 27.1±3.6%, p&amp;lt;0.01) and ALS (25.1±3.8 vs. 27.1±3.5%, p&amp;lt;0.01) were significantly lower in MGUS than in controls. The intergroup difference of RRSR (0.60±0.05 vs. 0.58±0.04) did not achieve the statistical significance (p=0.26) and none of the MGUS patients had RRSR&amp;gt;1. The figure depicts a LS bull'eye of a MGUS patient showing the prominent involvement of LV basal segments. Conclusions In presence of a normal LV ejection fraction, MGUS patients show a subclinical LV longitudinal systolic dysfunction. This is testified by a reduction of GLS and of regional LS which involves mainly LV basal segments, without substantial changes of relative regional strain ratio. LV regional longitudinal dysfunction could be useful to monitor LV myocardial mechanics during follow-up of MGUS patients. LS bull's eye in a MGUS patient Funding Acknowledgement Type of funding source: None

Very early detection of low dose anti-cancer therapy-related cardiotoxicity in lymphoma patients

Abstract Background and purpose Left ventricular (LV) global peak systolic longitudinal strain (GLS) by speckle-tracking echocardiography is a sensitive modality for the detection of subclinical LV systolic dysfunction and a powerful prognostic predictor. However, the clinical implication of LV GLS in lymphoma patients receiving anti-cancer therapy remains unknown. Methods We prospectively enrolled 74 patients (57.9±17.0 years old, 57% male) with lymphoma who underwent echocardiography prior to chemotherapy, post 3rd and 6th cycle and 1 year after chemotherapy. Cancer therapy-related cardiac dysfunction (CTRCD) is defined as the reduction of absolute GLS value from baseline of ≥15%. All the eligible patients underwent a cardiopulmonary exercise test (CPET) upon completion of 3 cycles of anti-cancer therapy. The primary outcome was defined as a composite of all-cause mortality and heart failure events. Results Among 36 (49%) patients with CTRCD, LV GLS was significantly decreased after the 3rd cycle of chemotherapy (20.1±2.6% vs. 17.5±2.3%, p&amp;lt;0.001). In the multivariable analysis, male sex and anemia (hemoglobin &amp;lt;11 g/dL) were found to be independent risk factors of CTRCD. Objectively, patients with CTRCD had lower minute oxygen consumption/kg (VO2/kg) and lower VO2/kg value at anaerobic threshold in the CPET. The incidence of the primary composite outcome was higher in the CTRCD group than in the non-CTRCD group (hazard ratio 3.21; 95% CI, 1.04–9.97; p=0.03). Conclusion LV GLS is capable of detecting early cardiac dysfunction in lymphoma patients receiving anti-cancer therapy. Patients with CTRCD not only had a reduced exercise capacity but also a higher risk of all-cause mortality and heart failure events. Change of LVEF and GLS after cancer Tx Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Ministry of Science and Technology (MOST), Taiwan

The integrated role of NT-pro BNP and STE-GLS for the early detection of chemotherapy-induced cardiotoxicity

Abstract Background Chemotherapeutic agents, used for the treatment of breast cancer, have many side effects, among them is cardiomyopathy. Ejection fraction (EF) is fails to detect the subtle alterations of left ventricular (LV) function. There comes the need for a more sensitive tool for the detection of preclinical chemotherapy-induced cardiomyopathy. Aim Detection of subclinical LV systolic dysfunction in breast cancer patients after 6 weeks of the initiation of their chemotherapeutic treatment, using N-terminal pro brain natriuretic peptide (NT-proBNP) plasma level as well as Speckle tracking echo-global longitudinal strain (STE-GLS). Methods Seventy-four asymptomatic, non-metastasizing breast cancer female patients were included. They were assessed before taking their first chemotherapeutic session and 6 weeks thereafter. Assessment included baseline clinical characteristics, conventional two-dimensional (2D) as well as three-dimensional (3D) echocardiography. Loops of different apical views were recorded for later offline STE-GLS analysis. Blood samples for NT-BNP plasma level were collected before and 6 weeks after the initiation of chemotherapy. Samples were later analyzed using a Sandwich ELISA technique. Results The median NT-proBNP almost doubled after 6 weeks of chemotherapy (73.50 vs 34.4 pg/L, p value &amp;lt;0.001). One patient died before her scheduled follow up visit, and the cause of death is unknown. Fifty patients showed NT-proBNP elevation at their follow up, compared to the baseline visit, 22 (44%) of them had worse (less negative) LV-GLS in their follow up visit. Five patients had an abnormally elevated NT-proBNP plasma level, all of them had a worse follow up LV-GLS. Only two patients showed significant reduction of LVEF &amp;gt;10% to less &amp;lt;53% (chemotherapy-induced cardiotoxicity) but their NT-proBNP did not exceed the cutoff limit. Conclusion The integration of LV-GLS and NT-proBNP is useful in the diagnosis of subclinical, subtle chemotherapy-induced cardiotoxicity. Early detection will prompt early cardioprotective measures and thus helps improving the clinical outcomes. Funding Acknowledgement Type of funding source: None

