Arq Bras CardiolabcArquivos Brasileiros de CardiologiaArq. Bras. Cardiol.0066-782X1678-4170Sociedade Brasileira de Cardiologia - SBCybMPdwXJchQ9SwwhXP9Rq5MS0066-782X201900100068510.5935/abc.20190211Short EditorialAre Myocardium Deformation Indices Influenced by Cardiac Load, Age or Body Mass Index?0000-0002-7152-1810SalemiVera Maria Cury1MeloMarcelo Dantas Tavares de2Universidade de São PauloFaculdade de MedicinaHospital das ClinicasSão PauloSPBrazilInstituto do Coração (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - BrazilUniversidade Federal da ParaíbaJoão PessoaPBBrazilUniversidade Federal da Paraíba, João Pessoa, PB - BrazilMailing Address: Vera Maria Cury Salemi, Av. Jandira, 185 ap 41B. Postal Code 04080-000, São Paulo, SP - Brazil. E-mail: verasalemi@cardiol.br, verasalemi@uol.com.br041120191020191134685686This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly citedKeywordsEchocardiography/methodsMyocardium DeformationHypertensionHeart FailureStrainHypertrophic Cardiomyopathy
The typical findings of myocardium deformation indices (MDI) in many cardiac diseases, the low cost of the echocardiographic exam, the large availability, the vast implementation of this tool for clinical practice and the prognostic value has allowed the detection of earlier myocardium dysfunction than the traditional measurement of left ventricular (LV) ejection fraction.1 Moreover, there are typical MDI patterns in different forms of hypertrophy: decreased values in septum MDI in hypertrophic cardiomyopathy (HCM) or where hypertrophy is more accentuated, or a segmental decrease in mutation carriers in a pre-clinical phase of disease, before development of hypertrophy;2 apical sparing in amyloidosis;3 striped pattern of myocardium deformation in glycogen storage cardiomyopathy (PRKAG2);4 and decrease in subepicardial longitudinal strain in Anderson-Fabry disease.5 In hypertension with concentric and eccentric hypertrophy, the MDI patterns are related to different geometric patterns,6 but they are frequently preserved in athletes.4
The question whether MDI would be reliable in different machines and vendors was demonstrated that the accuracy of these indices were better than conventional echocardiography measurements and they are reliable for daily echocardiographic practice.7
The paper published in the same issue of this journal showed that the authors evaluated the LV global longitudinal strain in 45 patients divided into 2 groups: with HCM and the association with hypertension with HCM, and showed that strain was decreased in the latter group compared to the first one.8 It is noticeable the difference between both groups about their age, body mass index (BMI) and blood pressure. Besides, many studies have demonstrated that global longitudinal strain could be affected by those variables mentioned, as demonstrated in a paper of 266 healthy subjects, 39.2 ± 17.5 years, 137 women, submitted to transthoracic echocardiography evaluation and showed that global longitudinal strain was progressively reduced with increasing age decades.9 Metabolic syndrome may also play a role in myocardial deformation showed in a study of 384 patients grouped according to BMI (normal weight < 25 kg/m2, overweight 25-29 kg/m2, and obesity ≥ 30 kg/m2), compared to healthy control group. Regardless of the presence or not of diabetes, overweight and obesity impair LV ejection fraction and global longitudinal strain.10 Interestingly, Russell et al.11 were the first to describe a new method that evaluated myocardial work using a non-invasive pressure-strain loop by echocardiogram.11 In a canine model, it was demonstrated a significant reduction in LV strain after aortic construction. On the other hand, LV pressure-strain loop area did not change, which means that myocardial work seems to be not affected by increasing the afterload, but global longitudinal strain could transient change by hemodynamics status.12 Therefore, we could be more precautious when we stratify the same cardiomyopathy simply by using global longitudinal strain, not considering afterload importance. Furthermore, the previous study compared 80 hypertensive patients, 80 HCM patients and 80 controls showed that longitudinal strain was lower in HCM patients, and also, the best parameter to differentiate both diseases was the MDI ratio of endocardium and epicardium layers. However, this parameter was not evaluated in the present study.13
The LV outflow tract obstruction is defined as peak LV gradient greater than or equal to 30 mmHg at rest or with provocation, is present in approximately two-thirds of patients with hypertrophic cardiomyopathy.14 This dynamic obstruction leads to an increase in left ventricle afterload which could impair the global longitudinal strain itself, as previous mentioned. However, the authors of this present study did not mention this feature which certainly affects the myocardial deformation. The myocardial thickness and mainly, the presence of fibrosis affect negatively the patients’ prognosis. Both parameters were not described in this present study and it is well known that they are related to a LV global longitudinal strain reduction.15 When myocardial work was analyzed in hypertrophic cardiomyopathy subjects, one variable called global constructive work was the only predictor of LV fibrosis at multivariable analysis (OR 1.01, 95% CI: 0.99 - 1.08, p = 0.04).16 A cutoff value of 1623 mmHg% (AUC 0.80, 95% CI: 0.66-0.93, p < 0.0001) was able to predict myocardial fibrosis with good sensitivity and fair specificity (82% and 67%, respectively).
