Skip to main content

Advertisement

Log in

Usefulness of layer-specific strain in diagnosis of coronary artery disease in patients with stable angina pectoris

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Novel software allows for layer-specific evaluation of myocardial strain by speckle tracking echocardiography (2DSTE). However, the potential of layer-specific strain at rest for diagnosing coronary artery disease (CAD) in patients with suspected stable angina pectoris (SAP) remains unknown. Our objective was to evaluate the usefulness of layer-specific 2DSTE at rest for diagnosis of CAD in patients with SAP. In total, 285 patients referred with clinically suspected SAP, normal ejection fraction, and no previous cardiac history were prospectively enrolled. All patients were examined by echocardiography, including 2DSTE, exercise ECG, and coronary angiography (CAG). Layer-specific 2DSTE was performed in three apical views to provide longitudinal peak systolic strains. Stenosis ≥ 70% in ≥ 1 major coronary artery on CAG was considered as significant CAD. Of 285 patients included, 104 had significant CAD (36%). Endocardial, epicardial, and mid-myocardial GLS were all significantly impaired in CAD patients (P < 0.001). Multivariable analysis including baseline clinical parameters, conventional echocardiographic measurements, Duke score, and layer-specific strain measurements revealed epicardial [odds ratio 1.19 (P = 0.048)] and mid-myocardial [odds ratio 1.16 (P = 0.047)] global longitudinal strain (GLS) as the only independent predictors of CAD. In direct comparison, epicardial and mid-myocardial GLS had a significantly higher diagnostic performance compared to endocardial GLS (P = 0.038 and P = 0.031, respectively). In conclusion, layer-specific GLS from 2DSTE at rest was significantly impaired in patients with significant CAD. In addition, epicardial and mid-myocardial GLS were independent predictors of CAD.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Maciver DH (2012) The relative impact of circumferential and longitudinal shortening on left ventricular ejection fraction and stroke volume. Exp Clin Cardiol 17(1):5–11

    PubMed  PubMed Central  Google Scholar 

  2. Task Force M, Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, Ferreira JR, Gersh BJ, Gitt AK, Hulot JS, Marx N, Opie LH, Pfisterer M, Prescott E, Ruschitzka F, Sabate M, Senior R, Taggart DP, van der Wall EE, Vrints CJ, Guidelines ESCCfP, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Document R, Knuuti J, Valgimigli M, Bueno H, Claeys MJ, Donner-Banzhoff N, Erol C, Frank H, Funck-Brentano C, Gaemperli O, Gonzalez-Juanatey JR, Hamilos M, Hasdai D, Husted S, James SK, Kervinen K, Kolh P, Kristensen SD, Lancellotti P, Maggioni AP, Piepoli MF, Pries AR, Romeo F, Ryden L, Simoons ML, Sirnes PA, Steg PG, Timmis A, Wijns W, Windecker S, Yildirir A, Zamorano JL (2013) 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 34(38):2949–3003. https://doi.org/10.1093/eurheartj/eht296

    Article  Google Scholar 

  3. Reisner SA, Lysyansky P, Agmon Y, Mutlak D, Lessick J, Friedman Z (2004) Global longitudinal strain: a novel index of left ventricular systolic function. J Am Soc Echocardiogr 17(6):630–633. https://doi.org/10.1016/j.echo.2004.02.011

    Article  PubMed  Google Scholar 

  4. Leitman M, Lysyansky P, Sidenko S, Shir V, Peleg E, Binenbaum M, Kaluski E, Krakover R, Vered Z (2004) Two-dimensional strain-a novel software for real-time quantitative echocardiographic assessment of myocardial function. J Am Soc Echocardiogr 17(10):1021–1029. https://doi.org/10.1016/j.echo.2004.06.019

    Article  PubMed  Google Scholar 

  5. Choi JO, Cho SW, Song YB, Cho SJ, Song BG, Lee SC, Park SW (2009) Longitudinal 2D strain at rest predicts the presence of left main and three vessel coronary artery disease in patients without regional wall motion abnormality. Eur J Echocardiogr 10(5):695–701. https://doi.org/10.1093/ejechocard/jep041

