Abstract
Aims
Non-invasive left ventricular (LV) pressure–strain loop (PSL) provides a novel method of quantifying myocardial work (MW) with potential advantages over conventional global longitudinal ...strain (GLS) by incorporating measurements of myocardial deformation and LV pressure. We investigated different patterns of LV PSL and global MW index (GWI) in patients with hypertension (HTN) and dilated cardiomyopathy (CMP).
Methods and results
Seventy-four patients underwent transthoracic echocardiography and strain analysis before coronary angiography. Patients were divided into three groups: control, HTN, and CMP. GWI was calculated as the area of the LV PSL as a product of strain × systolic blood pressure. MW efficiency (GWE) is derived from the percentage ratio of constructive work (GCW) to sum of constructive work (GCW) and wasted work (GWW). Influences of HTN and LV function on its relationship with MW were evaluated. GLS and LV ejection fraction were preserved in the HTN group with no difference from controls. GWI was significantly higher in moderate to severe HTN patients (P = 0.004) as a compensatory mechanism to preserve LV contractility and function against an increase in afterload. GWE was preserved in HTN patients due to the proportional increase in GCW and GWW. GLS, GWI, and GWE were significantly reduced in CMP (P < 0.05), with a trend in rightward shift and reduction in the LV PSL.
Conclusion
GWI is a potential new technique that allows better understanding of the relationship between LV remodelling and increased wall stress under different loading conditions.
Noninvasive detection of functionally significant coronary artery disease (CAD) by echocardiography remains challenging, with the need to perform stress imaging to detect ischemia. The aim of this ...study was to determine whether global myocardial work (MW), derived from noninvasive left ventricular (LV) pressure-strain loops at rest, can predict significant CAD in patients without regional wall motion abnormalities and preserved LV ejection fraction (EF).
One hundred and fifteen patients referred for coronary angiography who had EF ≥ 55%, no resting regional wall motion abnormalities, and no chest pain were assessed using echocardiography. Global MW was derived from noninvasive LV pressure-strain loops constructed from speckle-tracking echocardiography indexed to brachial systolic blood pressure. Global constructive work represented the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation. Global wasted work represented energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation. Global MW efficiency was derived from the percentage ratio of constructive work to the sum of constructive work and wasted work.
Patients with significant CAD demonstrated a significantly reduced global MW (P < .001) compared with those without CAD. Global longitudinal strain was significantly reduced (P < .001) in patients with multivessel CAD but not those with single-vessel CAD (P = .47). Receiver operating characteristic curve analysis demonstrated that global MW was the most powerful predictor of significant CAD (area under the curve = 0.786) and was superior to global longitudinal strain (area under the curve = 0.693). The optimal cutoff global MW value to predict significant CAD was 1,810 mm Hg% (sensitivity, 92%; specificity, 51%).
Noninvasive global MW derived using LV pressure-strain loops at rest is a more sensitive index than global longitudinal strain to detect significant CAD in patients with no regional wall motion abnormalities and normal EF. This is a potential valuable clinical tool to assist in the early diagnosis of CAD.
This volumeexamines the ways in which multilingual women authors incorporate several languages into their life writing. It compares the work of six contemporary authors who write predominantly in ...French. It analyses the narrative strategies they develop to incorporate more than one language into their life writing: French and English, French and Creole, or French and German, for example. The book demonstrates how women writers transform languages to invent new linguistic formations and how they create new formulations of subjectivity within their self-narrative. It intervenes in current debates over global literature, national literatures and translingual and transnational writing, which constitute major areas of research in literary and cultural studies. It also contributes to debates in linguistics through its theoretical framework of translanguaging. It argues that multilingual authors create new paradigms for life writing and that they question our understanding of categories such as "French literature".
Myocardial Work: A New Type of Strain Imaging? Chan, Jonathan; Edwards, Natalie F A; Scalia, Gregory M ...