In conclusion, MDI are an important tool helping to distinguish HCM from other cardiomyopathies, as well as, they present value for risk stratification impact. However, it is extremely recommended to take into account the hemodynamic status whenever analyze MDI data. Moreover, it is a diagnostic challenge the presence of overlapping of hypertrophic cardiomyopathy and hypertension. Myocardial work may play a role to solve this.
Short Editorial related to the article: Strain Analysis of Left Ventricular Function in the Association of Hypertrophic Cardiomyopathy and Systemic Arterial Hypertension
References1 Badano LP, Kolias TJ, Muraru D, Abraham TP, Aurigemma G, Edvardsen T, et al. Industry representatives; Reviewers: This document was reviewed by members of the 2016-2018 EACVI Scientific Documents Committee. Standardization of left atrial, right ventricular, and right atrial deformation imaging using two-dimensional speckle tracking echocardiography: a consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging. 2018;19(6):591-600.BadanoLPKoliasTJMuraruDAbrahamTPAurigemmaGEdvardsenTIndustry representatives; Reviewers: This document was reviewed by members of the 2016-2018 EACVI Scientific Documents Committee. Standardization of left atrial, right ventricular, and right atrial deformation imaging using two-dimensional speckle tracking echocardiography: a consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imagingEur Heart J Cardiovasc Imaging20181965916002 Baudry G, Mansencal N, Reynaud A, Richard P, Dubourg O, Komajda M, et al. Global and regional echocardiographic strain to assess the early phase of hypertrophic cardiomyopathy due to sarcomeric mutations. Eur Heart J Cardiovasc Imaging. 2019,jez084 [Internet] [Cited in 2019 july 23]. Available from: https://doi.org/10.1093/ejhci/jez084BaudryGMansencalNReynaudARichardPDubourgOKomajdaMGlobal and regional echocardiographic strain to assess the early phase of hypertrophic cardiomyopathy due to sarcomeric mutationsEur Heart J Cardiovasc Imaging2019Internet2019 july 23Available from: https://doi.org/10.1093/ejhci/jez0843 Pradel S, Magne J, Jaccard A, Fadel BM, Boulogne C, Salemi VMC, et al. Left ventricular assessment in patients with systemic light chain amyloidosis: a 3-dimensional speckle tracking transthoracic echocardiographic study. Int J Cardiovasc Imaging. 2019;35(5):845-54.PradelSMagneJJaccardAFadelBMBoulogneCSalemiVMCLeft ventricular assessment in patients with systemic light chain amyloidosis: a 3-dimensional speckle tracking transthoracic echocardiographic studyInt J Cardiovasc Imaging20193558458544 Pena JLB, Santos WC, Araújo SA, Dias GM, Sternick EB. How Echocardiographic Deformation Indices Can Distinguish Different Types of Left Ventricular Hypertrophy. Arq Bras Cardiol. 2018;111(5):758-9.PenaJLBSantosWCAraújoSADiasGMSternickEBHow Echocardiographic Deformation Indices Can Distinguish Different Types of Left Ventricular HypertrophyArq Bras Cardiol201811157587595 Esposito R, Santoro C, Sorrentino R, Riccio E, Citro R, Buonauro A, et al. Anderson-Fabry Federico II Naples, ITalY (AFFINIITY) Group. Layer-specific longitudinal strain in Anderson-Fabry disease at diagnosis: A speckle tracking echocardiography analysis. Echocardiography. 2019;36(7):1273-81.EspositoRSantoroCSorrentinoRRiccioECitroRBuonauroAAnderson-Fabry Federico II Naples, ITalY (AFFINIITY) Group: Layer-specific longitudinal strain in Anderson-Fabry disease at diagnosis: A speckle tracking echocardiography analysisEchocardiography2019367127312816 Xu TY, Yang Y, Li JJ, Li Y, Wang JG. Left ventricular deformation in relation to the geometric pattern in hypertensive patients. Medicine (Baltimore). 