Left ventricular (LV) diastolic filling is characterized by the formation of intraventricular rotational bodies of fluid (termed "vortex rings") that optimize the efficiency of LV ejection. The aim... Show moreLeft ventricular (LV) diastolic filling is characterized by the formation of intraventricular rotational bodies of fluid (termed "vortex rings") that optimize the efficiency of LV ejection. The aim of the present study was to evaluate the morphology and dynamics of LV diastolic vortex ring formation early after acute myocardial infarction (AMI), in relation to LV diastolic function and infarct size. A total of 94 patients with a first ST-segment elevation AMI (59 +/- 11 years; 78% men) were included. All patients underwent primary percutaneous coronary intervention. After 48 hours, the following examinations were performed: 2-dimensional echocardiography with speckle-tracking analysis to assess the LV systolic and diastolic function, the vortex formation time (VFT, a dimensionless index for characterizing vortex formation), and the LV untwisting rate; contrast echocardiography to assess LV vortex morphology; and myocardial contrast echocardiography to identify the infarct size. Patients with a large infarct size LV segments) had a significantly lower VFT (p < 0.001) and vortex sphericity index (p <0.001). On univariate analysis, several variables were significantly related to the VFT, including anterior AMI, LV end-systolic volume, LV ejection fraction, grade of diastolic dysfunction, LV untwisting rate, and infarct size. On multivariate analysis, the LV untwisting rate (beta = -0.43, p <0.001) and infarct size (beta = -0.33, p = 0.005) were independently associated with VFT. In conclusion, early in AMI, both the LV infarct size and the mechanical sequence of diastolic restoration play key roles in modulating the morphology and dynamics of early diastolic vortex ring formation. (C) 2010 Elsevier Inc. All rights reserved. (Am J Cardiol 2010;106:1404-1409) Show less
Shanks, M.; Bertini, M.; Delgado, V.; Ng, A.C.T.; Nucifora, G.; Bommel, R.J. van; ... ; Bax, J.J. 2010
Objectives This study sought to examine the changes in diastolic dyssynchrony with cardiac resynchronization therapy (CRT). Background Little is known about the effect of CRT on diastolic... Show moreObjectives This study sought to examine the changes in diastolic dyssynchrony with cardiac resynchronization therapy (CRT). Background Little is known about the effect of CRT on diastolic dyssynchrony. Methods Consecutive heart failure patients (n = 266, age 65.7 +/- 10.0 years) underwent color-coded tissue Doppler imaging at baseline, 48 h, and 6 months after CRT. Systolic and diastolic dyssynchrony were defined as maximal time delay in peak systolic and early diastolic velocities, respectively, in 4 basal LV segments. CRT responders were defined as those with >= 15% decrease in LV end-systolic volume at 6 months. Results Baseline LVEF was 25.2 +/- 8.1%; 63.5% patients were CRT responders. Baseline incidence of systolic and diastolic dyssynchrony, and a combination of both was 46.2%, 51.9%, and 28.6%, respectively. Compared to nonresponders, responders had longer baseline systolic (79.2 +/- 43.4 ms vs. 45.4 +/- 30.4 ms; p < 0.001) and diastolic (78.5 +/- 52.0 ms vs. 50.1 +/- 38.2 ms; p < 0.001) delays. In follow-up, systolic delays (45.4 +/- 31.6 ms at 48 h; 38.9 +/- 26.2 ms at 6 months; p < 0.001) and diastolic delays (49.4 +/- 36.3 ms at 48 h; 37.7 +/- 26.0 ms at 6 months; p < 0.001) improved only in responders. Conclusions At baseline: 1) diastolic dyssynchrony was more common than systolic dyssynchrony in HF patients; 2) nonresponders had less baseline diastolic dyssynchrony compared to responders. After CRT: 1) diastolic dyssynchrony improved only in responders. Further insight into the pathophysiology of diastolic dyssynchrony and its changes with CRT may provide incremental information on patient-specific treatments. (J Am Coll Cardiol 2010;56:1567-75) (C) 2010 by the American College of Cardiology Foundation Show less
Shanks, M.; Siebelink, H.M.J.; Delgado, V.; Veire, N.R.L. van de; Ng, A.C.T.; Sieders, A.; ... ; Bax, J.J. 2010
