Influence of arterial hypertension on regional 2D strain analysis in patients with non-ST elevation acute coronary syndrome

    Authors

    Abstract

    **Background:** In our previous research (1) we have shown 2D analysis of regional longitudinal peak systolic strain (LPSS) to be superior to visual assessment of regional wall motion abnormalities (RWMA) in detection of ischemia-induced loss of myocardial contractility due to non-ST elevation acute coronary syndrome (NSTE-ACS). (2, 3) The reduction of LPSS in basal segments in patients with arterial hypertension (AH) is well documented. The aim of this study was to assess the impact AH has on the accuracy of regional analysis in predicting the localization of significant stenosis in NSTE-ACS. **Methods:** We performed a retrospective analysis of patients admitted to University Hospital Centre Zagreb from January 2013 till December 2015 due to NSTE-ACS. Exclusion criteria were no coronary angiography, absence of ECHO, and prior coronary artery disease. Total of 123 patients (62±12 years, 68% male) were included. 4 blinded clinicians performed regional LPSS analysis using 18-segment model, while RWMA, interpreted by clinician performing the echo, were categorized according to the wall motion score guidelines. **Results:** Significant correlation between flow limiting stenosis (>70% narrowing on angiography), worse RWMA and a decrease of regional LPSS in basal segments was found for all 3 coronary vessels (**Table 1**). Patients with AH (73%) showed a lower regional LPSS and worse RWMA in all basal segments, with only lateral and posterior ones varying significantly (**Figure 1**). However, regression analysis accounting for AH as a covariant, showed the regional changes in basal segments to be a sole result of coronary disease (**Table 2**). AH was found to have no impact on reliability of LPSS and RWMA in predicting the localization of significant stenosis in NSTE-ACS (average method sensitivities: 59% vs 38%). ### TABLE 1: Regional 2D regional longitudinal peak systolic strain and visual regional wall motion abnormalities assessment according to segments and location of coronary stenosis. | **Segment** | **Lesion location** | **LPSS** **(normal vs pathologic)** | **LPSS Sig.** | **RWMA to CAS** **Correlation** **Coefficient** | **RWMA** **Correlatin** **Sig.** | | --- | --- | --- | --- | --- | --- | | Basal anterior | LAD | -14.1±4.1% vs -12.3±5.4% | 0.044* | 0.232 | 0.032* | | Basal lateral | LCx | -14.7±4.9% vs -10.9±6.5% | 0.001* | 0.262 | 0.015* | | Basal posterior | LCx | -16.2±5.3% vs -12.0±5.7% | <0.001* | 0.354 | 0.001* | | Basal inferior | RCA | -16.3±4.8% vs -11.9±6.3% | <0.001* | 0.163 | 0.133 | | Basal inferoseptum | RCA | -11.5±5.2% vs -10.1±3.8% | 0.139 | 0.186 | 0.087 | | Basal anteroseptum | LAD | -14.4±5.8% vs -12.6±4.9% | 0.076 | 0.179 | 0.098 | [†] RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain; CAS – coronary artery stenosis; LAD – left anterior descending coronary artery; LCx – left circumflex coronary artery; RCA – right coronary artery; * P<0.05 FIGURE 1. Differences in 2D regional longitudinal peak systolic strain in patients with and without arterial hypertension. AH - arterial hypertension; RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain. ### TABLE 2: Multivariable regression analysis models showing interrelation between ratio of longitudinal peak systolic strain and visual regional wall motion abnormalities, and cororonary artery stenosis with arterial hypertension as covariate. | **Segment** | **Lesion location** | **Model 1 (LPSS): Sig. (AH) / Sig. (CAS)** | **Model 2 (RWMA): Sig. (AH) / Sig. (CAS)** | | --- | --- | --- | --- | | Basal anterior | LAD | 0.115 / 0.047* | 0.126 / 0.079 | | Basal lateral | LCx | 0.141 / 0.002* | 0.196 / 0.048* | | Basal posterior | LCx | 0.114 / <0.001* | 0.143 / 0.011* | | Basal inferior | RCA | 0.309 / <0.001* | 0.232 / 0.117 | | Basal inferoseptum | RCA | 0.309 / 0.170 | 0.457 / 0.046* | | Basal anteroseptum | LAD | 0.584 / 0.081 | 0.304 / 0.099 | [†] RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain; AH – arterial hypertension; CAS – coronary artery stenosis; LAD – left anterior descending coronary artery; LCx – left circumflex coronary artery; RCA – right coronary artery; * P<0.05 **Conclusion:** Changes in regional myocardial contractility, detected by either LPSS or RWMA, in patients with NSTE-ACS should be attributed to coronary disease irrespectively of the presence of AH.

