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 Table of Contents  
ORIGINAL RESEARCH
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 18-21

Global Longitudinal Strain in Patients with ST-Elevation Myocardial Infarction Post-percutaneous Coronary Intervention Using Speckle Tracking Echocardiography


Department of Cardiology, SNMC, Jodhpur, Rajasthan, India

Date of Submission06-Aug-2019
Date of Decision24-Nov-2019
Date of Acceptance05-Jan-2020
Date of Web Publication11-Apr-2020

Correspondence Address:
Dr. Swati Mahajan
Department of Cardiology, SNMC, R/O C-9 Shastri Nagar, Jodhpur - 342 003, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_38_19

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  Abstract 

Background: Routinely, two-dimensional (2D) left ventricular ejection fraction (LVEF) is used to assess the left ventricular (LV) systolic function. Lately, global longitudinal peak systolic strain (GLPSS) has emerged to be a more sensitive tool for assessing LV systolic function. We aimed to assess the superiority of GLPSS by 2D speckle-tracking echocardiography in patients with ST-elevation myocardial infarction (STEMI) before and within 48 h after percutaneous coronary intervention (PCI) over 2D-LVEF calculated using the Simpson's biplane method of disks. Materials and Methods: A total of 70 patients with STEMI who underwent PCI were included in this study, which was conducted in the Department of Cardiology, MDM hospital, Jodhpur, Rajasthan, India, between November 2018 and February 2019. Patients having preexisting cardiomyopathy, moderate-to-severe valvular heart disease, morbid obesity, and poor echocardiographic window were excluded from the study. Echocardiography before and within 48 h of PCI was done. 2D-LVEF was calculated using Simpson's method. GLPSS was assessed using the automated function imaging technique. Results: Post-PCI GLPSS increased significantly compared to pre-PCI value (−17.68 vs. −16.65;P < 0.002). 2D-LVEF, on the contrary, did not show any significant increase post-PCI (40.1 vs. 40.57;P = 0.98). Furthermore, the improvement in the average GLPSS was significantly higher when the target vessel revascularized was nonleft anterior descending (LAD) than LAD (−18.32 vs. −17.46;P < 0.001) . Conclusion: The assessment of LV systolic function after PCI in patients with STEMI was superior with GLPSS when compared to 2D LVEF. As strain imaging is an inexpensive tool, it can be applied easily to assess LV function in the large subset of population.

Keywords: Global longitudinal peak systolic strain, left ventricular ejection fraction, speckle-tracking echocardiography, ST-elevation myocardial infarction


How to cite this article:
Mahajan S, Sanghvi S, Sarda P, Yadav PS. Global Longitudinal Strain in Patients with ST-Elevation Myocardial Infarction Post-percutaneous Coronary Intervention Using Speckle Tracking Echocardiography. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:18-21

How to cite this URL:
Mahajan S, Sanghvi S, Sarda P, Yadav PS. Global Longitudinal Strain in Patients with ST-Elevation Myocardial Infarction Post-percutaneous Coronary Intervention Using Speckle Tracking Echocardiography. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Jun 1];4:18-21. Available from: http://www.jiaecho.org/text.asp?2020/4/1/18/282204




  Introduction Top


The assessment of global and regional left ventricular (LV) function is important in patients with coronary artery disease (CAD). Over the past three decades, the role of percutaneous coronary intervention (PCI) has evolved in the management of CAD; hence, in order to ascertain the benefit of PCI in the treatment of patients with CAD, one should address the patient-specific parameters, including LV function at baseline.[1],[2] Conventionally, LV function assessment relies upon the measurement of ejection fraction (EF). LVEF is an important parameter for the prognostication of patients presenting with acute myocardial infarction. In a multicenter study, patients with myocardial infarction (MI) with LVEF <40% experienced more mortality than the patients with LVEF ≥ 40% when followed for a period of 1 year.[3] However, there have been certain limitations of EF, which include dependence on preload and afterload, intraobserver, and interobserver variability. It is also influenced by LV geometry, like in athletes who may have dilated hearts, EF may yield slightly low values, whereas higher values may be obtained among the patients with LV hypertrophy.[4],[5] The measurement of global longitudinal peak systolic strain (GLPSS) using speckle-tracking echocardiography (STE) has emerged as an important tool for assessing LV systolic function. The accuracy of this technique has been validated against cardiac magnetic resonance imaging.[6]