Association of urine albumin‐to‐creatinine ratio with subclinical systolic dysfunction in hypertensive patients but not normotensive subjects: Danyang study

The association of albuminuria, as measured by urine albumin-to-creatinine ratio (UACR) concentration, with subclinical cardiac dysfunction in hypertensive patients is unclear. Our study aimed to examine its relationship in hypertensive patients compared with that in normotensive patients. The study participants were recruited from Danyang, a city of Jiangsu Province from 2017 to 2019. Categorical and continuous analyses were performed with sex-specific UACR tertiles and natural logarithmically transformed UACR, respectively. Comprehensive echocardiography including conventional imaging, tissue Doppler imaging, and 2D speckle tracking was performed using Philips CX50 device. The 2857 participants (mean age=52.7±11.8years) included 1673 (58.6%) women, 1125 (39.4%) hypertensive patients, 546 (19.1%) patients with microalbuminuria, and 38 (1.3%) patients with macroalbuminuria. Comorbidities were increasingly prevalent across the tertiles of UACR. Increased left ventricular (LV) mass index, decreased global longitudinal strain (GLS) and LV ejection fraction, lower E/A ratio and e' velocity, and higher E/e' ratio were significantly associated with higher UACR on unadjusted analyses (p≤.01). After adjustment for covariates, UACR was only independently associated with lower GLS (tertile 3=20.7% vs. tertile 1=20.9%; p=.04). The results of hypertensive patients (p≤.04) but not normotensive patients (p≥.16) were similar to those of the total cohort. Subgroup analyses revealed similar results in patients without coronary artery disease, or without LV hypertrophy, or without diabetes. In conclusion, increased UACR is associated with worse subclinical systolic function in Chinese hypertensive patients but not in normotensive participants.

Echocardiographic strain

Echocardiography is a readily available imaging modality used to evaluate cardiac function. Recently, the addition of strain measurements has provided additional information by evaluating the intrinsic myocardial function and detecting subclinical systolic dysfunction. As with any emerging technique or application, it is imperative to understand how the information gathered in the study can be applied to clinical practice. This review article examines how echocardiographic strain analysis can be applied to clinical practice and its use as a promising prognostic resource in many cardiovascular conditions.

The additive effects of type 2 diabetes mellitus on left ventricular deformation and myocardial perfusion in essential hypertension: a 3.0 T cardiac magnetic resonance study

BackgroundType 2 diabetes mellitus (T2DM) increases the risks of heart failure and mortality in patients with hypertension, however the underlying mechanism is unclear. This study aims to investigate the impact of coexisting T2DM on left ventricular (LV) deformation and myocardial perfusion in hypertensive individuals.Materials and methodsSeventy hypertensive patients without T2DM [HTN(T2DM−)], forty patients with T2DM [HTN(T2DM+)] and 37 age- and sex-matched controls underwent cardiac magnetic resonance examination. Left ventricular (LV) myocardial strains, including global radial (GRPS), circumferential (GCPS) and longitudinal peak strain (GLPS), and resting myocardial perfusion indices, including upslope, time to maximum signal intensity (TTM), and max signal intensity (MaxSI), were measured and compared among groups by analysis of covariance after adjusting for age, sex, body mass index (BMI) and heart rate followed by Bonferroni’s post hoc test. Backwards stepwise multivariable linear regression analyses were performed to determine the effects of T2DM on LV strains and myocardial perfusion indices in patients with hypertension.ResultsBoth GRPS and GLPS deteriorated significantly from controls, through HTN(T2DM−), to HTN(T2DM+) group; GCPS in HTN(T2DM+) group was lower than those in both HTN(T2DM−) and control groups. Compared with controls, HTN(T2DM−) group showed higher myocardial perfusion, and HTN(T2DM+) group exhibited lower perfusion than HTN(T2DM−) group and controls. Multiple regression analyses considering covariates of systolic blood pressure, age, sex, BMI, heart rate, smoking, indexed LV mass and eGFR demonstrated that T2DM was independently associated with LV strains (GRPS: p = 0.002, model R2= 0.383; GCPS: p < 0.001, model R2= 0.472; and GLPS: p = 0.002, model R2= 0.424, respectively) and perfusion indices (upslope: p < 0.001, model R2= 0.293; TTM: p < 0.001, model R2= 0.299; and MaxSI: p < 0.001, model R2= 0.268, respectively) in hypertension. When both T2DM and perfusion indices were included in the regression analyses, both T2DM and TTM were independently associated with GRPS (p = 0.044 and 0.017, model R2= 0.390) and GCPS (p = 0.002 and 0.001, model R2= 0.424), and T2DM but not perfusion indices was independently associated with GLPS (p = 0.002, model R2= 0.424).ConclusionIn patients with hypertension, T2DM had an additive deleterious effect on subclinical LV systolic dysfunction and myocardial perfusion, and impaired myocardial perfusion by coexisting T2DM was associated with deteriorated LV systolic dysfunction.

