Prognostic utility of early systolic lengthening by speckle tracking echocardiography in patients with type 2 diabetes

Abstract Background Early systolic lengthening (ESL) has recently recognized as a predictor of cardiovascular events in patients with myocardial ischemia. Our aim was to evaluate the prognostic value of ESL in patients with type 2 diabetes. Methods In this prospective study we conducted speckle tracking examinations in 743 patients with type 2 diabetes (62% male; age 63±10 years; diabetes duration 11 [5, 17] years). Patients were free from interventricular conduction disturbances, atrial fibrillation, heart failure and ischemic heart disease at study inclusion. We assessed the ESL index, defined as: (−100 x [peak positive systolic strain / global longitudinal strain (GLS)]), and duration of ESL, defined as time from onset of QRS complex on the electrocardiogram to time of peak positive systolic strain. Measurements were averaged from 18 myocardial segments. Results During the median follow-up time of 4.8 years [IQR 4, 5.3 years], 93 (13%) patients experienced major adverse cardiovascular events (MACE), a composite of incident heart failure, myocardial infarction and cardiovascular death. Because GLS modified the association with MACE (P interaction &amp;lt;0.05), the population was stratified by the median GLS value (low &amp;gt;−15% and high ≤−15%). In patients with low GLS, the ESL index (HR 1.47 per 1% increase [1.12 to 1.93], P=0.005) and ESL duration (HR 1.73 per 1ms increase [1.10 to 2.72], P=0.017) were associated with MACE. Both associations remained significant in multivariable models adjusted for clinical, echocardiographic and speckle tracking measurements (Figure). No associations were found in patients with high GLS (Figure). Conclusion Assessment of ESL yields novel and independent prognostic information on major adverse cardiovascular events in patients with diabetes type 2 and reduced longitudinal strain. Forest plot: ESL and risk of MACE by GLS Funding Acknowledgement Type of funding source: None </jats:sec

1270Early systolic lengthening in patients with ST-segment elevation myocardial infarction: a novel predictor of cardiovascular events

Abstract Background Early systolic lengthening (ESL) may occur in ischemic myocardial segments with reduced contractile force. We sought to evaluate the prognostic potential of ESL in patients with ST-segment elevated myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Methods We prospectively enrolled 372 patients with STEMI who were treated with primary PCI. All patients underwent a speckle tracking echocardiographic examination with a median of 2 days (interquartile range 1, 3 days) after the PCI. We assessed a novel viability index, the ESL index, defined as: (100 x [peak positive systolic strain/peak negative global strain]), obtained as the average value from all 18 segments. We also calculated ESL duration from 18 segments, defined as time from onset of QRS complex on the electrocardiogram to time to peak of positive systolic strain. Results During a median follow-up time of 5.3 years (interquartile range 2.5, 6.0), 145 (39%) experienced major adverse cardiovascular events (MACEs), which was a composite of incident heart failure, new myocardial infarction and all-cause mortality. The ESL index and ESL duration were significantly increased in culprit lesion areas (6.7±6.2% vs. 5.0±4.1% and 43±33ms vs. 33±24ms, P&lt;0.001 for both). In Cox proportional hazards models the ESL index (HR 1.27 per 1% increase, 95% CI 1.13–1.43, P&lt;0.001, Fig A) and ESL duration (HR 1.49 per 1ms increase, 95% CI 1.15–1.92, P=0.002, Fig B) yielded prognostic information on MACE. Both associations remained significant after adjusting for clinical (age, sex, hypertension, heart rate), echocardiographic (LVMI, E/e', WMSI, LVEF, postsystolic index) and invasive (postprocedural TIMI flow, TnI) confounders. Additionally, tertiles of the ESL index and ESL duration yielded significant prognostic information on MACE (Fig C-D). ESL index and ESL duration and MACE Conclusions Assessment of ESL following primary PCI in patients with STEMI yields independent and significant prognostic information on the future risk of cardiovascular events. </jats:sec

Prognostic Value of Early Systolic Lengthening by Strain Imaging in Type 2 Diabetes

Background: Patients with type 2 diabetes (T2D) have increased risk for subclinical myocardial disease. Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, is a sensitive marker of myocardial dysfunction. The aims of this study were to investigate the prognostic value of ESL in patients with T2D and to determine if global longitudinal strain (GLS) modifies this relationship. Methods: In this prospective study, speckle-tracking echocardiography was conducted in 703 patients with T2D (62% men; mean age, 63 ± 10 years; median diabetes duration, 11 years; interquartile range, 6–17 years). Patients had no histories of significant heart disease. ESL index was assessed as [−100 × (peak positive systolic strain/maximal strain)] and ESL duration as time from QRS complex on the electrocardiogram to time of peak positive systolic strain. P values ≤ .004 were considered to indicate statistical significance. Results: During a median follow-up time of 4.8 years (interquartile range, 4.1–5.3 years), 86 patients (12%) experienced major adverse cardiovascular events (MACE), a composite of incident heart failure, myocardial infarction, and cardiovascular death. In multivariate models, only the ESL index (hazard ratio [HR], 1.06 per 1% increase; 95% CI, 1.01–1.010; P = .004) but not ESL duration (HR, 1.02 per 1-ms increase; 95% CI, 1.00–1.03; P = .036) were associated with MACE. GLS modified this relationship (P for interaction &lt; .05) such that in patients with low GLS (&gt;−18%), ESL index (HR, 1.06 per 1% increase; 95% CI, 1.02–1.10; P = .003) was associated with MACE, but ESL duration was not (HR, 1.02 per 1-ms increase; 95% CI, 1.00–1.04; P = .005). No associations were found for high GLS (&lt;−18%). Conclusions: In patients with T2D and no histories of heart disease, ESL provides prognostic information on MACE and may potentially aid in cardiovascular risk stratification.</p