    Keywords

    acute coronary syndrome, arterial hypertension, regional wall motion assessment

    DOI

    https://doi.org/10.15836/ccar2018.402

    Literature

    1. Lovrić D, Gašparović K, Rešković Lukšić V, Pašalić M, Došen D, Ljubas Maček J, et al. Comparison of regional 2D strain analysis to visual wall motion abnormality assessment in patients with non-ST elevation acute coronary syndrome. Cardiol Croat. 2017;12(4):119–20. https://doi.org/10.15836/ccar2017.119
    2. Montgomery DE, Puthumana JJ, Fox JM, Ogunyankin KO. Global longitudinal strain aids the detection of non-obstructive coronary artery disease in the resting echocardiogram. Eur Heart J Cardiovasc Imaging. 2012 Jul;13(7):579–87. https://doi.org/10.1093/ejechocard/jer282
    3. Choi JO, Cho SW, Song YB, Cho SJ, Song BG, Lee SC, et al. Longitudinal 2D strain at rest predicts the presence of left main and three vessel coronary artery disease in patients without regional wall motion abnormality. Eur J Echocardiogr. 2009 Jul;10(5):695–701. https://doi.org/10.1093/ejechocard/jep041
    Cardiologia Croatica
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    Influence of arterial hypertension on regional 2D strain analysis in patients with non-ST elevation acute coronary syndrome

    Extended Abstract
    Issue11-12
    Published
    Pages402-403
    PDF via DOIhttps://doi.org/10.15836/ccar2018.402
    acute coronary syndrome
    arterial hypertension
    regional wall motion assessment

    Authors

    Mia Dubravčić*ORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Daniel LovrićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Marijan PašalićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Vlatka Rešković LukšićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Kristina GašparovićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Dejan DošenORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Jana Ljubas MačekORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Zvonimir OstojićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Marija BrestovacORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Davor MiličićORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska
    Jadranka Šeparović HanževačkiORCIDMedicinski fakultet Sveučilišta u Zagrebu, Klinički bolnički centar Zagreb, Zagreb, Hrvatska