BACKGROUND quantification of mitral regurgitation severity with 2-dimensional (2D) imaging techniques remains challenging. The present study compared the accuracy of 2D transesophageal... Show moreBACKGROUND quantification of mitral regurgitation severity with 2-dimensional (2D) imaging techniques remains challenging. The present study compared the accuracy of 2D transesophageal echocardiography (TEE) and 3-dimensional (3D) TEE for quantification of mitral regurgitation, using MRI as the reference method. METHODS AND RESULTS two-dimensional and 3D TEE and cardiac MRI were performed in 30 patients with mitral regurgitation. Mitral effective regurgitant orifice area (EROA) and regurgitant volume (Rvol) were estimated with 2D and 3D TEE. With 3D TEE, EROA was calculated using planimetry of the color Doppler flow from en face views and Rvol was derived by multiplying the EROA by the velocity time integral of the regurgitant jet. Finally, using MRI, mitral Rvol was quantified by subtracting the aortic flow volume from left ventricular stroke volume. Compared with 3D TEE, 2D TEE underestimated the EROA by a mean of 0.13 cm(2). In addition, 2D TEE underestimated the Rvol by 21.6% when compared with 3D TEE and by 21.3% when compared with MRI. In contrast, 3D TEE underestimated the Rvol by only 1.2% when compared with MRI. Finally, one third of the patients in grade 1 and ≥50% of the patients in grade 2 and 3, as assessed with 2D TEE, would have been upgraded to a more severe grade, based on the 3D TEE and MRI measurements. CONCLUSIONS quantification of mitral EROA and Rvol with 3D TEE is feasible and accurate as compared with MRI and results in less underestimation of the Rvol as compared with 2D TEE. Show less
Background Quantification of segmental left ventricular (LV) strain by speckle-tracking echocardiography can identify transmural infarcts in patients with chronic ischemic cardiomyopathy. The aim... Show moreBackground Quantification of segmental left ventricular (LV) strain by speckle-tracking echocardiography can identify transmural infarcts in patients with chronic ischemic cardiomyopathy. The aim of the study was to explore the relationship between the LV longitudinal peak systolic strain (LPSS) of the infarct, periinfarct, and remote zones and monomorphic ventricular tachycardia (VT) inducibility on electrophysiologic (EP) study. Methods A total of 134 patients with chronic ischemic cardiomyopathy scheduled for EP study were included. The protocol consisted of clinical, electrocardiographic, and echocardiographic evaluation, including LV longitudinal strain analysis using speckle-tracking echocardiography, immediately before EP study. An infarct segment was defined as a longitudinal strain value of greater than -5%, and a periinfarct segment was defined as immediately adjacent to an infarct segment. Results The infarct zone had the most impaired longitudinal strain (-0.5% +/- 3.0%), whereas the periinfarct and remote zones had more preserved longitudinal strain (-10.8% +/- 1.9% and -14.5% +/- 3.0%, respectively; analysis of variance, P < .001). Seventy-two (54%) patients had inducible monomorphic VT on EP study. There was no significant difference in LV ejection fraction (31% +/- 9% vs 32% +/- 11%, P = .29) between inducible and noninducible patients. Longitudinal peak systolic strain of the periinfarct zone was more impaired in inducible patients (-9.8% +/- 1.5% vs -11.0% +/- 2.1%, P = .001), but no differences in LPSS of the infarct (-0.5% +/- 3.2% vs -0.4% +/- 2.7%, P = .75) and remote (-14.6% +/- 2.8% vs -14.5% +/- 3.4%, P = .92) zones were observed. Only LPSS of the periinfarct zone (OR 1.43, 95% CI 1.15-1.78, P = .001) was independently related to monomorphic VT inducibility on multiple logistic regression. Conclusions Longitudinal strain analysis may be a useful imaging tool to risk stratify ischemic patients for malignant ventricular arrhythmia. (Am Heart J 2010; 160: 729-36.) Show less
Background Although most patients who improve in clinical status after cardiac resynchronization therapy (CRT) also show a significant left ventricular (LV) reverse remodeling, some patients do not... Show moreBackground Although most patients who improve in clinical status after cardiac resynchronization therapy (CRT) also show a significant left ventricular (LV) reverse remodeling, some patients do not show echocardiographic improvement. The aim of the present study was to evaluate the degree of agreement between clinical and echocardiographic response to CRT in a large cohort of heart failure patients, and to evaluate the characteristics of patients with clinical response but without echocardiographic response. Methods In 440 consecutive heart failure patients (mean age 66 +/- 11 years, 81% men) treated with CRT, agreement between clinical and echocardiographic responses at 6 months of follow-up were evaluated. The combined clinical response was defined as: >= 1-point New York Heart Association functional class improvement or >= 15% increase in 6-minute walk test. Echocardiographic response was defined