GLPSS, in contrast to LVEF, is more reproducible and is operator independent.[7] Its superiority over LVEF to predict cardiac events and all-cause mortality has been demonstrated in patients with heart failure.[8] It has also emerged as a prognostic marker in patients with MI, valvular heart disease, and cardiomyopathies.[9],[10],[11] The aims of this study were as follows:

  1. To assess the LV systolic function in patients with acute ST-elevation MI (STEMI), by calculating LVEF using Simpson's biplane method of disks, and GLPSS by using STE before and after PCI
  2. To assess the superiority of GLPSS over LVEF to detect the early improvement in LV function post-PCI.



  Materials and Methods Top


This was an observational study, which was conducted between November 2018 and February 2019 in the Department of Cardiology, MDM hospital, Jodhpur, Rajasthan, India. A total of 70 patients between the age of 18 and 80 years of both gender presenting with acute STEMI as diagnosed by electrocardiogram (defined as new ST elevation at the J point in at least 2 contiguous leads ≥ 2 mm in men or ≥ 1.5 mm in women in leads V2–V3 and/or of ≥ 1 mm in other contiguous chest or limb leads),[12] admitted in the department of cardiology, who underwent PCI were enrolled in this study. A detailed clinical history was obtained, and examination of all these patients was performed. Routine blood test, electrolyte, and renal function were obtained for all participants.

Exclusion criteria

The exclusion criteria were as follows:

  • Patients having preexisting cardiomyopathy
  • Moderate-to-severe valvular heart disease
  • Morbid obesity and poor echocardiographic window
  • Pulmonary edema
  • Left bundle branch block
  • Sustained atrial fibrillation and ectopics
  • Congenital heart disease
  • Cor pulmonale
  • Moderate-to-large pericardial effusion.


All patients underwent two-dimensional (2D) echocardiography before PCI and within 48 h postprocedure. A standard echocardiographic study was done using echocardiography machine GE Healthcare Vivid Ultrasound E9 according to the guidelines of the American Society of Echocardiography.[13] Data acquisition was performed using 3.5MHz transducer. LV function was assessed by measuring EF using Simpson's biplane method of disks as well as 2D speckle tracking to assess GLPSS.

GLPSS was calculated pre- and post-PCI [Figure 1] by using automated function imaging technique using an apical 3-chamber view, apical 4-chamber view, and apical 2-chamber view. All echocardiograms were read by two cardiologists in a blinded manner with inter-observer and intra-observer variability of 2.4% ± 2% and 1.3% ± 1%, respectively. The paired t-test was used to compare either LV EF or GLPSS between pre- and post-PCI. The independent t-test was used to compare either change in EF (Delta EF) or GLPSS (Delta GLPSS) between target vessel revascularization involving left anterior descending (LAD) artery and non-LAD. Informed consent for participation in this study was obtained.
Figure 1: Pre- and post-percutaneous coronary intervention strain in a patient of anterior wall myocardial infarction

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  Results Top


A total of 70 patients presenting with STEMI, found to be having obstructive CAD on coronary angiography were enrolled in this study. The clinical characteristics of the patients are shown in [Table 1]. Nearly 54.28% of patients were younger than 60 years. The majority of the patients were male (78.57%). As many as, 40% of the patients were diabetics. Forty-two patients had anterior wall MI, 20 had inferior wall MI, and eight patients had lateral wall MI. Culprit's vessel was LAD in 60%, right coronary artery in 22.86%, and left circumflex in 17.14% of the patients. All patients underwent PCI.
Table 1: Clinical characteristics of 70 patients with acute ST-elevation myocardial infarction who underwent percutaneous coronary intervention