    Article  PubMed  Google Scholar 

  6. Biering-Sorensen T, Hoffmann S, Mogelvang R, Zeeberg Iversen A, Galatius S, Fritz-Hansen T, Bech J, Jensen JS (2014) Myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris. Circ Cardiovasc Imaging 7(1):58–65. https://doi.org/10.1161/CIRCIMAGING.113.000989

    Article  PubMed  Google Scholar 

  7. Montgomery DE, Puthumana JJ, Fox JM, Ogunyankin KO (2012) Global longitudinal strain aids the detection of non-obstructive coronary artery disease in the resting echocardiogram. Eur Heart J Cardiovasc Imaging 13(7):579–587. https://doi.org/10.1093/ejechocard/jer282

    Article  PubMed  Google Scholar 

  8. Eek C, Grenne B, Brunvand H, Aakhus S, Endresen K, Smiseth OA, Edvardsen T, Skulstad H (2010) Strain echocardiography predicts acute coronary occlusion in patients with non-ST-segment elevation acute coronary syndrome. Eur J Echocardiogr 11(6):501–508. https://doi.org/10.1093/ejechocard/jeq008

    Article  PubMed  Google Scholar 

  9. Adamu U, Schmitz F, Becker M, Kelm M, Hoffmann R (2009) Advanced speckle tracking echocardiography allowing a three-myocardial layer-specific analysis of deformation parameters. European J Echocardiogr 10(2):303–308. https://doi.org/10.1093/ejechocard/jen238

    Article  Google Scholar 

  10. Kim SA, Park SM, Kim MN, Shim WJ (2016) Assessment of left ventricular function by layer-specific strain and its relationship to structural remodelling in patients with hypertension. Can J Cardiol 32(2):211–216. https://doi.org/10.1016/j.cjca.2015.04.025

    Article  PubMed  Google Scholar 

  11. Sarvari SI, Haugaa KH, Zahid W, Bendz B, Aakhus S, Aaberge L, Edvardsen T (2013) Layer-specific quantification of myocardial deformation by strain echocardiography may reveal significant CAD in patients with non-ST-segment elevation acute coronary syndrome. JACC Cardiovasc Imaging 6(5):535–544. https://doi.org/10.1016/j.jcmg.2013.01.009

    Article  PubMed  Google Scholar 

  12. Zhang L, Wu WC, Ma H, Wang H (2016) Usefulness of layer-specific strain for identifying complex CAD and predicting the severity of coronary lesions in patients with non-ST-segment elevation acute coronary syndrome: Compared with Syntax score. Int J Cardiol 223:1045–1052. https://doi.org/10.1016/j.ijcard.2016.08.277

    Article  PubMed  Google Scholar 

  13. Qaseem A, Fihn SD, Williams S, Dallas P, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of P (2012) Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 157(10):729–734. https://doi.org/10.7326/0003-4819-157-10-201211200-00010

    Article  Google Scholar 

  14. Norum IB, Ruddox V, Edvardsen T, Otterstad JE (2015) Diagnostic accuracy of left ventricular longitudinal function by speckle tracking echocardiography to predict significant coronary artery stenosis. A systematic review. BMC Med Imaging 15:25. https://doi.org/10.1186/s12880-015-0067-y

    Article  PubMed  Google Scholar 

  15. Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F, Daly C, De Backer G, Hjemdahl P, Lopez-Sendon J, Marco J, Morais J, Pepper J, Sechtem U, Simoons M, Thygesen K, Priori SG, Blanc JJ, Budaj A, Camm J, Dean V, Deckers J, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo J, Zamorano JL, Task Force on the Management of Stable Angina Pectoris of the European Society of C, Guidelines ESCCfP (2006) Guidelines on the management of stable angina pectoris: executive summary: the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J 27(11):1341–1381. https://doi.org/10.1093/eurheartj/ehl001

