Global Longitudinal Strain of Left Ventricle as а Supplement by Standart and ABCE Stress Echocardiography in Risk Stratification in Coronary Artery Disease

Aim     In a prospective observational study of risk stratification in patients with ischemic heart disease (IHD) using stress echocardiography (Stress ECHO), to evaluate the significance of left ventricular (LV) global longitudinal strain (GLS) as an independent prognostic marker or as an adjunct to the existing markers.

Material and methods            This study included 273 patients (60.4% men, mean age 60.9±9.5 years) with known (n=109; 39.9%) or suspected (n=164; 60.1%; IHD pretest probability (PT): 17 [11-26]% (interquartile ranges: Me [Q1; Q3])) IHD. All patients underwent Stress ECHO with physical exercise (PE) on a recumbent bicycle ergometer (n=165; 60.4%), vasodilator (adenosine triphosphate (ATP), n=74; 27.1%), and other stress tests (n=34; 12.5%). The Stress ECHO protocol included assessment of local contractile disorders (LCD), B-lines, LV contractile reserve (CR), and heart rate reserve. Additionally, LV GLS was assessed at rest and at the test peak, and GLS reserve and GLS change (ΔGLS) were calculated. The prospective follow-up period was 20 [13-25] months. The composite cardiovascular end point (CVE) included death from cardiovascular causes, acute coronary syndrome, revascularization, and stroke/transient ischemic attack, and was calculated until the first event.

Results            Prognostic values were obtained for 272 (99.6%) patients. During the follow-up period, 114 cardiovascular complications (CVC) occurred in 87 (31.9%) patients (1 to 3 in each patient). According to the multivariate regression analysis of the Stress ECHO results, the independent predictors for the CVE were the emergence of new LCDs at the peak of stress testing (odds ratio (OR) 2.95; 95% confidence interval (CI): 1.51-5.76; p=0.02) and ΔGLS (OR 0.90; 95% CI: 0.81-0.99; p=0.039). With the use of ATP, the risk of developing CVC was described by a similar model, that had an even higher level of significance (OR for LCD 36.21; 95% CI: 3.09-424.09; p=0.004; OR for ΔGLS 0.48; 95% CI: 0.25-0.94; p=0.032). In PE Stress ECHO, the GLS index added to the LCD did not demonstrate an independent prognostic value. The ROC analysis identified a threshold value for ΔGLS as a predictor of unfavorable prognosis. The threshold absolute value was 1.2 in the entire group and 0.2 in the ATP Stress ECHO subgroup. In case of difficulties in assessing the LCD at the testing peak, an alternative model was used with evaluation of the IHD PT (OR 1.09; 95% CI: 1.04-1.14; p<0.001), emergence of angina at the testing peak (OR 5.07; 95% CI: 1.81-14.26; p=0.002), reduced LV CR (OR 2.18; 95% CI 0.73-6.53; p=0.162), and ΔGLS (OR 0.83; 95% CI 0.72-0.95; p=0.008).

Conclusion      In Stress ECHO performed for risk stratification in IHD, the ΔGLS value, regardless of and in addition to LCDs, is a predictor of CVC. The absolute value of ΔGLS <1.2 in the entire group and ΔGLS <0.2 in the ATP subgroup indicates an unfavorable prognosis for the next 1.5 years.

1. Federal State Statistics Service. Health in Russia. 2023. Statistical book. - M.: Rosstat; 2023. - 179p.

2. Barbarash O.L., Karpov Yu.A., Panov A.V., Akchurin R.S., Alekyan B.G., Alekhin M.N. et al. 2024 Clinical practice guidelines for Stable coronary artery disease. Russian Journal of Cardiology. 2024;29(9):166–229. DOI: 10.15829/1560-4071-2024-6110

3. Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. European Heart Journal. 2024;45(36):3415–537. DOI: 10.1093/eurheartj/ehae177

4. Picano E, Pierard L, Peteiro J, Djordjevic-Dikic A, Sade LE, Cortigiani L et al. The clinical use of stress echocardiography in chronic coronary syndromes and beyond coronary artery disease: a clinical consensus statement from the European Association of Cardiovascular Imaging of the ESC. European Heart Journal - Cardiovascular Imaging. 2024;25(2):e65–90. DOI: 10.1093/ehjci/jead250

5. Ciampi Q, Zagatina A, Cortigiani L, Wierzbowska-Drabik K, Kasprzak JD, Haberka M et al. Prognostic value of stress echocardiography assessed by the ABCDE protocol. European Heart Journal. 2021;42(37):3869–78. DOI: 10.1093/eurheartj/ehab493

