Echocardiographic reference ranges for normal left ventricular 2D strain: results from the EACVI NORRE study
01 May 2017-European Journal of Echocardiography (Oxford University Press)-Vol. 18, Iss: 8, pp 833-840
TL;DR: The NORRE study provides contemporary, applicable 2D echocardiographic reference ranges for LV longitudinal, radial, and circumferential strain and highlights the importance of age- and gender-specific reference values for LV strain.
Abstract: Aims - To obtain the normal ranges for 2D echocardiographic (2DE) measurements of left ventricular (LV) strain from a large group of healthy volunteers accounting for age and gender. Methods and results - A total of 549 (mean age: 45.6 ± 13.3 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. 2DE data sets have been analysed with a vendor-independent software package allowing homogeneous measurements irrespective of the echocardiographic equipment used to acquire the data sets. The lowest expected values of LV strains and twist calculated as ± 1.96 standard deviations from the mean were -16.7% in men and -17.8% in women for longitudinal strain, -22.3% and -23.6% for circumferential strain, 20.6% and 21.5% for radial strain, and 2.2 degrees and 1.9 degrees for twist, respectively. In multivariable analysis, longitudinal strain decreased with age whereas the opposite occurred with circumferential and radial strain. Male gender was associated with lower strain for longitudinal, circumferential, and radial strain. Inter-vendor differences were observed for circumferential and radial strain despite the use of vendor-independent software. Importantly, no intervendor differences were noted in longitudinal strain. Conclusion - The NORRE study provides contemporary, applicable 2D echocardiographic reference ranges for LV longitudinal, radial, and circumferential strain. Our data highlight the importance of age- and gender-specific reference values for LV strain.
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Charité1, University of Groningen2, Cardiff University3, University of Rennes4, University of Milan5, National University of Singapore6, University of Liège7, Brigham and Women's Hospital8, Boston University9, Utrecht University10, University of Zurich11, University of Amsterdam12, University of Belgrade13, National and Kapodistrian University of Athens14, University of Cyprus15
TL;DR: A new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm', is recommended, which requires comprehensive echocardiography and requires comprehensive natriuretic peptide levels and is typically performed by a cardiologist.
Abstract: Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1 : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2 : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.
825 citations
University of Liège1, Mie University2, The Heart Research Institute3, François Rabelais University4, Leipzig University5, Hospital Universitario La Paz6, University of Mainz7, French Institute of Health and Medical Research8, University of Rennes9, University of Messina10, University of Padua11, University of Chicago12
TL;DR: The NORRE study provides useful 2DE reference ranges for novel indices of non-invasively derived indices of myocardial work (MW) from a large group of healthy volunteers over a wide range of ages and gender.
Abstract: Aims - To obtain the normal ranges for 2D echocardiographic (2DE) indices of myocardial work (MW) from a large group of healthy volunteers over a wide range of ages and gender. Methods and results - A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from left ventricle (LV) pressure-strain loops. Peak LV systolic pressure was non-invasively derived from brachial artery cuff pressure. The lowest values of MW indices in men and women were 1270 mmHg% and 1310 mmHg% for GWI, 1650 mmHg% and 1544 mmHg% for GCW, and 90% and 91% for GWE, respectively. The highest value for GWW was 238 mmHg% in men and 239 mmHg% in women. Men had significant lower values of GWE and higher values of GWW. GWI and GCW significantly increased with age in women. Conclusion - The NORRE study provides useful 2DE reference ranges for novel indices of non-invasive MW.
178 citations
Cites methods from "Echocardiographic reference ranges ..."
...Global Longitudinal Strain (GLS) was obtained as previously reported.(16) After calculating GLS, inserting values of brachial blood pressure and indicating the time of valvular events by echocardiography, the software derived non-invasive PSLs....
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TL;DR: The NORRE study provides contemporary, applicable echocardiographic reference ranges for LA function and highlights the importance of age-specific reference values for LA functions.
Abstract: Aims - To obtain the normal ranges for echocardiographic measurements of left atrial (LA) function from a large group of healthy volunteers accounting for age and gender. Methods and results - A total of 371 (median age 45 years) healthy subjects were enrolled at 22 collaborating institutions collaborating in the Normal Reference Ranges for Echocardiography (NORRE) study of the European Association of Cardiovascular Imaging (EACVI). Left atrial data sets were analysed with a vendor-independent software (VIS) package allowing homogeneous measurements irrespective of the echocardiographic equipment used to acquire data sets. The lowest expected values of LA function were 26.1%, 48.7%, and 41.4% for left atrial strain (LAS), 2D left atrial emptying fraction (LAEF), and 3D LAEF (reservoir function); 7.7%, 24.2%, and -0.53/s for LAS-active, LAEF-active, and LA strain rate during LA contraction (SRa) (pump function) and 12.0% and 21.6% for LAS-passive and LAEF-passive (conduit function). Left atrial reservoir and conduit function were decreased with age while pump function was increased. All indices of reservoir function and all LA strains had no difference in both gender and vendor. However, inter-vendor differences were observed in LA SRa despite the use of VIS. Conclusion - The NORRE study provides contemporary, applicable echocardiographic reference ranges for LA function. Our data highlight the importance of age-specific reference values for LA functions.
