Elsevier

JACC: Cardiovascular Imaging

Volume 15, Issue 9, September 2022, Pages 1525-1541
JACC: Cardiovascular Imaging

Original Research
Reverse Remodeling Assessed by Left Atrial and Ventricular Strain Reflects Treatment Response to Sacubitril/Valsartan

https://doi.org/10.1016/j.jcmg.2022.03.019Get rights and content
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Abstract

Background

The left ventricular global longitudinal strain (LVGLS) and left atrial reservoir strain (LARS) are considered as sensitive and reliable markers of cardiac remodeling and function. However, their temporal changes during optimal management of heart failure with reduced ejection fraction (HFrEF) are unknown.

Objectives

This study investigated the time trajectories of the LARS and LVGLS in patients with HFrEF treated with angiotensin receptor–neprilysin inhibitors, and assessed whether the LARS and LVGLS could define left heart reverse remodeling (LHRR) and reflect the treatment response and prognosis.

Methods

Using a retrospective cohort of patients with HFrEF prescribed sacubitril/valsartan, we assessed the time trajectories of the LVGLS and LARS in 409 patients (1,258 echocardiograms), and investigated their association with the occurrence of cardiovascular death and hospitalization for heart failure (HHF), after the determination of LHRR, during a median follow-up of 27.1 (IQR: 18.3-36.3) months.

Results

Among patients with HFrEF prescribed sacubitril/valsartan, both the LVGLS and LARS improved over time. The improvements in the LVGLS and LARS were prominent within 6 months of sacubitril/valsartan treatment: the LVGLS improved from 10.2% (IQR: 7.9%-12.7%) to 13.9% (IQR: 10.5%-16.3%) (P < 0.001), and the LARS improved from 11.4% (IQR: 8.4%-15.6%) to 15.9% (IQR: 11.5%-21.4%) (P < 0.001). These improvements were larger among patients who did not experience the study outcome than in patients with events. Improvement in the LVGLS to ≥13% and LARS to ≥12.5% (ie, complete LHRR) was significantly associated with a lower risk of cardiovascular death and HHF, and this association was stronger than that of changes in other conventional echocardiographic parameters.

Conclusions

In patients with HFrEF treated with sacubitril/valsartan, the LVGLS and LARS were improved, typically within 6 months of treatment. Complete LHRR, defined by improvement in the LVGLS and LARS, can be an indicator of treatment response and prognosis.

Key Words

angiotensin receptor–neprilysin inhibitor (ARNI)
heart failure with reduced ejection fraction (HFrEF)
left atrial reservoir strain (LARS)
left ventricular global longitudinal strain (LVGLS)
reverse remodeling

Abbreviations and Acronyms

AF
atrial fibrillation
ARNI
angiotensin receptor–neprilysin inhibitor
AUC
area under the curve
CRT
cardiac resynchronization therapy
HF
heart failure
HFrEF
heart failure with reduced ejection fraction
HHF
hospitalization for heart failure
IPTW
inverse probability of treatment weighting
LA
left atrium
LARS
left atrial reservoir strain
LAVI
left atrial volume index
LHRR
left heart reverse remodeling
LOA
limits of agreement
LV
left ventricle
LVEF
left ventricular ejection fraction
LVESV
left ventricular end-systolic volume
LVGLS
left ventricular global longitudinal strain
PS
propensity score
ROC
receiver-operating characteristic

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