    Article  Google Scholar 

  16. Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, Brindis RG, Douglas PS (2010) Low diagnostic yield of elective coronary angiography. N Engl J Med 362(10):886–895. https://doi.org/10.1056/NEJMoa0907272

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Hoffmann S, Jensen JS, Iversen AZ, Sogaard P, Galatius S, Olsen NT, Bech J, Fritz-Hansen T, Biering-Sorensen T, Badskjaer J, Pietersen A, Mogelvang R (2012) Tissue Doppler echocardiography improves the diagnosis of coronary artery stenosis in stable angina pectoris. Eur Heart J Cardiovasc Imaging 13(9):724–729. https://doi.org/10.1093/ehjci/jes001

    Article  PubMed  Google Scholar 

  18. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ, Chamber Quantification Writing G, American Society of Echocardiography's G, Standards C, European Association of E (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18(12):1440–1463. https://doi.org/10.1016/j.echo.2005.10.005

    Article  Google Scholar 

  19. Negishi K, Negishi T, Kurosawa K, Hristova K, Popescu BA, Vinereanu D, Yuda S, Marwick TH (2015) Practical guidance in echocardiographic assessment of global longitudinal strain. JACC Cardiovasc Imaging 8(4):489–492. https://doi.org/10.1016/j.jcmg.2014.06.013

    Article  PubMed  Google Scholar 

  20. Saunamäki KEK, Krusell L, Mickley H, Rokkedal J, Schnohr P (2002) Guidelines for clinical exercise testing in relation to ischemic heart disease (composed by a committee appointed by the Danish Society of Cardiology). https://wwwcardiodk/component/docman/doc_download/124-klinisk-arbejdstest?Itemid=118. Accessed 19 Sept 2016

  21. Mark DB, Hlatky MA, Harrell FE Jr, Lee KL, Califf RM, Pryor DB (1987) Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 106(6):793–800

    Article  CAS  PubMed  Google Scholar 

  22. Ma C (2002) From the help desk: comparing areas under receiver operating characteristic curves from two or more probit or logit models. Stata J 2:301–313

    Article  Google Scholar 

  23. Shimoni S, Gendelman G, Ayzenberg O, Smirin N, Lysyansky P, Edri O, Deutsch L, Caspi A, Friedman Z (2011) Differential effects of coronary artery stenosis on myocardial function: the value of myocardial strain analysis for the detection of coronary artery disease. J Am Soc Echocardiogr 24(7):748–757. https://doi.org/10.1016/j.echo.2011.03.007

    Article  PubMed  Google Scholar 

  24. Nucifora G, Schuijf JD, Delgado V, Bertini M, Scholte AJ, Ng AC, van Werkhoven JM, Jukema JW, Holman ER, van der Wall EE, Bax JJ (2010) Incremental value of subclinical left ventricular systolic dysfunction for the identification of patients with obstructive coronary artery disease. Am Heart J 159(1):148–157. https://doi.org/10.1016/j.ahj.2009.10.030

    Article  PubMed  Google Scholar 

  25. Segall GM, Atwood JE, Botvinick EH, Dae MW, Lucas JR (1995) Variability of normal coronary anatomy: implications for the interpretation of thallium-SPECT myocardial perfusion images in single-vessel disease. J Nucl 36(6):944–951

    CAS  Google Scholar 

  26. Gjesdal O, Hopp E, Vartdal T, Lunde K, Helle-Valle T, Aakhus S, Smith HJ, Ihlen H, Edvardsen T (2007) Global longitudinal strain measured by two-dimensional speckle tracking echocardiography is closely related to myocardial infarct size in chronic ischaemic heart disease. Clin Sci (London, England: 1979) 113(6):287–296. https://doi.org/10.1042/cs20070066

    Article  Google Scholar 

  27. Geyer H, Caracciolo G, Abe H, Wilansky S, Carerj S, Gentile F, Nesser HJ, Khandheria B, Narula J, Sengupta PP (2010) Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications. J Am Soc Echocardiogr 23(4):351–369; (quiz 453–355). https://doi.org/10.1016/j.echo.2010.02.015