3080Postsystolic shortening yields novel and independent prognostic information on cardiovascular events and mortality in patients with type 2 diabetes

Abstract Background Cardiovascular disease is the leading cause of death and disability in patients with type 2 diabetes. We aimed to evaluate if postsystolic shortening, a marker of impaired myocardial function, may provide prognostic information on cardiovascular events and mortality in patients with type 2 diabetes. Method We prospectively studied 783 patients with diabetes type 2 (63% male, age 65 [58, 70] years; HbA1c 54 [48, 65] mmol/mol; diabetes duration 11 [6, 17] years) who underwent speckle tracking echocardiography. Patients with left bundle branch block, atrial fibrillation and a history of heart failure and myocardial infarction were excluded. The primary endpoint was the composite of incident heart failure, myocardial infarction and cardiovascular death. The secondary endpoint was all-cause death. We defined the postsystolic index (PSI) as: [100x (maximum strain in cardiac cycle – peak systolic strain)/ (maximum strain in cardiac cycle)]. Results During the median follow-up of 4.9 years [4.2, 5.3], 87 patients (11%) reached the primary endpoint and 80 (10%) died from any cause. Each 1% increase in the PSI was associated with the primary (HR 1.07 95% CI 1.02–1.13, P&lt;0.001, Fig A) and secondary endpoint (HR 1.09 95% CI 1.04–1.14, P&lt;0.001, Fig B). After adjusting for age, sex, hypertension, smoking, duration of diabetes, cholesterol, eGFR, left ventricular ejection fraction and mass index, E/A-ratio, deceleration time and left atrial volume index, the PSI remained an independent predictor of both endpoints; primary (HR 1.07 per 1% increase 95% CI 1.01–1.14, P=0.028) and secondary endpoint (HR 1.07 per 1% increase, 95% CI 1.01–1.14, P=0.022). PSI and the endpoints Conclusion In patients with type 2 diabetes, assessment of PSI yields novel and independent prognostic information on cardiovascular events and mortality. Hence, PSI may offer guidance on risk stratification in patients with type 2 diabetes. </jats:sec

The prognostic value of myocardial deformational patterns is reduced in patients with heart failure

Abstract Background Early systolic lengthening (ESL) and postsystolic shortening are considered highly specific for myocardial ischemia. We aimed to investigate the prognostic potential of both deformational patterns in patients with heart failure (HF) and to determine if a history of ischemic heart disease modified this relationship. Method A total of 884 patients with systolic HF (66±12 years, male 73%, mean ejection fraction 28±9%) underwent speckle tracking echocardiography. Of these, 61% suffered from ischemic cardiomyopathy (ICM). Patients were followed for all-cause mortality. We assessed the ESL index: [−100x (peak positive strain/maximal strain)] and the postsystolic index (PSI): [100x (postsystolic strain/maximal strain)]. Both parameters were averaged across 18 myocardial segments. Results During a median follow-up of 3.4 years [interquartile range 1.9 to 4.8], 132 patients (15%) died. In multivariable survival analyses adjusted for potential confounders (age, sex, BMI, mean arterial pressure, cholesterol, heart rate, CABG/PCI, left ventricular ejection fraction and mass index, left atrial volume index, tricuspid annular plane systolic excursion, E-wave, E/e', deceleration time, and global longitudinal strain) neither the ESL index (HR 1.02 per 1% increase [0.97 to 1.08], P=0.40) nor PSI (HR 1.00 per 1% increase [0.98 to 1.01], P=0.69) were associated with all-cause mortality. ICM modified the relationship (P interaction unadjusted/adjusted=0.001/0.008; Figure) such that per 1% increase in ESL index in patients with ICM was significantly associated with all-cause mortality (unadjusted: HR 1.09 [1.04 to 1.15], P&amp;lt;0.001 and adjusted: HR 1.06 [1.00 to 1.13], P=0.045) but not in those without (unadjusted: HR 1.02 [1.01 to 1.03], P=0.002 and adjusted: HR 0.99 [0.90 to 1.09], P=0.086). ICM did not modify the relationship between PSI and all-cause mortality (P interaction unadjusted/adjusted=0.15/0.13). Conclusion Our results indicate that in this cohort of undifferentiated HF patients with reduced ejection fraction the prognostic value of deformational patterns was reduced. However, the ESL index may provide some information on prognosis in patients with ICM. ESL and interaction with ICM Funding Acknowledgement Type of funding source: None </jats:sec