|Year : 2021 | Volume
| Issue : 1 | Page : 1-4
Can Strain Imaging Predict Left Ventricle Remodeling? A Study from Eastern India
Rakesh Agarwal1, Soumya Kanti Dutta1, Rashmi Baid2, Dhurjati Prasad Sinha1
1 Department of Cardiology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
2 Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
|Date of Submission||16-May-2020|
|Date of Decision||26-Jul-2020|
|Date of Acceptance||02-Aug-2020|
|Date of Web Publication||04-Feb-2021|
Dr. Rakesh Agarwal
Department of Cardiology, IPGMER and SSKM Hospital, Kolkata - 700 020, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Even persistently patent infarct-related artery has been shown to be associated with left ventricle (LV) remodeling. The purpose of this study was to evaluate the role of LV strain imaging by echocardiography in predicting LV remodeling in patients undergoing coronary revascularization. Materials and Methods: A total of 104 patients between the ages of 18 and 75 years of age undergoing percutaneous transluminal coronary angioplasty (PTCA) for acute coronary syndrome (ACS) were selected and subsequently followed up for 3 months. Echocardiography was obtained before PTCA and subsequently 3 months later with global longitudinal strain (GLS) measurements. Results: In our study, 24% patients studied developed LV remodeling at 1 month even after clinical, angiographic, and procedural success of percutaneous intervention. A value of LV GLS <−10.8 predicted the development of LV remodeling with 80% sensitivity and 86% specificity with lower values having higher specificity. Conclusions: GLS assessment by echocardiography in the acute setting is feasible and easy to do with no complications and may be used with considerable sensitivity in predicting patients with adverse remodeling after ACSs.
Keywords: Echocardiography, left ventricle remodeling, strain imaging
|How to cite this article:|
Agarwal R, Dutta SK, Baid R, Sinha DP. Can Strain Imaging Predict Left Ventricle Remodeling? A Study from Eastern India. J Indian Acad Echocardiogr Cardiovasc Imaging 2021;5:1-4
|How to cite this URL:|
Agarwal R, Dutta SK, Baid R, Sinha DP. Can Strain Imaging Predict Left Ventricle Remodeling? A Study from Eastern India. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2021 [cited 2021 Jul 23];5:1-4. Available from: https://www.jiaecho.org/text.asp?2021/5/1/1/308726
| Introduction|| |
Management of acute coronary syndrome (ACS) by thrombolysis or primary percutaneous coronary intervention (PCI) has long been plagued by late occurrence of left ventricle (LV) remodeling.
Morbidity and mortality after an acute coronary event are high. It has been estimated that one-third of the acute myocardial infarction (AMI) patients die even before reaching hospital. Half are estimated to be dead by the time they reach a hospital. Public health initiatives, education about symptoms, early care seeking, early activation of the emergency medical services, prehospital fibrinolysis, and quick transport can avoid some of these fatalities.
The incidence of coronary heart disease and related AMI in the Indian population has been increasing in the past few decades being 11%–16% compared to 2%–5% in the western population. While in hospital mortality has been estimated to be around 8%, data on long-term mortality on the Indian population have been lacking.
With emerging and evolving techniques, the success rate of revascularization by PCI has increased. However, this has not translated into decreased rates of LV remodeling with almost a third of patients with ACS developing remodeling.
Even persistently patent infarct-related artery (IRA) has been shown to be associated with LV remodeling. Conventionally, LV systolic function has been assessed using ejection fraction (EF) on echocardiography. While LVEF has its own prognostic implications, it isn't very helpful in risk stratification of ACS patients or prediction of LV remodeling in the future. Early diagnosis and prediction of patients who will develop LV remodeling after ACS has recently been studied extensively with newer modalities of imaging coming up.
Assessment of myocardial viability has been suggested to select patients likely to benefit from revascularization with those having viable myocardium having favorable prognosis. However, even in patients with viability in the VIAMI trial, only 46% of patients had improvement in EF with patients showing a no-significant increased LV end-diastolic volume (LVEDV). Further, use of either of these modalities is hindered by resource limitation as in our setup.
Global longitudinal strain (GLS) expresses longitudinal shortening as a percentage and is derived from speckle tracking. Different software use different algorithms to measure GLS. They usually involve tracing of the myocardium after its selection and defining end-systolic and end-diastolic frames.
The purpose of this study was to evaluate the role of LV strain imaging by echocardiography in predicting LV remodeling in patients undergoing coronary revascularization. Patients undergoing coronary revascularization by percutaneous transluminal coronary angioplasty (PTCA) for ACS were subjected to standard two-dimensional (2D) echocardiography and LV strain imaging at baseline, and their baseline characteristics were noted. At 3-month follow–up, these patients were subjected to echocardiography again to look for parameters of LV remodeling, LV systolic function, and strain imaging.