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[Figure 2] shows changes in GLPSS and LVEF pre-PCI and post-PCI. Average GLPSS was significantly improved post-PCI (−17.68 [post-PCI] vs. −16.65 [pre-PCI], P < 0.002). In contrast when compared to the pre-PCI value, post-PCI EF did not show any significant increase when assessed within 48 h of the procedure (40.1 vs. 40.57, P = 0.98). Also, change in EF preprocedure and postprocedure (Delta EF) [Figure 3]a was assessed according to the target vessel revascularized. No statistically significant difference was seen in delta EF in the LAD and non-LAD group (P = 0.610). However, the change in GLPSS (Delta GLPSS) [Figure 3]b was significantly higher in the non-LAD group than in the LAD group (P < 0.001).
Figure 2: Change in left ventricular ejection fraction and global longitudinal peak systolic strain pre- and post-percutaneous coronary intervention

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Figure 3: (a) Delta left ventricular ejection fraction according to vessel revascularized (left anterior descending vs. non-left anterior descending); (b) Delta global longitudinal peak systolic strain according to vessel revascularized (left anterior descending vs. non-left anterior descending)

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  Discussion Top


Following acute MI, due to interrupted blood supply, the affected myocardium develops ischemia or infarction depending upon the duration of arterial occlusion and the presence or absence of collaterals. Part of the affected myocardium is stunned or hibernating. Restoring the blood supply allows the stunned and hibernating myocardium to recover in most of the patients. In our study, we measured GLPSS and LVEF before and after PCI. Post-PCI measurement was made no later than 48 h. The study demonstrated a significant improvement in GLPSS as early as 48 h as compared to EF. It also demonstrated that the improvement in GLPSS was more when non-LAD vessels were revascularized. Similar discrimination according to the vessel revascularized was not seen in EF. Our findings were in agreement with Rifqi et al., who demonstrated that LV functions recovered early post-PCI when measured by GLPSS, and the improvement was correlated with revascularization of non-LAD vessels.[14]

GLPSS has been correlated to the extent of scar tissue post-MI. In a study by Ismail et al., a total of 30 patients with STEMI who underwent primary PCI (PPCI) were subjected to the measurement of GLPSS and EF before and within 24 h post-PPCI. They found an excellent inverse correlation between infarct size and GLPSS.[15] Similar findings were observed by Munk et al.[16] who compared STE and LVEF in 227 patients with STEMI. They performed echocardiogram on day 1 and on day 30 postevent and found that GLS was more accurate than LVEF and end-systolic volume index in assessing myocardial recovery. In another study by Park et al., they assessed the patients with acute MI using longitudinal strain by STE and tissue Doppler and traditional echocardiography using EF. Patients had undergone revascularization by either thrombolysis or PCI. They found that strain predicted LV dilation and was an independent predictor of death and heart failure during the 18 months of follow-up.[17]

Our study showed the improvement in the LV systolic function after revascularization when measured using STE than LVEF. It also showed the differential recovery in the myocardial functions with respect to the target vessel revascularized when assessed using GLPSS. In response to the decreased blood supply, the affected myocardium undergoes stunning or hibernation which may recover once the blood supply is restored.[18] The difference in the recovery of different arterial territories may be due to the difference in the area subtended and hence the area of stunned myocardium. Similar findings were observed by the study conducted by Rifqi et al.[14] There is a paucity of data on this differential nature of recovery and hence warrants more studies.

Limitations

  1. The number of patients in the study was small
  2. Patients were assessed before and within 48 h of PCI
  3. Longterm followup was not done.


Long-term follow-up will be required to understand the importance of speckle tracking in the identification of major adverse clinical events.


