Baker Heart and Diabetes Institute, Melbourne, Australia; Cardiology Department, Western Health, Melbourne, Australia; Department of Medicine; and University of Melbourne, Melbourne, Australia.
Baker Heart and Diabetes Institute, Melbourne, Australia; Cardiology Department, Western Health, Melbourne, Australia; Department of Medicine; and University of Melbourne, Melbourne, Australia.
J Am Soc Echocardiogr. 2022 Feb;35(2):187-195. doi: 10.1016/j.echo.2021.09.003. Epub 2021 Sep 8.
Heart failure (HF) remains a common complication for patients with coronary artery disease (CAD), especially after acute myocardial infarction. Although left ventricular ejection fraction (LVEF) is conventionally used to assess cardiac function for risk stratification, it has been shown in other settings to underestimate the risk of HF compared with global longitudinal strain (GLS). Moreover, most evidence pertains to early-onset HF. We sought the clinical and myocardial predictors for late-onset HF in patients with CAD.
We analyzed echocardiograms (including GLS) in 334 patients with CAD (ages 65 ± 11 years, 77% male) who were enrolled in the Nurse-Led Intervention for Less Chronic Heart Failure trial, a prospective, randomized controlled trial that compared standard care with nurse-led intervention to prevent HF in individuals at risk of incident HF. Long-term (9 years) follow-up was obtained via data linkage. Analysis was performed using a competing-risk model.
Baseline LVEF values were normal or mildly impaired (LVEF ≥ 40%) in all subjects. After a median of 9 years of follow-up, 50 (15%) of the 334 patients had new HF admissions, and 68 (20%) died. In a competing-risk model, HF was associated with GLS (hazard ratio = 1.15 [1.05-1.25], P = .001), independent of estimated glomerular filtration rate (hazard ratio = 0.98 [0.97-0.99], P = .045), Charlson comorbidity score (hazard ratio = 1.64 [1.25-2.15], P < .001), or E/e' (hazard ratio = 1.08 [1.02-1.14], P = .01). Global longitudinal strain-but not conventional echocardiographic measures-added incremental value to a clinical model based on age, gender, and Charlson score (area under the curve, 0.78-0.83, P = .01). Global longitudinal strain was still associated with HF development in patients taking baseline angiotensin convertase enzyme inhibitors (hazard ratio = 1.21 [1.11-1.31], P < .01) and baseline beta-blockers (1.17 [1.09, 1.26]; P < .01). Mortality was associated with older men, risk factors (hypertension or diabetes), and comorbidities (AF and chronic kidney disease).
Global longitudinal strain is independently associated with risk of incident HF in patients admitted with CAD and provides incremental prognostic value to standard markers. Identifying an at-risk subgroup using GLS may be the focus of future randomized controlled trails to enable targeted therapeutic intervention.
心力衰竭（HF）仍然是冠心病（CAD）患者的常见并发症，尤其是在急性心肌梗死后。尽管左心室射血分数（LVEF）常用于评估心脏功能以进行风险分层，但在其他情况下，与整体纵向应变（GLS）相比，它被证明低估了 HF 的风险。此外，大多数证据都涉及早发性 HF。我们研究了 CAD 患者中迟发性 HF 的临床和心肌预测因素。
我们分析了 334 例 CAD 患者（年龄 65±11 岁，77%为男性）的超声心动图（包括 GLS），这些患者参加了护士主导的干预以减少慢性心力衰竭试验，这是一项前瞻性、随机对照试验，比较了标准护理与护士主导的干预措施，以预防有 HF 风险的个体发生 HF。通过数据链接获得了长达 9 年的长期随访。使用竞争风险模型进行分析。
所有患者的基线 LVEF 值均正常或轻度受损（LVEF≥40%）。中位随访 9 年后，334 例患者中有 50 例（15%）出现新发 HF 入院，68 例（20%）死亡。在竞争风险模型中，HF 与 GLS 相关（危险比=1.15[1.05-1.25]，P=0.001），与估计肾小球滤过率（危险比=0.98[0.97-0.99]，P=0.045）、Charlson 合并症评分（危险比=1.64[1.25-2.15]，P<0.001）或 E/e'（危险比=1.08[1.02-1.14]，P=0.01）独立相关。GLS-而非传统的超声心动图指标-在基于年龄、性别和 Charlson 评分的临床模型中增加了增量价值（曲线下面积，0.78-0.83，P=0.01）。在服用基线血管紧张素转换酶抑制剂（危险比=1.21[1.11-1.31]，P<0.01）和基线β受体阻滞剂（1.17[1.09,1.26]；P<0.01）的患者中，GLS 仍与 HF 发展相关。死亡率与年龄较大的男性、危险因素（高血压或糖尿病）和合并症（AF 和慢性肾脏病）相关。
GLS 与 CAD 入院患者 HF 发病风险独立相关，并为标准标志物提供了增量预后价值。使用 GLS 识别高危亚组可能是未来随机对照试验的重点，以便能够进行针对性的治疗干预。
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