by a reduction in LV end-systolic volume (LVESV) >= 15%. Results At 6 months of follow-up, clinical response was observed in 84% (n = 370) of the patients. Significant reduction in LVESV was noted in 63% (n = 276). The majority of patients who improved clinically did show LV reverse remodeling (72%, n = 268). Importantly, 28% (n = 102) of patients who improved clinically did not show significant LV reverse remodeling. The patients with clinical response but without echocardiographic response had more often ischemic heart failure as compared to patients with positive clinical and echocardiographic response (69.6% vs 57.5%; P = .021). Moreover, patients with such discordant responses had more narrow QRS complex (148 +/- 31 vs 159 +/- 31 milliseconds; P = .004), and showed less LV dyssynchrony than patients with concordant positive responses (90 +/- 77 vs 171 +/- 105 milliseconds; P < .001). Conclusions Although there is a good concordance between echocardiographic and clinical response to CRT, up to 28% of the population experienced clinical response without significant LV reverse remodeling. Subjects with such discrepant responses have more frequently ischemic heart failure and show more narrow QRS complex and less LV dyssynchrony than patients with both clinical and echocardiographic response. (Am Heart J 2010; 160: 737-43.) Show less
Bertini, M.; Borleffs, C.J.W.; Delgado, V.; Ng, A.C.T.; Piers, S.R.D.; Shanks, M.; ... ; Veire, N.R.L. van de 2010
Heart failure and atrial fibrillation (AF) frequently coexist and AF worsens heart failure prognosis. Device-based diagnostics derived from implantable cardioverter-defibrillator (ICD)... Show moreHeart failure and atrial fibrillation (AF) frequently coexist and AF worsens heart failure prognosis. Device-based diagnostics derived from implantable cardioverter-defibrillator (ICD) interrogation provide an accurate method for detecting AF episodes. This study sought to determine clinical and echocardiographic predictors of AF occurrence, including an index of total atrial conduction time derived by tissue Doppler imaging (PA-TDI duration), in patients with heart failure. Moreover, the role of PA-TDI duration on the prediction of AF occurrence in subgroups of patients with and without history of AF was explored. A cohort of 495 heart failure patients who underwent ICD implantation was studied. Baseline echocardiographic parameters of systolic and diastolic function were evaluated together with clinical parameters. Furthermore, PA-TDI duration was measured. All patients were prospectively followed up after ICD implantation for AF occurrence detected by ICD interrogation. A total of 142 (29%) patients experienced AF over a follow-up period of 16.4 +/- 11.2 months. PA-TDI duration was longer in patients with AF occurrence when compared with patients without AF occurrence (154 +/- 27 vs. 135 +/- 24 ms, P < 0.001). On Cox-multivariable analysis, female gender [hazard ratio = 1.60; 95% confidence intervals (CI) = 1.09-2.35; P = 0.017], history of AF (hazard ratio = 2.22; 95% CI, 1.51-3.27; P < 0.001), and PA-TDI duration (hazard ratio = 1.27; 95% CI, 1.13-1.42; P < 0.001) were independent predictors of AF occurrence. In the subgroups of patients with and without history of AF, PA-TDI duration remained an independent predictor of AF occurrence. PA-TDI duration may be useful to risk-stratify for AF occurrence in heart failure patients with and without a history of AF. Show less
Background: Subclinical hyperthyroidism is associated with cardiovascular morbidity. Recent advances in echocardiography imaging have allowed sophisticated evaluation of myocardial tissue... Show moreBackground: Subclinical hyperthyroidism is associated with cardiovascular morbidity. Recent advances in echocardiography imaging have allowed sophisticated evaluation of myocardial tissue properties. Objective: To investigate the myocardial effects of long-term exogenous subclinical hyperthyroidism using two-dimensional speckle tracking echocardiography imaging (2D-STE). Design: Prospective, single-blinded, placebo-controlled randomized trial of 6 months duration with two parallel groups. Patients and methods: Totally 25 patients with a history of differentiated thyroid carcinoma on long-term TSH-suppressive levothyroxine (L-T-4) substitution were randomized to persistent TSH-suppressive L-T4 substitution (low-TSH group) or restoration of euthyroidism. Additionally 40 euthyroid controls were studied. Results (proposal): At baseline, the group of patients showed normal left ventricular (LV) systolic function but impaired diastolic function as assessed with conventional echocardiographic parameters. Importantly, 2D-STE analysis demonstrated the presence of subclinical LV systolic and diastolic dysfunction with impaired circumferential and longitudinal strain and strain rate at the isovolumic relaxation time. After restoration of euthyroidism, a significant improvement in LV systolic and diastolic function as assessed with 2D-STE strain was observed. Conclusion: Prolonged subclinical hyperthyroidism leads to systolic and diastolic dysfunction, which is reversible after restoration of euthyroidism. 2D-STE is a more sensitive technique to evaluate subtle changes in LV performance of these patients. Show less
Shanks, M.; Delgado, V.; Bertini, M.; Ng, A.C.T.; Nucifora, G.; Bommel, R.J. van; ... ; Bax, J.J. 2010
The analysis of left ventricular (LV) mechanics provides novel insights into the effects of cardiac resynchronization therapy (CRT) on LV performance. Currently, advances in speckle-tracking... Show moreThe analysis of left ventricular (LV) mechanics provides novel insights into the effects of cardiac resynchronization therapy (CRT) on LV performance. Currently, advances in speckle-tracking echocardiographic analysis have permitted the characterization of subendocardial and subepicardial LV twist. The aim of this study was to investigate the role of the acute changes in subendocardial and subepicardial LV twist for the prediction of midterm beneficial effects of CRT. A total of 84 patients with heart failure scheduled for CRT were recruited. All patients underwent echocardiography before and <48 hours after CRT implantation and at 6-month follow-up. The assessment of LV volumes, ejection fractions, and mechanical dyssynchrony (systolic dyssynchrony index) was performed with real-time 3-dimensional echocardiography. The assessment of subendocardial and subepicardial LV twist was performed with 2-dimensional speckle-tracking echocardiography. A favorable outcome was defined as the occurrence of a reduction -15% in LV end-systolic volume associated with an improvement of >= 1 New York Heart Association functional class at 6-month follow-up. At 6-month follow-up, 53% of the patients showed favorable outcomes. Ischemic cause of heart failure, baseline systolic dyssynchrony index, immediate improvement in the LV ejection fraction, immediate improvement in systolic dyssynchrony index, and immediate improvement in subendocardial and subepicardial LV twist were significantly related to favorable outcomes. However, in multivariate logistic regression analysis, only the immediate improvement of subepicardial LV twist was independently related to favorable outcomes (odds ratio 2.31, 95% confidence interval 1.29 to 4.15, p = 0.005). Furthermore, the immediate improvement of subepicardial LV twist had incremental value over established parameters. In conclusion, the immediate improvement of subepicardial LV twist (but not subendocardial LV twist) is independently related to favorable outcomes after CRT. (C) 2010 Elsevier Inc. All rights reserved. (Am J Cardiol 2010;106:682-687) Show less
Delgado, V.; Ng, A.C.T.; Veire, N.R. van de; Kley, F. van der; Schuijf, J.D.; Tops, L.F.; ... ; Bax, J.J. 2010
Aortic regurgitation after transcatheter aortic valve implantation (TAVI) is one of the most frequent complications. However, the underlying mechanisms of this complication remain unclear. The... Show moreAortic regurgitation after transcatheter aortic valve implantation (TAVI) is one of the most frequent complications. However, the underlying mechanisms of this complication remain unclear. The present evaluation studied the anatomic and morphological features of the aortic valve annulus that may predict aortic regurgitation after TAVI. In 53 patients with severe aortic stenosis undergoing TAVI, multi-detector row computed tomography (MDCT) assessment of the aortic valve apparatus was performed. For aortic valve annulus sizing, two orthogonal diameters were measured (coronal and sagittal). In addition, the extent of valve calcifications was quantified. At 1-month follow-up after procedure, MDCT was repeated to evaluate and correlate the prosthesis deployment to the presence of aortic regurgitation. Successful procedure was achieved in 48 (91%) patients. At baseline, MDCT demonstrated an ellipsoid shape of the aortic valve annulus with significantly larger coronal diameter when compared with sagittal diameter (25.1 +/- 2.4 vs. 22.9 +/- 2.0 mm, P < 0.001). At follow-up, MDCT showed a non-circular deployment of the prosthesis in six (14%) patients. Moderate post-procedural aortic regurgitation was observed in five (11%) patients. These patients showed significantly larger aortic valve annulus (27.3 +/- 1.6 vs. 24.8 +/- 2.4 mm, P = 0.007) and more calcified native valves (4174 +/- 1604 vs. 2444 +/- 1237 HU, P = 0.005) at baseline and less favourable deployment of the prosthesis after TAVI. Multi-detector row computed tomography enables an accurate sizing of the aortic valve annulus and constitutes a valuable imaging tool to evaluate prosthesis location and deployment after TAVI. In addition, MDCT helps to understand the underlying mechanisms of post-procedural aortic regurgitation. Show less
