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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 90-95

Applying resting global longitudinal strain by two-dimensional speckle tracking as a noninvasive diagnostic tool in predicting coronary artery disease


Department of Cardiology, Sri Ramchandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission24-Mar-2021
Date of Decision22-Jun-2022
Date of Acceptance01-Jul-2022
Date of Web Publication19-Aug-2022

Correspondence Address:
Ramesh Sankaran
Sri Ramchandra Institute of Higher Education and Research, No. 1, Ramachandra Nagar, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_15_21

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  Abstract 


Background: Two-dimensional speckle-tracking echocardiography (2D STE) has been used by many cardiologists globally for assessing the left ventricle (LV) function by having global longitudinal strain (GLS) as an important parameter; however, it is not incorporated into daily practice and some studies have proved to be a better diagnostic value for evaluation of detecting significant coronary artery disease (CAD) and also in predicting the culprit coronary artery. Methods: We enrolled 100 consecutive symptomatic patients with suspected CAD who have undergone angiogram in our institute. Out of these, 21 patients had poor echo window and were excluded. The patients were divided into two groups those presenting with acute coronary syndrome ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and others with stable angina. All patients underwent a 2D echocardiogram, 2D strain imaging, and coronary angiogram. Results: GLS correlated well with ejection fraction in our study. GLS was more impaired in patients with double- and triple-vessel disease than in patients with single-vessel disease. The number of patients presented with STEMI is 26 (anterior wall myocardial infarction – 20 and inferior wall myocardial infarction – 6), 23 had NSTEMI, and 30 had stable angina. The results of regional peak systolic strain had a stronger correlation with coronary angiogram in stable angina (P = 0.03), but in ACS patients, it was not significant (P = 0.136). This correlation was better in patients with adequate LV systolic function (P < 0.05) than patients with left ventricular systolic dysfunction (P = 1.0). Conclusion: 2D STE is a simple, noninvasive, and reproducible diagnostic tool in the evaluation of CAD and is immensely helpful in the localization of culprit vessel in chronic coronary syndrome.

Keywords: Coronary artery disease, global longitudinal strain, speckle-tracking imaging, two-dimensional echocardiography


How to cite this article:
Sankaran R, Sadhanandham S, Senguttuvan N, Muralidharan TR, Balakrishnan VK, Panchanatham M, Boppana D, Balasubramaniyan JV. Applying resting global longitudinal strain by two-dimensional speckle tracking as a noninvasive diagnostic tool in predicting coronary artery disease. J Pract Cardiovasc Sci 2022;8:90-5

How to cite this URL:
Sankaran R, Sadhanandham S, Senguttuvan N, Muralidharan TR, Balakrishnan VK, Panchanatham M, Boppana D, Balasubramaniyan JV. Applying resting global longitudinal strain by two-dimensional speckle tracking as a noninvasive diagnostic tool in predicting coronary artery disease. J Pract Cardiovasc Sci [serial online] 2022 [cited 2022 Dec 9];8:90-5. Available from: https://www.j-pcs.org/text.asp?2022/8/2/90/354128




  Introduction Top


Regional myocardial function assessment by two-dimensional (2D) echocardiography is a useful modality in the diagnosis and treatment of coronary artery disease (CAD). The left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) are routinely used parameters. Usually, this approach is subjective and has high interoperator variability. Nowadays, the late 2D global longitudinal strain (GLS) by speckle tracking is being increasingly used in CAD assessment.[1] Myocardial deformation which is an energy-requiring process becomes abnormal early in ischemic heart disease. In the subendocardium which is vulnerable to ischemia, longitudinal mechanics is predominant. Hence, measurement of myocardial strain imaging can be a useful diagnostic modality to assess regional myocardial function for the detection of CAD.[2] In patients with CAD, subclinical left ventricle (LV) dysfunction correlates with significant obstructive CAD, and impaired GLS by 2D speckle-tracking echocardiography (STE) correlates well with the severity of CAD.[3]

GLS parameters by 2D STE are useful in the prediction of cardiac events in patients with chronic coronary syndrome than in acute myocardial infarction patients.[4] When GLS is compared with EF and WMSI, GLS had a better outcome toward predicting and monitoring of prognosis in CAD patients.[5] Moreover, global longitudinal systolic strain could be used as an independent predictor of significant CAD and impaired regional longitudinal systolic strain helps in the identification of high-risk patients by identifying the stenotic or culprit coronary artery.[6] Several studies have shown that GLS parameters obtained during rest gives the best accuracy in predicting insignificant CAD than in non-CAD patients and have better sensitivity and specificity.[7],[8] Very few studies have shown that changes in LVGLS have a strong association in predicting the severity of CAD and not many studies have been done in India to our knowledge. Hence, in this study, we tried to correlate regional peak systolic strain with corresponding CAD and peak GLS with the severity of CAD.


