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Background: Transthoracic echocardiography (TTE) is essential in the diagnosis of cardiovascular diseases (CVD), including but not limited to heart failure (HF) and heart valve disease (HVD). However, its dependence on expert acquisition means that its accessibility in rural areas may be limited, leading to delayed management decisions and potential missed diagnoses. Artificial intelligence-guided (AI)-TTE offers a solution by permitting non-expert image acquisition. The impact of AI-TTE on the timing of diagnosis and early initiation of cardioprotection is undefined., Methods: AGILE-Echo (use of Artificial intelligence-Guided echocardiography to assIst cardiovascuLar patient managEment) is a randomized-controlled trial conducted in 5 rural and remote areas around Australia. Adults with CV risk factors and exercise intolerance, or concerns regarding HVD are randomized into AI-TTE or usual care (UC). AI-TTE participants may have a cardiovascular problem excluded, identified (leading to AI-guided interventions) or unresolved (leading to conventional TTE). UC participants undergo usual management, including referral for standard TTE. The primary endpoint is a composite of HVD or HF diagnosis at 12-months. Subgroup analysis, stratified based on age range and sex, will be conducted. All statistical analyses will be conducted using R., Results: Of the first 157 participants, 78 have been randomized into AI-TTE (median age 68 [IQR 17]) and 79 to UC (median age 65 [IQR 17], P = .034). HVD was the primary concern in 37 participants (23.6%) while 84.7% (n = 133) experienced exercise intolerance. The overall 10-year HF incidence risk was 13.4% and 20.0% (P = .089) for UC and AI-TTE arm respectively. Atrial remodeling, left ventricular remodeling and valvular regurgitation were the most common findings. Thirty-three patients (42.3%) showed no abnormalities., Conclusions: This randomized-controlled trial of AI-TTE will provide proof-of-concept for the role of AI-TTE in identifying pre-symptomatic HF or HVD when access to TTE is limited. Additionally, this could promote the usage of AI-TTE in rural or remote areas, ultimately improving health and quality of life of community dwelling adults with risks, signs or symptoms of cardiac dysfunction., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Speckle-tracking echocardiography (STE) can assess myocardial motion in non-LV chambers-including assessment of left atrial (LA) and right ventricular (RV) strain. This review seeks to highlight the diagnostic, prognostic, and clinical significance of these parameters in heart failure, atrial fibrillation (AF), diastolic dysfunction, pulmonary hypertension (PH), tricuspid regurgitation, and heart transplant recipients., Recent Findings: Impaired LA strain reflects worse LV diastolic function in individuals with and without HF, and this is associated with decreased exercise capacity. Initiating treatments targeting these functional aspects may enhance exercise capacity and potentially prevent heart failure (HF). Impaired LA strain also identifies patients with a high risk of AF, and this recognition may lead to preventive strategies. Impaired RV strain has significant clinical and prognostic implications across various clinical scenarios, including HF, PH, tricuspid regurgitation, or in heart transplant recipients. STE should not be limited to the assessment of deformation of the LV myocardium. The use of LA and RV strain is supported by a substantial evidence base, and these parameters should be used more widely., (© 2024. The Author(s).)

Background: Current guidelines recommend using sequential cardiac imaging to monitor for cancer treatment-related cardiac dysfunction (CTRCD) in patients undergoing potentially cardiotoxic chemotherapy. Multiple different imaging cardiac modalities are available and there are few prospective head-to-head comparative studies to help guide treatment., Objectives: To perform an exploratory prospective cohort study of "real-world" CTRCD comparing multigated acquisition nuclear ventriculography (MUGA) at the referring cancer specialist's discretion with a novel echocardiographic strategy at an Australian tertiary hospital., Method: Patients were recruited from haematology and oncology outpatient clinics if they were scheduled for treatment with anthracyclines and/or trastuzumab. Patients underwent simultaneous MUGA-based cardiac imaging (conventional strategy) at a frequency according to evidenced-based guidelines in addition to researcher-conducted echocardiographic imaging. The echocardiographic imaging was performed in all patients at time points recommended by international society guidelines. Outcomes included adherence to guideline recommendations, concordance between MUGA and echocardiographic left ventricular ejection fraction (LVEF) measurements, and detection of cardiac dysfunction (defined as >5% LVEF decrement from baseline by three-dimensional [3D]-LVEF). A secondary end point was accuracy of global longitudinal strain in predicting cardiac dysfunction., Results: In total, 35 patients were recruited, including 15 with breast cancer, 19 with haematological malignancy, and one with gastric cancer. MUGA and echocardiographic LVEF measurements correlated poorly with limits of agreement of 30% between 3D-LVEF and MUGA-LVEF and 37% for 3D-LVEF and MUGA-LVEF. Only one case (2.9%) of CTRCD was diagnosed by MUGA, compared with 12 (34.2%) cases by echocardiography. Four (4) patients had >10% decrement in 3D-LVEF that was not detected by MUGA. Global longitudinal strain at 2 months displayed significant ability to predict CTRCD (area under the curve, 0.75, 95% confidence interval, 0.55-0.94)., Conclusions: The MUGA correlates poorly with echocardiographic assessment with substantial discrepancy between MUGA and echocardiography in CTRCD diagnosis. Echocardiographic and MUGA imaging strategies should not be considered equivalent for imaging cancer patients, and a single imaging modality should ideally be used per patient to prevent misdiagnosis by inter-modality variation These findings should be considered hypothesis-generating and require confirmation with larger studies., Competing Interests: Conflicts of Interest There are no conflicts of interest to disclose., (Crown Copyright © 2024. Published by Elsevier B.V. All rights reserved.)