127 citations
TL;DR: The majority of patients present objective data of myocardial injury/dysfunction during or after cancer therapy, but severe CTox, with a strong prognostic relationship, was comparatively rare and should be reflected in protocols for clinical and research practices.
Abstract: AIM Cardiotoxicity (CTox) is a major side effect of cancer therapies, but uniform diagnostic criteria to guide clinical and research practices are lacking. METHODS AND RESULTS We prospectively studied 865 patients, aged 54.7 ± 13.9; 16.3% men, scheduled for anticancer therapy related with moderate/high CTox risk. Four groups of progressive myocardial damage/dysfunction were considered according to current guidelines: normal, normal biomarkers (high-sensitivity troponin T and N-terminal natriuretic pro-peptide), and left ventricular (LV) function; mild, abnormal biomarkers, and/or LV dysfunction (LVD) maintaining an LV ejection fraction (LVEF) ≥50%; moderate, LVD with LVEF 40-49%; and severe, LVD with LVEF ≤40% or symptomatic heart failure. Cardiotoxicity was defined as new or worsening of myocardial damage/ventricular function from baseline during follow-up. Patients were followed for a median of 24 months. Cardiotoxicity was identified in 37.5% patients during follow-up [95% confidence interval (CI) 34.22-40.8%], 31.6% with mild, 2.8% moderate, and 3.1% with severe myocardial damage/dysfunction. The mortality rate in the severe CTox group was 22.9 deaths per 100 patients-year vs. 2.3 deaths per 100 patients-year in the rest of groups, hazard ratio of 10.2 (95% CI 5.5-19.2) (P < 0.001). CONCLUSIONS The majority of patients present objective data of myocardial injury/dysfunction during or after cancer therapy. Nevertheless, severe CTox, with a strong prognostic relationship, was comparatively rare. This should be reflected in protocols for clinical and research practices.
113 citations
TL;DR: Twelve‐month treatment with GLP‐1RA, SGLT‐2i, and their combination showed a greater improvement of vascular markers and effective cardiac work than insulin treatment in type 2 diabetes mellitus.
Abstract: Background We investigated the effects of insulin, glucagon‐like peptide‐1 receptor agonists (GLP‐1RA), sodium‐glucose cotransporter‐2 inhibitors (SGLT‐2i), and their combination on vascular and ca...
82 citations
References
More filters
TL;DR: This document describes the development and use of angiotensin-converting enzyme, a non-volatile substance that acts as a “spatially aggregating substance” to reduce the chances of heart attack in women.
Abstract: 2-D
: two-dimensional
3-D
: three-dimensional
5-FU
: 5-fluorouracil
ACE
: angiotensin-converting enzyme
ARB
: angiotensin II receptor blocker
ASE
: American Society of Echocardiography
BNP
: B-type natriuretic peptide
CABG
: coronary artery bypass graft
CAD
: coronary artery
1,875 citations
TL;DR: No abstract available Keywords: European Society of Cardiology; arrhythmias; cancer therapy; cardio-oncology; cardiotoxicity; chemotherapy; early detection; ischaemia; myocardial dysfunction; surveillance.
Abstract: No abstract available
Keywords: European Society of Cardiology; arrhythmias; cancer therapy; cardio-oncology; cardiotoxicity; chemotherapy; early detection; ischaemia; myocardial dysfunction; surveillance.
1,421 citations
Cleveland Clinic1, MedStar Washington Hospital Center2, University of Texas Health Science Center at Houston3, University of Pennsylvania4, Harvard University5, McMaster University6, McGill University7, University of Padua8, European Institute of Oncology9, University of Chicago10, Oslo University Hospital11, Temple University12, University of Liège13, Memorial Sloan Kettering Cancer Center14, Menzies Research Institute15, Mayo Clinic16
TL;DR: The noninvasive evaluation of LVEF has gained importance, and notwithstanding the limitations of the techniques used for its calculation, has emerged as the most widely used strategy for monitoring the changes in cardiac function, both during and after the administration of potentially car- diotoxic cancer treatment.
Abstract: Cardiac dysfunction resulting from exposure to cancer therapeutics
was first recognized in the 1960s, with the widespread introduction
of anthracyclines into the oncologic therapeutic armamentarium.