2019;98(4):e14257.XuTYYangYLiJJLiYWangJGLeft ventricular deformation in relation to the geometric pattern in hypertensive patientsMedicine (Baltimore)2019984e142577 Ünlü S, Mirea O, Duchenne J, Pagourelias ED, Bézy S, Thomas JD, et al. Comparison of Feasibility, Accuracy, and Reproducibility of Layer-Specific Global Longitudinal Strain Measurements Among Five Different Vendors: A Report from the EACVI-ASE Strain Standardization Task Force. J Am Soc Echocardiogr. 2018;31(3):374-80.ÜnlüSMireaODuchenneJPagoureliasEDBézySThomasJDComparison of Feasibility, Accuracy, and Reproducibility of Layer-Specific Global Longitudinal Strain Measurements Among Five Different Vendors: A Report from the EACVI-ASE Strain Standardization Task ForceJ Am Soc Echocardiogr20183133743808 Gil TCP, Castier MB, Gondar AFP, ales AF, Santos MO, de Lima FCS, et al. Strain analysis of left ventricular function in the association of hypertrophic cardiomyopathy and systemic arterial hypertension. Arq Bras Cardiol. 2019; 113(4):677-684.GilTCPCastierMBGondarAFPalesAFSantosMOde LimaFCSStrain analysis of left ventricular function in the association of hypertrophic cardiomyopathy and systemic arterial hypertensionArq Bras Cardiol201911346776849 Alcidi GM, Esposito R, Evola V, Santoro C, Lembo M, Sorrentino R, et al. Normal reference values of multilayer longitudinal strain according to age decades in a healthy population: A single-centre experience. Eur Heart J Cardiovasc Imaging. 2018;19(12):1390-6.AlcidiGMEspositoREvolaVSantoroCLemboMSorrentinoRNormal reference values of multilayer longitudinal strain according to age decades in a healthy population: A single-centre experienceEur Heart J Cardiovasc Imaging201819121390139610 Blomstrand P, Sjöblom P, Nilsson M, Wijkman M, Engvall M, Länne T, et al. Overweight and obesity impair left ventricular systolic function as measured by left ventricular ejection fraction and global longitudinal strain. Cardiovasc Diabetol. 2018;17(1):113.BlomstrandPSjöblomPNilssonMWijkmanMEngvallMLänneTOverweight and obesity impair left ventricular systolic function as measured by left ventricular ejection fraction and global longitudinal strainCardiovasc Diabetol201817111311311 Russell K, Eriksen M, Aaberge L, Wilhelmsen N, Skulstad H, Remme EW, et al. A novel clinical method for quantification of regional left ventricular pressure-strain loop area: a non-invasive index of myocardial work. Eur Heart J. 2012;33(6):724-33.RussellKEriksenMAabergeLWilhelmsenNSkulstadHRemmeEWA novel clinical method for quantification of regional left ventricular pressure-strain loop area: a non-invasive index of myocardial workEur Heart J201233672473312 Boe E, Russell K, Eek C, Eriksen M, Remme EW, Smiseth OA, et al. Non-invasive myocardial work index identifies acute coronary occlusion in patients with non-ST-segment elevation-acute coronary syndrome. Eur Heart J Cardiovasc Imaging. 2015;16(11):1247-55.BoeERussellKEekCEriksenMRemmeEWSmisethOANon-invasive myocardial work index identifies acute coronary occlusion in patients with non-ST-segment elevation-acute coronary syndromeEur Heart J Cardiovasc Imaging201516111247125513 Sun JP, Xu TY, Ni XD, Yang XS, Hu JL, Wang SC, et al. Echocardiographic strain in hypertrophic cardiomyopathy and hypertensive left ventricular hypertrophy. Echocardiography. 2019;36(2):257-65.SunJPXuTYNiXDYangXSHuJLWangSCEchocardiographic strain in hypertrophic cardiomyopathy and hypertensive left ventricular hypertrophyEchocardiography201936225726514 Veselka J, Anavekar NS, Charron P. Hypertrophic obstructive cardiomyopathy. Lancet. 