Diagnostic accuracy of left ventricular longitudinal function by speckle tracking echocardiography to predict significant coronary artery stenosis. A systematic review

Background Patients evaluated for acute and chronic chest pain comprise a large, heterogeneous group that often provides diagnostic challenges. Although speckle tracking echocardiography (STE) has proved to have diagnostic value in acute coronary syndrome it is not commonly incorporated in everyday practice. The purpose of the present systematic review was to assess the diagnostic accuracy of left ventricular (LV) longitudinal function by STE to predict significant coronary artery stenosis (CAD+) or not (CAD-) verified by coronary angiography in patients with chest pain suspected to be of cardiac ischemic origin. Methods 4 electronic databases; Embase, Medline, Cochrane and PubMed ahead-of print were searched for per 19.05.14. Only full-sized articles including > 40 patients were selected. Results A total of 166 citations were identified, 16 full-size articles were assessed of which 6 were found eligible for this review. Of 781 patients included 397 (60 %) had CAD+. The overall weighted mean global longitudinal strain (GLS) was −17.2 % (SD = 2.6) among CAD+ vs. -19.2 % (SD = 2.8) in CAD- patients. Mean area under curve in 4 studies for predicting CAD+ ranged from 0.68 to 0.80. The study cut-off levels for prediction of CAD+ in the ROC analysis varied between −17.4 % and −19.7 % with sensitivity from 51 % to 81 % and specificity between 58 % and 81 %. In 1 study GLS obtained during dobutamine stress echocardiography (DSE) had the best accuracy. Regional strain measurements were not uniform, but may have potential in detecting CAD. Conclusions GLS measurements at rest only have modest diagnostic accuracy in predicting CAD+ among patients presenting with acute or chronic chest pain. The results from regional strain, layer specific strain and DSE need to be verified in larger studies

Prognostic utility of blood pressure-adjusted global and basal systolic longitudinal strain

Assessment of global longitudinal systolic strain (GLS) and longitudinal systolic strain of the basal segments (BLS) has shown prognostic value in cardiac disorders. However, strain is reduced with increased afterload. We assessed the prognostic value of GLS and BLS adjusted for afterload. GLS and BLS were determined in 272 subjects with normal ejection fraction and no known coronary disease, or significant valve disease. Systolic blood pressure (SP) and diastolic blood pressure (DP) obtained at the time of echocardiography were used to adjust GLS and BLS as follows: strain×SP (mmHg)/120 mmHg and strain×DP (mmHg)/80 mmHg. Patients were followed for cardiac events and mortality. The mean age was 53±15 years and 53% had hypertension. There were 19 cardiac events and 70 deaths over a mean follow-up of 26±14 months. Cox analysis showed that left ventricular mass index (P=0.001), BLS (P<0.001), and DP-adjusted BLS (P<0.001) were independent predictors of cardiac events. DP-adjusted BLS added incremental value (P<0.001) to the other two predictors and had an area under the curve of 0.838 for events. DP (P=0.001), age (P=0.001), ACE inhibitor use (P=0.017), and SP-adjusted BLS (P=0.012) were independent predictors of mortality. SP-adjusted BLS added incremental value (P=0.014) to the other independent predictors. In conclusion, DP-adjusted BLS and SP-adjusted BLS were independent predictors of cardiac events and mortality, respectively. Blood pressure-adjusted strain added incremental prognostic value to other predictors of outcome

Prediction of outcome in patients with severe aortic stenosis treated with transcatheter aortic valve implantation