  Conclusion Top


Improvement in LV functions by restoring the patency of the culprit artery and recovery of LV functions occurs as early as within 48 h postrevascularization. GLPSS is a cheap, easy to apply, and a highly sensitive tool to assess this recovery, whereas EF may fail to detect the same. Hence, it can be easily applied to assess LV functions in the large subset of the population without incurring any additional cost.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Perk G, Tunick PA, Kronzon I. Non-Doppler two dimensional strain imaging by echocardiography—from technical considerations to clinical applications. J Am Soc Echocardiogr 2007;20:234-43.  Back to cited text no. 1
    
2.
Dandel M, Lehmkuhl H, Knosalla C, Suramelashvili N, Hetzer R. Strain and strain rate imaging by echocardiography-basic concepts and clinical applicability. Curr Cardiol Rev 2009;5:133-48.  Back to cited text no. 2
    
3.
White HD; The Multicenter Post-Infarction Research Group. Risk stratification and survival after myocardial infarction. N Engl J Med 1983;309:331-6.  Back to cited text no. 3
    
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Cikes M, Sutherland GR, Anderson LJ, Bijnens BH. The role of echocardiographic deformation imaging in hypertrophic myopathies. Nat Rev Cardiol 2010;7:384-96.  Back to cited text no. 4
    
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Sharma S, Merghani A, Mont L. Exercise and the heart: The good, the bad, and the ugly. Eur Heart J 2015;36:1445-53.  Back to cited text no. 5
    
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Amundsen BH, Helle-Valle T, Edvardsen T, Torp H, Crosby J, Lyseggen E, et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography: Validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol 2006;47:789-93.  Back to cited text no. 6
    
7.
Belghitia H, Brette S, Lafitte S, Reant P, Picard F, Serri K, et al. Automated function imaging: A new operator-independent strain method for assessing left ventricular function. Arch Cardiovasc Dis 2008;101:163-9.  Back to cited text no. 7
    
8.
Cho GY, Marwick TH, Kim HS, Kim MK, Hong KS, Oh DJ. Global 2-dimensional strain as a new prognosticator in patients with heart failure. J Am Coll Cardiol 2009;54:618-24.  Back to cited text no. 8
    
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Ersbøll M, Valeur N, Mogensen UM, Andersen MJ, Møller JE, Velazquez EJ, et al. Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction. J Am Coll Cardiol 2013;61:2365-73.  Back to cited text no. 9
    
10.
Saito M, Okayama H, Yoshii T, Higashi H, Morioka H, Hiasa G, et al. Clinical significance of global two-dimensional strain as a surrogate parameter of myocardial fibrosis and cardiac events in patients with hypertrophic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2012;13:617-23.  Back to cited text no. 10
    
11.
Bartko PE, Heinze G, Graf S, Clavel MA, Khorsand A, Bergler-Klein J, et al. Two-dimensional strain for the assessment of left ventricular function in low flow-low gradient aortic stenosis, relationship to hemodynamics, and outcome: A substudy of the multicenter TOPAS study. Circ Cardiovasc Imaging 2013;6:268-76.  Back to cited text no. 11
    
12.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third universal definition of myocardial infarction. Circulation 2012;126:2020-35.  Back to cited text no. 12
    
13.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015;16:233-70.  Back to cited text no. 13
    
14.
Rifqi S, Sungkar S, Sobirin MA, Uddin I, Furuse Y, Nugroho MA, et al. Early recovery of left ventricular function after revascularization of coronary artery disease detected by myocardial strain. Biomed Res India 2017;28:1487-92.  Back to cited text no. 14
    
15.
Ismail AM, Samy W, Aly R, Fawzy S, Hussein K, et al. Longitudinal strain in patients with STEMI using speckle tracking echocardiography. Egypt J Critical Care Med 2015;3:45-53.  Back to cited text no. 15
    
16.
Munk K, Andersen NH, Nielsen SS, Bibby BM, Bøtker HE, Nielsen TT, et al. Global longitudinal strain by speckle tracking for infarct size estimation. Eur J Echocardiogr 2011;12:156-65.  Back to cited text no. 16
    
17.
Park YH, Kang SJ, Song JK, Lee EY, Song JM, Kang DH, et al. Prognostic value of longitudinal strain after primary reperfusion therapy in patients with anterior-wall acute myocardial infarction. J Am Soc Echocardiogr 2008;21:262-7.  Back to cited text no. 17
    
18.
Wijns W, Vatner SF, Camici PG. Hibernating myocardium. N Engl J Med 1998;339:173-81.  Back to cited text no. 18
    


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