Disagreement of strain measurements among different vendors has provided an obstacle to the clinical use of strain. A joint standardization task force between professional societies and industry was ...initiated to reduce intervendor variability of strain. Although feedback from this process has been used in software upgrades, little is known about the effects of efforts to improve conformity. The aim of this study was to assess whether intervendor agreement for global longitudinal strain (GLS) has improved after standardization initiatives.
Eighty-two subjects (mean age, 52 ± 21 years; 55% men) prospectively underwent two sequential examinations using two most common ultrasound systems (Vivid E9 and iE33). GLS was calculated using proprietary software (EchoPAC-PC BT12 E12 and BT13 E13 vs QLAB version 8.0 Q8, QLAB version 9.0 Q9, and QLAB version 10.0 Q10). Agreements in GLS were evaluated with Bland-Altman plots. Coefficients of variation (CVs) were compared using the Friedman test and compared with CVs of left ventricular volumes and ejection fraction (LVEF).
Median GLS using E12 was -19.2% (interquartile range IQR, -15.2% to -23.2%), compared with -19.3% (IQR, -14.9% to -23.7%) for E13, -15.7% (IQR, -11.4% to -20%) for Q8, -19% (IQR, -15.7% to -22.3%) for Q9, and -18.7% (IQR, -15.7% to -21.7%) for Q10. The CVs of prestandardization GLS (12 ± 8% E12/Q8 and 14 ± 8 E13/Q8) were significantly larger than that of LVEF (5 ± 5) (P < .001). Since standardization, the CVs of GLS have shown improvement (6 ± 4 E12/Q9, 7 ± 4 E12/Q10, 6 ± 4 E13/Q9, and 7 ± 4 E13/Q10) and are similar to those of LVEF.
Subsequent to the joint standardization task force, there has been improvement in between-vendor concordance in GLS between two leading ultrasound manufactures, the variability of which is now analogous to that of LVEF. The removal of concerns about measurement variability should allow wider use of GLS.
Abstract Objectives This study sought to show the degree to which experience and training affect the precision and validity of global longitudinal strain (GLS) measurement and to evaluate the ...variability of strain measurement after feedback. Background The application of GLS for the detection of subclinical dysfunction has been recommended in an expert consensus document and is being used with increasing frequency. The role of experience in the precision and validity of GLS measurement is unknown, as is the efficacy of training. Methods Fifty-eight readers, divided into 4 groups on the basis of their experience with GLS, calculated GLS from speckle strain analysis of 9 cases with various degrees of image quality. Intraclass correlation coefficients (ICCs), mean difference, standard deviation (SD), and coefficient of variation (CV) were compared against the measurements of a reference group that had experience with >1,000 cases of strain measurement. Individualized feedback was distributed, and repeat measurements were performed by 40 readers. Comparisons with the baseline variation provided information about whether feedback was effective. Results The ICC for GLS was significantly greater than that for ejection fraction regardless of image quality. Experience with strain measurement affected the concordance in strain values among the readers; the group with the highest level of experience showed significantly better ICC than those with no experience, although the ICC of the inexperienced readers was still very good (0.996 vs. 0.975, p = 0.0002). As experience increased, the mean difference, SD, and CV became significantly smaller. The CV of segmental strain analysis showed significant improvement after training, regardless of experience. Conclusions The favorable interobserver agreement of GLS makes it more attractive than ejection fraction for follow-up of left ventricular function by multiple observers. Although experience is important, the precision of GLS was high for all groups. Training appears to be of most value for the assessment of segmental strain.
Background An updated 2016 echocardiographic algorithm for diagnosing left ventricular (LV) diastolic dysfunction (DD) was recently proposed. We aimed to assess the reliability of the 2016 ...echocardiographic LVDD grading algorithm in predicting elevated LV filling pressure and clinical outcomes compared to the 2009 version. Methods We retrospectively identified 460 consecutive patients without atrial fibrillation or significant mitral valve disease who underwent transthoracic echocardiography within 24 hours of elective heart catheterization. LV end-diastolic pressure (LVEDP) and the time constant of isovolumic pressure decay (Tau) were determined. The association between DD grading by 2009 LVDD Recommendations and 2016 Recommendations with hemodynamic parameters and all-cause mortality were compared. Results The 2009 LVDD Recommendations classified 55 patients (12%) as having normal, 132 (29%) as grade 1, 156 (34%) as grade 2, and 117 (25%) as grade 3 DD. Based on 2016 Recommendations, 177 patients (38%) were normal, 50 (11%) were indeterminate, 124 (27%) patients were grade 1, 75 (16%) were grade 2, 26 (6%) were grade 3 DD, and 8 (2%) were cannot determine. The 2016 Recommendations had superior discriminatory accuracy in predicting LVEDP ( P < .001) but were not superior in predicting Tau. During median follow-up of 416 days (interquartile range: 5 to 2004 days), 54 patients (12%) died. Significant DD by 2016 Recommendations was associated with higher risk of mortality ( P = .039, subdistribution HR1.85 95% CI, 1.03-3.33) in multivariable competing risk regression. Conclusions The grading algorithm proposed by the 2016 LV diastolic dysfunction Recommendations detects elevated LVEDP and poor prognosis better than the 2009 Recommendations.