2017;389(10075):1253-67.VeselkaJAnavekarNSCharronPHypertrophic obstructive cardiomyopathyLancet2017389100751253126715 Haland TF, Almaas VM, Hasselberg NE, Saberniak J, Leren IS, Hopp E, et al. Strain echocardiography is related to fibrosis and ventricular arrhythmias in hypertrophic cardiomyopathy. Eur Heart J Cardiovasc Imaging. 2016;17(6):613-21.HalandTFAlmaasVMHasselbergNESaberniakJLerenISHoppEStrain echocardiography is related to fibrosis and ventricular arrhythmias in hypertrophic cardiomyopathyEur Heart J Cardiovasc Imaging201617661362116 Galli E, Vitel E, Schnell F, Le Rolle V, Hubert A, Lederlin M, et al. Myocardial constructive work is impaired in hypertrophic cardiomyopathy and predicts left ventricular fibrosis. Echocardiography. 2019;36(1):74-82.GalliEVitelESchnellFLe RolleVHubertALederlinMMyocardial constructive work is impaired in hypertrophic cardiomyopathy and predicts left ventricular fibrosisEchocardiography20193617482MinieditorialOs Índices de Deformação Miocárdica são Influenciados pela Carga Cardíaca, Idade ou Índice de Massa Corporal?0000-0002-7152-1810SalemiVera Maria Cury1MeloMarcelo Dantas Tavares de2Instituto do Coração (InCor) do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - BrazilUniversidade Federal da Paraíba, João Pessoa, PB - BrazilCorrespondência: Vera Maria Cury Salemi, Av. Jandira, 185 ap 41B. CEP 04080-000, São Paulo, SP - Brasil. E-mail: verasalemi@cardiol.br, verasalemi@uol.com.brPalavras-chaveEcocardiografia/métodosDeformação Miocárdicahipertensão arterialInsuficiência CardíacaStrainCardiomiopatia Hipertrófica.
Os achados típicos de índices de deformação miocárdica (IDM) em muitas doenças cardíacas, o baixo custo do exame ecocardiográfico, a ampla disponibilidade, a vasta implementação dessa ferramenta para a prática clínica e seu valor prognóstico têm permitido a detecção da disfunção miocárdica mais precocemente do que a medição tradicional da fração de ejeção do ventrículo esquerdo (VE).1 Além disso, há padrões típicos de IDM nas diferentes formas de hipertrofia: valores reduzidos do IDM septal na cardiomiopatia hipertrófica (CH) ou onde a hipertrofia for mais acentuada, ou redução segmentar nos portadores da mutação em estágio pré-clínico da doença, antes do desenvolvimento da hipertrofia;2 preservação apical na amiloidose;3 deformação miocárdica em padrão listrado na cardiomiopatia de armazenamento de glicogênio (PRKAG2);4 e redução do strain longitudinal subepicárdico na doença de Anderson-Fabry.5 Na hipertensão com hipertrofia concêntrica e excêntrica, os padrões do IDM estão relacionados a diferentes padrões geométricos,6 embora frequentemente eles se encontrem preservados nos atletas.4
Em relação à confiabilidade do IDM em máquinas e fornececedores diferentes, foi demonstrada uma maior precisão desses índices quando comparados com as medições por ecocardiografia convencional, além de se mostrarem confiáveis para a prática ecocardiográfica diária.7
Em estudo publicado sobre o mesmo tema deste periódico, os autores avaliaram o strain longitudinal global do VE em 45 pacientes, divididos em 2 grupos: pacientes com CMH e pacientes com CMH e HAS, e demonstraram que o strain diminuiu no último grupo em relação ao primeiro.8 São evidentes as diferenças entre os dois grupos no tocante à idade, ao índice de massa corporal (IMC) e à pressão arterial. Além disso, vários estudos já demonstraram que o strain longitudinal global pode ser afetado por essas variáveis, como foi demonstrado em um estudo com 266 pacientes saudáveis (39,2 ± 17,5 anos, 137 