© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12666
Echocardiography
ORIGINAL INVESTIGATION
Two-Dimensional Speckle Tracking Echocardiography Prognostic Parameters in Patients after Acute Myocardial Infarction Maciej Haberka, M.D.,* Jerzy Liszka, M.D.,† Andrzej Kozyra, M.D.,* Maciej Finik, M.D.,† and Zbigniew Gaz sior, M.D.* *2nd Department of Cardiology, Medical University of Silesia, Katowice, Poland; and †Department of Cardiology, Multidisciplinary Hospital, Jaworzno, Poland
Aim: The aim of the study was to evaluate the left ventricle (LV) function with speckle tracking echocardiography (STE) and to assess its relation to prognosis in patients after acute myocardial infarction (AMI). Methods: Sixty-three patients (F/M = 16/47 pts; 62.33 11.85 years old) with AMI (NSTEMI/ STEMI 24/39 pts) and successful percutaneous coronary intervention (PCI) with stent implantation (thrombolysis in myocardial infarction; TIMI 3 flow) were enrolled in this study. All patients underwent baseline two-dimensional conventional echocardiography and STE 3 days (baseline) and 30 days after PCI. All patients were followed up for cardiovascular clinical endpoints, major adverse cardiovascular endpoint (MACE), and functional status (Canadian Cardiovascular Society and New York Heart Association). Results: During the follow-up (31.9 5.1 months), there were 3 cardiovascular deaths, 15 patients had AMI, 2 patients had cerebral infarction, 24 patients reached the MACE. Baseline LV torsion (P = 0.035), but none of the other strain parameters were associated with the time to first unplanned cardiovascular hospitalization. Univariate analysis showed that baseline longitudinal two-chamber and four-chamber strain (sLa2 0 and sLa4 0) and the same parameters obtained 30 days after the AMI together with transverse four-chamber strain (sLa2 30, sLa4 30, and sTa4 30) were significantly associated with combined endpoint (MACE). The strongest association in the univariate analysis was found for the baseline sLa2. However, in multivariable analysis only a left ventricular remodeling (LVR – 27% pts) was significantly associated with MACE and strain parameters were not associated with the combined endpoint. Conclusion: The assessment of LV function with STE may improve cardiovascular risk prediction in postmyocardial infarction patients. (Echocardiography 2014;00:1–7) Key words: speckle tracking echocardiography, left ventricular remodeling, strain, clinical endpoints Several studies have shown that left ventricle (LV) systolic dysfunction evaluated in the conventional echocardiography is a powerful predictor of clinical complications after acute myocardial infarction (AMI). Due to known limitations of the ejection fraction (EF) or wall-motion score index (WMSI), recently speckle tracking echocardiography (STE) was introduced into the clinical practice. Left ventricle ejection fraction (LVEF) may be affected by loading conditions; STE provides more precise and accurate assessment of systolic function and active myocardial deformation in different directions corresponding to myocardial layers.1,2 Various studies have shown sensitivity of STE parameters in predicting postinfarction complications, including left ventricle remodeling (LVR).3 Our aim was to evaluate the value of twoAddress for correspondence and reprint requests: Maciej Haberka, M.D., Ziołowa 45/47, 40-635 Katowice, Poland. Fax: 004-832-2523032; E-mail: [email protected]
dimensional (2D) STE in the prediction of poor clinical outcomes in a relatively long follow-up of patients after acute coronary syndrome and primary coronary angioplasty. Methods: Sixty-three patients (F/M = 16/47 pts; 62.33 11.85 years old) with first AMI-ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI) and successful percutaneous coronary intervention (PCI) with stent implantation (thrombolysis in myocardial infarction [TIMI] grade 3 flow) were enrolled in this study. All patients included in the study group had typical anginal chest pain and significantly increased cardiac markers (CPK – creatine phosphokinase [CPK], creatine phophokinasemyocardial bound isoenzyme [CPK-MB], Troponin I). Pharmacotherapy used in all patients also followed the European Society of Cardiology (ESC) recommendations.4 Echocardiographic 1
Haberka, et al.