Afterload is an important determinant of left ventricular (LV) and atrial (LA) function, including myocardial strain. Central blood pressure (CBP) is the major component of cardiac afterload and independently associated with cardiovascular risk. However, the optimal means of calibrating CBP is unclear-standard CBP assessment uses systolic (SBP) and diastolic blood pressure (DBP) from brachial waveforms, but calibration with mean pressure (MAP) and DBP purports to be more accurate. Therefore, we sought to determine which CBP is best associated with LA and LV strain. CBP was measured using both standard and MAP based calibration methods in 546 participants (age 70.7 ± 4.7 years, 45% male) with risk factors for heart failure. Echocardiography was performed in all patients and strain analysis conducted to assess LA/LV function. The associations of CBP with LA and LV strain were assessed using linear regression. MAP-derived CSBP (150 ± 20 mmHg) was higher than standard CSBP (128 ± 15 mmHg) and brachial SBP (140 ± 17 mmHg, p < 0.001), whereas DBPs were similar (84 ± 10, 83 ± 10, and 82 ± 10 mmHg). MAP-derived CSBP was not independently associated with LV strain (p > 0.05), however was independently associated with LA reservoir strain (p < 0.05). Brachial and central DBP were more strongly associated with LA reservoir/conduit and LV strain than brachial and central SBP. LA pump strain was not independently associated with any SBP or DBP parameter (p > 0.05). MAP-derived CBP was more accurate in identifying patients with abnormal LA and LV strain than brachial SBP and standard CBP calibration. In conclusion, CBP calibrated using MAP and DBP may be more accurate in identifying patients with abnormal LA and LV function than standard brachial calibration methods., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: In patients at risk of cancer therapy-related cardiac dysfunction (CTRCD), initiation of cardioprotective therapy (CPT) is constrained by the low sensitivity of ejection fraction (EF) for minor changes in left ventricular (LV) function. Global longitudinal strain (GLS) is a robust and sensitive marker of LV dysfunction, but existing observational data have been insufficient to support a routine GLS-guided strategy for CPT., Objectives: This study sought to identify whether GLS-guided CPT prevents reduction in LVEF and development of CTRCD in high-risk patients undergoing potentially cardiotoxic chemotherapy, compared with usual care., Methods: In this international, multicenter, prospective, randomized controlled trial, 331 anthracycline-treated patients with another heart failure risk factor were randomly allocated to CPT initiation guided by either ≥12% relative reduction in GLS (n = 166) or >10% absolute reduction of LVEF (n = 165). Patients were followed for EF and development of CTRCD (symptomatic EF reduction of >5% or >10% asymptomatic to <55%) over 1 year., Results: Of 331 randomized patients, 2 died, and 22 withdrew consent or were lost to follow-up. Among 307 patients (age: 54 ± 12 years; 94% women; baseline LVEF: 59 ± 6%; GLS: -20.6 ± 2.4%) with a median (interquartile range) follow-up of 1.02 years (0.98 to 1.07 years), most (n = 278) had breast cancer. Heart failure risk factors were prevalent: 29% had hypertension, and 13% had diabetes mellitus. At the 1-year follow-up, although the primary outcome of change in LVEF was not significantly different between the 2 arms, there was significantly greater use of CPT, and fewer patients met CTRCD criteria in the GLS-guided than the EF-guided arm (5.8% vs. 13.7%; p = 0.02), and the 1-year EF was 57 ± 6% versus 55 ± 7% (p = 0.05). Patients who received CPT in the EF-guided arm had a larger reduction in LVEF at follow-up than in the GLS-guided arm (9.1 ± 10.9% vs. 2.9 ± 7.4%; p = 0.03)., Conclusions: Although the change in LVEF was not different between the 2 arms as a whole, when patients who received CPT were compared, those in the GLS-guided arm had a significantly lower reduction in LVEF at 1 year follow-up. Furthermore, GLS-guided CPT significantly reduced a meaningful fall of LVEF to the abnormal range. The results support the use of GLS in surveillance for CTRCD. (Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes [SUCCOUR]; ACTRN12614000341628)., Competing Interests: Author Disclosures This study was supported in part by a project grant (1119955) from the National Health and Medical Research Council, Canberra, Australia, and an unrestricted grant from General Electric Healthcare, Horten, Norway. At the Centre Hospitalier Universitaire (CHU) de Québec site, the study was funded by the Fondation du CHU de Québec. Dr. Thavendiranathan is supported by the Canadian Institutes of Health Research New Investigator Award (147814), the Ontario Early Research Award, and a Canada Research Chair in Cardio-oncology. Dr. Negishi is supported by a Fellowship (award reference no. 101868) from the National Heart Foundation of Australia. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Left atrial (LA) strain is a prognostic biomarker with utility across a spectrum of acute and chronic cardiovascular pathologies. There are limited data on intervendor differences and no data on intermodality differences for LA strain. We sought to compare the intervendor and intermodality differences between transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) derived LA strain. We hypothesized that various components of atrial strain would show good intervendor and intermodality correlation but that there would be systematic differences between vendors and modalities., Methods and Results: We evaluated 54 subjects (43 patients with a clinical indication for CMR and 11 healthy volunteers) in a study comparing TTE- and CMR-derived LA reservoir strain (ƐR), conduit strain (ƐCD), and contractile strain (ƐCT). The LA strain components were evaluated using four dedicated types of post-processing software. We evaluated the correlation and systematic bias between modalities and within each modality. Intervendor and intermodality correlation was: ƐR [intraclass correlation coefficient (ICC 0.64-0.90)], ƐCD (ICC 0.62-0.89), and ƐCT (ICC 0.58-0.77). There was evidence of systematic bias between vendors and modalities with mean differences ranging from (3.1-12.2%) for ƐR, ƐCD (1.6-8.6%), and ƐCT (0.3-3.6%). Reproducibility analysis revealed intraobserver coefficient of variance (COV) of 6.5-14.6% and interobserver COV of 9.9-18.7%., Conclusion: Vendor derived ƐR, ƐCD, and ƐCT demonstrates modest to excellent intervendor and intermodality correlation depending on strain component examined. There are systematic differences in measurements depending on modality and vendor. These differences may be addressed by future studies, which, examine calibration of LA geometry/higher frame rate imaging, semi-quantitative approaches, and improvements in reproducibility., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: The World Health Organisation previously recommended routine screening in school-aged children in countries with a high prevalence of rheumatic heart disease (RHD); however, it is unclear if screening-detected (latent) valve disease will inevitably evolve to a pathological lesion. Understanding the natural history of latent RHD is essential prior to recommendation of screening in endemic areas. Studies documenting the progression of latent RHD have had contrasting conclusions about the pathogenicity of latent valvular lesions. This review provides estimates of rates of progression of latent RHD., Methods and Findings: In this systematic review and meta-analysis, we searched EMBASE, MEDLINE, Global Index Medicus, Africa Wide, Cochrane Database of Systematic Reviews and Global Health Database for studies published before April 30, 2019. Study data were extracted from all studies which reported follow-up data on progression of latent valve lesions. Studies with control cohorts were used to calculate comparative prevalence ratios. This study is registered with PROSPERO, number CRD42019119427. We identified 12 studies reporting follow-up data on latent RHD for 950 people in 9 countries. The estimated pooled prevalence rate for progression per year of latent RHD was 5%/year (95% CI 2-8). Eight studies reported on the progression of borderline latent RHD with an estimated pooled prevalence of 2%/year (95% CI 0-4). Three studies included control groups. There was a significant increase in the risk of progression of valvular disease in the latent group compared with controls (RR = 3.57 (95%CI = 1.65-7.70, P = 0.001). The overall risk of bias was low. Given most studies included penicillin administration we were unable to document the natural history of latent RHD. Furthermore, we were unable to perform a sensitivity analysis to determine the effect of administering penicillin prophylaxis on progression of valve disease given prescription of penicillin was not standardised., Conclusion: Latent RHD has a slow rate of progression but it is significantly higher compared to controls, with definite latent RHD having a higher rate of progression compared with borderline latent disease. There are a massive number of individuals at risk for RHD in the developing world as well as logistical challenges of screening and delivering penicillin prophylaxis. The low rate of progression from untargeted screening may be an important consideration in resource-constrained environments., Competing Interests: The authors have declared that no competing interests exist.