Specific aims of the study were:
- Assessment of LV remodeling in patients undergoing PTCA after ACS by echocardiography
- Evaluation of the role of echocardiography strain in predicting LV remodeling at 1 month of follow-up.
| Materials and Methods|| |
This was an observational prospective study carried out on outdoor and admitted patients in the Department of Cardiology at IPGMER and SSKM Hospital, Kolkata. A total of 104 patients between the ages of 18 and 75 years of age undergoing PTCA for ACS were selected and subsequently followed up for 3 months.
Patients undergoing successful PTCA for ACS were included in the study.
Successful PTCA was defined as thrombolysis in myocardial infarction trial flow grade 3 and residual stenosis of the IRA < 30%.
- Patients not willing to undergo the study
- Patient with previous history of ACS, coronary angioplasty, cardiac surgery, or structural heart disease
- Patients with life-limiting noncardiac disease.
LV remodeling for the purpose of this study was defined as:
- Increase in LVEDV > 15% and/or
- Increase in left ventricular end-systolic volume (LVESV) > 15% and/or
- Decrease in LVEF >5%.
Vivid S6 of GE Healthcare was used for calculating strain values.
| Results|| |
A total of 104 patients were studied, comprising 40 female patients and 64 male patients. Forty patients had presented with anterior wall myocardial infarction, 39 had presented with inferior wall myocardial infarction, and 25 patients had presented with non-ST elevation myocardial infarction. Baseline characteristics of the patients were as in [Figure 1].
|Figure 1: Baseline characteristics of the patients. DT: Deceleration time of mitral early inflow velocity, E/A: Mitral inflow early to late diastolic velocity ratio, E/E': Early diastolic mitral inflow to mitral annular velocity ratio, EF: Ejection fraction, ET: Ejection time, GLS: Global longitudinal strain, IVCT: Isovolumic contraction time, IVRT: Isovolumic relaxation time, IVSd: End-diastolic interventricular septal thickness, LVEDV: Left ventricular end-diastolic volume, LVESV: Left ventricular end-systolic volume, LVIDd: End-diastolic left ventricular internal dimension, LVIDs: End-systolic left ventricular internal dimension, MAPSE: Mitral annular plane systolic excursion, pwD: End-diastolic posterior wall thickness|
Click here to view
Twenty-five patients of 104 studied (24.04%) developed LV remodeling. The mean age was similar in the two groups. The mean age in remodeling group was 51.56 years, while that in the no remodeling group, it was 55.97 years.
Baseline LV dimensions in systole and diastole were also not statistically different in the two groups.
GLS was statistically different in the two groups. The mean strain in remodeling group was −9.08% versus −13.45% in the no remodeling group.
Ejection time and E/E' were also statistically different in the two groups. ET in remodeling group was 244.52 ms compared to 265.33 ms in the no remodeling group. E/E' between the two groups was 13.84 versus 11.17 in the remodeling versus no remodeling groups, respectively.
A GLS cutoff of −10.8% had a sensitivity of 80% and specificity exceeding 86% to identify patients who went on to develop adverse LV remodeling [Figure 2] and [Figure 3].
|Figure 2: Receiver operating characteristic for global longitudinal strain in predicting left ventricle remodeling|
Click here to view
|Figure 3: Data for different global longitudinal strain parameters in predicting left ventricle remodeling|
Click here to view
| Discussion|| |
First introduced as postprocessing of tissue Doppler imaging velocity converted to strain and strain rate, strain imaging has more recently also been derived from digital speckle-tracking analysis. Strain echocardiography has been considered to be superior to visual estimation of wall motion of regional systolic function. LV strain imaging is now being increasingly used to understand the pathology and physiology of myocardial ischemia.
LV remodeling is frequent in population presenting with ACS. In our study, 24% of patients studied developed LV remodeling at 1 month even after clinical, angiographic, and procedural success of PCI. The incidence of LV remodeling has been quite high. About 58% of patients with STEMI developed LV remodeling in one study at 6 months. This was despite the fact that 86% of patients were reperfused and 83% had successful reperfusion. In other studies, LV remodeling has been estimated to occur in 24%–34% of patients treated with primary PCI.,,
It has traditionally been difficult to assess which patients will respond favorably to PCI despite successful PCI being done at the right time and for the right indication. Late LV remodeling is a known harbinger of significant cardiac morbidity and mortality.
The accuracy of STE against magnetic resonance imaging (MRI) has been compared and studied in a number of research papers. 2D speckle-tracking imaging has been shown to predict both LV recovery and adverse remodeling with significant accuracy as compared to cardiac MRI. In our patient population, LV GLS was shown to predict the development of late LV remodeling defined as an increase in LVEDV or LVESV by 15% or more or a decline in EF by 5% or more. These values were obtained 3 months after the successful PCI.