examinations were performed 3 days (baseline), 30 and 90 days after the AMI. All patients were followed up (31.9 5.1 months) for cardiovascular mortality, acute coronary syndrome (ACS), cerebral infarction, major adverse cardiovascular endpoint ([MACE]; cardiovascular death, ACS, cerebral infarction, or unplanned coronary revascularization), cardiovascular hospitalizations and functional status (CCS, NYHA), which were related to the conventional and STE obtained at the baseline, 30 days after the AMI and also to the left ventricular remodeling (LVR) assessed 90 days after the AMI. The major exclusion criteria were: history of myocardial infarction or any other heart muscle and valvular disease (e.g., heart failure, cardiomyopathies, significant valvular defects, myocarditis) with persistent regional or global LV wallmotion abnormalities, any significant general disorder of potential influence on regional or global LV wall motion, significant arrhythmia (including atrial fibrillation and advanced extrasystolic arrhythmia), previous pacemaker or cardioverterdefibrillator implantation, significant heart valve defects, uncompleted reperfusion therapy (coronary artery bypass grafting or repeated PCI) and very poor image quality. Subjects were recruited (from September 2009 to December 2010) and completed the study at the 2nd Department of Cardiology at the Medical University of Silesia. The study protocol was approved by the local Medical University of Silesia Ethics Committee and all patients submitted written informed consent for the study procedures. Echocardiography: Two-dimensional transthoracic echocardiography (TTE) was performed in all patients on admission to the hospital (not included in the study results), 3 days (baseline examination “0”), 30 days (“30”), and 90 days (“90”) after the AMI. Both 2DTTE with the routine parameters and 2DSTE were ECG gated. All the patients were examined using a 3.5 MHz transducer in the standard views: parasternal (long axis and short axis—basal, midventricular, apical level) and apical (two-, three- and four-chamber). The images and video clips containing cine loop format were recorded by one expert (90–103 frames per second) and then analyzed off line independently by two experts. All the measurements used for statistical analysis were averaged from the three consecutive beats. The LV was divided into 17 segments, evaluated, and scored (1-normal, 2hypokinesis, 3-akinesis, 4-dyskinesis, 5-aneurysmal) and the global WMSI was calculated for each TTE examination.5 LV volumes and EF were determined using the modified Simpson biplane 2
technique. The LV remodeling was defined as ≥20% increase in LV end-diastolic volume (EDV) and/or LV end-systolic volume (ESV) assessed 90 days after the AMI.6,7 Myocardial tissue deformation was analyzed off line using commercially available software (STE Toshiba, Tokyo, Japan) using recorded 2D gray-scale images. The end-systole was defined as an aortic valve closure in the apical five-chamber view. The endocardial borders were traced manually in an end-systole with the myocardium in the region of interest (ROI). Then, the position and the width of the ROI were optimized. The software analyzed the speckles within the myocardium and calculated segmental strain. The peak longitudinal strain and peak transverse strain were calculated as the average of peak values for each of the segments in the apical twochamber and four-chamber views (longitudinal and transverse) strain and parasternal short-axis views at three levels (transverse and circumferential strain). Rotation was estimated using basal and apical short-axis views: the clockwise rotation was defined as negative and the counterclockwise rotation was defined as positive when determined from the apical aspect. The LV twist was defined as the absolute difference between apical and basal rotation values. The feasibility of LV segments analysis with STE was 94% for the longitudinal strain and 89% for the transverse, circumferential strain and torsion analysis. Only one patient had to be excluded due to a very bad image quality of most LV segments. The inter-observer variability and intra-observer variability in patients’ recordings analysis were 93 and 95%. Statistical Analysis: The strain values are expressed in percentages and rotation is expressed in degrees. All results presented in the text, tables are expressed as means standard deviation or number and percentage. The results’ normal distribution was analyzed with the Kolmogorov–Smironov test. Levene, Brown and Forsyth test was used to verify the homogeneity of variance in the group. Baseline clinical parameters and the results of diagnostic tests were compared using the t-tests for normally distributed continuous variable (Student’s t-test); in case of abnormal distribution, the Mann–Whitney U-test was used. Pearson’s test with Yates’ correction was used for qualitative variables. The Kruskal–Wallis test was used to assess the variables within several subgroups. Frequency analysis was performed with the chisquare test. Cumulative incidences of MACE were calculated by the Kaplan–Meier method and were compared using the log-rank test. Hazard ratios were estimated using a Cox proportional hazards