Left atrial (LA) strain is a sensitive measure of LA mechanics. However, its relationship with rhythm outcomes after catheter ablation in patients with atrial fibrillation (AF) is not well ...established. The aim of this study was to evaluate whether baseline LA global longitudinal strain (LAε) predicts rhythm outcomes in patients who undergo catheter ablation for AF.
In 256 patients with AF (paroxysmal, 204; persistent, 52), comprehensive echocardiography was performed with assessment of LAε by using Velocity Vector Imaging to calculate average strain values from apical four- and two-chamber views before ablation (median, 41 days; interquartile range, 1-95 days).
After a median of 8.0 months (interquartile range, 4.0-23.3 months) of follow-up, 149 patients (58%) had maintained sinus rhythm and 107 patients (42%) had recurrence of AF. In our study cohort (mean age 59 ± 11 years; mean left ventricular ejection fraction, 58 ± 10%), impaired total LAε (LAεtotal) was associated with greater left ventricular mass index (r = -0.245, P < .001) and worsening left ventricular diastolic function (ratio of transmitral flow peak early diastolic velocity to peak early diastolic velocity of the mitral annulus: r = -0.357, P < .001; maximal LA volume index: r = -0.393, P < .001). Patients with LAεtotal < 23.2% showed a higher incidence of AF recurrence compared with patients with LAεtotal ≥ 23.2% (log-rank P < .001). In multivariate Cox proportional-hazards analysis, LAεtotal was independently related to rhythm outcomes (hazard ratio, 0.944; 95% confidence interval, 0.915-0.975; P < .001) after AF ablation. Moreover, LAεtotal provided incremental predictive value for rhythm outcomes over clinical features (increment in global χ(2) = 14.63, P < .001).
In patients with AF, baseline LAεtotal was associated with rhythm outcome after catheter ablation.
Abstract Background End-stage renal disease is a major clinical and public health problem, and cardiovascular disease accounts for half of the mortality in hemodialysis patients. An existing ...mortality risk score (AROii score) or N-terminal pro-brain natriuretic peptide (NT-proBNP) level have modest predictive power, but there is room for improvement. There are emerging cardiac biomarkers (soluble isoforms of ST2 sST2, galectin-3 Gal-3), and uremic toxicity (indoxyl sulfate IS). We sought to determine whether these biomarkers predict cardiovascular outcomes in hemodialysis patients, and have incremental prognostic value over the clinical score and NT-proBNP level. Methods A total of 423 hemodialysis patients were prospectively followed for primary (all-cause death) and secondary endpoints (a composite of all-cause death or cerebro-cardiovascular events). Results During a mean follow-up of 2.1 ± 0.4 years, there were 48 all-cause deaths and 78 composite outcomes. sST2, Gal-3, and NT-proBNP were associated with all-cause deaths but IS was not in both log-rank test and receiver operating characteristic analysis. Both sST2 and Gal-3 had independent and incremental prognostic value for both outcomes over the AROii score and NT-proBNP. Although adding sST2 did not reclassify over the model based AROii score and NT-proBNP for all-cause death, further addition of Gal-3 did. Subgroup analyses of patients with left ventricular ejection fraction measurement (n=301) corroborated these results, where the two biomarkers remained independent and incremental for both all-cause death and composite outcome after adjusting for the risk score and the ejection fraction. Conclusions Both sST2 and Gal-3 had independent and incremental prognostic values over NT-proBNP and an established risk score in patients with hemodialysis. Assessment of sST2 and Gal-3 further enhances risk stratification.
Objectives The purposes of this study were to examine left atrial (LA) functional reserve in patients with heart failure (HF) with preserved ejection fraction (HFpEF) and to determine whether LA ...strain has an incremental diagnostic value over clinical and conventional echocardiographic parameters. Background Patients with HFpEF have multiple cardiovascular reserve abnormalities. Although the LA is dysfunctional in HFpEF, the diagnostic value of LA strain remains unknown. Methods The LA at rest and during passive leg lifts was echocardiographically assessed in 40 patients with HFpEF and in 46 patients with hypertension without HF (HT controls). Global peak atrial longitudinal strain during ventricular systole (global LAS ) and booster strain during atrial contraction (global LAB ) were assessed using speckle tracking. Results Patients with HFpEF had an enlarged LA and reduced LA emptying fraction compared with HT controls at rest, while LA stroke volume (SV) was similar between the groups. During leg lifts, increases in LA reservoir and contractile function (i.e., global LAS and LAB ) were blunted in HFpEF patients compared with HT controls, resulting in impaired LASV responses. Global LAS and LAB during leg lifts accurately differentiated HFpEF from HT controls (areas under the curve: 0.95 and 0.92, respectively). Resting global LAS had a significant incremental diagnostic value over clinical (age and sex) and conventional echocardiographic parameters (E/E′ ratio, left ventricular mass index, and maximum LA volume index) (global chi-square: 49.6 vs. 30.8; p < 0.0001). The diagnostic value was further improved by adding global LAS during leg lifts (global chi-square: 72.2 vs. 49.6; p < 0.0001). Conclusions An enlarged LA compensates for LA dysfunction and maintains LASV at rest in patients with HFpEF. However, depressed LA reserve affects LA performance during leg lifts. Evaluation of LA function, including LA strain using leg lifts, might provide incremental diagnostic value for HFpEF.
