Global longitudinal strain is a more reproducible measure of left ventricular function than ejection fraction regardless of echocardiographic training

Sigve Karlsen, Thomas Dahlslett, Bjørnar Grenne, Benthe Sjøli, Otto Smiseth, Thor Edvardsen, Harald Brunvand, Sigve Karlsen, Thomas Dahlslett, Bjørnar Grenne, Benthe Sjøli, Otto Smiseth, Thor Edvardsen, Harald Brunvand

Abstract

Background: Left ventricular ejection fraction (LVEF) is an established method for evaluation of left ventricular (LV) systolic function. Global longitudinal strain (GLS) by speckle tracking echocardiography seems to be an important additive method for evaluation of LV function with improved reproducibility compared with LVEF. Our aim was to compare reproducibility of GLS and LVEF between an expert and trainee both as echocardiographic examiner and analyst.

Methods: Forty-seven patients with recent Acute Coronary Syndrome (ACS) underwent echocardiographic examination by both an expert echocardiographer and a trainee. Both echocardiographers, blinded for clinical data and each other's findings, performed image analysis for evaluation of intra- and inter- observer variability. GLS was measured using speckle tracking echocardiography. LVEF was calculated by Simpson's biplane method.

Results: The trainee measured a GLS of - 19.4% (±3.5%) and expert - 18.7% (±3.2%) with an Intra class correlation coefficient (ICC) of 0.89 (0.74-0.95). LVEF by trainee was 50.3% (±8.2%) and by expert 53.6% (±8.6%), ICC coefficient was 0.63 (0.32-0.80). For GLS the systematic difference was 0.21% (- 4.58-2.64) vs. 4.08% (- 20.78-12.62) for LVEF.

Conclusion: GLS is a more reproducible method for evaluation of LV function than LVEF regardless of echocardiographic training.

Keywords: Echocardiographic training; Global longitudinal strain; Left ventricular ejection fraction.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Images obtained by expert echocardiographer analyzed by both trainee and expert. Scatterplot for GLS (a) and LVEF (b). Bland-Altman plot for GLS (c) and LVEF (d). Dotted line illustrates 95% confidence interval and colored dotted line illustrate fixed bias
Fig. 2
Fig. 2
Images obtained by trainee echocardiographer analyzed by both trainee and expert. Scatterplot for GLS (a) and LVEF (b). Bland-Altman plot for GLS (c) and LVEF (d). Dotted line illustrates 95% confidence interval and colored dotted line illustrate fixed bias
Fig. 3
Fig. 3
Analysis of expert analysis of expert images versus trainee analysis of trainee images. Scatterplot for GLS (a) and LVEF (b). Bland-Altman plot for GLS (c) and LVEF (D). Dotted line illustrates 95% confidence interval and colored dotted line illustrate fixed bias
Fig. 4
Fig. 4
Trainee analyzing images obtained by both expert and trainee. Scatterplot for GLS (a) and LVEF (b). Bland-Altman plot for GLS (c) and LVEF (d). Dotted line illustrates 95% confidence interval and colored dotted line illustrate fixed bias
Fig. 5
Fig. 5
Expert analyzing images obtained by both expert and trainee. Scatterplot for GLS (a) and LVEF (b). Bland-Altman plot for GLS (c) and LVEF (d). Dotted line illustrates 95% confidence interval and colored dotted line illustrate fixed bias
Fig. 6
Fig. 6
Correlation of EDD and E/E’ in trainee analysis of trainee and expert images displayed in scatterplot and Bland-Altman plot. Dotted line illustrates 95% confidence interval