Speckle Tracking Echocardiography and Prognosis
model. The clinical and echocardiographic variables were included in the multivariable Cox proportional hazard analysis if the univariable model P-value was
Echocardiography
ORIGINAL INVESTIGATION
Two-Dimensional Speckle Tracking Echocardiography Prognostic Parameters in Patients after Acute Myocardial Infarction Maciej Haberka, M.D.,* Jerzy Liszka, M.D.,† Andrzej Kozyra, M.D.,* Maciej Finik, M.D.,† and Zbigniew Gaz sior, M.D.* *2nd Department of Cardiology, Medical University of Silesia, Katowice, Poland; and †Department of Cardiology, Multidisciplinary Hospital, Jaworzno, Poland
Aim: The aim of the study was to evaluate the left ventricle (LV) function with speckle tracking echocardiography (STE) and to assess its relation to prognosis in patients after acute myocardial infarction (AMI). Methods: Sixty-three patients (F/M = 16/47 pts; 62.33 11.85 years old) with AMI (NSTEMI/ STEMI 24/39 pts) and successful percutaneous coronary intervention (PCI) with stent implantation (thrombolysis in myocardial infarction; TIMI 3 flow) were enrolled in this study. All patients underwent baseline two-dimensional conventional echocardiography and STE 3 days (baseline) and 30 days after PCI. All patients were followed up for cardiovascular clinical endpoints, major adverse cardiovascular endpoint (MACE), and functional status (Canadian Cardiovascular Society and New York Heart Association). Results: During the follow-up (31.9 5.1 months), there were 3 cardiovascular deaths, 15 patients had AMI, 2 patients had cerebral infarction, 24 patients reached the MACE. Baseline LV torsion (P = 0.035), but none of the other strain parameters were associated with the time to first unplanned cardiovascular hospitalization. Univariate analysis showed that baseline longitudinal two-chamber and four-chamber strain (sLa2 0 and sLa4 0) and the same parameters obtained 30 days after the AMI together with transverse four-chamber strain (sLa2 30, sLa4 30, and sTa4 30) were significantly associated with combined endpoint (MACE). The strongest association in the univariate analysis was found for the baseline sLa2. However, in multivariable analysis only a left ventricular remodeling (LVR – 27% pts) was significantly associated with MACE and strain parameters were not associated with the combined endpoint. Conclusion: The assessment of LV function with STE may improve cardiovascular risk prediction in postmyocardial infarction patients. (Echocardiography 2014;00:1–7) Key words: speckle tracking echocardiography, left ventricular remodeling, strain, clinical endpoints Several studies have shown that left ventricle (LV) systolic dysfunction evaluated in the conventional echocardiography is a powerful predictor of clinical complications after acute myocardial infarction (AMI). Due to known limitations of the ejection fraction (EF) or wall-motion score index (WMSI), recently speckle tracking echocardiography (STE) was introduced into the clinical practice. Left ventricle ejection fraction (LVEF) may be affected by loading conditions; STE provides more precise and accurate assessment of systolic function and active myocardial deformation in different directions corresponding to myocardial layers.1,2 Various studies have shown sensitivity of STE parameters in predicting postinfarction complications, including left ventricle remodeling (LVR).3 Our aim was to evaluate the value of twoAddress for correspondence and reprint requests: Maciej Haberka, M.D., Ziołowa 45/47, 40-635 Katowice, Poland. Fax: 004-832-2523032; E-mail: [email protected]
dimensional (2D) STE in the prediction of poor clinical outcomes in a relatively long follow-up of patients after acute coronary syndrome and primary coronary angioplasty. Methods: Sixty-three patients (F/M = 16/47 pts; 62.33 11.85 years old) with first AMI-ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI) and successful percutaneous coronary intervention (PCI) with stent implantation (thrombolysis in myocardial infarction [TIMI] grade 3 flow) were enrolled in this study. All patients included in the study group had typical anginal chest pain and significantly increased cardiac markers (CPK – creatine phosphokinase [CPK], creatine phophokinasemyocardial bound isoenzyme [CPK-MB], Troponin I). Pharmacotherapy used in all patients also followed the European Society of Cardiology (ESC) recommendations.4 Echocardiographic 1
Haberka, et al.