Journal of the American Society of Echocardiography,
10/2020, Letnik:
33, Številka:
10
Journal Article
Early detection of acute cellular rejection (ACR) by echocardiography shows potential clinical benefit as ACR remains a significant contributor to morbidity and mortality. This retrospective, ...longitudinal study sought to investigate the use of novel left (LV) and right ventricular (RV) strain analysis to detect biopsy proven ACR. 46 heart transplant patients (Mean age 46 ± 16 years) with biopsy proven ACR were grouped according to biopsy results: 1R-ACR (n = 36) and 2R-ACR (n = 10). Serial two-dimensional transthoracic echocardiography with strain analysis was performed. Echocardiographic parameters were serially measured: (1) rejection free period (0R-ACR); (2) pre-ACR period (pre-ACR); (3) during ACR (1R-ACR or 2R-ACR) and (4) post-ACR (Post-ACR). Significant reductions for LV Global Longitudinal Strain (LV GLS) and LV Early diastolic Strain rate (LV ESr) were observed between 0R-ACR and pre-ACR (LV GLS 0R-ACR: 17.3% vs Pre-2R ACR: 15.4%, p = 0.016; LV ESr 0R-ACR: 1.00/s vs Pre-2R ACR: 0.74/s, p = 0.007) with LV ESr demonstrating the highest sensitivity (92%) and specificity (81%) to predict ACR. LV ESr and the E/LV ESr ratio were significantly different (p = 0.0001; p = 0.016) during pre-1R ACR period vs 0R whereas LV GLS showed no significant differences for grade 1R-ACR. Diastolic mechanical dispersion showed significant increases in dispersion during ACR for the 1R-ACR group and early significant increases pre-2R ACR. Systolic and diastolic RV strain parameters showed a similar trend for both ACR groups. Systolic and diastolic strain parameters can detect myocardial dysfunction before biopsy confirmed 2R-ACR. Early diastolic strain rate parameters are most sensitive detecting subclinical myocardial dysfunction pre-ACR. Novel strain parameters are potentially useful clinical tool for prediction of early ACR in heart transplant.
Purpose
Two-dimensional (2D) strain analysis is a sensitive method for detecting myocardial dysfunction in acute cellular rejection (ACR) from post-transplant complications. This study aims to ...evaluate the utility of novel left (LV) and right ventricular (RV) strain parameters for prognostic risk stratification associated with ACR burden at 1-year post transplantation.
Methods
128 Heart transplant patients, assessed between 2012 and 2018, underwent transthoracic echocardiography and endomyocardial biopsy. 2D strain analysis was performed and history of rejection burden was assessed and grouped according to ACR burden at 1-year post transplantation. The primary endpoint was all-cause mortality at 6-years follow up.
Results
21 patients met primary the endpoint. Multivariate analysis of 6-year all-cause mortality showed LV global longitudinal strain (LV GLS) (Hazard Ratio HR = 1.21, CI = 1.06–1.49), LV early diastolic strain rate (LV ESr) (HR = 1.31, CI = 1.12–1.54), RV GLS (HR = 1.12, CI = 1.02–1.25) and RV ESr (HR = 1.26, CI = 1.12–1.47) were significant predictors of outcome. Univariate analysis also showed LV GLS, LV ESr, RV GLS and RV ESr were significant predictors of outcome. Optimal cut-off for predicting 6-year mortality for LV GLS by receive operator characteristic was 15.5% (sensitivity: 92%, specificity: 79%). Significant reductions (p < 0.05) in LV GLS, RV GLS and LV and RV ESr between rejection groups were seen.
Conclusions
Non-invasive LV and RV strain parameters are predictors of mortality in post-transplant patient with ACR. LV GLS and LV ESr are superior to other strain and conventional echo parameters.
To evaluate relapse rates and disease-modifying drug (DMD) treatment in US women with multiple sclerosis (MS) and a live birth.
This retrospective administrative claims database study used US ...commercial health plan data from women with MS and a live birth from January 1, 2006, to June 30, 2015. Relapses and DMD treatment were evaluated 1-year prepregnancy, during pregnancy, during puerperium (6 weeks postpregnancy), and 1-year postpregnancy. Relapse was defined as MS-related hospitalization, emergency room visit, or outpatient visit with corticosteroid prescription within 7 days. Generalized estimating equation models for longitudinal data tested for differences between prepregnancy vs the other time periods.
A total of 2,158 patients were eligible. The odds of relapse declined during pregnancy (odds ratio OR 0.623, 95% confidence interval CI 0.521-0.744;
< 0.0001), increased during puerperium (OR 1.710, 95% CI 1.358-2.152;
< 0.0001), and ended at a higher level during the last 3 postpartum quarters (OR 1.216, 95% CI 1.052-1.406;
= 0.0081). The proportion of women with DMD treatment was rather low overall: approximately 20% prepregnancy, bottoming to 1.9% during the second trimester, and peaking at 25.5% 9 to 12 months postpartum. DMD treatment declined significantly during pregnancy (OR 0.171, 95% CI 0.144-0.203;
< 0.0001), remained lower during puerperium (OR 0.361, 95% CI 0.312-0.418;
< 0.0001), and ended at a higher level during the last 3 postpartum quarters (OR 1.259, 95% CI 1.156-1.371;
< 0.0001).
The rate of MS relapse decreased during pregnancy, increased 6 months postpartum, and decreased 6 to 12 months postpartum. DMD treatment was uncommon in the year before pregnancy, further decreased immediately prepregnancy and during pregnancy, and increased postpartum.
To compare pregnancy prevalence and complications in women with and without multiple sclerosis (MS).
This retrospective US administrative claims study used data from January 1, 2006, to June 30, ...2015. All data for women with MS were included. A nationally representative 5% random sample from approximately 58 million women without MS was used to compute the dataset. Annual pregnancy rates, identified via diagnosis/procedure codes and adjusted for covariates, were estimated via logistic regression. Claims for pregnancy and labor/delivery complications were compared using propensity score matching.