References

    1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, Gonzalez-Juanatey JR, Harjola VP, Jankowska EA, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the heart failure association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–2200. doi: 10.1093/eurheartj/ehw128.
    1. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440–1463. doi: 10.1016/j.echo.2005.10.005.
    1. Hoffmann R, Barletta G, von Bardeleben S, Vanoverschelde JL, Kasprzak J, Greis C, Becher H. Analysis of left ventricular volumes and function: a multicenter comparison of cardiac magnetic resonance imaging, cine ventriculography, and unenhanced and contrast-enhanced two-dimensional and three-dimensional echocardiography. J Am Soc Echocardiogr. 2014;27(3):292–301. doi: 10.1016/j.echo.2013.12.005.
    1. Stanton T, Leano R, Marwick TH. Prediction of all-cause mortality from global longitudinal speckle strain: comparison with ejection fraction and wall motion scoring. Circ Cardiovasc Imaging. 2009;2(5):356–364. doi: 10.1161/CIRCIMAGING.109.862334.
    1. Grenne B, Eek C, Sjoli B, Dahlslett T, Uchto M, Hol PK, Skulstad H, Smiseth OA, Edvardsen T, Brunvand H. Acute coronary occlusion in non-ST-elevation acute coronary syndrome: outcome and early identification by strain echocardiography. Heart. 2010;96(19):1550–1556. doi: 10.1136/hrt.2009.188391.
    1. Dahlslett T, Karlsen S, Grenne B, Eek C, Sjoli B, Skulstad H, Smiseth OA, Edvardsen T, Brunvand H. Early assessment of strain echocardiography can accurately exclude significant coronary artery stenosis in suspected non-ST-segment elevation acute coronary syndrome. J Am Soc Echocardiogr. 2014;27(5):512–519. doi: 10.1016/j.echo.2014.01.019.
    1. Kalam K, Otahal P, Marwick TH. Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction. Heart. 2014;100(21):1673–1680. doi: 10.1136/heartjnl-2014-305538.
    1. Negishi T, Negishi K, Thavendiranathan P, Cho GY, Popescu BA, Vinereanu D, Kurosawa K, Penicka M, Marwick TH, Investigators S. Effect of experience and training on the concordance and precision of strain measurements. JACC Cardiovasc Imaging. 2017;10(5):518–522. doi: 10.1016/j.jcmg.2016.06.012.
    1. Marwick TH, Leano RL, Brown J, Sun JP, Hoffmann R, Lysyansky P, Becker M, Thomas JD. Myocardial strain measurement with 2-dimensional speckle-tracking echocardiography: definition of normal range. JACC Cardiovasc Imaging. 2009;2(1):80–84. doi: 10.1016/j.jcmg.2007.12.007.
    1. Sjoli B, Grenne B, Smiseth OA, Edvardsen T, Brunvand H. The advantage of global strain compared to left ventricular ejection fraction to predict outcome after acute myocardial infarction. Echocardiography. 2011;28(5):556–563. doi: 10.1111/j.1540-8175.2011.01384.x.
    1. Ersboll M, Valeur N, Mogensen UM, Andersen MJ, Moller JE, Velazquez EJ, Hassager C, Sogaard P, Kober L. Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction. J Am Coll Cardiol. 2013;61(23):2365–2373. doi: 10.1016/j.jacc.2013.02.061.
    1. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the Management of Acute Coronary Syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC) Eur Heart J. 2016;37(3):267–315. doi: 10.1093/eurheartj/ehv320.
    1. Zamorano JL, Lancellotti P, Rodriguez Munoz D, Aboyans V, Asteggiano R, Galderisi M, Habib G, Lenihan DJ, Lip GYH, Lyon AR, et al. 2016 ESC position paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for practice guidelines: the task force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC) Eur Heart J. 2016;37(36):2768–2801. doi: 10.1093/eurheartj/ehw211.
    1. Grenne B, Eek C, Sjoli B, Skulstad H, Aakhus S, Smiseth OA, Edvardsen T, Brunvand H. Changes of myocardial function in patients with non-ST-elevation acute coronary syndrome awaiting coronary angiography. Am J Cardiol. 2010;105(9):1212–1218. doi: 10.1016/j.amjcard.2009.12.036.
    1. Quinones MA. American College of Cardiology/American Heart Association clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians--American Society of internal medicine task force on clinical competence. Circulation. 2003;107(7):1068–1089. doi: 10.1161/01.CIR.0000061708.42540.47.
    1. Popescu BA, Andrade MJ, Badano LP, Fox KF, Flachskampf FA, Lancellotti P, Varga A, Sicari R, Evangelista A, Nihoyannopoulos P, et al. European Association of Echocardiography recommendations for training, competence, and quality improvement in echocardiography. J Am Soc Echocardiogr. 2009;10(8):893–905. doi: 10.1093/ejechocard/jep151.
    1. Sjoli B, Orn S, Grenne B, Ihlen H, Edvardsen T, Brunvand H. Diagnostic capability and reproducibility of strain by Doppler and by speckle tracking in patients with acute myocardial infarction. JACC Cardiovasc Imaging. 2009;2(1):24–33. doi: 10.1016/j.jcmg.2008.10.007.