Asymptomatic left ventricular diastolic dysfunction (ALVDD) (diastolic abnormalities and normal ejection fraction in the absence of symptoms) is associated with incident heart failure (HF) and decreased survival. Abnormalities of diastolic function might therefore be included in the definition of stage B HF, which denotes individuals at risk for the development of HF. Imaging techniques, especially echocardiography, are necessary for the recognition of preclinical left ventricular (LV) diastolic disturbances, as well as further tracking of pathological changes and responses to treatment. The transition of ALVDD to symptomatic HF is underlain by multiple factors, including both cardiovascular and noncardiovascular determinants. The initiation of management strategies targeting cardiovascular and systemic comorbidities in patients identified as having ALVDD may delay symptomatic progression and improve prognosis., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Improvement in left ventricular (LV) systolic reserve, including exertional increase in global longitudinal strain (GLS), may contribute to the clinical benefit from therapeutic interventions in heart failure with preserved ejection fraction (HFpEF). However, GLS is an afterload-dependent parameter, and its measurements may not adequately reflect myocardial contractility recruitment with exercise. The estimation of myocardial work (MW) allows correction of GLS for changing afterload. We sought to investigate the associations of GLS and MW parameters with the response of exercise capacity to spironolactone in HFpEF., Methods and Results: We analysed 114 patients (67 ± 8 years) participating in the STRUCTURE study (57 randomized to spironolactone and 57 to placebo). Resting and immediately post-exercise echocardiograms were performed at baseline and at 6-month follow-up. The following indices of MW were assessed: global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency. The amelioration of exercise intolerance at follow-up in the spironolactone group was accompanied by a significant improvement in exertional increase in GCW (P = 0.002) but not in GLS and other MW parameters. Increase in exercise capacity at 6 months was independently correlated with change in exertional increase in GCW from baseline to follow-up (β = 0.24; P = 0.009) but not with GLS (P = 0.14); however, no significant interaction with the use of spironolactone on peak VO2 was found (P = 0.97)., Conclusion: GCW as a measure of LV contractile response to exertion is a better determinant of exercise capacity in HFpEF than GLS. Improvement in functional capacity during follow-up is associated with improvement in exertional increment of GCW., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: Although atrial fibrillation (AF) is a significant population health burden, and an avoidable cause of stroke, AF screening remains controversial. The aim of this study was to investigate whether coincidental echocardiography could provide information about patients at risk for AF., Methods: Asymptomatic participants ≥65 years of age with more than one AF risk factor (N = 445) undergoing echocardiography for risk evaluation were followed over a median of 15 months for incident AF. Left atrial volume index (LAVi), left ventricular (LV) global longitudinal strain (GLS; absolute value), left atrial (LA) strain, and LV mass were measured. During the follow-up period, AF was diagnosed clinically by primary care physicians or by using a single-lead portable electrocardiographic monitoring device (five 60-sec recordings performed by participants over 1 week)., Results: AF was diagnosed in 45 patients (10%; mean age, 70.5 ± 4.2 years; 55% women). AF detection was higher in those with LV hypertrophy, GLS < 16%, LAVi > 34 mL/m 2 , and LA reservoir strain < 34%. GLS, LAVi, and LA reservoir strain were independently associated with AF (P < .05). Those with AF had reduced GLS, higher LAVi, and higher LV mass (P < .05), but LA strain was similar in both groups (P > .05). GLS and LAVi were the strongest predictors, and cut points of 14.3% for GLS and 39 mL/m 2 were associated with increased risk for developing AF. Those with all four risk parameters (LV hypertrophy, GLS < 16%, LA reservoir strain < 34%, and LAVi > 34 mL/m 2 ) had a 60% AF detection rate, compared with 7% without these features (P = .004)., Conclusion: Echocardiography is widely used in patients at risk for AF, and simple LV and LA measurements may be used to enrich the process of AF screening., (Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: Left atrial (LA) enlargement is associated with atrial fibrillation (AF), but new-onset AF often occurs in the absence of LA enlargement. AF may be related to myocardial fibrosis, and even though left ventricular fibrosis is associated with mechanical dispersion, this phenomenon is not well studied in AF. We hypothesized that detection of LA dysfunction and mechanical dispersion using strain echocardiography is useful for predicting new-onset AF., Methods: Baseline echocardiography was performed at entry in 576 community-based participants at risk of heart failure or AF. In this case-control study, we compared 35 individuals with new-onset AF (age 70 ± 4 years; 57% men) over 2 years of follow-up with 35 age- and sex-matched individuals who did not develop AF from the same cohort. Using speckle-tracking echocardiography, we measured the LA strain in each of 12 segments in the two- and four-chamber views. LA mechanical dispersion was defined as the SD of time to peak positive strain corrected by the R-R interval (SD-TPS, %)., Results: There was no significant difference in LA volume index (32.5 ± 9.2 mL/m 2 vs 29.5 ± 8.3 mL/m 2 ; P = .16); patients with new-onset AF had significantly worse LA pump strain (16.6% ± 4.3% vs 20.6% ± 4.3%; P < .01) and reservoir strain (31.4% ± 7.7% vs 38.0% ± 7.3%; P < .01) than those without AF. SD-TPS was significantly higher in patients with AF than in those without it (6.3% ± 2.3% vs 3.9% ± 1.6%; P < .01). SD-TPS was independently associated with new-onset AF after adjustment for patient characteristics, LA volume, and strain (hazard ratio = 1.26; 95% CI, 1.10-1.45; P < .01). In the nested Cox models, the model based on the LA volume and strain for predicting new onset AF was significantly improved by adding SD-TPS (P < .01)., Conclusions: LA dispersion obtained from strain echocardiography seems to provide incremental information about LA volume and function in the prediction of new-onset AF and warrants testing in a larger study., (Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: The authors used cluster analysis of data from cardiovascular domains associated with exercise intolerance to help define prognostic phenotypes of patients with heart failure with preserved ejection fraction (HFpEF)., Methods: Resting and postexercise echocardiography was performed in 177 patients with HFpEF and 51 asymptomatic control subjects sharing a common clinical profile. Patterns of features that determine exercise capacity were sought from automated hierarchical clustering of left ventricular (LV) diastolic and systolic function, left atrial function, right ventricular function, ventricular-arterial coupling, chronotropic reserve and myocardial fibrosis., Results: Automated clustering separated a distinct subgroup characterized by a relatively isolated impairment of LV systolic reserve. The clinical factors identified by this process were used to define two phenotypes of patients with symptomatic HFpEF: those with reduced chronotropic and/or diastolic reserve (abnormal CR/DR; n = 137) and those with preserved heart rate reserve and exertional E/e' ratio < 14 (normal CR/DR; n = 40). Change in global LV strain rate from rest to exercise was similar in patients with abnormal CR/DR (0.16 ± 0.18 sec -1 ) and those with normal CR/DR (0.21 ± 0.17 sec -1 ) and significantly lower than in asymptomatic subjects (0.54 ± 0.20 sec -1 ; P < .001 for all). However, although the former group also showed abnormal longitudinal deformation, ventricular-arterial coupling, and cardiac output responses to exercise, the latter group showed only reduced LV systolic reserve. The normal CR/DR group had a lower incidence of cardiovascular hospitalization or death (P = .003) and heart failure hospitalization (P = .002) than the abnormal CR/DR group during 2-year follow-up., Conclusions: Diminished LV systolic reserve may represent the major identifiable cardiac functional abnormality associated with exercise intolerance in some patients with HFpEF. Despite significant functional limitation, these patients are characterized by a better prognosis than subjects with HFpEF with more physiologic abnormalities., (Copyright © 2019 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Exercise intolerance is the clinical hallmark of the failing heart. Evidence of hemodynamic derangement is not always present at rest, often necessitating dynamic challenges to accentuate abnormalities. Although cardiac catheterization, particularly with exercise, remains the gold standard method for hemodynamic assessment, it is limited by practicality, access, risk, and its invasive nature; consequently, there is a need to better understand noninvasive measures. Echocardiography and cardiac MRI offer promising modalities to quantify ventriculo-vascular interactions. Significant heterogeneity exists around exercise protocols, and there is a need to develop consensus methodology and to validate these noninvasive measures in all forms of heart failure., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Objectives: In this individual participant data meta-analysis on left ventricular global longitudinal strain (LVGLS), our objective was to: 1) describe its distribution; 2) identify the most predictive cutoff values; and 3) assess its impact on mortality in asymptomatic patients with significant aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF)., Background: The evidence supporting the prognostic role of LVGLS in asymptomatic patients with AS has been obtained from several relatively small studies., Methods: A literature search was performed for studies published between 2005 and 2017 without language restriction according to the following criteria: "aortic stenosis" AND "longitudinal strain." The corresponding authors of selected studies were contacted and invited to share their data that we computerized in a specific database. The primary endpoint was all-cause mortality., Results: Among the 10 studies included, 1,067 asymptomatic patients with significant AS and LVEF >50% were analyzed. The median of LVGLS was 16.2% (from 5.6% to 30.1%). There were 91 deaths reported during follow-up with median of 1.8 (0.9 to 2.8) years, resulting in a pooled crude mortality rate of 8.5%. The LVGLS performed well in the prediction of death (area under the curve: 0.68). The best cutoff value identified was LVGLS of 14.7% (sensitivity, 60%; specificity, 70%). Using random effects model, the risk of death for patients with LVGLS <14.7% is multiplied by >2.5 (hazard ratio: 2.62; 95% confidence interval: 1.66 to 4.13; p < 0.0001), without significant heterogeneity between studies (I 2  = 18.3%; p = 0.275). The relationship between LVGLS and mortality remained significant in patients with LVEF ≥60% (p = 0.001)., Conclusions: This individual participant data meta-analysis demonstrates that in asymptomatic patients with significant AS and normal LVEF, impaired LVGLS is associated with reduced survival. These data emphasize the potential usefulness of LVGLS for risk stratification and management of these patients., (Copyright © 2018 American College of Cardiology Foundation. All rights reserved.)

Left ventricular (LV) systolic dysfunction is an adverse consequence of the pressure overload of severe aortic stenosis (AS). The enlargement of the interstitial space with reactive fibrosis and subsequently with replacement fibrosis and cell death has been suggested to be the main driver of the transition to symptoms, heart failure, and adverse cardiovascular events even after aortic valve replacement (AVR). Early and accurate recognition of myocardial dysfunction offers the potential to optimize the timing of intervention in severe AS. In the asymptomatic patient, an LV ejection fraction (EF) cutpoint of <50% has been used for this purpose. However, in most asymptomatic patients, an LVEF <50% is uncommon, and patients with an LVEF of 50% to 59% fare almost as badly. Moreover, the presence of a small LV cavity, the reliability and automation of the global longitudinal strain (GLS) signal, and the independent prognostic role of GLS are reasons why GLS could be expected to be a better marker of subclinical LV dysfunction in these patients. This review seeks to define whether the existing EF cutoff in AS should be modified or whether GLS should replace it as the marker of subclinical LV dysfunction., (Copyright © 2019. Published by Elsevier Inc.)

Objectives: This study sought to identify whether atrial strain could be used as an imaging biomarker to predict atrial fibrillation (AF)., Background: AF is found in up to 30% of cryptogenic cerebrovascular accidents (CVAs), which themselves account for 30% to 40% of ischemic CVA., Methods: This observational study evaluated all patients who had an echocardiogram (transthoracic echocardiogram [TTE]) following presentation with cryptogenic CVA from 2010 to 2014. The TTEs were evaluated for reservoir strain (ƐR), contractile strain (ƐCt), and conduit atrial strain (ƐCd) using speckle tracking. Baseline clinical and TTE characteristics of patients who developed AF over 5 years of follow-up and those who did not were compared. The independent and incremental predictive value of atrial strain over established clinical models was assessed. Discriminatory cutpoints were defined using a Classification and Regression Tree (CART) analysis to identify patients at risk of developing AF., Results: Of 538 patients, 61 (11%) developed AF, and this occurred within 2 years in 85% of patients. Patients who developed AF were older, had higher clinical risk scores, had higher LA volume, and had lower atrial strain than did those who did not develop AF. The area under the receiver-operating characteristic curve was 0.85 for ƐR, 0.83 for ƐCt, and 0.76 for ƐCd (all p < 0.001). The nested Cox regression model showed that ƐR (p = 0.03) and ƐCt (p < 0.001) demonstrated independent and incremental predictive value over the clinical risk. CART analysis identified ƐR ≤21.4%, ƐCd >10.4%, and CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology Atrial Fibrillation) score >7.8% as discriminatory for AF, with a 13-fold greater hazard of AF (p < 0.001) in patients with increased clinical risk and reduced ƐR. However, validation is needed for these strain cutoffs for detection of AF., Conclusions: Left atrial strain adds independent and incremental predictive value to current risk-prediction models for AF following cryptogenic CVA. Further studies should examine the implications of these findings for AF monitoring or empiric anticoagulation., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The goal of this study was to compare echocardiographic measurements of global longitudinal strain (GLS) (using 3 apical views) with single-view longitudinal strain (LS, 4- or 2-chamber [4CV&#95;LS and 2CV&#95;LS, respectively]) for detection of cancer-therapy related cardiotoxicity., Background: GLS is useful for the detection of cardiotoxicity, but the need for repeated measurements poses a significant burden on busy echocardiography laboratories. A single-view LS measurement, possibly at point of care, could improve efficiency., Methods: Seventeen international centers prospectively recruited 108 patients (mean age 54 ± 13 years) at high risk for cardiotoxicity as part of the ongoing SUCCOUR (Strain Surveillance for Improving Cardiovascular Outcomes During Chemotherapy) randomized controlled trial. Echocardiography performed at baseline and follow-up were analyzed in a core laboratory setting blinded to clinical information. Peak systolic GLS and LS were measured from raw data. Cardiotoxicity was defined by reduction in left ventricular ejection fraction >0.10 to <0.55 or a relative drop in GLS by ≥12%., Results: Cardiotoxicity developed in 46 patients by either criteria. Baseline and follow-up 2-dimensional left ventricular ejection fraction were 61 ± 4% and 58 ± 5%, respectively (p < 0.001). The baseline GLS (-20.9 ± 2.4%) was not different from 4CV&#95;LS (-20.7 ± 2.5%; p = 0.09) or 2CV&#95;LS (-21.1 ± 3.1%; p = 0.25). The follow-up GLS (-19.5 ± 2.4%) was also similar to 4CV&#95;LS (-19.5 ± 2.6%; p = 0.80) and 2CV&#95;LS (-19.7 ± 3.1%; p = 0.19). There was good correlation between GLS and 4CV&#95;LS at baseline (r = 0.86; p < 0.001) and follow-up (r = 0.89; p < 0.001) and with 2CV&#95;LS at baseline (r = 0.87; p < 0.001) and follow-up (r = 0.88; p < 0.001). However, there was 15% to 22% disagreement between GLS and 4CV&#95;LS or 2CV&#95;LS for the detection of cardiotoxicity. The interobserver and intraobserver reproducibility was higher for GLS (intraclass correlation: 0.93 to 0.95; coefficient of variance: 2.9% to 3.7%) compared with either single-chamber-based LS measurement (intraclass correlation: 0.85 to 0.91; coefficient of variance: 4.1% to 4.8%)., Conclusions: Although there was good correlation between GLS and single-view LS measurements, single-view LS measurement led to disagreement in the diagnosis of cardiotoxicity in up to 22% of patients. GLS measurements were more reproducible than single-view LS. GLS based on 3 apical views should remain the preferred technique for detection of cardiotoxicity. (Strain Surveillance for Improving Cardiovascular Outcomes During Chemotherapy [SUCCOUR]; ACTRN12614000341628)., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Informal training in preclinical research may be a contributor to the poor reproducibility of preclinical cardiology research and low rates of translation into clinical research and practice. Mouse echocardiography is a widely used technique to assess cardiac structure and function in drug intervention studies using disease models. The interobserver variability of clinical echocardiographic measurements has been shown to improve with formalized training, but preclinical echocardiography lacks similarly critical standardization of training. The aims of this investigation were to assess the interobserver variability of echocardiographic measurements from studies in mice and address any technical impediments to reproducibility by implementing standardized guidelines through formalized training. In this prospective, single-site, observational cohort study, 13 scientists performing preclinical echocardiographic image analysis were assessed for measurement of short-axis M-mode-derived dimensions and calculated left ventricular (LV) mass. Ten M-mode images of mouse hearts acquired and analyzed by an expert researcher with a spectrum of LV mass were selected for assessment and validated by autopsy weight. After the initial observation, a structured formal training program was introduced, and accuracy and reproducibility were reevaluated. Mean absolute percentage error for expert-calculated LV mass was 6 ± 4% compared with autopsy LV mass and 25 ± 21% for participants before training. Standardized formal training improved participant mean absolute percentage error by ~30% relative to expert-calculated LV mass ( P < 0.001). Participants initially categorized with high-range error (25-45%) improved to low-moderate error ranges (<15-25%). This report reveals an example of technical skill training insufficiency likely endemic to preclinical research and provides validated guidelines for echocardiographic measurement for adaptation to formalized in-training programs. NEW & NOTEWORTHY The informal training common to academic/research institutions may be a contributor to the relatively poor reproducibility observed for preclinical cardiac research. In our observation of echocardiography analysis in murine models, we present evidence of moderate interobserver variability in standard preclinical research practice at an Australian heart research institute. These observations give rise to our recommendations for practical guidelines for echocardiography analysis in an adaptable approach to general preclinical research skill training. Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/preclinical-echocardiography-training-and-guidelines/ .

Aims: Appropriate Use Criteria (AUC) for echocardiography were developed in 2007 to facilitate decision-making, reduce variability in test utilization, and encourage rational use of imaging. However, there is little evidence that the AUC have favourably influenced ordering behaviour. This study explores the factors that contribute to clinicians requesting echocardiograms with a focus on appropriate use., Methods and Results: Semi-structured face-to-face interviews with cardiologists and non-cardiologists who had requested echocardiograms were conducted at an Australian tertiary hospital. The interview guide included hypothetical clinical scenarios to better understand decision-making in ordering echocardiograms and the actions they could take when receiving test reports. Interviews underwent thematic analysis. Seventeen clinicians were interviewed, ten of whom were cardiologists. All participants ordered echocardiograms to support their clinical decision-making. Awareness of the AUC was low. The categorization of tests as 'appropriate' or 'inappropriate' was considered ineffective as it failed to reflect the decision-making process. The decision to request echocardiograms was influenced by a number of personal and systemic factors as well as guidelines and protocols. Training and experience, patients' expectations, and management of uncertainty were key personal factors. Systemic factors involved the accessibility of services and health insurance status of the patient., Conclusion: Factors that influenced the ordering of echocardiograms by clinicians at a tertiary care hospital did not appear to be amenable to control with AUC. Alternative approaches may be more effective than the AUC in addressing the overuse of echocardiography., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Left ventricular (LV) ejection fraction (LVEF) is a simple measure of global systolic function that pervades the risk evaluation and management of many cardiovascular diseases. However, this parameter is limited not only by technical challenges, but also by pathophysiological entities where the ratio of stroke volume to LV cavity size is preserved. The assessment of global longitudinal strain (GLS) from speckle-tracking analysis of 2-dimensional echocardiography has become a clinically feasible alternative to LVEF for the measurement of myocardial function. Evidence gathered over the last decade has shown GLS to be more sensitive to left ventricular dysfunction (LVD) than LVEF and to provide additional prognostic information. The technology is validated, reproducible within an acceptable range, and widely available. GLS has been proposed as the test of choice in guidelines for monitoring of asymptomatic cardiotoxicity related to chemotherapy. It also has the potential to improve risk stratification, redefine criteria for disease classification, and determine treatment in asymptomatic LVD resulting from a variety of etiologies. GLS provides utility across the spectrum of heart failure (and LVEF) as well as in the evaluation of valvular heart disease. There is a strong case for incorporation of GLS into clinical decision making. This review appraises the evidence addressing the utility of GLS as a complementary metric to LVEF for incorporation into mainstream clinical practice., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: The detection of non-ischaemic (mainly hypertension, diabetes, and obesity) stage B heart failure (SBHF) may facilitate the recognition of those at risk of progression to overt HF and HF prevention. We sought the relationship of specific electrocardiographic (ECG) markers of SBHF to echocardiographic features of SBHF and their prognostic value for development of HF. The ECG markers were Cornell product (Cornell-P), P-wave terminal force in lead V1 (PTFV1), ST depression in lead V5 V6 (minSTmV5V6), and increased heart rate. Echocardiographic assessment of SBHF included left ventricular hypertrophy (LVH), impaired global longitudinal strain (GLS), and diastolic dysfunction (DD)., Method and Results: Asymptomatic subjects ≥65 years without prior cardiac history, but with HF risks, were recruited from the local community. At baseline, they underwent clinical assessment, 12-lead ECG, and comprehensive echocardiography. New HF was assessed clinically at mean follow-up of 14 ± 4 months, and echocardiography was repeated in subjects with HF. Of the 447 study subjects (age 71 ± 5, 47% men) with SBHF, 13% had LVH, 32% impaired GLS, and 65% ≥grade I DD (10% ≥grade II DD). Forty were lost to follow-up. Clinical HF developed in 47 of 407, of whom 20% had echocardiographic LVH, 51% abnormal GLS, and 76% DD at baseline. Baseline LVH and abnormal GLS (not grade I DD) were independently associated with outcomes (clinical HF and cardiovascular death). Cornell-P and heart rate (not minSTmV5V6 nor PTFV1) were independently associated with LVH, impaired GLS, and DD. Cornell-P and minSTV5V6 (not heart rate nor PTFV1) were independently associated with outcomes. More ECG abnormalities improved sensitivity, but ECG-markers were not independent of or incremental to echocardiographic markers to predict HF in SBHF., Conclusions: In this elderly study population, ECG markers showed low diagnostic sensitivity for non-ischaemic SBHF and low prognostic value for outcomes. Cornell-P and minSTmV5V6 had predictive value for outcomes in non-ischaemic SBHF independent of age, gender, and common comorbidities but were not incremental to echocardiography., (© 2017 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Background: Type 2 diabetes mellitus (T2DM) may alter cardiac structure and function, but obesity, hypertension (HTN), or aging can induce similar abnormalities., Objectives: This study sought to link cardiac phenotypes in T2DM patients with clinical profiles and outcomes using cluster analysis., Methods: Baseline echocardiography and a composite endpoint (cardiovascular mortality and hospitalization) were evaluated in 842 T2DM patients from 2 prospective cohorts. A cluster analysis was performed on echocardiographic variables, and the association between clusters and clinical profiles and outcomes was assessed., Results: Three clusters were identified. Cluster 1 patients had the lowest left ventricular (LV) mass index and ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e') ratio, had the highest left ventricular ejection fraction (LVEF), and were predominantly male with the lowest rate of obesity or HTN. Cluster 2 patients had the highest strain and highest E/e' ratio, were the oldest, were predominantly female, and had the lowest rate of isolated T2DM (without HTN or obesity). Cluster 3 patients had the highest LV mass index and volumes and the lowest LVEF and strain, were predominantly male, and shared similar age and rate of obesity and HTN as cluster 1 patients. After follow-up of 67 months (interquartile range: 40 to 87), the composite endpoint occurred in 56 of 521 patients (10.8%). Clusters 2 (hazard ratio: 2.37; 95% confidence interval: 1.15 to 4.88) and 3 (hazard ratio: 2.19; 95% confidence interval: 1.00 to 4.82) had a similar outcome, which was worse than cluster 1., Conclusions: Cluster analysis of echocardiographic variables identified 3 different echocardiographic phenotypes of T2DM patients that were associated with distinct clinical profiles and highlighted the prognostic value of LV remodeling and subclinical dysfunction., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Load dependence is an important source of variation in left ventricular (LV) deformation. This impacts on the precision of information obtained from serial measurements. However, it is clinically important to distinguish actual myocardial dysfunction from changes associated with altered loading conditions. We sought to investigate the association of changes of loading parameters with changes in LV longitudinal (GLS) and circumferential (GCS) strains., Methods and Results: Baseline and a 12-month follow-up 2D echocardiograms were performed in 191 Stage A heart failure patients with uncomplicated hypertension. These patients underwent simultaneous measurement of conventional and central blood pressures (BPs) and haemodynamic measurements by applanation tonometry. Significant, but weak correlations (r = 0.15-0.28) of LV strain parameters and their changes over the follow-up period were shown for the majority of LV afterload-associated variables, including central and brachial systolic, diastolic, and mean BPs; 24-h systolic and diastolic BPs; peak reservoir and excess pressures; central augmented pressure (CAP) and pulse pressure; augmentation index; and arterial elastance index (EaI). Central mean BP, EaI, and changes in CAP and EaI over follow-up were independent contributors to LV deformation in multivariable analysis. No improvement in the Bland-Altman 95% limits of agreement and correlation coefficients was seen with LV afterload correction of GLS and GCS using central BP indices., Conclusions: LV longitudinal and circumferential strains in a population without apparent heart disease is relatively insusceptible to changes in LV afterload within physiological range, which, therefore, seem unlikely to be a significant confounder in repeated GLS or GCS observations., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Background: Left atrial (LA) strain imaging enables the quantitative assessment of LA function. The clinical relevance of these measurements is dependent on the provision of information incremental to the left ventricular (LV) evaluation. The aim of this study was to test the hypothesis that LA pump function but not reservoir function is independent of measurement of LV mechanics., Methods: Echocardiography was undertaken in a community-based study of 576 participants ≥65 years of age with one or more risk factors (e.g., hypertension, diabetes mellitus, obesity). Strain analysis was conducted using a dedicated software package, using R-R gating. LV function was classified as normal in the presence of global longitudinal strain (GLS) (≤-18%) or global circumferential strain (GCS) (≤-22%). The associations between GLS or GCS and LA reservoir, conduit, and pump strain were assessed using univariate and multivariate linear regression., Results: Patients (mean age 71 ± 5 years, 54% women) with reduced GLS had higher blood pressure and rates of diabetes and obesity (P < .05). LA reservoir strain and conduit strain were lower in the group with impaired GLS (38.2 ± 7.3% vs 39.9 ± 6.4% [P = .004] and 18.7 ± 5.7% vs 20.5 ± 5.1% [P < .001], respectively), but there was no difference in LA pump strain (19.5 ± 5.5% vs 19.3 ± 4.6%, P = .72). GLS was independently associated with LA reservoir and conduit strain (P < .05) but not independently associated with LA pump strain (P = .91). Reduced GCS was associated with a larger body mass index, male sex, and diabetes (P < .05). There were no differences in LA reservoir, conduit, and pump strain in patients with normal and abnormal GCS (P > .05)., Conclusions: The application of LA strain is specific to the component measured. LA pump strain is independent of LV mechanics., (Copyright © 2017 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: Right ventricular (RV) free wall strain (RVFWS) is a feasible method for quantitation and follow-up of RV function and may have benefits over traditional markers such as fractional area change. However, like all ejection phase parameters, RVFWS is difficult to assess in the presence of changing afterload. The aim of this study was to compare RVFWS and traditional RV function parameters for tracking progress of RV function in patients with pulmonary arterial hypertension (PAH) over a range of pulmonary artery systolic pressure (PASPs)., Methods: Sequential echocardiograms were collected retrospectively at two time points between 2005 and 2015 in 187 patients (71% women; mean age, 63 ± 14 years) undergoing pulmonary vasodilator therapy for group 1 PAH. Patients were either studied during PAH therapy (n = 111) or before and after treatment initiation (n = 76). Standard measurements of RV and left ventricular function and PASP were performed, and speckle-tracking strain was used to calculate RVFWS. The linear response of RVFWS to afterload (PASP) was assessed using a standard regression equation. Because it is unclear if the response might be nonlinear, a quadratic association (PASP squared) was also used in the regression model., Results: At visit 1, patients with PAH showed impaired functional capacity (mean 6-min walk distance, 371 ± 131 m), increased PASP (mean, 54 ± 26 mm Hg), and borderline RVFWS (mean, 18 ± 6%). Patients before PAH therapy showed more pronounced reduction in 6-min walk distance (mean, 302 ± 136 m) and RVFWS (mean, 16 ± 5%). RVFWS at baseline was associated with PASP (R 2  = 0.25, P = .001), RV end-diastolic area (R 2  = 0.36, P < .001), and fractional area change (R 2  = 0.21, P < .001). Change in RVFWS was more strongly associated with ΔPASP (std β = -0.20, P = .02) than ΔPASP squared (std β = 0.11, P = .20). RVFWS showed strength over fractional area change for sequential RV assessment over a range of PASP changes., Conclusions: Afterload changes should be taken into account in the evaluation of RVFWS during PAH follow-up, with the relationship to PASP likely to be linear., (Copyright © 2017 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to show the degree to which experience and training affect the precision and validity of global longitudinal strain (GLS) measurement and to evaluate the variability of strain measurement after feedback., Background: The application of GLS for the detection of subclinical dysfunction has been recommended in an expert consensus document and is being used with increasing frequency. The role of experience in the precision and validity of GLS measurement is unknown, as is the efficacy of training., Methods: Fifty-eight readers, divided into 4 groups on the basis of their experience with GLS, calculated GLS from speckle strain analysis of 9 cases with various degrees of image quality. Intraclass correlation coefficients (ICCs), mean difference, SD, and coefficient of variation (CV) were compared against the measurements of a reference group that had experience with >1,000 cases of strain measurement. Individualized feedback was distributed, and repeat measurements were performed by 40 readers. Comparisons with the baseline variation provided information about whether feedback was effective., Results: The ICC for GLS was significantly greater than that for ejection fraction regardless of image quality. Experience with strain measurement affected the concordance in strain values among the readers; the group with the highest level of experience showed significantly better ICC than those with no experience, although the ICC of the inexperienced readers was still very good (0.996 vs. 0.975; p = 0.0002). As experience increased, the mean difference, SD, and CV became significantly smaller. The CV of segmental strain analysis showed significant improvement after training, regardless of experience., Conclusions: The favorable interobserver agreement of GLS makes it more attractive than ejection fraction for follow-up of left ventricular function by multiple observers. Although experience is important, the precision of GLS was high for all groups. Training appears to be of most value for the assessment of segmental strain., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The appropriateness of repeat transthoracic echocardiography (TTE) for stable heart failure (HF) is based on timing of the follow-up examination, but this lacks scientific support. We sought the association of routine follow-up TTE on survival and readmission in stable HF., Methods: Patients with HF were selected from consecutive HF admissions from 2008 to 2012. Groups were divided into: no follow-up TTE; routine <1year with no change in status ("rarely appropriate"), ≥1year follow-up with no change in status ("maybe appropriate") and TTE due to change in clinical status ("appropriate"). Survival analysis was performed for the combined endpoint of HF readmission and death, and a separate analysis was performed for HF readmission, with death as a competing risk., Results: Of 550 HF patients, 141 had a follow-up TTE, including 41 (29%) within 1year. The event-free time in years was similar between no TTE (1.10years [95%CI: 0.69, 1.49], routine TTE <1year (2.61years [95% CI: 1.08, 3.04], routine >1year (2.45years [95% CI: 1.37, 5.78]); all were greater than symptomatic patients (0.09years [95% CI: 0.02, 1.80]). HF readmission was independently associated with statins, renal disease, coronary angiography and NYHA class, but not follow-up TTE timing. There were no differences in the cumulative incidence for death between groups. There were no differences in change in management in routine TTE <1year and ≥1year., Conclusion: The distinction of appropriateness of routine repeat TTE in stable HF patients, based on testing <1 or ≥1year after index admission appears unjustified., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Recent advances in the assessment of myocardial function have facilitated the direct measurement of atrial function using speckle-tracking echocardiography. Currently, normal reference ranges for atrial function using speckle-tracking echocardiography are based on a few initial studies, with variations among modestly sized (n = 100-350) studies., Methods: The authors searched the PubMed, Embase, and Scopus databases for the key terms "left atrial/atrial/atrium" and "strain/function/deformation/stiffness" and "speckle tracking/Velocity Vector Imaging/edge tracking." Studies of global left atrial function using speckle-tracking were selected if they involved >30 normal or healthy participants without any cardiac risk factors. Normal ranges for reservoir strain, conduit strain, and contractile strain were computed using a random-effects model. Meta-regression and subgroup analysis was performed to explore between-study heterogeneity., Results: Forty studies (2,542 healthy subjects) satisfied the inclusion criteria. Meta-analysis revealed a normal reference range for reservoir strain of 39% (95% CI, 38%-41%, from 40 articles), for conduit strain of 23% (95% CI, 21%-25%, from 14 articles), and for contractile strain of 17% (95% CI, 16%-19%, from 18 articles). Meta-regression identified heart rate (P = .02) and body surface area (P = .003) as contributors to this heterogeneity. Subgroup