6. Cortigiani L, Huqi A, Ciampi Q, Bombardini T, Bovenzi F, Picano E. Integration of Wall Motion, Coronary Flow Velocity, and Left Ventricular Contractile Reserve in a Single Test: Prognostic Value of Vasodilator Stress Echocardiography in Patients with Diabetes. Journal of the American Society of Echocardiography. 2018;31(6):692–701. DOI: 10.1016/j.echo.2017.11.019

7. Gaibazzi N, Ciampi Q, Cortigiani L, Wierzbowska-Drabik K, Zagatina A, Djordjevic-Dikic A et al. Multiple Phenotypes of Chronic Coronary Syndromes Identified by ABCDE Stress Echocardiography. Journal of the American Society of Echocardiography. 2024;37(5):477–85. DOI: 10.1016/j.echo.2023.12.003

8. Smiseth OA, Torp H, Opdahl A, Haugaa KH, Urheim S. Myocardial strain imaging: how useful is it in clinical decision making? European Heart Journal. 2016;37(15):1196–207. DOI: 10.1093/eurheartj/ehv529

9. Karpov R.S., Pavlyukova E.N., Boshchenko A.A., Vrublevsky A.V., Tereshenkova E.K. New ultrasonic technologies in clinical practice. Siberian Medical Journal (Tomsk). 2015;30(2):15–21.

10. Foldyna B, Udelson JE, Karády J, Banerji D, Lu MT, Mayrhofer T et al. Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond–Forrester for the contemporary era and clinical implications: insights from the PROMISE trial. European Heart Journal - Cardiovascular Imaging. 2019;20(5):574–81. DOI: 10.1093/ehjci/jey182

11. Sicari R, Pasanisi E, Venneri L, Landi P, Cortigiani L, Picano E. Stress echo results predict mortality: a large-scale multicenter prospective international study. Journal of the American College of Cardiology. 2003;41(4):589–95. DOI: 10.1016/S0735-1097(02)02863-2

12. Ciampi Q, Zagatina A, Cortigiani L, Gaibazzi N, Borguezan Daros C, Zhuravskaya N et al. Functional, Anatomical, and Prognostic Correlates of Coronary Flow Velocity Reserve During Stress Echocardiography. Journal of the American College of Cardiology. 2019;74(18):2278–91. DOI: 10.1016/j.jacc.2019.08.1046

13. Kelshiker MA, Seligman H, Howard JP, Rahman H, Foley M, Nowbar AN et al. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis. European Heart Journal. 2022;43(16):1582–93. DOI: 10.1093/eurheartj/ehab775

14. Zhuravleva O.A., Ryabova T.R., Vrublevsky A.V., Svyazova N.N., Margolis N.Yu., Boshchenko A.A. Stress Echocardiography by the ABCDE Protocol ln the Assessment of Prognosis of Stable Coronary Heart Disease. Kardiologiia. 2024;64(4):22–30. DOI: 10.18087/cardio.2024.4.n2572

15. Gupta K, Kakar TS, Gupta A, Singh A, Gharpure N, Aryal S et al. Role of left ventricle deformation analysis in stress echocardiography for significant coronary artery disease detection: A diagnostic study meta‐analysis. Echocardiography. 2019;36(6):1084–94. DOI: 10.1111/ echo.14365

16. Stepanova A.I., Radova N.F., Alekhin M.N. Speckle Tracking Stress Echocardiography on Treadmill in Assessment of the Functional Significance of the Degree of Coronary Artery Disease. Kardiologiia. 2021;61(3):4–11. DOI: 10.18087/cardio.2021.3.n1462

17. Atabaeva L.S., Saidova M.A., Shitov V.N., Staroverov I.I. Myocardial deformation analysis combined with contrast stress-echocardiography — an additional method for assessment of myocardial ischemia. Russian Cardiology Bulletin. 2021;16(2):43–52. DOI: 10.17116/Cardiobulletin20211602143

18. Rodriguez-Zanella H, Arbucci R, Fritche-Salazar JF, Ortiz-Leon XA, Tuttolomondo D, Lowenstein DH et al. Vasodilator Strain Stress Echocardiography in Suspected Coronary Microvascular Angina. Journal of Clinical Medicine. 2022;11(3):711. DOI: 10.3390/ jcm11030711

19. Romano S, Romer B, Evans K, Trybula M, Shenoy C, Kwong RY et al. Prognostic Implications of Blunted Feature-Tracking Global Longitudinal Strain During Vasodilator Cardiovascular Magnetic Resonance Stress Imaging. JACC: Cardiovascular Imaging. 2020;13(1):58–65. DOI: 10.1016/j.jcmg.2019.03.002

20. Lowenstein Haber DM, Arbucci R, Amor M, Merlo P, Saad A, Lowen stein JA. Pathophysiology and Prognosis of Apical Longitudinal Strain During Dipyridamole Stress Echocardiography. Revista Argentina de Cardiologia. 2022;90(2):92–8. DOI: 10.7775/rac.v90.i2.20502