    1. Sjoli B, Orn S, Grenne B, Vartdal T, Smiseth OA, Edvardsen T, Brunvand H. Comparison of left ventricular ejection fraction and left ventricular global strain as determinants of infarct size in patients with acute myocardial infarction. J Am Soc Echocardiogr. 2009;22(11):1232–1238. doi: 10.1016/j.echo.2009.07.027.
    1. Biering-Sorensen T, Hoffmann S, Mogelvang R, Zeeberg Iversen A, Galatius S, Fritz-Hansen T, Bech J, Jensen JS. Myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris. Circ Cardiovasc Imaging. 2014;7(1):58–65. doi: 10.1161/CIRCIMAGING.113.000989.
    1. Mollema SA, Delgado V, Bertini M, Antoni ML, Boersma E, Holman ER, Stokkel MP, van der Wall EE, Schalij MJ, Bax JJ. Viability assessment with global left ventricular longitudinal strain predicts recovery of left ventricular function after acute myocardial infarction. Circ Cardiovasc Imaging. 2010;3(1):15–23. doi: 10.1161/CIRCIMAGING.108.802785.
    1. Eek C, Grenne B, Brunvand H, Aakhus S, Endresen K, Smiseth OA, Edvardsen T, Skulstad H. Strain echocardiography predicts acute coronary occlusion in patients with non-ST-segment elevation acute coronary syndrome. Eur J Echocardiogr. 2010;11(6):501–508. doi: 10.1093/ejechocard/jeq008.
    1. Haugaa KH, Grenne BL, Eek CH, Ersboll M, Valeur N, Svendsen JH, Florian A, Sjoli B, Brunvand H, Kober L, et al. Strain echocardiography improves risk prediction of ventricular arrhythmias after myocardial infarction. JACC Cardiovasc Imaging. 2013;6(8):841–850. doi: 10.1016/j.jcmg.2013.03.005.
    1. Yamada A, Luis SA, Sathianathan D, Khandheria BK, Cafaro J, Hamilton-Craig CR, Platts DG, Haseler L, Burstow D, Chan J. Reproducibility of regional and global longitudinal strains derived from two-dimensional speckle-tracking and doppler tissue imaging between expert and novice readers during quantitative dobutamine stress echocardiography. J Am Soc Echocardiog. 2014;27(8):880–887. doi: 10.1016/j.echo.2014.04.016.
    1. Otterstad JE, Froeland G, St John Sutton M, Holme I. Accuracy and reproducibility of biplane two-dimensional echocardiographic measurements of left ventricular dimensions and function. Eur Heart J. 1997;18(3):507–513. doi: 10.1093/oxfordjournals.eurheartj.a015273.
    1. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1–39. doi: 10.1016/j.echo.2014.10.003.
    1. Delgado V, Mollema SA, Ypenburg C, Tops LF, van der Wall EE, Schalij MJ, Bax JJ. Relation between global left ventricular longitudinal strain assessed with novel automated function imaging and biplane left ventricular ejection fraction in patients with coronary artery disease. J Am Soc Echocardiogr. 2008;21(11):1244–1250. doi: 10.1016/j.echo.2008.08.010.
    1. Gjesdal O, Helle-Valle T, Hopp E, Lunde K, Vartdal T, Aakhus S, Smith HJ, Ihlen H, Edvardsen T. Noninvasive separation of large, medium, and small myocardial infarcts in survivors of reperfused ST-elevation myocardial infarction: a comprehensive tissue Doppler and speckle-tracking echocardiography study. Circ Cardiovasc Imaging. 2008;1(3):189–196. doi: 10.1161/CIRCIMAGING.108.784900.
    1. Cho GY, Marwick TH, Kim HS, Kim MK, Hong KS, Oh DJ. Global 2-dimensional strain as a new prognosticator in patients with heart failure. J Am Coll Cardiol. 2009;54(7):618–624. doi: 10.1016/j.jacc.2009.04.061.
    1. Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G, Galderisi M, Marwick T, Nagueh SF, Sengupta PP, et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr. 2011;24(3):277–313. doi: 10.1016/j.echo.2011.01.015.
    1. Teske AJ, De Boeck BW, Melman PG, Sieswerda GT, Doevendans PA, Cramer MJ. Echocardiographic quantification of myocardial function using tissue deformation imaging, a guide to image acquisition and analysis using tissue Doppler and speckle tracking. Cardiovasc Ultrasound. 2007;5:27. doi: 10.1186/1476-7120-5-27.
    1. Medvedofsky D, Kebed K, Laffin L, Stone J, Addetia K, Lang RM, Mor-Avi V. Reproducibility and experience dependence of echocardiographic indices of left ventricular function: side-by-side comparison of global longitudinal strain and ejection fraction. Echocardiography. 2017;34(3):365–370. doi: 10.1111/echo.13446.
    1. Voigt JU, Pedrizzetti G, Lysyansky P, Marwick TH, Houle H, Baumann R, Pedri S, Ito Y, Abe Y, Metz S, et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/industry task force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging. 2015;16(1):1–11. doi: 10.1093/ehjci/jeu184.

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