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CLINICAL RESEARCH: CARDIAC IMAGING

Global 2-Dimensional Strain as a New Prognosticator in Patients With Heart Failure

Goo-Yeong Cho, MD, PhD^_*,_*, Thomas H. Marwick, MD, PhD, Hyun-Sook Kim, MD, PhD, Min-Kyu Kim, MD, Kyung-Soon Hong, MD, PhD and Dong-Jin Oh, MD, PhD

^_* Department of Medicine, Seoul National University, Seoul, South Korea
Department of Medicine, University of Queensland, Brisbane, Queensland, Australia
Department of Medicine, Hallym University Medical Center, Seoul, South Korea

Manuscript received November 28, 2008; revised manuscript received April 6, 2009, accepted April 14, 2009.

^_* Reprint requests and correspondence: Dr. Goo-Yeong Cho, Department of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam City, Gyeonggi-do, 463-802, South Korea (Email: cardioch{at}medimail.co.kr).

Objectives: We sought to evaluate whether global 2-dimensional (2D) strain offers additional benefit over left ventricular ejection fraction (LVEF) to predict clinical events in heart failure.

Background: Although 2D strain based on speckle tracking has been proposed as a simple and reproducible tool to detect systolic dysfunction, the relationship of 2D strain and prognosis has not been studied.

Methods: Two hundred one patients (age 63 ± 11 years, 34% female, LVEF 34 ± 13%) hospitalized for acute heart failure underwent clinical evaluation and conventional and tissue Doppler echocardiography. Using dedicated software, we measured the global longitudinal strain (GLS) in apical 4- and 2-chamber views and the global circumferential strain (GCS) in a parasternal short-axis view. Cardiac events were defined as readmission for heart failure or cardiac death.

Results: There were 23.4% clinical events during 39 ± 17 months of follow-up. In univariate analysis, age, left atrial volume, left ventricular volume, LVEF, ratio of early transmitral flow to early diastolic annular velocity (E/e'), and both GLS and GCS were predictive of cardiac events. In multivariate Cox models, age (hazard ratio [HR]: 1.06, 95% confidence interval [CI]: 1.01 to 1.10, p = 0.017) and GCS (HR: 1.15, 95% CI: 1.04 to 1.28; p = 0.006) were independently associated with cardiac events. By Cox proportional hazards model, the addition of GCS markedly improved the prognostic utility of a model containing ejection fraction, E/e', and GLS.

Conclusions: GCS is a powerful predictor of cardiac events and appears to be a better parameter than ejection fraction in patients with acute heart failure.

Key Words: congestive heart failure • prognosis • ventricular function • strain

Abbreviations and Acronyms   2D = 2-dimensional   CI = confidence interval   E/e' = ratio of early transmitral flow to early diastolic annular velocity   EF = ejection fraction   GCS = global circumferential strain   GLS = global longitudinal strain   HR = hazard ratio   LV = left ventricle/ventricular   LVEF = left ventricular ejection fraction   ROC = receiver-operating characteristic

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