  Methods Top


Study population, inclusion and exclusion criteria

This study was conducted in the cardiology department of Sri Ramachandra Institute of Higher Studies and Research (SRIHER), 100 consecutive symptomatic patients with CAD who underwent coronary angiogram were included in the study from March 2020 to September 2020. Out of these, 21 patients had poor echo window and were excluded. Therefore, the final total number of participants enrolled in the study is 79. These patients were divided into two groups those presented with acute coronary syndrome ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and others with stable angina and for all these patients 2D echocardiogram, 2D strain, and coronary angiogram data were retrieved subsequently from the hospital database. Other exclusion criteria considered included were patients having a history of cardiomyopathy, significant valvular heart disease, congenital heart disease, previous cardiac surgery, and arrhythmias that affect the analysis of GLS.

Transthoracic two-dimensional echocardiogram evaluation

2D echocardiographic evaluation was done using GE VIVID 95 equipped with M4S transducer with a capability of frequency of 1.5 MHz and a frame rate of 60–70. LVEF was calculated using biplane Simpson's method. Strain analysis was performed offline using EchoPAC strain software and optimal gray scale images were obtained in apical three-chamber, two-chamber, and four-chamber views. After manual tracing endocardium and epicardium of left ventricle beginning from annulus of mitral valve in these views. Software provided an average valve of GLS for 16 segments of LV. Regional peak systolic strain was obtained for the 16th segment and the 17th apical segment.

Coronary angiogram

A coronary angiogram was done for all patients. Coronary stenosis of >70% cutoff value was considered significant. We correlated GLS and regional peak systolic strain with coronary angiogram results.

Statistical analysis

Analysis was done using IBM SPSS version 22.0 (IBM Corp., Armonk, NY) and all P value with < 0.05 and 95% confidence interval was considered statistically significant. Shapiro–Wilk test was conducted to assess normal distribution. The categorical variables are expressed in percentages and proportions and continuous variables as mean and standard deviation. The global strain was considered the primary outcome variable and different segments of LV were considered explanatory variables. Two study groups ACS and Chronic Coronary Syndrome (CCS) were compared using Chi-square test/Fisher's exact test and independent sample t-test.


  Results Top


A total of 100 consecutive patients were enrolled and evaluated in this study. Due to a poor echo window, 21 patients were excluded from the study and the final study population was n = 79. These patients were presented into two groups: Acute Coronary Syndrome (STEMI and NSTEMI) (n = 49) and stable angina or chronic coronary syndrome (n = 30). The mean age of study population was 60.23 ± 9.6 years, males were 81% (n = 64) and females were 18.99% (n = 15). Comorbidities were present in almost 88% (n = 69) of the total patients (n = 79), out of these patients 60% (n = 42) had diabetes mellitus and 40% (n = 27) had hypertension. Mild chronic kidney disease was present in three patients. The number of diseased vessel prevalence was seen, in which 49.37% (n = 39) patients had triple-vessel disease, 24.05% (n = 19) patients had double-vessel disease, 20.25% (n = 16) patients had single-vessel disease. LAD was the most common diseased artery with 86% and then followed by left circumflex artery (LCX) with 67% and right coronary artery (RCA) with 63% of all patients. Only 13.92% (n = 11) patients had moderate LV dysfunction and 11.39% (n = 9) patients had severe LV dysfunction [Table 1].
Table 1: Clinical characteristics of the study population (n=79)

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There was a good relationship between peak systolic GLS and ejection fraction [Table 2]. GLS correlated well with ejection fraction in our study (P < 0.05), 2D GLS was − 15.85% ± 3.79% with adequate LV function, −9.9% ± 2.39% in moderate LV systolic dysfunction, and − 11.3% ± 6.39% in severe LV dysfunction patients [Table 3]. GLS was more impaired in patients with double- and triple-vessel disease than in patients with single-vessel disease. [Table 4] summarizes the results of regional peak systolic strain which had a stronger correlation with coronary angiogram for (P = 0.03) in patients with stable angina. In patients presenting with acute coronary syndrome correlation with coronary angiogram was not significant (P = 0.136) were seen in [Figure 1],[Figure 2],[Figure 3]. This correlation was better in patients with adequate left ventricular systolic function (P < 0.05) than patients with left ventricular systolic dysfunction (P = 1.0).
Figure 1: Strain in patient with inferior wall myocardial infarction, he had right coronary artery disease.