examinations were performed 3 days (baseline), 30 and 90 days after the AMI. All patients were followed up (31.9 5.1 months) for cardiovascular mortality, acute coronary syndrome (ACS), cerebral infarction, major adverse cardiovascular endpoint ([MACE]; cardiovascular death, ACS, cerebral infarction, or unplanned coronary revascularization), cardiovascular hospitalizations and functional status (CCS, NYHA), which were related to the conventional and STE obtained at the baseline, 30 days after the AMI and also to the left ventricular remodeling (LVR) assessed 90 days after the AMI. The major exclusion criteria were: history of myocardial infarction or any other heart muscle and valvular disease (e.g., heart failure, cardiomyopathies, significant valvular defects, myocarditis) with persistent regional or global LV wallmotion abnormalities, any significant general disorder of potential influence on regional or global LV wall motion, significant arrhythmia (including atrial fibrillation and advanced extrasystolic arrhythmia), previous pacemaker or cardioverterdefibrillator implantation, significant heart valve defects, uncompleted reperfusion therapy (coronary artery bypass grafting or repeated PCI) and very poor image quality. Subjects were recruited (from September 2009 to December 2010) and completed the study at the 2nd Department of Cardiology at the Medical University of Silesia. The study protocol was approved by the local Medical University of Silesia Ethics Committee and all patients submitted written informed consent for the study procedures. Echocardiography: Two-dimensional transthoracic echocardiography (TTE) was performed in all patients on admission to the hospital (not included in the study results), 3 days (baseline examination “0”), 30 days (“30”), and 90 days (“90”) after the AMI. Both 2DTTE with the routine parameters and 2DSTE were ECG gated. All the patients were examined using a 3.5 MHz transducer in the standard views: parasternal (long axis and short axis—basal, midventricular, apical level) and apical (two-, three- and four-chamber). The images and video clips containing cine loop format were recorded by one expert (90–103 frames per second) and then analyzed off line independently by two experts. All the measurements used for statistical analysis were averaged from the three consecutive beats. The LV was divided into 17 segments, evaluated, and scored (1-normal, 2hypokinesis, 3-akinesis, 4-dyskinesis, 5-aneurysmal) and the global WMSI was calculated for each TTE examination.5 LV volumes and EF were determined using the modified Simpson biplane 2
technique. The LV remodeling was defined as ≥20% increase in LV end-diastolic volume (EDV) and/or LV end-systolic volume (ESV) assessed 90 days after the AMI.6,7 Myocardial tissue deformation was analyzed off line using commercially available software (STE Toshiba, Tokyo, Japan) using recorded 2D gray-scale images. The end-systole was defined as an aortic valve closure in the apical five-chamber view. The endocardial borders were traced manually in an end-systole with the myocardium in the region of interest (ROI). Then, the position and the width of the ROI were optimized. The software analyzed the speckles within the myocardium and calculated segmental strain. The peak longitudinal strain and peak transverse strain were calculated as the average of peak values for each of the segments in the apical twochamber and four-chamber views (longitudinal and transverse) strain and parasternal short-axis views at three levels (transverse and circumferential strain). Rotation was estimated using basal and apical short-axis views: the clockwise rotation was defined as negative and the counterclockwise rotation was defined as positive when determined from the apical aspect. The LV twist was defined as the absolute difference between apical and basal rotation values. The feasibility of LV segments analysis with STE was 94% for the longitudinal strain and 89% for the transverse, circumferential strain and torsion analysis. Only one patient had to be excluded due to a very bad image quality of most LV segments. The inter-observer variability and intra-observer variability in patients’ recordings analysis were 93 and 95%. Statistical Analysis: The strain values are expressed in percentages and rotation is expressed in degrees. All results presented in the text, tables are expressed as means standard deviation or number and percentage. The results’ normal distribution was analyzed with the Kolmogorov–Smironov test. Levene, Brown and Forsyth test was used to verify the homogeneity of variance in the group. Baseline clinical parameters and the results of diagnostic tests were compared using the t-tests for normally distributed continuous variable (Student’s t-test); in case of abnormal distribution, the Mann–Whitney U-test was used. Pearson’s test with Yates’ correction was used for qualitative variables. The Kruskal–Wallis test was used to assess the variables within several subgroups. Frequency analysis was performed with the chisquare test. Cumulative incidences of MACE were calculated by the Kaplan–Meier method and were compared using the log-rank test. Hazard ratios were estimated using a Cox proportional hazards
Speckle Tracking Echocardiography and Prognosis
model. The clinical and echocardiographic variables were included in the multivariable Cox proportional hazard analysis if the univariable model P-value was
