Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
German Center for Cardiovascular Research (DZHK), partner site Rhine-Main, Mainz, Germany.
JAMA Cardiol. 2021 Apr 1;6(4):448-456. doi: 10.1001/jamacardio.2020.7184.
Global longitudinal strain (GLS) is an emerging echocardiographic biomarker of cardiac function in heart failure (HF). Evidence from large-scale studies comprehensively investigating GLS for its association with clinical phenotypes and mortality in asymptomatic and symptomatic chronic HF is limited.
To assess the factors associated with GLS and its prognostic value in patients with chronic HF.
DESIGN, SETTING, AND PARTICIPANTS: The observational, prospective MyoVasc cohort study enrolled 3289 individuals with asymptomatic to symptomatic HF between January 17, 2013, and April 27, 2018. The median follow-up was 3.2 years (interquartile range, 2.0-4.0 years). Participants with stages A to D HF according to American Heart Association (AHA) criteria were examined at a dedicated study center. Echocardiography was performed with GLS measurement by independent reviewers. Data were analyzed from September 2, 2019, to January 15, 2020.
All-cause and cardiac mortality were recorded by structured follow-up and validated via death certificates.
In the study sample, data on GLS were available on 2440 individuals, of whom 2186 (mean [SD] age, 65.0 [10.5] years; 1418 [64.9%] men) were classified as having AHA HF stages A to D. Mean (SD) GLS worsened across AHA stages from stage A (n = 434; -19.44 [3.15%]) to stage B (n = 629; -18.01 [3.46%]) to stages C/D (n = 1123; -15.52 [4.64%]). Age (β = -0.27; 95% CI, -0.47 to -0.067; per decade, P = .009), female sex (β = -1.2; 95% CI, -1.6 to -0.77; per decade, P < .001), obesity (β = 0.64; 95% CI, 0.25-1.0; P = .001), atrial fibrillation (β = 1.2; 95% CI, 0.69-1.6; P < .001), myocardial infarction (β = 1.5; 95% CI, 1.00-2.1; P < .001), and estimated glomerular filtration rate (β = -0.53; 95% CI, -0.73 to -0.32; per SD, P < .001) were independently associated with GLS in multivariable regression analysis. Global longitudinal strain was associated with the severity of HF as reflected by N-terminal prohormone B-type natriuretic protein (NT-proBNP) levels after additionally adjusting for cardiac structure and function (P < .001). During follow-up, GLS was associated with all-cause mortality (hazard ratio [HR] per SD, 1.55; 95% CI, 1.19-2.01; P < .001) and cardiac death (HR per SD, 2.32; 95% CI, 1.57-3.42; P < .001) independent of image quality, observer variability, clinical profile, HF medications, NYHA class, and cardiac structure and function. After further adjustment for the NT-proBNP level, GLS remained associated with cardiac death (HR per SD, 1.60; 95% CI, 1.07-2.41; P = .02) but not all-cause mortality (HR per SD, 1.26; 95% CI, 0.95-1.66; P = .11).
In patients with chronic HF, GLS was associated with clinical and cardiac status, reflected neurohormonal activation, and was associated with cardiac mortality independent of clinical and cardiac status. These findings suggest that GLS may serve as a useful tool to improve risk stratification in patients with HF.
重要性： 全球纵向应变（GLS）是心力衰竭（HF）心脏功能的新兴超声心动图生物标志物。关于 GLS 与无症状和有症状的慢性 HF 的临床表型和死亡率的关联的大型研究的证据有限。
目的： 评估慢性 HF 患者 GLS 相关的因素及其预后价值。
设计、地点和参与者： 这项观察性、前瞻性的 MyoVasc 队列研究纳入了 2013 年 1 月 17 日至 2018 年 4 月 27 日期间无症状至有症状 HF 的 3289 名个体。中位随访时间为 3.2 年（四分位距，2.0-4.0 年）。根据美国心脏协会（AHA）标准，在专门的研究中心检查 HF 处于 A 期到 D 期的患者。由独立的审查者进行超声心动图检查并测量 GLS。数据分析于 2019 年 9 月 2 日至 2020 年 1 月 15 日进行。
主要结果和措施： 通过结构随访记录全因和心脏死亡率，并通过死亡证明进行验证。
结果： 在研究样本中，2440 名个体提供了 GLS 数据，其中 2186 名（平均[标准差]年龄，65.0[10.5]岁；1418[64.9%]为男性）被分类为 AHA HF 处于 A 期到 D 期。随着 AHA 阶段的进展，GLS 逐渐恶化，从 A 期（n=434；-19.44[3.15%]）到 B 期（n=629；-18.01[3.46%]），再到 C/D 期（n=1123；-15.52[4.64%]）。年龄（β=-0.27；95%CI，-0.47 至-0.067；每十年，P=0.009）、女性（β=-1.2；95%CI，-1.6 至-0.77；每十年，P<0.001）、肥胖（β=0.64；95%CI，0.25-1.0；P=0.001）、心房颤动（β=1.2；95%CI，0.69-1.6；P<0.001）、心肌梗死（β=1.5；95%CI，1.00-2.1；P<0.001）和估计肾小球滤过率（β=-0.53；95%CI，-0.73 至-0.32；每 SD，P<0.001）在多变量回归分析中与 GLS 独立相关。GLS 与 NT-proBNP 水平反映的 HF 严重程度相关，在进一步调整心脏结构和功能后（P<0.001）。在随访期间，GLS 与全因死亡率（每 SD 的 HR，1.55；95%CI，1.19-2.01；P<0.001）和心脏死亡（每 SD 的 HR，2.32；95%CI，1.57-3.42；P<0.001）相关，与图像质量、观察者变异性、临床特征、HF 药物、NYHA 分级以及心脏结构和功能无关。在进一步调整 NT-proBNP 水平后，GLS 仍然与心脏死亡相关（每 SD 的 HR，1.60；95%CI，1.07-2.41；P=0.02），但与全因死亡率无关（每 SD 的 HR，1.26；95%CI，0.95-1.66；P=0.11）。
结论和相关性： 在慢性 HF 患者中，GLS 与临床和心脏状况相关，反映神经激素激活，并与心脏死亡相关，与临床和心脏状况无关。这些发现表明，GLS 可能是一种有用的工具，可用于改善 HF 患者的风险分层。