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Figure 2: GLS in stable coronary artery disease patient who had a triple-vessel disease. GLS: Global longitudinal strain.

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Figure 3: Global strain RCA versus CAG RCA. LAD: Left anterior descending, RCA: Right coronary artery, CAG: Global Strain Gauge, LCx: Left circumflex artery.

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Table 2: Correlation of Left ventricular ejection fraction and global longitudinal strain

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Table 3: Comparing severity of coronary artery disease and Left ventricular GLS

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Table 4: Global longitudinal strain versus coronary angiography

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Predicting the involvement of the coronary artery by 2D STE through GLS has shown that the sensitivity and specificity of predicting LAD involvement are 82.09% and 63.64%. The sensitivity and specificity of predicting LCX disease are 86.54% and 42.31% and that of RCA disease is 69.34% and 34.48% all those graphs were represented below.


  Discussion Top


2D STE as a clinical diagnostic tool in the evaluation of CAD, predicting the severity of disease and localization of the culprit coronary artery using the GLS and Peak Systolic Longitudinal Strain. (PSLS) is a pioneering method for assessment.[9] Hence, there is a need for early assessment for CAD in terms of predicting the severity of these diseases by routine use of 2D STE, GLS, and PSLS measurements. European Society of Cardiology (ESC) 2019 guidelines recommend clinical likelihood to have CAD is mostly based on having an LV dysfunction which can be assessed early by GLS and PSLS.[10] After synthesizing optimum evidence, it remains uncertain how far the GLS and PSLS can be user defined in predicting the severity and localization of coronary artery in both the different groups of patients such as ACS and chronic coronary syndrome. Hence, there was a need for assessment of GLS and PSLS in both these groups of patients, to predict the significant CAD.

In our study, findings show that GLS was lower among patients with significant CAD (−14.02 ± 4.37), and more were in patients with double- and triple-vessel disease than in patients with single vessel disease were represented in the “[Patient-1-Figure 2]” [Patient-1-Figure 4], [Patient-2-Figure 1], [Patient-2-Figure 2], [Patient-3-Figure 3]”. GLS correlated well with ejection fraction in our study, 2D GLS was − 15.85 ± 3.79 in patients with EF >55%, GLS was − 13.43 ± 3.24 in patients with mild LV systolic dysfunction, l and − 9.9 ± 2.39% in patients with moderate LV systolic dysfunction. A study conducted in 2017, found that resting GLS of less than − 15.6% may predict significant obstructive disease and they also found resting GLS had higher diagnostic accuracy in chronic coronary syndrome.[3]



In another study conducted by Montgomery et al.,[11] the mean valve of GLS was − 19.1 ± 3.4 in patients without CAD compared to − 16.8 ± 3.2 in patients with CAD. GLS value ≤−17.8% may predict significant coronary artery stenosis (>50%) with 81% sensitivity and 51% specificity. Many studies have been done to validate the growing use of 2D STE and it has been found that it is extremely useful in identifying patients with severe CAD who do not have early signs of RWMA and left ventricular dysfunction. A Study by Liou et al. in their meta-analysis found that the mean value of GLS for those with and without CAD was −16.5% and −19.7%, respectively. They found that GLS was useful in detecting moderate-to-severe obstructive CAD in symptomatic patients.[2] GLS diagnostic cutoff valve was variable in different studies. These variable values could be explained by different factors affecting GLS including blood pressure, diastolic function, different equipment, and 2D software used in these studies.[12] In our study, we tried to localize culprit vessel using regional peak systolic strain. We found that 2D echo strain had a higher correlation with coronary angiogram in chronic coronary syndrome (P < 0.003) than in patients presenting with acute coronary syndrome (P < 0197). 2D strain correlated better in patients with preserved ejection fraction than with patients with left ventricular systolic dysfunction.

Our study concurred with previous studies that STE is useful in diagnosing CAD in appropriate patients.[13],[14] Strain analysis identifies patients with ACS who are in need for urgent reperfusion therapy, thus elevating the need for 2D STE.[15]





Strain imaging analysis is a simple noninvasive investigation to identify CAD with good accuracy and reproducibility. Furthermore, our study adds and validates other studies that 2D STE is having good diagnostic accuracy and specificity in identifying, especially high-risk patients. Adding more evidence to existing evidence suggests that these methods should be used routinely in echocardiography by cardiologists and sonographers. In developing countries like India, there is a need for much emphasizing in practicing 2D STE and other advanced techniques in cardiovascular imaging.

Study limitations

Some limitations recognized in our study are (1) Single-centered study; (2) sample size, need more numbers to validate the study; (3) a cross-sectional study design as it is not seeing the prognosis.

Ethics clearance

Data taken for this study was stored data. Patient sample directly not used for this study. So, no need of ethical clearance for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Reisner SA, Lysyansky P, Agmon Y, Mutlak D, Lessick J, Friedman Z. Global longitudinal strain: A novel index of left ventricular systolic function. J Am Soc Echocardiogr 2004;17:630-3.  Back to cited text no. 1
    
2.
Liou K, Negishi K, Ho S, Russell EA, Cranney G, Ooi SY. Detection of obstructive coronary artery disease using peak systolic global longitudinal strain derived by two-dimensional speckle-tracking: A systematic review and meta-analysis. J Am Soc Echocardiogr 2016;29:724-35.e4.  Back to cited text no. 2
    
3.
Radwan H, Hussein E. Value of global longitudinal strain by two dimensional speckle tracking echocardiography in predicting coronary artery disease severity. Egypt Heart J 2017;69:95-101.  Back to cited text no. 3
    
4.
Scharrenbroich J, Hamada S, Keszei A, Schröder J, Napp A, Almalla M, et al. Use of two-dimensional speckle tracking echocardiography to predict cardiac events: Comparison of patients with acute myocardial infarction and chronic coronary artery disease. Clin Cardiol 2018;41:111-8.  Back to cited text no. 4
    
5.
Stanton T, Leano R, Marwick TH. Prediction of all-cause mortality from global longitudinal speckle strain: Comparison with ejection fraction and wall motion scoring. Circ Cardiovasc Imaging 2009;2:356-64.  Back to cited text no. 5
    
6.
Biering-Sørensen T, Hoffmann S, Mogelvang R, Zeeberg Iversen A, Galatius S, Fritz-Hansen T, et al. Myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris. Circ Cardiovasc Imaging 2014;7:58-65.  Back to cited text no. 6
    
7.
Norum IB, Ruddox V, Edvardsen T, Otterstad JE. Diagnostic accuracy of left ventricular longitudinal function by speckle tracking echocardiography to predict significant coronary artery stenosis. A systematic review. BMC Med Imaging 2015;15:25.  Back to cited text no. 7
    
8.
Alaika O, Jamai S, Doghmi N, Cherti M. Diagnostic accuracy of global longitudinal strain for detecting significant coronary artery disease in diabetic patients without regional wall motion abnormality. J Saudi Heart Assoc 2020;32:425-33.  Back to cited text no. 8
    
9.
Xing X, Li D, Chen S, Wang L, Li Z, He L. Evaluation of left ventricular systolic function in patients with different types of ischemic heart disease by two-dimensional speckle tracking imaging. J Cardiothorac Surg 2020;15:325.  Back to cited text no. 9
    
10.
Saraste A, Knuuti J. ESC 2019 guidelines for the diagnosis and management of chronic coronary syndromes: Recommendations for cardiovascular imaging. Herz 2020;45:409-20.  Back to cited text no. 10
    
11.
Montgomery DE, Puthumana JJ, Fox JM, Ogunyankin KO. Global longitudinal strain aids the detection of non-obstructive coronary artery disease in the resting echocardiogram. Eur Heart J Cardiovasc Imaging 2012;13:579-87.  Back to cited text no. 11
    
12.
Negishi K, Lucas S, Negishi T, Hamilton J, Marwick TH. What is the primary source of discordance in strain measurement between vendors: Imaging or analysis? Ultrasound Med Biol 2013;39:714-20.  Back to cited text no. 12
    
13.
Choi JO, Cho SW, Song YB, Cho SJ, Song BG, Lee SC, et al. 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 2009;10:695-701.  Back to cited text no. 13
    
14.
Dahlslett T, Karlsen S, Grenne B, Eek C, Sjøli B, Skulstad H, et al. Early assessment of strain echocardiography can accurately exclude significant coronary artery stenosis in suspected non-ST-segment elevation acute coronary syndrome. J Am Soc Echocardiogr 2014;27:512-9.  Back to cited text no. 14
    
15.
Eek C, Grenne B, Brunvand H, Aakhus S, Endresen K, Smiseth OA, et al. Strain echocardiography predicts acute coronary occlusion in patients with non-ST-segment elevation acute coronary syndrome. Eur J Echocardiogr 2010;11:501-8.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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