Shanks, M.; Ng, A.C.T.; Veire, N.R.L. van de; Antoni, M.L.; Bertini, M.; Delgado, V.; ... ; Bax, J.J. 2010
This study examined the prognostic value of novel diastolic indexes in ST-elevation acute myocardial infarction (AMI), derived from strain and strain rate analysis using 2-dimensional speckle... Show moreThis study examined the prognostic value of novel diastolic indexes in ST-elevation acute myocardial infarction (AMI), derived from strain and strain rate analysis using 2-dimensional speckle tracking imaging. Echocardiograms were obtained within 48 hours of admission in 371 consecutive patients with first ST-elevation AMI (59.7 +/- 11.6 years old). Indexes of diastolic function including mean strain rate during isovolumic relaxation (SRIVR), mean early diastolic strain rate (SRE) and mean diastolic strain at peak transmitral E wave (E) were obtained from 3 apical views. Mean early diastolic velocity from 4 basal segments by color-coded tissue Doppler imaging was measured. Indexes of diastolic filling including E/SRIVR, E/SRE, E/diastolic strain at E, and E/early diastolic velocity were calculated. The primary end point (composite of death, hospitalization for heart failure, repeat MI, and repeat revascularization) occurred in 84 patients (22.6%) during a mean follow-up of 17.3 +/- 12.2 months. Mean SRIVR (p < 0.001), multivessel disease (p < 0.001), Thrombolysis In Myocardial Infarction grade 0 to 1 flow after percutaneous coronary intervention (p = 0.004), and left ventricular ejection fraction (p = 0.008) were independent predictors of the combined end point on Cox regression analysis. Mean SRIVR showed incremental prognostic value over baseline clinical and echocardiographic variables (global chi-square increase from 41.0 to 51.6, p < 0.001). After dividing patient population based on median SRIVR, patients with SRIVR <= 0.24/second had significantly higher event rates than others (hazard ratio 2.74, 95% confidence interval 1.61 to 4.67, p < 0.001). In conclusion, SRIVR was incremental to left ventricular ejection fraction, Thrombolysis In Myocardial Infarction grade 0 to 1 flow after percutaneous coronary intervention, and multivessel disease and superior to other diastolic indexes in predicting future cardiovascular events after AMI. SRIVR may be useful in identifying high-risk patients soon after AMI. (C) 2010 Elsevier Inc. All rights reserved. (Am J Cardiol 2010;105:592-597) Show less
Weger, A. de; Tavilla, G.; Ng, A.C.T.; Delgado, V.; Kley, F. van der; Schuijf, J.D.; ... ; Klautz, R.J.M. 2010
Aims Aortic regurgitation after transcatheter aortic valve implantation (TAVI) is one of the most frequent complications. However, the underlying mechanisms of this complication remain unclear. The... Show moreAims Aortic regurgitation after transcatheter aortic valve implantation (TAVI) is one of the most frequent complications. However, the underlying mechanisms of this complication remain unclear. The present evaluation studied the anatomic and morphological features of the aortic valve annulus that may predict aortic regurgitation after TAVI. Methods and results In 53 patients with severe aortic stenosis undergoing TAVI, multi-detector row computed tomography (MDCT) assessment of the aortic valve apparatus was performed. For aortic valve annulus sizing, two orthogonal diameters were measured (coronal and sagittal). In addition, the extent of valve calcifications was quantified. At 1-month follow-up after procedure, MDCT was repeated to evaluate and correlate the prosthesis deployment to the presence of aortic regurgitation. Successful procedure was achieved in 48 (91%) patients. At baseline, MDCT demonstrated an ellipsoid shape of the aortic valve annulus with significantly larger coronal diameter when compared with sagittal diameter (25.1 +/- 2.4 vs. 22.9 +/- 2.0 mm, P < 0.001). At follow-up, MDCT showed a non-circular deployment of the prosthesis in six (14%) patients. Moderate post-procedural aortic regurgitation was observed in five (11%) patients. These patients showed significantly larger aortic valve annulus (27.3 +/- 1.6 vs. 24.8 +/- 2.4 mm, P = 0.007) and more calcified native valves (4174 +/- 1604 vs. 2444 +/- 1237 HU, P = 0.005) at baseline and less favourable deployment of the prosthesis after TAVI. Conclusion Multi-detector row computed tomography enables an accurate sizing of the aortic valve annulus and constitutes a valuable imaging tool to evaluate prosthesis location and deployment after TAVI. In addition, MDCT helps to understand the underlying mechanisms of post-procedural aortic regurgitation. Show less