From 2006 to 2014, the adjusted proportion of women with MS and pregnancy increased from 7.91% to 9.47%; the adjusted proportion without MS and with pregnancy decreased from 8.83% to 7.75%. The difference in linear trend (0.17% increase and 0.15% decrease in per-annum pregnancy rates) was significant (
statistic = 7.8;
< 0.0001). After matching (n = 2,115 per group), a higher proportion of women with MS than without had claims for premature labor (31.4% vs 27.4%;
= 0.005), infection (13.3% vs 10.9%;
= 0.016), cardiovascular disease (3.0% vs 1.9%;
= 0.028), anemia/acquired coagulation disorders (2.5% vs 1.3%;
= 0.007), neurologic complications (1.6% vs 0.6%;
= 0.005), sexually transmitted diseases (0.4% vs 0.1%;
= 0.045), acquired fetal damage (27.8% vs 23.5%;
= 0.002), and congenital fetal malformations (13.2% vs 10.3%;
= 0.004).
Pregnancy rates in this population of women with MS have been increasing. High rates of claims for several peripartum complications were observed in women with and those without MS. Claims data provide knowledge of interactions patients have with the health care system and are valuable initial exploratory analyses.
Sensitivity and specificity of ESE to determine hemodynamically significant coronary artery disease (CAD) is limited by subjective qualitative interpretation resulting in false-positive results. The ...objective of this study was to determine whether resting myocardial work estimated from non-invasive left ventricular pressure-strain loops can help improve the interpretation of exercise stress echocardiography (ESE). Resting global myocardial work was performed on 288 patients referred for clinically indicated ESE with no resting regional wall motion abnormalities and normal ejection fraction (≥ 55%). Coronary angiography was used to validate the presence of significant CAD in those with a positive ESE. Resting global myocardial work index (GWI) was significantly reduced (p < 0.001) in patients with true-positive (1544 ± 354 mmHg%) compared to negative (1819 ± 317 mmHg%) and false-positive (1857 ± 344 mmHg%) ESE. A GWI of ≤ 1391 mmHg (AUC 0.73; sensitivity 94%; specificity 73%) predicted true-positive ESE. Predictors of a true-positive ESE were (1) lower myocardial work efficiency (odds ratio 0.731, 95% CI 0.58–0.92, p = 0.007), (2) lower GWI (odds ratio 0.997, 95% CI 0.996–0.999, p = 0.006) (3) male gender (odds ratio 5.47, 95% CI 1.84–16.31, p = 0.002) and (4) E/eʹ ratio (odds ratio 1.15, CI 1.01–1.31, p = 0.032). Myocardial work is a potentially valuable quantitative parameter that provides incremental value over qualitative ESE interpretation and improves appropriate patient selection for coronary angiography.
Nonadherence to disease-modifying drugs (DMDs) for multiple sclerosis (MS) is associated with poorer clinical outcomes, including higher rates of relapse and disease progression, and higher medical ...resource use. A systematic review and quantification of adherence and persistence with oral DMDs would help clarify the extent of nonadherence and nonpersistence in patients with MS to help prescribers make informed treatment plans and optimize patient care. The objectives were to: 1) conduct a systematic literature review to assess the availability and variability of oral DMD adherence and/or persistence rates across 'real-world' data sources; and 2) conduct meta-analyses of the rates of adherence and persistence for once- and twice-daily oral DMDs in patients with MS using real-world data.
A systematic review of studies published between January 2010 and April 2018 in the PubMed database was performed. Only studies assessing once- and twice-daily oral DMDs were available for inclusion in the analysis. Study quality was evaluated using a modified version of the Newcastle-Ottawa Scale, a tool for assessing quality of observational studies. The random effects model evaluated pooled summary estimates of nonadherence.
From 510 abstracts, 31 studies comprising 16,398 patients with MS treated with daily oral DMDs were included. Overall 1-year mean medication possession ratio (MPR; n = 4 studies) was 83.3% (95% confidence interval CI 74.5-92.1%) and proportion of days covered (PDC; n = 4 studies) was 76.5% (95% CI 72.0-81.1%). Pooled 1-year MPR ≥80% adherence (n = 6) was 78.5% (95% CI 63.5-88.5%) and PDC ≥80% (n = 5 studies) was 71.8% (95% CI 59.1-81.9%). Pooled 1-year discontinuation (n = 20) was 25.4% (95% CI 21.6-29.7%).
Approximately one in five patients with MS do not adhere to, and one in four discontinue, daily oral DMDs before 1 year. Opportunities to improve adherence and ultimately patient outcomes, such as patient education, medication support/reminders, simplified dosing regimens, and reducing administration or monitoring requirements, remain. Implementation of efforts to improve adherence are essential to improving care of patients with MS.
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