analyses revealed heterogeneity due to sample size (n > 100 vs N < 100, P = .02)., Conclusions: The normal reference ranges for the three components of left atrial function are demonstrated. The between-study heterogeneity is explained partly by heart rate, body surface area, and sample size., (Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Adoption of appropriate use criteria has not had a major impact on the frequency of "rarely appropriate" tests, with the rarely appropriate tests rate remaining at ∼20% in most institutions. We sought whether access to hand-held ultrasound (HHU) could be an alternative means of reducing rarely appropriate requests. We compared 2 approaches to rarely appropriate requests; "standard transthoracic echocardiography" (SE) as requested (control) and HHU as a gatekeeper (HHU). Patients were followed up for 6 months and assessed for end points including time until scan, repeat echocardiography/cost of either strategy, new major pathology, and change in management. The most common rarely appropriate requests in both groups were assessment of infective endocarditis without positive blood cultures and precordial murmur evaluation in absence of any other signs or symptoms of cardiovascular disease. The groups had comparable age, gender, requesting physician, and inpatient versus outpatient distribution. HHU led to a 59% reduction in rarely appropriate requests requiring SE. HHU significantly reduced time to decision for inpatients (0 [interquartile range 0, 1] vs 2 days [interquartile range 1, 4], p <0.001) and total cost of echocardiography (109 ± 86 vs 181 ± 37 USD, p <0.001). New major pathology was identified in 29% and 23% of HHU and SE, respectively. There was no difference with respect to change in management. In conclusion, HHU can be an effective gatekeeper to SE for rarely appropriate echocardiograms, reducing time to echocardiography and cost while satisfying the referring physician and avoiding repeat requests for SE. HHU provides a safety net that identifies potential important findings in rarely appropriate requests., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: We sought whether simple clinical markers could be used in a questionnaire for recognition of inappropriate (or rarely appropriate, RA) tests at point-of-service. Most applications of appropriateness criteria (AC) for transthoracic echocardiogram (TTE) have been at the point of order, but a simple means of identifying RA tests in an audit process would be of value., Design, Setting and Participants: The study was performed in 2 major hospitals in Tasmania. 2 reviewers created a questionnaire based on 4 questions most commonly associated with RA (suspected endocarditis with no positive blood cultures or new murmur, lack of cardiovascular symptoms or no change in clinical status or cardiac examination, routine surveillance and previous TTE within a year) in a derivation cohort of 814 patients. This was prospectively applied to 499 TTEs to calculate sensitivity and specificity for prediction of RA, and validated in the external group (n=880)., Results: Of 499 prospective TTEs, the questionnaire selected 18% requests as being potentially RA. As 7.4% were actually RA (κ 89%), the sensitivity and specificity of the questionnaire were 84% and 87%, respectively. In the external validation cohort, the model found 11% requests needed to be screened for appropriateness with a sensitivity and specificity of 80% and 95%., Conclusions: A questionnaire based on 4 questions detects a high proportion of RA TTE, and could be used for audit., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Type 2 diabetes mellitus (T2DM) is a well-recognized risk factor for cardiovascular diseases and cardiac death. While the increased mortality of patients with DM has traditionally been attributed to coronary artery disease, approximately half of the mortality has other causes, including non-ischemic heart failure (HF). In this context, effective screening and diagnosis of cardiac structural and functional abnormalities are crucial for preventive strategies and for predicting prognosis. This review discusses various echocardiographic diagnostic modalities, including tissue Doppler imaging (TDI) and two-dimensional (2D) speckle-tracking echocardiography (STE) for screening, risk stratification, and guidance of management of patients with T2DM.

Background: The distinction between right ventricular (RV) dysfunction due to an acute etiology (pulmonary embolism [PE]) or chronic afterload (pulmonary arterial hypertension [PAH]) has important therapeutic implications. The aim of this study was to test the hypothesis that RV remodeling would alter RV free wall strain (RVFWS) and differentiate chronic from acute RV afterload., Methods: In this retrospective study, patients with PE (n = 45) who underwent echocardiography within 48 hours of computed tomographic pulmonary angiography were matched 1:1 for age, gender, and pulmonary artery systolic pressure with patients with PAH (n = 45) and a larger unmatched PAH control group (n = 116). RV function was evaluated with end-diastolic area, fractional area change (FAC), and RVFWS by two-dimensional speckle-tracking. The ability of RVFWS to distinguish acute from chronic RV dysfunction was assessed using receiver operating characteristic curves, and its incremental value was sought with stepwise models., Results: RV end-diastolic area, FAC, and RVFWS were significantly impaired in patients with PE (P < .001), with no significant differences in other clinical variables. In matched patients, receiver operating characteristic curve analysis revealed that RVFWS had significantly better discriminative power than the McConnell sign (P = .02), with a cutoff of -17.9%, sensitivity of 87.5%, specificity of 62.5%, and an area under the curve of 0.76. Sequential logistic regression demonstrated an incremental and independent benefit of using RVFWS to predict acute PE versus chronic PAH (P = .01). Observer concordance was superior for RVFWS compared with FAC (P < .01)., Conclusions: RVFWS is more predictive than RV end-diastolic area and less variable than FAC in distinguishing acute from chronic RV pressure overload. RVFWS adds incremental and independent information to standard measures of RV function in assessing the acuity of pulmonary hypertension., (Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Hypertension remains a major contributor to the global burden of disease. The measurement of blood pressure continues to have pitfalls related to both physiological aspects and acute variation. As the left ventricle (LV) remains one of the main target organs of hypertension, and echocardiographic measures of structure and function carry prognostic information in this setting, the development of a consensus position on the use of echocardiography in this setting is important. Recent developments in the assessment of LV hypertrophy and LV systolic and diastolic function have prompted the preparation of this document. The focus of this work is on the cardiovascular responses to hypertension rather than the diagnosis of secondary hypertension. Sections address the pathophysiology of the cardiac and vascular responses to hypertension, measurement of LV mass, geometry, and function, as well as effects of treatment., (Copyright © 2015 American Society of Echocardiography. This article has been co-published in the European Heart Journal – Cardiovascular Imaging. Published by Elsevier Inc. All rights reserved.)

Background: While echocardiographic grading of left ventricular (LV) diastolic dysfunction (DD) is used every day, the relationship between echocardiographic DD grade and hemodynamic abnormalities is uncertain., Methods: We identified 460 consecutive patients who underwent transthoracic echocardiography within 24 h of elective left heart catheterization and had: normal sinus rhythm, no confounding structural heart disease, no change in medications between catheterization and echo, and complete echocardiographic data. Patients were grouped based on echocardiographic DD grade. Hemodynamic tracings were used to determine time constant of isovolumic pressure decay (Tau), LV end-diastolic pressure (LVEDP) and end-diastolic volume index at a pressure of 20 mmHg (EDVi20)., Results: Normal diastolic function was found in 55 (12.0%) patients, while 132 (28.7%) patients had grade 1, 156 (33.9%) grade 2 and 117 (25.4%) grade 3 DD. The median value for Tau was 46.9 ms for the overall population (interquartile range 38.6-58.1 ms), with a prevalence of a prolonged Tau (>48 ms) of 47.5%. While there was an association between DD grade and Tau (p = 0.003), LV dysfunction (ejection fraction <50%) was more strongly associated with increased Tau (p < 0.001) than was DD grade (p = 0.19). There was also an association between DD grade and LVEDP (p < 0.001), with both LV dysfunction (p = 0.029) and DD grade (p < 0.001) independently associated with LVEDP. Calculated EDVi20 was related to DD grade, but this relationship was driven by findings of paradoxically increased compliance in patients with severe DD., Conclusions: Although echocardiographic grading of DD was related to invasive hemodynamics in this population, the relationship was modest.