Surgical aortic valve replacement (SAVR) has until the last decade been the standard treatment for patients with aortic stenosis (AS). However, many patients were not offered surgical treatment due to high age or unacceptable surgical risk estimated by surgical risk scores. Transcatheter aortic valve implantation (TAVI) is a less invasive treatment modality where the valve is implanted using a catheter. Initially reserved for patients not eligible for open surgery, TAVI is now performed in patients with intermediate and even low risk for open surgery. Despite expanding indications to include lower risk patients, one of the main challenges in clinical practice is evaluating patients not candidates for SAVR where the question arises whether or not they will tolerate and/or benefit from interventional treatment. Surgical risk scores have shown rather low accuracy predicting unfavourable outcome in patients treated with TAVI. Several TAVI specific risk scores have been developed, albeit none has been incorporated into routine clinical practice. We investigated if preoperative echocardiographic measures, including speckle-tracking analysis, in addition to clinical parameters could aid in the prediction of unfavourable early and mid-term outcome after TAVI in high-risk elderly patients with AS. Furthermore, it aims to evaluate how novel TAVI risk scores perform compared to established surgical risk scores in this population. We found both clinical and echocardiographic parameters to be predictive of short and mid-term mortality after TAVI. However, speckle-tracking analysis for left-and right ventricular functional assessment did not yield additional predictive value. Risk scores specific for TAVI showed a trend toward better predictive accuracy compared to surgical risk scores. A multimodal and multidisciplinary approach is needed when evaluating elderly high-risk patients for TAVI with no single clinical or echocardiographic parameter being the decisive factor. Risk scores are best used as a foundation for informed consent rather than exclusion from interventional treatment

Perspectives in noninvasive imaging for chronic coronary syndromes

Both the latest European guidelines on chronic coronary syndromes and the American guidelines on chest pain have underlined the importance of noninvasive imaging to select patients to be referred to invasive angiography. Nevertheless, although coronary stenosis has long been considered the main determinant of inducible ischemia and symptoms, growing evidence has demonstrated the importance of other underlying mechanisms (e.g., vasospasm, microvascular disease, energetic inefficiency). The search for a pathophysiology-driven treatment of these patients has therefore emerged as an important objective of multimodality imaging, integrating "anatomical" and "functional" information. We here provide an up-to-date guide for the choice and the interpretation of the currently available noninvasive anatomical and/or functional tests, focusing on emerging techniques (e.g., coronary flow velocity reserve, stress-cardiac magnetic resonance, hybrid imaging, functional-coronary computed tomography angiography, etc.), which could provide deeper pathophysiological insights to refine diagnostic and therapeutic pathways in the next future

New echocardiographic and translational tools in valvular and ischemic heart disease

The advent of new methodologies applied to echocardiography, such as tissue Doppler imaging, 2D speckle tracking for myocardial deformation, and myocardial work assessment, has provided additional tools, capable of finer and earlier diagnosis of myocardial dysfunction. In addition, the ability to evaluate endothelial function and measure platelet aggregation has allowed to identify patients at increased risk for cardiovascular events and potential target of pharmacological treatment. In this research project we explored the role of these innovative and advanced tools, like strain parameters, myocardial work indices, and percentage of platelet aggregation, in the diagnosis of physiopathological mechanism underlying valvular and ischemic heart disease. Furthermore, we evaluated the prognostic value of speckle tracking echocardiography in aortic stenosis patients, from asymptomatic status to transcatheter aortic valve implantation, and its accuracy in the prediction of coronary artery disease. Finally, we investigated how factors such as hyperglycemia, hypercholesterolemia and uremia affect endothelial and platelet function, detecting new compounds able to counteract their pathological effects. To date, most of these investigated methodologies are mainly used for research purpose; further and larger studies are needed to definitely attest their adding value, in order to include their use in the routine clinical practice

Non-Invasive Imaging in Diabetic Cardiomyopathy

There is increasing recognition of a specific diabetic cardiomyopathy beyond ischemic cardiomyopathy, which leads to structural and functional myocardial abnormalities. The aim of this review is to summarize the recent literature on diagnostic findings and prognostic significance of non-invasive imaging including echocardiography, nuclear imaging, computed tomography and cardiovascular magnetic resonance in diabetic cardiomyopathy

The years 2015-2016 in the European Heart Journal-Cardiovascular Imaging. Part I

International audienceThe multimodality cardiovascular imaging journal, European Heart Journal-Cardiovascular Imaging, was launched in 2012. It has gained an impressive impact factor of 5.99 during its 5 first years and is now established as the most important cardiovascular imaging journal in Europe. The most important studies from the journal's forth and fifth years will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease