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Utility of Longitudinal Strain Imaging by Speckle Tracking in Predicting Obstructive Coronary Artery Disease in Patients Without Jebmh.com Original Research Article Utility of Longitudinal Strain Imaging by Speckle Tracking in Predicting Obstructive Coronary Artery Disease in Patients without Regional Wall Motion Abnormality on 2D Echocardiography Kiran Gopinath1, Sajan Zulfikar Ahmad2, Sunitha Viswanathan3, George Alummoottil Koshy4 1Consultant Cardiologist, Department of Cardiology, NIMS Hospital, Trivandrum, Kerala, India. 2Assistant Professor, Department of Cardiology, Pushpagiri Medical College, Thiruvalla, Kerala, India. 3Professor and Head, Department of Cardiology, Medical College, Trivandrum, Kerala, India. 4Professor, Department of Cardiology, Medical College, Trivandrum, Kerala, India. ABSTRACT BACKGROUND Strain imaging by speckle tracking is a well-established method to assess left Corresponding Author: ventricular function. The objective of this study was to define the utility of strain Dr. Sajan Ahmad Z, imaging in predicting obstructive coronary artery disease (CAD) in a subset of #16 FG, Skyline Edge, Thirumoolapuram, patients who do not have regional wall motion abnormality (RWMA) on routine 2D Thiruvalla- 689115, echocardiography. Kerala, India. E-mail: [email protected] METHODS DOI: 10.18410/jebmh/2019/683 This is a prospective study. Consecutive patients with no RWMA scheduled to undergo coronary angiography (CAG) for clinical indications were included in the Financial or Other Competing Interests: None. study. Longitudinal strain imaging by speckle tracking using automated functional imaging (AFI) was done by a single investigator prior to CAG. All angiograms were How to Cite This Article: reported by a second investigator who was blinded to the strain imaging findings. Gopinath K, Sajan Ahmad Z, Obstructive CAD was defined as ≥ 70% luminal stenosis of epicardial coronary Viswanathan S, et al. Utility of arteries and/or ≥ 50% luminal stenosis of LMCA. longitudinal strain imaging by speckle tracking in predicting obstructive coronary artery disease in patients RESULTS without regional wall motion abnormality 129 patients were enrolled over a 7 month period (mean age 56.07±10.7, males on 2D echocardiography. J. Evid. Based 69%, females 31%). For detecting obstructive CAD, strain imaging had a Med. Healthc. 2019; 6(52), 3259-3264. sensitivity of 97% for LAD, 90.69% for RCA, 91.6% for LCX, a negative predictive DOI: 10.18410/jebmh/2019/683 value of 81.81% for LAD, 91.3% for RCA, 92.3% for LCX, a specificity of 15.2% for LAD, 13.9% for RCA, 22.8% for LCX and a positive predictive value of 57.6% Submission 02-12-2019, Peer Review 09-12-2019, for LAD, 34.5% for RCA and 21.3% for LCX territories. Patients with obstructive Acceptance 24-12-2019, CAD had a lower global strain value of -18.37 ± 4.13 as compared to -21.18 ± Published 26-12-2019. 3.81 in patients who did not have obstructive CAD (p value <0.01). CONCLUSIONS Peak longitudinal strain imaging by speckle tracking is a very sensitive (ranging from 90.69% to 97.14%) test with a high negative predictive value (ranging from 75% to 92.3%) for identifying obstructive coronary artery lesions o n coronary angiography. These properties make strain imaging a good screening test to rule out significant CAD, especially when the pre-test probability is low. KEYWORDS Strain Echocardiography, Speckle Tracking, Coronary Angiography J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 52/Dec. 30, 2019 Page 3259 Jebmh.com Original Research Article BACKGROUND test, history of previous unstable angina or Non ST elevation myocardial infarction- NSTEMI) who are being taken up for Strain imaging has come of age in the field of elective coronary angiography without regional wall motion echocardiography and is increasingly being used in clinical abnormalities in the routine 2D echocardiogram, were practice, including in coronary artery disease (CAD). selected for the study. Patients who have had a prior Speckle tracking is an established and reliable method for angiogram which has shown obstructive coronary artery obtaining two dimensional (2D) strain measurements. disease, Left Bundle Branch Block (LBBB) on baseline Tracking the motion of naturally occurring acoustic markers electrocardiogram, hypertrophic cardiomyopathy, dilated is the basis of speckle tracking. Strain abnormalities may cardiomyopathy, restrictive cardiomyopathy, significant appear even before regional wall motion abnormalities valvular heart disease, history of adriamycin chemotherapy (RWMA) in the ischemic cascade. Previous studies have in the past, were excluded from the study. All the selected reported 93.8% accuracy in predicting regional wall motion patients underwent strain echocardiography by speckle abnormalities in patients with ST elevation myocardial tracking prior to coronary angiography (Figure 1). Approval infarction (STEMI).1 Left ventricular (LV) strain for the study was obtained from the Institutional Review abnormalities have been reported to have a sensitivity of Board and Ethics Committee. 79% and specificity of 79% for detection of severe coronary artery disease, even if no regional wall motion abnormalities Echocardiography are noted on routine 2D echocardiography.2 The echocardiography machine used was Vivid E-9 In coronary artery disease (CAD), strain imaging has manufactured by GE (General Electric) using Automated been found to be useful to indirectly quantify the extent of Functional Imaging (AFI) software. Conventional myocardial damage and evaluation of the effectiveness of echocardiographic analysis was done using a 3.5 MHz Active coronary revascularization. Strain abnormalities have been Matrix Array probe. The same probe was used for event found to revert following revascularization. Augmentation of timing. Aortic valve opening and closure was marked out strain and strain rate during dobutamine stress imaging is a using pulse Doppler interrogation of the valve. Apical 3- good indicator of myocardial viability.3,4,5 Strain rate chamber, apical 4-chamber and apical 2-chamber views were imaging has also been used to differentiate transmural from taken. Automatic functional imaging was used for strain non-transmural infarction.6 There are studies on regional analysis. Three endocardial identification points- two at the correlation of strain with coronary angiography, which have base at the mitral annulus and one at the LV apex at the end shown a sensitivity of 68% and a specificity of 77%.7 Normal systolic period were marked out. The software then traced values for strain analysis vary between studies.8 out the endocardial border and the myocardial layer based Though longitudinal strain imaging by speckle tracking on these points. After confirming that the tracing was has widespread application in clinical studies, the optimal adequate and the endocardial border was adequately utility of this imaging modality in the clinical evaluation of defined, the images were approved. The software then coronary artery disease is yet to be defined. Since calculated the peak systolic longitudinal strain (PSLS) and abnormalities in strain appear before regional wall motion constructed a bull’s eye image of the 17 left ventricular abnormalities, this study was designed to evaluate the segments. Strain imaging was done for all patients by the performance of strain analysis in predicting obstructive principal investigator prior to the coronary angiography. This lesions in coronary angiography in a subgroup of patients investigator was blinded to the subsequent angiographic with suspected coronary artery disease who had no wall findings. All patients were subjected to strain analysis prior motion in routine two dimensional echocardiography. The to angiogram by a single operator, to avoid inter-observer aim of the study was to assess the sensitivity, specificity, variability. The quality of images acquired for strain analysis positive and negative predictive value of peak longitudinal was verified by two senior cardiologists. A pilot study was strain analysis by speckle tracking in patients who are to done in 51 patients using tissue Doppler derived strain to undergo coronary angiography (CAG) for clinical indications optimize imaging and segmental analysis. and have a no wall motion abnormalities in resting 2D echocardiography. Angiography Angiographic findings were assessed by the second investigator who was blinded to echocardiographic findings METHODS of strain analysis. Significant coronary artery disease was defined as a ≥70% epicardial coronary artery luminal diameter stenosis and/or a ≥50% left main luminal diameter Study Population stenosis. All coronary angiograms were read and analysed The study was conducted as a descriptive cross sectional by a single investigator. Lesions in the left main coronary study at the Department of Cardiology at Government artery (LMCA), left anterior descending (LAD) coronary Medical College, Trivandrum, Kerala, India, a major tertiary artery, major diagonals, left circumflex artery (LCX), obtuse care teaching hospital in Kerala, India. One hundred and marginals, ramus intermedius (RI), right coronary artery twenty nine consecutive patients with clinical indications for (RCA) and lesions in the PDA and PLB were assessed. coronary angiography (symptoms suggestive of coronary Dominance of the coronary anatomy was assessed as this is artery disease/effort angina and/or positive exercise stress J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 52/Dec. 30, 2019 Page 3260 Jebmh.com Original Research Article important is assigning
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