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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.

Background: Dyspnea is a common clinical challenge in patients with type 2 diabetes and may be a sign of heart failure (HF). We sought to evaluate the predictive value dyspnea with and without an echocardiographic substrate in patients with type 2 diabetes without known heart disease., Methods: A total of 724 patients with type 2 diabetes followed at specialized clinics participated in this prospective cohort study. Clinical evaluation, comprehensive echocardiography and follow-up through national registers were performed. An echocardiographic substrate was either left ventricular hypertrophy, increased left atrial size, E/e' > 15, or LV ejection fraction<50%. The end-points were cardiovascular (CVD) events and all-cause mortality., Results: Median follow-up was 4.8 years [Interquartile range: 4.1, 5.3] for CVD event and 77 patients suffered a CVD event. Dyspnea was significantly associated with CVD event: Hazard ratio (HR): 1.58 (95% confidence interval: 1.01-2.48), p = 0.04. Stratifying by evidence of echocardiographic substrate revealed high risk individuals: CVD event: 0.71 (0.35-1.46), p = NS in patients with dyspnea and no echocardiographic substrate and 2.85 (1.74-4.67), p < 0.001 in patients with dyspnea with echocardiographic substrate). This pattern was similar in multivariable analyses. Also, C-statistics improved from 0.66 (0.60-0.72) to 0.69 (0.63-0.75), p < 0.001 and net reclassification index was 27.5%(5.0-50.0), p = 0.01 for CVD event. The results were similar for all-cause mortality except dyspnea was only a borderline significant predictor., Conclusion: In patients with type 2 diabetes complaining of dyspnea, identifying an echocardiographic substrate - thus indicating patients with HF - accurately stratifies patients with increased risk of CV events and all-cause mortality., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aims: Layer‐specific global longitudinal strain (GLS) has been demonstrated to predict outcome in various patient cohorts. However, little is known regarding the prognostic value of layer‐specific GLS in the general population and whether different layers entail differential prognostic information. The aim of the present study was to investigate the prognostic value of whole wall (GLSWW), endomyocardial (GLSEndo), and epimyocardial (GLSEpi) GLS in the general population. Methods and results: A total of 4013 citizens were included in the present study. All 4013 had two‐dimensional speckle tracking echocardiography performed and analysed. Outcome was a composite endpoint of incident heart failure and/or cardiovascular death. Mean age was 56 years and 57% were female. During a median follow‐up time of 3.5 years, 133 participants (3.3%) reached the composite outcome. Sex modified the relationship between all GLS parameters and outcome. In sex‐stratified analysis, no GLS parameter remained significant predictors of outcome in females. In contrast, GLSWW [hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.02–1.31, per 1% decrease] and GLSEpi (HR 1.19, 95% CI 1.04–1.38, per 1% decrease) remained as significant predictors of outcome in males after multivariable adjustment (including demographic, clinical, biochemistry, and echocardiographic parameters). Lastly, only in males did GLS parameters provide incremental prognostic information to general population risk models. Conclusions: In the general population, sex modifies the prognostic value of GLS resulting in GLSEpi being the only layer‐specific prognosticator in males, while no GLS parameter provides independent prognostic information in females. [ABSTRACT FROM AUTHOR]

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Aims Echocardiography is suggested in the diagnostic work-up of patients with Type 2 diabetes (T2D). We investigated which echocardiographic parameters that best predicted cardiovascular disease (CVD) and whether this was persistent in both genders in a large cohort of outpatients with T2D. Methods and results We performed comprehensive echocardiography in 933 patients with T2D followed at specialized out-patients clinics in Copenhagen, Denmark. Follow-up was performed using national registries and included admission with future CVD events and non-CVD death as competing risk. Median follow-up was 4.8 years and 138 CVD events occurred. In univariable and multivariable analyses, a wide range of structural, diastolic, and systolic measurements predicted CVD including mean E / e ʹ [hazard ratio (HR) 1.06, 95% confidence interval: (1.03–1.10), P  < 0.001, C-statistics 0.74 (0.70–0.78)] and global longitudinal strain (GLS) [1.10 (1.01–1.20), P  = 0.03, C-statistics 0.73 (0.69–0.77)]. However, this was modified by gender. In men, mean E / e ʹ remained the strongest predictor in multivariable analyses and performed best measured by highest C-statistics [HR 1.15, 95% confidence interval: (1.08–1.21), P  < 0.001, C-statistics 0.75 (0.71–0.80)] whereas in women this was GLS [1.39 (1.14–1.70), P  = 0.001, C-statistics 0.79 (0.70–0.87)]. These findings persisted when excluding patients with known heart disease and when regarding all-cause mortality as a competing risk. Conclusion A range of echocardiographic parameters predicted CVD in patients with Type 2 diabetes, however, in multivariable analyses, mean E / e ʹ was the strongest predictor and had the highest model performance. Importantly, this study identifies a hitherto undescribed gender interaction as mean E / e ʹ performed best in men, whereas in women this was GLS. [ABSTRACT FROM AUTHOR]