mulheres) submetidos à avaliação ecocardiográfica transtorácica. Adionalmente, foi observada uma progressiva redução do strain longitudinal global, conforme o aumento da idade em décadas.9 A síndrome metabólica também pode desempenhar um papel importante na deformação miocárdica, como demonstrado em um estudo com 384 pacientes agrupados conforme o IMC (peso normal < 25 kg/m2, sobrepeso 25-29 kg/m2, e obesidade ≥ 30 kg/m2), quando comparados com o grupo controle saudável. Independentemente da presença ou não de diabetes, o sobrepeso e a obesidade prejudicam a fração de ejeção do VE e o strain longitudinal global.10 Curiosamente, Russell et al.,11 foram os primeiros a descreverem um novo método não invasivo para avaliar o trabalho miocárdico utilizando uma curva de pressão/deformação por ecocardiografia.11 Em um modelo experimental em cães, foi demonstrada redução significativa do strain do VE após a constrição da aorta. Em contrapartida, a área da curva de pressão/deformação do VE não mudou, o que significa que o trabalho miocárdico não parece ser afetado pelo aumento da pós-carga, mas o strain longitudinal global pode ser alterado transitoriamente pelo padrão hemodinâmico.12 Consequentemente, nós poderíamos ser mais cautelosos ao estratificarmos a mesma cardiomiopatia usando simplesmente o strain longitudinal global, sem levar em conta a importância da pós-carga. Além disso, um estudo anterior, que comparou 80 pacientes hipertensos, 80 pacientes com CMH e 80 controles, mostrou que o strain longitudinal foi menor nos pacientes com CMH, e também que o melhor parâmetro para diferenciar ambas as doenças foi a razão entre o IDM das camadas do endocárdio e epicárdio. Entretanto, esse parâmetro não foi analisado nesse estudo.13
A obstrução do trato de saída do VE, definida por gradiente máximo maior ou igual a 30 mmHg em repouso ou ao teste provocativo, está presente em aproximadamente dois terços dos pacientes com cardiomiopatia hipertrófica.14 Essa obstrução dinâmica leva ao aumento de pós-carga no ventrículo esquerdo, o que pode prejudicar o próprio strain longitudinal global, como mencionado anteriormente. Contudo, os autores desse estudo não mencionaram essa característica que certamente afeta a deformação miocárdica. A espessura do miocárdio e, principalmente, a presença de fibrose afeta negativamente o prognóstico dos pacientes. Ambos os parâmetros não foram descritos nesse estudo, mas sabe-se que eles estão relacionados com a redução do strain longitudinal global do VE.15 Quando o trabalho miocárdico foi analisado nos indivíduos com cardiomiopatia hipertrófica, uma variável chamada “trabalho construtivo global” foi o único preditor de fibrose do VE em análise multivariada (OR 1,01; IC 95%: 0,99 - 1,08, p = 0,04).16 Um valor de corte de 1,623 mmHg% (AUC 0,80; IC 95%: 0,66-0,93, p < 0,000) foi capaz de prever a fibrose miocárdica com boa sensibilidade e razoável especificidade (82% e 67%, respectivamente).
Em suma, o IDM é uma ferramenta importante para ajudar a distinguir a CMH de outras cardiomiopatias, além de apresentar valor para impacto de estratificação de risco. Todavia, é extremamente recomendado levar em consideração o padrão hemodinâmico sempre que os dados do IDM forem analisados. Além disso, a presença de sobreposição de cardiomiopatia hipertrófica e hipertensão representa um desafio diagnóstico. O trabalho miocárdico pode desempenhar um papel na solução desse problema.
Minieditorial referente ao artigo: Avaliação da Função Ventricular Esquerda na Associação de Cardiomiopatia Hipertrófica e Hipertensão Arterial Sistêmica pela Técnica de Strain