A value of LV GLS <−10.8 predicted the development of LV remodeling with 80% sensitivity and 86% specificity with lower values having higher specificity. This could in a way provide a basis for selecting patients who could develop favorable versus unfavorable results with PCI and also an explanation of likelihood of the PCI not being beneficial to the patient.
In 2016, a meta-analysis comprising more than 3000 patients and including 23 prospective studies was done. It revealed that peak LV systolic strain values between −12.8% and −10.2% predicted adverse LV remodeling accurately. The use of circumferential LV strain and torsional strain was additive in predicting LV adverse remodeling. There was a strong association between peak GLS and LV remodeling.
While patients should undergo PCI as per the standard guidelines, those with lower GLS values have a guarded prognosis despite a successful PCI as shown in our study. In other studies, it has been shown that LV strain values between −10.1% and −12.8% may predict LV remodeling. We have shown a strong correlation between LV GLS and remodeling with high sensitivity and specificity.
In the group of patients who developed LV remodeling, the E/E' was statistically higher, probably reflecting the higher diastolic dysfunction and LV filling pressures that these patients have. In addition, they were likely to have lower ejection times and higher values of Tei indices which reflect a more composite index of having both lowered systolic and diastolic functions.
While our study does demonstrate that LV strain is capable of predicting adverse LV remodeling, it remains to be seen if this is reproduced in larger studies. A number of patients may go on to develop LV remodeling after a period of 3 months after PCI which likely underestimates the risk as assessed in our study. Percentage of patients developing LV remodeling may be significantly higher, and the burden of disease may be greater than thought.
Furthermore, we do not know if these patients who develop LV remodeling can respond favorably as we did not assess the long-term prognosis of these patients. Whether these patients respond favorably to standard heart failure therapies or not remains to be seen. Whether their response to standard heart failure therapies is affected by the LV strain results also remains to be seen. Our study was limited by its short time span of follow-up (3 months) and the relatively small number of patients we studied (104). Larger and longer prospective studies could give newer insights into the role of LV strain imaging in AMI patients.
| Conclusions|| |
In conclusions it may be said that:
- GLS assessment by echocardiography in the acute setting is feasible and easy to do with no complications
- There is a high proportion of patients (~24%) who develop adverse left ventricular remodeling after successful PTCA for ACS
- Assessment of LV GLS has a high sensitivity and specificity in predicting patients who may develop LV remodeling. LV GLS cutoff of −10.8 has a sensitivity of 80% and specificity of 86% in predicting LV remodeling in this subset of patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Terkelsen CJ, Sørensen JT, Maeng M, Jensen LO, Tilsted HH, Trautner S, et al
. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010 Aug 18;304:763-71. doi: 10.1001/jama.2010.1139. PMID: 20716739.
Sharma M, Ganguly NK. Premature coronary artery disease in Indians and its associated risk factors. Vasc Health Risk Manag. 2005;1:217-25.
Ajay VS, Prabhakaran D. Coronary heart disease in Indians: Implications of the INTERHEART study. Indian J Med Res 2010;132:561-6. doi:10.4103/0971-5916.73396
Ola RK, Meena CB, Ramakrishnan S, Agarwal A, Bhargava S. Detection of left ventricular remodeling in acute ST elevation myocardial infarction after primary percutaneous coronary intervention by two dimensional and three dimensional echocardiography. J Cardiovasc Echogr 2018;28:39-44. doi:10.4103/jcecho.jcecho_32_17.
Cahill TJ, Kharbanda RK. Viability testing to guide myocardial revascularisation in patients with heart failure. Indian J Thorac Cardiovasc Surg. 2018;34(Suppl 3):206-12. doi:10.1007/s12055-017-0637-4.
Farah E, Cogni AL, Minicucci MF, et al
. Prevalence and predictors of ventricular remodeling after anterior myocardial infarction in the era of modern medical therapy. Med Sci Monit 2012;18:CR276-81.
Funaro S, La Torre G, Madonna M, Galiuto L, Scarà A, Labbadia A, et al
. Incidence, determinants, and prognostic value of reverse left ventricular remodelling after primary percutaneous coronary intervention: results of the Acute Myocardial Infarction Contrast Imaging (AMICI) multicenter study. Eur Heart J 2009;30:566-75.
Gold MR, Daubert C, Abraham WT, Ghio S, St John Sutton M, Hudnall JH, et al
. The effect of reverse remodeling on long-term survival in mildly symptomatic patients with heart failure receiving cardiac resynchronization therapy: Results of the REVERSE study. Heart Rhythm 2015;12:524-30.
Huttin O, Coiro S, Selton-Suty C, Juillière Y, Donal E, Magne J, et al
. Prediction of left ventricular remodeling after a myocardial infarction: role of myocardial deformation: A systematic review and meta-analysis. PLoS One. 2016;11:e0168349. Published 2016 Dec 30. doi:10.1371/journal.pone.0168349.
[Figure 1], [Figure 2], [Figure 3]