Aims: Two‐dimensional speckle tracking echocardiography (2DSTE) detects early signs of left ventricular dysfunction; however, it is unknown whether layer‐specific global longitudinal strain (GLS) has incremental value in diagnosis of patients with reversible ischemia assessed by single photon emission computed tomography (SPECT). Methods and Results: Eighty patients with stable angina pectoris (SAP), normal left ventricular ejection fraction (LVEF), and no history of ischemic heart disease were retrospectively identified to have been examined by 2DSTE, SPECT, and coronary angiography (CAG). Patients with a normal SPECT constituted the control group, and patients with a positive SPECT were divided into patients with or without (true‐ or false‐ positive SPECT) significant stenosis assessed by CAG. GLS was measured for two myocardial layers (endocardial and epicardial) and as well as mid‐myocardial GLS. Patients with reversible ischemia had significantly lower GLS compared to the control group (GLSEndocardial: −19.0 ± 4.4% vs −21.4 ± 3.7%, P = .011; GLSEpicardial: −14.3 ± 2.9% vs −16.3 ± 2.9%, P = .004); GLSMid‐myocardial: −16.5 ± 3.6% vs −18.6 ± 3.2%, P = .006. This difference was even more evident in patients with a true‐positive SPECT (GLSEndocardial: −18.0 ± 4.4% vs −21.4 ± 3.7%, P < .001; GLSEpicardial: −13.6 ± 3.0% vs −16.3 ± 2.9%, P < .001); GLSMid‐myocardial: −15.6 ± 3.6% vs −18.6 ± 3.2%, P < .001. Notably, no significant differences existed in patients with a false‐positive SPECT. GLSEpicardial was the only independent predictor of coronary artery disease. In conclusion: In patients with SAP and preserved LVEF, layer‐specific GLS at rest identifies patients with reversible ischemia. This seems to be evident only in patients with a true‐positive SPECT, thus, 2DSTE at rest might improve the diagnostic accuracy of a positive SPECT. [ABSTRACT FROM AUTHOR]

Background Contemporary treatment of type 2 diabetes (T2D) has improved patient outcome and may also have affected myocardial structure and function. We aimed to describe the effect of T2D and T2D duration on cardiac structure and function in a large outpatient population. Methods We performed comprehensive echocardiography on a representative sample of 1004 persons including a representative sample of 770 patients with T2D without known heart disease and 234 age- and sex-matched controls. Results T2D was associated with increased left ventricular (LV) wall thicknesses and decreased LV internal diameter and the changes were pronounced with increasing diabetes duration ( P < 0.01 for all) but not with increased LV mass ( P = 0.74). It was also significantly associated with the prevalence of diastolic dysfunction (16.5% vs. 4.0%; P < 0.001), with indices of LV relaxation and elevated filling pressures expressed as e ' septal (mean: 6.9 (SD: 1.9) cm/s vs. 7.5 (2.4); P < 0.001) and E / e ' septal (median: 10.8 (interquartile range (IQR): 9.1–13.3) vs. 9.1 (7.2–11.1); P < 0.001) and global longitudinal strain (mean: − 14.1 (SD: 2.4) vs. − 15.0 (2.0), P < 0.001) but not with LV ejection fraction (median: 60.8 (IQR: 56.5–65.1) vs. 62.1 (57.9–65.4), P = 0.28). With the exception of global longitudinal strain, this was pronounced with increasing diabetes duration for all measures including increasing diastolic dysfunction (< 10 years: 10.8%, 10–20 years: 18.5%, > 20 years: 24.8%; P < 0.001). The increased risk of diastolic dysfunction persisted after multivariable adjustment ( P = 0.013). Conclusions In patients with T2D, LV structural and functional alterations persist and are accentuated with increasing diabetes duration despite reductions in overall risk of cardiovascular disease in this patient population. [ABSTRACT FROM AUTHOR]