Heart failure (HF) associated with anthracyclines was then recognized
as an important side effect. As a result, physicians learned to limit their
doses to avoid cardiac dysfunction. Several strategies have been used
over the past decades to detect it. Two of them evolved over time
to be very useful: endomyocardial biopsies and monitoring of left ven-
tricular (LV) ejection fraction (LVEF) by cardiac imaging. Examination
of endomyocardial biopsies proved to be the most sensitive and spe-
cific parameter for the identification of anthracycline-induced LV
dysfunction and became the gold standard in the 1970s. However,
the interest in endomyocardial biopsy has diminished over time
because of the reduction in the cumulative dosages used to treat ma-
lignancies, the invasive nature of the procedure, and the remarkable
progress made in noninvasive cardiac imaging. The noninvasive
evaluation of LVEF has gained importance, and notwithstanding the
limitations of the techniques used for its calculation, has emerged as
the most widely used strategy for monitoring the changes in cardiac
function, both during and after the administration of potentially car-
diotoxic cancer treatment.
1,316 citations
The Catholic University of America1, Icahn School of Medicine at Mount Sinai2, University of Trieste3, GE Healthcare4, Menzies Research Institute5, Siemens6, Hitachi7, Toshiba Medical Systems Corporation8, Philips9, University of Michigan10, University of Massachusetts Medical School11, Cleveland Clinic12, University of Padua13
TL;DR: This technical document is intended to provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocardiography and thus create a common standard.
Abstract: Recognizing the critical need for standardization in strain imaging, in 2010, the European Association of Echocardiography (now the European Association of Cardiovascular Imaging, EACVI) and the American Society of Echocardiography (ASE) invited technical representatives from all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. As an initial product of the work of the EACVI/ASE/Industry initiative to standardize deformation imaging, we prepared this technical document which is intended to provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocardiography and thus create a common standard.
1,032 citations
"Echocardiographic reference ranges ..." refers methods in this paper
...All strains were calculated over the entire cardiac wall.(16) LV twist was defined as the net difference between apical and basal rotations....
[...]
Cleveland Clinic1, MedStar Washington Hospital Center2, University of Texas Health Science Center at Houston3, University of Pennsylvania4, Harvard University5, McMaster University6, McGill University7, University of Padua8, European Institute of Oncology9, University of Chicago10, Oslo University Hospital11, Temple University12, University of Liège13, Memorial Sloan Kettering Cancer Center14, Menzies Research Institute15, Mayo Clinic16
TL;DR: The non-invasive evaluation of LVEF has gained importance, and notwithstanding the limitations of the techniques used for its calculation, has emerged as the most widely used strategy for monitoring the changes in cardiac function, both during and after the administration of potentially cardiotoxic cancer treatment.
Abstract: ### A. Definition, classification, and mechanisms of toxicity
Cardiac dysfunction resulting from exposure to cancer therapeutics was first recognized in the 1960s, with the widespread introduction of anthracyclines into the oncological therapeutic armamentarium.1 Heart failure (HF) associated with anthracyclines was then recognized as an important side effect. As a result, physicians learned to limit their doses to avoid cardiac dysfunction.2 Several strategies have been used over the past decades to detect it. Two of them evolved over time to be very useful: endomyocardial biopsies and monitoring of left ventricular (LV) ejection fraction (LVEF) by cardiac imaging. Examination of endomyocardial biopsies proved to be the most sensitive and specific parameter for the identification of anthracycline-induced LV dysfunction and became the gold standard in the 1970s. However, the interest in endomyocardial biopsy has diminished over time because of the reduction in the cumulative dosages used to treat malignancies, the invasive nature of the procedure, and the remarkable progress made in non-invasive cardiac imaging. The non-invasive evaluation of LVEF has gained importance, and notwithstanding the limitations of the techniques used for its calculation, has emerged as the most widely used strategy for monitoring the changes in cardiac function, both during and after the administration of potentially cardiotoxic cancer treatment.3–5
The timing of LV dysfunction can vary among agents. In the case of anthracyclines, the damage occurs immediately after the exposure;6 for others, the time frame between drug administration and detectable cardiac dysfunction appears to be more variable. Nevertheless, the heart has significant cardiac reserve, and the expression of damage in the form of alterations in systolic or diastolic parameters may not be overt until a substantial amount of cardiac reserve has been exhausted. Thus, cardiac damage may not become apparent until years or even decades after receiving the cardiotoxic treatment. This is particularly applicable to …
920 citations
"Echocardiographic reference ranges ..." refers background in this paper
...Therefore, global longitudinal strain is recommended as a routine measurement in patients undergoing chemotherapy.(7) Although normal range of LV strains has been derived from meta-analysis,(8) the inter-vendor variability, in particular, for circumferential and radial strain remain unknown....
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