Data from echocardiography provide a cornerstone in the management of heart failure. All imaging techniques can provide an ejection fraction, but the versatility of echocardiography makes it unique in the provision of volumes, diastolic function, right ventricular function, hemodynamics, and valvular regurgitation. The early detection of heart failure has been facilitated by the assessment of global longitudinal strain, which is also useful in later heart failure for the assessment of left ventricular synchrony. The use of echocardiography has been associated with favorable outcomes, probably on the basis of facilitation of appropriate therapy. This review examines the evidence provided by echocardiography and its application in specific settings. Although the guidelines emphasize that no single test satisfies all imaging requirements in heart failure, and other modalities can provide additional information about specific questions (especially tissue characterization), echocardiography is indispensable in the management of heart failure., (© 2015 by the Society of Nuclear Medicine and Molecular Imaging, Inc.)

Background: Disagreement of strain measurements among different vendors has provided an obstacle to the clinical use of strain. A joint standardization task force between professional societies and industry was initiated to reduce intervendor variability of strain. Although feedback from this process has been used in software upgrades, little is known about the effects of efforts to improve conformity. The aim of this study was to assess whether intervendor agreement for global longitudinal strain (GLS) has improved after standardization initiatives., Methods: Eighty-two subjects (mean age, 52 ± 21 years; 55% men) prospectively underwent two sequential examinations using two most common ultrasound systems (Vivid E9 and iE33). GLS was calculated using proprietary software (EchoPAC-PC BT12 [E12] and BT13 [E13] vs QLAB version 8.0 [Q8], QLAB version 9.0 [Q9], and QLAB version 10.0 [Q10]). Agreements in GLS were evaluated with Bland-Altman plots. Coefficients of variation (CVs) were compared using the Friedman test and compared with CVs of left ventricular volumes and ejection fraction (LVEF)., Results: Median GLS using E12 was -19.2% (interquartile range [IQR], -15.2% to -23.2%), compared with -19.3% (IQR, -14.9% to -23.7%) for E13, -15.7% (IQR, -11.4% to -20%) for Q8, -19% (IQR, -15.7% to -22.3%) for Q9, and -18.7% (IQR, -15.7% to -21.7%) for Q10. The CVs of prestandardization GLS (12 ± 8% [E12/Q8] and 14 ± 8 [E13/Q8]) were significantly larger than that of LVEF (5 ± 5) (P < .001). Since standardization, the CVs of GLS have shown improvement (6 ± 4 [E12/Q9], 7 ± 4 [E12/Q10], 6 ± 4 [E13/Q9], and 7 ± 4 [E13/Q10]) and are similar to those of LVEF., Conclusions: Subsequent to the joint standardization task force, there has been improvement in between-vendor concordance in GLS between two leading ultrasound manufactures, the variability of which is now analogous to that of LVEF. The removal of concerns about measurement variability should allow wider use of GLS., (Copyright © 2015 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: Heart failure (HF) readmissions are a common and serious problem of heterogeneous etiology. Left ventricular (LV) ejection fraction has not been found to be a consistent risk marker. However, LV strain has been shown to predict outcomes in other settings, so the aim of this study was to determine the association of LV strain with 30-day HF readmission, independent of and incremental to clinical and basic echocardiographic parameters., Methods: A total of 468 patients who underwent echocardiography at the time of the first admission for HF from July 2009 to June 2012 were retrospectively studied. Clinical parameters were comprehensively assessed, and standard echocardiographic parameters and two strain parameters (global longitudinal strain [GLS] and global circumferential strain) were measured using speckle-tracking. Patients were followed for all-cause 30-day hospital readmission or death after discharge, and the associations of parameters with outcome were assessed using Cox proportional hazards models., Results: Readmission within 30 days (n = 92 patients [20%]) was associated with greater impairment of LV GLS (-8.6% [interquartile range, -10.9% to -5.9%] vs -11.1% [interquartile range, -14.6% to -7.7%], P < .01). The association of GLS with readmission (hazard ratio, 1.13; 95% confidence interval, 1.07-1.19; P < .01) was independent of age, male gender, systolic blood pressure, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, and comorbidity, as well as renal function, sodium, hematocrit, LV mass, left atrial size, and mitral regurgitation. Global circumferential strain was associated with outcome but not was independent after adjustment with echocardiographic parameters. In sequential models for 30-day outcome, GLS added incremental information to clinical parameters and LV ejection fraction and significantly improved reclassification (categorical net reclassification improvement, 0.34; P = .04) when LV ejection fraction was >50%., Conclusions: GLS is associated with HF readmission, independent of and incremental to clinical and basic echocardiographic parameters., (Copyright © 2015 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Microbubbles are an excellent intravascular tracer, and both the rate of myocardial opacification (analogous to coronary microvascular perfusion) and contrast intensity (analogous to myocardial blood volume) provide unique insights into myocardial perfusion. A strong evidence base has been accumulated to show comparability with nuclear perfusion imaging and incremental diagnostic and prognostic value relative to wall motion analysis. This technique also provides the possibility to measure myocardial perfusion at the bedside. Despite all of these advantages, the technique is complicated, technically challenging, and has failed to scale legislative and financial hurdles. The development of targeted imaging and therapeutic interventions will hopefully rekindle interest in this interesting modality., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Although cardiovascular events in hemodialysis (HD) patients are the most frequent on the day after a long (2 days) interdialytic interval (IDT), it has been uncertain whether accumulation or elimination of large extracellular fluid volume, electrolyte, and/or uremic substances is the culprit for this. We sought to test our hypothesis that the long IDT alters echocardiographic parameters at rest and during exercise in stable maintenance HD patients compared with other IDTs., Methods: We performed a cross-sectional comparison using 1-way repeated analysis of variance or Friedman test of echocardiograms at 3 different IDTs, just after HD, after short IDT (1 day), and after long IDT, among 80 stable Japanese outpatients (age 61 ± 9 years, 60 males) on thrice weekly maintenance. End-systolic elastance (Ees), arterial elastance (Ea), and pressure-volume area (PVA) were estimated using a noninvasive single-beat technique. Ventricular-arterial coupling was assessed by Ea/Ees ratio. Measurements were repeated after 2-minute handgrip stress to evaluate cardiac reserve., Results: Resting left ventricular end-diastolic volume index and stroke volume index were significantly larger after a 1-day IDT compared with just after HD and even more after a 2-day IDT. Although Ees, Ea, and Ea/Ees ratio at rest remained similar between short and long intervals, stroke work (SW) and PVA were higher after the long interval. During handgrip stress, a significant increase in Ea without corresponding rise in Ees was observed only after long IDT, resulting in decreased stroke volume index, SW, and SW/PVA efficiency., Conclusions: In a selective Japanese outpatient population on maintenance HD, there were no differences in resting cardiovascular function measured by echocardiography at 3 different IDTs. However, exercise-induced afterload mismatch assessed by the changes in Ea, SV, SW, and SW/PVA efficiency was most pronounced in individuals after the long IDT compared with other IDTs. Our findings report potential pathophysiologic echocardiographic parameters that attempt to explain why cardiovascular events are highest on the day after the long IDT compared to other IDTs in dialysis patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The increasing cost of healthcare is a widespread international problem to which the cost of imaging has been an important contributor. Some imaging tests are ordered inappropriately and contribute to wasted use of resources. Appropriate use criteria have been developed in the USA in order to guide test selection, but there are a number of problems, including the evidence base for these criteria and the steps that can be taken to change physician practice. A restrictive approach to test ordering is difficult to fit to the nuances of clinical presentation and may compromise patient care. We propose an alternative approach to physician guidance based on the most common markers of inappropriate testing.