Background Though the electrocardiogram(ECG) and plasma pro-brain-natriuretic-peptide (pro-BNP) are widely used markers of subclinical cardiac injury and can be used to predict future cardiovascular disease(CVD), they could merely be markers of the same underlying pathology. We aimed to determine if ECG changes and pro-BNP are independent predictors of CVD and if the combination improves risk prediction in persons without known heart disease. Methods Pro-BNP and ECG were obtained on 5454 persons without known heart disease from the 4th round of the Copenhagen City Heart Study, a prospective cohort study. Median follow-up was 10.4 years. High pro-BNP was defined as above 90th percentile of age and sex adjusted levels. The end-points were all-cause mortality and the combination of admission with ischemic heart disease, heart failure or CVD death. Results ECG changes were present in 907 persons and were associated with high levels of pro-BNP. In a fully adjusted model both high pro-BNP and ECG changes remained significant predictors: all-cause mortality(high pro-BNP, no ECG changes: HR: 1.43(1.12–1.82);P = 0.005, low pro-BNP, ECG changes: HR: 1.22(1.05–1.42);P = 0.009, and both high pro-BNP and ECG changes: HR: 1.99(1.54–2.59);P < 0.001), CVD event(high pro-BNP, no ECG changes: HR: 1.94(1.45–2.58);P < 0.001, low pro-BNP, ECG changes: HR: 1.55(1.29–1.87);P < 0.001, and both high pro-BNP and ECG changes: HR: 3.86(2.94–5.08);P < 0.001). Adding the combination of pro-BNP and ECG changes to a fully adjusted model correctly reclassified 33.9%(26.5–41.3);P < 0.001 on the continuous net reclassification scale for all-cause mortality and 49.7%(41.1–58.4);P < 0.001 for CVD event. Conclusion Combining ECG changes and pro-BNP improves risk prediction in persons without known heart disease. [ABSTRACT FROM AUTHOR]

Background: Color Tissue Doppler imaging M-mode through the mitral leaflet is an easy and precise method to obtain the cardiac time intervals including the left ventricular ejection time (LVET). The aim of this study was to investigate whether the LVET can be used to predict cardiovascular morbidity and mortality following acute coronary syndrome (ACS). Methods: We retrospectively studied 390 patients with ACS (mean age 64 ±12 years, men 74%, STEMI 81%, mean LVEF 41±11%, mean LVET 256±35ms) who underwent echocardiography, following percutaneous coronary intervention. The LVET was measured. The primary endpoint was major adverse cardiac events (MACE) and consisted of heart failure, myocardial infarction and cardiovascular death. The secondary endpoint was all-cause mortality. Patients with prevalent HF were excluded. Results: During a median follow-up of 3 years, 180 patients (46%) reached the composite endpoint MACE, and 77 (20%) suffered from all-cause mortality. LVET was significantly associated with risk of MACE (HR 1.13; 95% CI (1.08-1.18), p<0.001) with a 13% increase in risk per 10ms decrease in LVET (figure). The association remained significant after adjusting for age, sex, hypertension, diabetes, body mass index, previous ischemic heart disease, STEMI, multivessel culprit lesions, left ventricular ejection fraction, left ventricular mass index, E/e', E/A and deceleration time (HR 1.10; 95% CI (1.03-1.17), p=0.002 per 10ms decrease). Additionally, the LVET predicted all-cause mortality and the association remained significant even after multivariable adjustment (HR 1.11; 95% CI (1.01-1.21), p=0.032 per 10ms decrease). Conclusion: In patients with ACS the LVET provides novel and independent prognostic information on the risk of cardiovascular morbidity and mortality. [ABSTRACT FROM AUTHOR]