The impact of left ventricular (LV) dyssynchrony after acute myocardial infarction (AMI) on LV ejection fraction (EF) is unknown. One hundred twenty-nine patients with a first ST-elevation AMI (58 ... Show moreThe impact of left ventricular (LV) dyssynchrony after acute myocardial infarction (AMI) on LV ejection fraction (EF) is unknown. One hundred twenty-nine patients with a first ST-elevation AMI (58 +/- 11 years, 78% men) and QRS duration <120 ms were included. All patients underwent primary percutaneous coronary intervention. Real-time 3-dimensional echocardiography and myocardial contrast echocardiography were performed to assess LV function, LV dyssynchrony, and infarct size. LV dyssynchrony was defined as the SD of the time to reach the minimum systolic volume for 16 LV segments, expressed in percent cardiac cycle (systolic dyssynchrony index [SDI]). Myocardial perfusion at myocardial contrast echocardiography was scored (1 = normal/homogenous; 2 = decreased/patchy; 3 = minimal/absent) using a 16-segment model; a myocardial perfusion index, expressing infarct size, was derived by summing segmental contrast scores and dividing by the number of segments. SDI in patients with AM! was 5.24 +/- 2.23% compared to 2.02 +/- 0.70% of controls (p <0.001). Patients with AMI and LVEF <45% had significantly higher SDI compared to patients with LVEF >= 45% (4.29 +/- 1.44 vs 6.95 +/- 2.40, p <0.001). At multivariate analysis, SDI was independently related to LVEF; in addition, the impact of SDI on LV systolic function was incremental to infarct size and anterior location of AM! (F change 16.9, p <0.001). In conclusion, LV synchronicity is significantly impaired soon after AMI. LV dyssynchrony is related to LVEF and has an additional detrimental effect on LV function, beyond infarct size and the anterior location of AMI. (C) 2010 Elsevier Inc. All rights reserved. (Am J Cardiol 2010;105:306-311) Show less
Background Left ventricular (LV) diastolic dysfunction and subclinical systolic dysfunction may be markers of coronary artery disease (CAD). However, whether these markers are useful for prediction... Show moreBackground Left ventricular (LV) diastolic dysfunction and subclinical systolic dysfunction may be markers of coronary artery disease (CAD). However, whether these markers are useful for prediction of obstructive CAD is unknown. Methods A total of 182 consecutive outpatients (54 +/- 10 years, 59% males) without known CAD and overt LV systolic dysfunction underwent 64-slice multislice computed tomography (MSCT) coronary angiography and echocardiography. The MSCT angiograms showing atherosclerosis were classified as showing obstructive (>= 50% luminal narrowing) CAD or not. Conventional echocardiographic parameters of LV systolic and diastolic function were obtained; in addition, (1) global longitudinal strain (GLS) and strain rate (indices of systolic function) and (2) global strain rate during the isovolumic relaxation period and during early diastolic filling (indices of diastolic function) were assessed using speckle-tracking echocardiography. In addition, the pretest likelihood of obstructive CAD was assessed using the Duke Clinical Score. Results Based on MSCT, 32% of patients were classified as having no CAD, whereas 33% showed nonobstructive CAD and the remaining 35% had obstructive CAD. Multivariate analysis of clinical and echocardiographic characteristics showed that only high pretest likelihood of CAD (odds ratio [OR] 3.21, 95% 1.02-10.09, P = .046), diastolic dysfunction (OR 3.72, 95% CI 1.44-9.57, P = .006), and GLS (OR 1.97, 95% CI 1.43-2.71, P < .001) were associated with obstructive CAD. A value of GLS >=-17.4 yielded high sensitivity and specificity in identifying patients with obstructive CAD (83% and 77%, respectively), providing a significant incremental value over pretest likelihood of CAD and diastolic dysfunction. Conclusions The GLS impairment aids detection of patients without overt LV systolic dysfunction having obstructive CAD. (Am Heart J 2010; 159: 148-57.) Show less