    Article  PubMed  Google Scholar 

  28. Biering-Sorensen T, Solomon SD (2015) Assessing contractile function when ejection fraction is normal: a case for strain imaging. Circ Cardiovasc Imaging 8(11):e004181. https://doi.org/10.1161/CIRCIMAGING.115.004181

    Article  PubMed  Google Scholar 

  29. Leitman M, Lysiansky M, Lysyansky P, Friedman Z, Tyomkin V, Fuchs T, Adam D, Krakover R, Vered Z (2010) Circumferential and longitudinal strain in 3 myocardial layers in normal subjects and in patients with regional left ventricular dysfunction. J Am Soc Echocardiogr 23(1):64–70. https://doi.org/10.1016/j.echo.2009.10.004

    Article  PubMed  Google Scholar 

  30. Shi J, Pan C, Kong D, Cheng L, Shu X (2016) Left ventricular longitudinal and circumferential layer-specific myocardial strains and their determinants in healthy subjects. Echocardiography 33(4):510–518. https://doi.org/10.1111/echo.13132

    Article  PubMed  Google Scholar 

  31. Myers JH, Stirling MC, Choy M, Buda AJ, Gallagher KP (1986) Direct measurement of inner and outer wall thickening dynamics with epicardial echocardiography. Circulation 74(1):164–172

    Article  CAS  PubMed  Google Scholar 

  32. Sabbah HN, Marzilli M, Stein PD (1981) The relative role of subendocardium and subepicardium in left ventricular mechanics. Am J Physiol 240(6):H920–926

    CAS  PubMed  Google Scholar 

  33. Hagemann CE, Hoffmann S, Olsen FJ, Jorgensen PG, Fritz-Hansen T, Jensen JS, Biering-Sorensen T (2018) Layer-specific global longitudinal strain reveals impaired cardiac function in patients with reversible ischemia. Echocardiography. https://doi.org/10.1111/echo.13830

    Article  PubMed  Google Scholar 

  34. Skaarup KG, Iversen A, Jørgensen PG, Olsen FJ, Grove GL, Jensen JS, Biering-Sørensen T (2018) Association between layer-specific global longitudinal strain and adverse outcomes following acute coronary syndrome. Eur Heart J. https://doi.org/10.1093/ehjci/jey004

    Article  Google Scholar 

  35. Camici PG, Prasad SK, Rimoldi OE (2008) Stunning, hibernation, and assessment of myocardial viability. Circulation 117(1):103–114. https://doi.org/10.1161/CIRCULATIONAHA.107.702993

    Article  PubMed  Google Scholar 

  36. Gjesdal O, Helle-Valle T, Hopp E, Lunde K, Vartdal T, Aakhus S, Smith HJ, Ihlen H, Edvardsen T (2008) Noninvasive separation of large, medium, and small myocardial infarcts in survivors of reperfused ST-elevation myocardial infarction: a comprehensive tissue Doppler and speckle-tracking echocardiography study. Circ Cardiovasc Imaging 1(3):189–196. https://doi.org/10.1161/circimaging.108.784900

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We thank Prof. Jan S. Jensen, our dear friend and esteemed colleague, for his contribution towards collecting the data and for intellectual discussion and critical revision of the manuscript. Regrettably, Prof. Jan S. Jensen passed away shortly before final completion of this manuscript.

Funding

This work was supported by the Fondsbørsvekselerer Henry Hansen og Hustrus Hovedlegat 2016 (TBS). The sponsor had no role in the study design, data collection, data analysis, data interpretation, or writing of the manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Christoffer A. Hagemann.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hagemann, C.A., Hoffmann, S., Hagemann, R.A. et al. Usefulness of layer-specific strain in diagnosis of coronary artery disease in patients with stable angina pectoris. Int J Cardiovasc Imaging 35, 1989–1999 (2019). https://doi.org/10.1007/s10554-019-01652-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10554-019-01652-3

Keywords

Navigation