Subclinical left ventricular dysfunction in Sjögren's syndrome assessed by four-dimensional speckle tracking echocardiography.

The aim of this study was to evaluate the left ventricular (LV) systolic strain by four-dimensional speckle tracking echocardiography (4D-STE) in order to provide the early detection of myocardial dysfunction in patients with Sjögren's syndrome (SS). Forty consecutive patients with primary SS diagnosed at the rheumatology outpatient clinic and 35 age- and sex-matched healthy volunteers were included in the study. 4DSTE was performed, and global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) were measured. 4DSTE results were compared with the healthy volunteers. No significant differences were observed between the GRS and GCS values of the two groups. A significant difference was observed in the GLS and GAS measurements between the two groups (P=.005 for GLS, P<.001 for GAS). Positive correlation was detected between disease duration and LV-GLS and LV-GAS. We demonstrated subclinical systolic dysfunction in SS patients by 4DSTE, which is a sensitive marker of ventricular dysfunction. Deterioration of the LV became more evident as duration of the disease increased. Therefore, we believe that a cardiac evaluation will be of benefit to patients with long-term SS.

Influence of Average Annual Mean Serum Ferritin Levels on Left Ventricular Function in Patients With β Thalassemia

Cardiac complications are the most important cause of mortality and morbidity in Beta-Thalassemia Major (B-TM). The aim of our study was to determine the influence of Average Annual Mean Serum Ferritin (AAMSF) levels on cardiac function in patients suffering from B-TM. In this cross-sectional study, 50 patients of 5-15 years with B-TM were enrolled in the absence of clinical signs and symptoms of cardiac dysfunction. Left ventricular function was studied by using tissue Doppler image (TDI), pulse wave Doppler (PWD). AAMSF level was measured for 12 months. Patient groups were subdivided into two groups, group A with AAMSF level below 1000 ng/ml and group with B with AAMSF level above 1000 ng/ml. The Case group included 24(48%) males and 26(52%) females which were compared with 50 healthy subjects composed of 27(54%) males and 23 (46%) females (control group). The AAMSF Levels were 1054.60±687.95 ng/ml. By using PDW, in patients with AAMSF below 1000 ng/ml, The Parameters of the E, A, E/A E-DT had no significant difference with health groups (P=0.808, P=0.820, P=0.231 and P=0.061, respectively). No significant difference was revealed in parameters of E’, IVCT and ET in patients with AAMSF below 1000 ng/ml by using TDI in comparison to control (P=0.155, P=0.683, P=0.222, respectively).however, other TDI indexes including A’, E’/A’, IVRT, S,’ LVMPI, E/E’ had a significant difference with health group (P=0.014, P=0.041, P=0.045, P=0.002, P=0.021, and P=0.002, respectively). At patients with above AAMSF 1000 ng/mL, both PDW and TDI parameters had significant differences with the health group. There was no correlation among AAMSF levels and PWD or TDI indexes. The evidence from this study suggests that subclinical systolic and diastolic LV dysfunction has happened with AAMSF level above 1000 ng/ml, and according to our result, TDI is found more useful than PWD for subclinical cardiac evaluation.

Left ventricular dysfunction in COPD without pulmonary hypertension.

We aimed to assess prevalence of left ventricular (LV) systolic and diastolic function in stable cohort of COPD patients, where LV disease had been thoroughly excluded in advance. 100 COPD outpatients in GOLD II-IV and 34 controls were included. Patients were divided by invasive mean pulmonary artery pressure (mPAP) in COPD-PH (≥25 mmHg) and COPD-non-PH (<25 mmHg), which was subdivided in mPAP ≤20 mmHg and 21-24 mmHg. LV myocardial performance index (LV MPI) and strain by tissue Doppler imaging (TDI) were used for evaluation of LV global and systolic function, respectively. LV MPI ≥0.51 and strain ≤-15.8% were considered abnormal. LV diastolic function was assessed by the ratio between peak early (E) and late (A) velocity, early TDI E´, E/E´, isovolumic relaxation time, and left atrium volume. LV MPI ≥0.51 was found in 64.9% and 88.5% and LV strain ≤-15.8% in 62.2.% and 76.9% in the COPD-non-PH and COPD-PH patients, respectively. Similarly, LV MPI and LV strain were impaired even in patients with mPAP <20 mmHg. In multiple regression analyses, residual volume and stroke volume were best associated to LV MPI and LV strain, respectively. Except for isovolumic relaxation time, standard diastolic echo indices as E/A, E´, E/E´ and left atrium volume did not change from normal individuals to COPD-non-PH. Subclinical LV systolic dysfunction was a frequent finding in this cohort of COPD patients, even in those with normal pulmonary artery pressure. Evidence of LV diastolic dysfunction was hardly present as measured by conventional echo indices.