Left ventricular ejection fraction (LVEF) is a predictor of adverse outcomes in hemodialysis patients. LVEF is, however, an integral parameter determined by contractility, loading condition, and ...coupling. We sought to determine whether these components would better predict adverse outcomes and have incremental prognostic value over a validated clinical score and EF.
Two hundred thirty-four hemodialysis patients were prospectively followed up for primary composite endpoint: all-cause death, nonfatal myocardial infarction, and hospitalization due to worsening heart failure (HF). Load-independent contractility (end-systolic elastance Ees and preload recruitable stroke work PRSW) and arterial afterload (arterial elastance Ea) were noninvasively estimated. Ventricular-arterial coupling was assessed using the Ea/Ees ratio. LV global longitudinal strain (GLS) and mitral E-wave over annular velocity E' ratio (E/E') were also measured.
During a median follow-up of 776 days, 30 patients developed the primary endpoint. Ees, PRSW, GLS, S', Ea/Ees, E/E', and EF were independently associated with the outcome after adjusting for the clinical score and prior HF hospitalization, whereas end-diastolic volume index or arterial afterload parameters were not. The nested Cox models indicated that Ea/Ees had independent and incremental predictive value over the model based on the score and either EF or E/E'. Furthermore, Ea/Ees continued to have predictive value after adjusting for GLS. The classification and regression analysis stratified event rates ranging from 4.2% to 68.8%.
LV contractility and Ea/Ees were independently associated with adverse outcome in hemodialysis patients. Ea/Ees had an incremental prognostic value over the clinical score and EF.
Abstract Background Selecting heart failure (HF) patients for intensive management to reduce readmissions requires effective targeting. However, available prediction scores are only modestly ...effective. We sought to develop a prediction score for 30-day all-cause rehospitalization or death in HF with the use of nonclinical and clinical data. Methods and Results This statewide data linkage included all patients who survived their 1st HF admission (with either reduced or preserved ejection fraction) to a Tasmanian public hospital during 2009–2012. Nonclinical data (n = 1,537; 49.5% men, median age 80 y) included administrative, socioeconomic, and geomapping data. Clinical data before discharge were available from 977 patients. Prediction models were developed and internally and externally validated. Within 30 days of discharge, 390 patients (25.4%) died or were rehospitalized. The nonclinical model (length of hospital stay, age, living alone, discharge during winter, remoteness index, comorbidities, and sex) had fair discrimination (C-statistic 0.66 95% confidence interval (CI) 0.63–0.69). Clinical data (blood urea nitrogen, New York Heart Association functional class, albumin, heart rate, respiratory rate, diuretic use, angiotensin-converting enzyme inhibitor use, arrhythmia, and troponin) provided better discrimination (C-statistic 0.72 95% CI 0.68–0.76). Combining both data sources best predicted 30-day rehospitalization or death (C-statistic 0.76 95% CI 0.72–0.80). Conclusions Clinical data are stronger predictors than nonclinical data, but combining both best predicts 30-day rehospitalization or death among HF patients.
This investigation sought to quantify the risk factors for short-term readmission in patients with heart failure (HF). Electronic databases were systematically searched for studies reporting relative ...risk, odds ratio, and hazard ratio for the combined primary outcome of all-cause hospital readmission or all-cause mortality ≤90 days from discharge of patients with HF. Clinical characteristics, study design, type and incidence of outcome, univariable effect sizes for each risk factor, and their associated 95% confidence intervals were extracted. Each univariable effect size was pooled and computed in a separate meta-analysis using random-effects models weighted by inverse variance. The frequency of significance of each risk factor in multivariable models was also assessed to confirm their independence. Sixty-nine studies (2,038,524 patients) were included and 144 factors were reported, including 32 reported more than twice. The significant associations of the combined primary outcome were chronic lung disease, chronic kidney disease, atherosclerotic vascular disease (peripheral, coronary, and cerebrovascular), diabetes, anemia, lower systolic blood pressure, previous admission, multidisciplinary treatment, and use of beta-blockade and angiotensin-converting enzyme inhibition or angiotensin receptor blockade. In multivariable analyses, most of these variables remained independently associated with the combined primary outcome. However, age, male gender, black race, hypertension, dyslipidemia, smoking, atrial fibrillation, cancer, and uses of diuretics, aldosterone antagonists, and digoxin were not significant. In conclusion, noncardiovascular co-morbidities, poor physical condition, history of admission, and failure to use evidence-based medication are more strongly associated with 90-day readmission or death than standard risks in patients with HF.
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