    Abstract

    **Background:** In our previous research (1) we have shown 2D analysis of regional longitudinal peak systolic strain (LPSS) to be superior to visual assessment of regional wall motion abnormalities (RWMA) in detection of ischemia-induced loss of myocardial contractility due to non-ST elevation acute coronary syndrome (NSTE-ACS). (2, 3) The reduction of LPSS in basal segments in patients with arterial hypertension (AH) is well documented. The aim of this study was to assess the impact AH has on the accuracy of regional analysis in predicting the localization of significant stenosis in NSTE-ACS. **Methods:** We performed a retrospective analysis of patients admitted to University Hospital Centre Zagreb from January 2013 till December 2015 due to NSTE-ACS. Exclusion criteria were no coronary angiography, absence of ECHO, and prior coronary artery disease. Total of 123 patients (62±12 years, 68% male) were included. 4 blinded clinicians performed regional LPSS analysis using 18-segment model, while RWMA, interpreted by clinician performing the echo, were categorized according to the wall motion score guidelines. **Results:** Significant correlation between flow limiting stenosis (>70% narrowing on angiography), worse RWMA and a decrease of regional LPSS in basal segments was found for all 3 coronary vessels (**Table 1**). Patients with AH (73%) showed a lower regional LPSS and worse RWMA in all basal segments, with only lateral and posterior ones varying significantly (**Figure 1**). However, regression analysis accounting for AH as a covariant, showed the regional changes in basal segments to be a sole result of coronary disease (**Table 2**). AH was found to have no impact on reliability of LPSS and RWMA in predicting the localization of significant stenosis in NSTE-ACS (average method sensitivities: 59% vs 38%). ### TABLE 1: Regional 2D regional longitudinal peak systolic strain and visual regional wall motion abnormalities assessment according to segments and location of coronary stenosis. | **Segment** | **Lesion location** | **LPSS** **(normal vs pathologic)** | **LPSS Sig.** | **RWMA to CAS** **Correlation** **Coefficient** | **RWMA** **Correlatin** **Sig.** | | --- | --- | --- | --- | --- | --- | | Basal anterior | LAD | -14.1±4.1% vs -12.3±5.4% | 0.044* | 0.232 | 0.032* | | Basal lateral | LCx | -14.7±4.9% vs -10.9±6.5% | 0.001* | 0.262 | 0.015* | | Basal posterior | LCx | -16.2±5.3% vs -12.0±5.7% | <0.001* | 0.354 | 0.001* | | Basal inferior | RCA | -16.3±4.8% vs -11.9±6.3% | <0.001* | 0.163 | 0.133 | | Basal inferoseptum | RCA | -11.5±5.2% vs -10.1±3.8% | 0.139 | 0.186 | 0.087 | | Basal anteroseptum | LAD | -14.4±5.8% vs -12.6±4.9% | 0.076 | 0.179 | 0.098 | [†] RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain; CAS – coronary artery stenosis; LAD – left anterior descending coronary artery; LCx – left circumflex coronary artery; RCA – right coronary artery; * P<0.05 FIGURE 1. Differences in 2D regional longitudinal peak systolic strain in patients with and without arterial hypertension. AH - arterial hypertension; RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain. ### TABLE 2: Multivariable regression analysis models showing interrelation between ratio of longitudinal peak systolic strain and visual regional wall motion abnormalities, and cororonary artery stenosis with arterial hypertension as covariate. | **Segment** | **Lesion location** | **Model 1 (LPSS): Sig. (AH) / Sig. (CAS)** | **Model 2 (RWMA): Sig. (AH) / Sig. (CAS)** | | --- | --- | --- | --- | | Basal anterior | LAD | 0.115 / 0.047* | 0.126 / 0.079 | | Basal lateral | LCx | 0.141 / 0.002* | 0.196 / 0.048* | | Basal posterior | LCx | 0.114 / <0.001* | 0.143 / 0.011* | | Basal inferior | RCA | 0.309 / <0.001* | 0.232 / 0.117 | | Basal inferoseptum | RCA | 0.309 / 0.170 | 0.457 / 0.046* | | Basal anteroseptum | LAD | 0.584 / 0.081 | 0.304 / 0.099 | [†] RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain; AH – arterial hypertension; CAS – coronary artery stenosis; LAD – left anterior descending coronary artery; LCx – left circumflex coronary artery; RCA – right coronary artery; * P<0.05 **Conclusion:** Changes in regional myocardial contractility, detected by either LPSS or RWMA, in patients with NSTE-ACS should be attributed to coronary disease irrespectively of the presence of AH.

    Literature

    1. 1.
      Lovrić D, Gašparović K, Rešković Lukšić V, Pašalić M, Došen D, Ljubas Maček J, et al. Comparison of regional 2D strain analysis to visual wall motion abnormality assessment in patients with non-ST elevation acute coronary syndrome. Cardiol Croat. 2017;12(4):119–20.DOI
    2. 2.
      Montgomery DE, Puthumana JJ, Fox JM, Ogunyankin KO. Global longitudinal strain aids the detection of non-obstructive coronary artery disease in the resting echocardiogram. Eur Heart J Cardiovasc Imaging. 2012 Jul;13(7):579–87.DOI
    3. 3.
      Choi JO, Cho SW, Song YB, Cho SJ, Song BG, Lee SC, et al. Longitudinal 2D strain at rest predicts the presence of left main and three vessel coronary artery disease in patients without regional wall motion abnormality. Eur J Echocardiogr. 2009 Jul;10(5):695–701.DOI