Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.Nghiên cứu biến đổi sức căng cơ tim ở bệnh nhân nhồi máu cơ tim cấp có ST chênh lên sau can thiệp động mạch vành qua da thì đầu bằng phương pháp siêu âm đánh dấu mô.MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES NGUYEN ANH TUAN RESEARCH on THE CHANgES IN MYOCARDIAL STRAIN IN PATIENTS AFTER ACUT.
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES - NGUYEN ANH TUAN RESEARCH on THE CHANgES IN MYOCARDIAL STRAIN IN PATIENTS AFTER ACUTE ST ELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION BY SPECKLE TRACKING ECHOCARDIOGRAPHY Speciality: Internal Cardiovascular Code: 62.72.01.41 ABSTRACT OF MEDICAL PHD THESIS Hanoi – 2023 THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supervisor: PhD Nguyen Thi Thu Hoai Ass, Prof PhD Pham Nguyen Son Reviewer: This thesis will be presented at Institute Council at: 108 Institute of Clinical Medical and Pharmaceutical Sciences Day Month Year 2023 The thesis can be found at: National Library of Vietnam Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences Central Institute for Medical Science Infomation and Tecnology INTRODUCTION Necessity of the thesis Acute ST elevation myocardial infarction (STEMI) is the myocardial necrosis caused by acute total occlusion coronary artery with ST segment elevation on electrocardiogram Although, there are a lot of advantages on diganosis, treatment STEMI, specially reperfusion methods such as Percutaneous cororary intervention (PCI), the heart failure, Major adverve cardiac event (MACE) such as: re-infarction, stroke and re-hospitalization…and other complications: arrhythmias and left ventricular remoderling (LVR)… commonly happen Quantitative left ventricular function plays an important role in treatment and prognosis of patients with myocardial infarction Echocardiography has been becoming common method to assessment of left ventricular and risk stratification of patients with myocardial infarction Ejection fraction (EF) and wall motion score index (WMSI) are commomny used in the clinical practice However, EF will be normal if infact region is outside of the view of echocardigraphy, or compensative movement of other myocardial regions or chance in preload and afterload EF depends on geometry formular Assessment of abnormal regional motion is often subjective Speckle tracking echocardiography is a new method that could objectively evaluate left ventricular function and early detection of subtle changes of not only cardiac wall regional function but also global cardiac function It does not depend on angle of ultrasound beam It has been evaluated more useful than EF in assessment of left ventricular function Quantitative of global longitudinal strain (GLS) can early detection of dysfunction region in longitudinal direction and early detection patients at high risk of adverse events after myocardial infarction even EF in normal range GLS could also predict LVR in patient with myocardial infarction Meaning of the study 2D speckle tracking echocardiography in patients with ST elevation myocardial infarction after PCI could early detection patients with left ventricular dysfunction even EF in normal range It also showed an improvement in cardiac function over time GLS could also predict MACE, mortality and LVR in STEMI patients after PCI Thereby it hepls clinicans early identify patients with high risks to manage and monitor more closely Objectives of the study To survey the change in myocardial strain by 2D speckle tracking echocardiography in patients after acute ST elevation myocardial infarction (STEMI) were treated with primary percutaneous coronary intervention (PCI) To study the predictive value of left ventricular global longitudinal strain (GLS) for major adverse cardiac events (MACE) and mortality in patients after acute ST elevation myocardial infarction (STEMI) were treated with primary PCI Layout of thesis The thesis has 127 pages, including pages of introduction, 31 pages of overview, 24 pages of objects and methods, 34 pages of research results, 33 pages of discussion, pages of conclusion and page of recommendation There are 37 results tables, 18 charts, figures, 18 pictures and 191 references (11 Vietnamese and 180 English) Chapter OVERVIEW 1.1 Overview of acute myocardial infarction 1.1.1 Definition of myocardial infarction According to The fourth universal definition of myocardial infarction 2018 The term myocardial infarction (MI) should be used when there is evidence of acute myocardial injury with clinical evidence of acute myocardial ischemia and elevated cardiac troponin values (cTn) with at least one value above the 99th percentile upper reference limit (URL) and at least one of the following: Symptoms of myocardial ischaemia or/and new ischaemic ECG changes, or/and development of pathological Q waves on ECG, or/and imaging evidence of new loss of viable myocardium or new regional wall motion abnormality, or/and Identification of a coronary thrombus by angiography or autopsy 1.1.2 Pathology of acute myocardial infarction Myocardial infacrtion is myocardial necrosis due to obstruction of blood flow to the myocardium Common causes are cracking, rupture, ulceration, erosion of the atherosclerotic plaque or coronary artery spasm or thrombosis from elsewhere The main mechanism of acute MI is the sudden rupture of the atherosclerotic plaque As a result, a thrombus is formed that completely fills the lumen, leading to sudden myocardial ischemia and myocardial necrosis 1.1.3 Complication of ST elevation myocardial infarction Common complications are: LVR, heart failure, arrhythmia, recurrent MI, mechanical complications 1.1.4 Prognosis of ST elevation myocardial infarction Based on clinical features, laboratory tests, prognostic models such as TIMI score, GRACE score 1.2 Role of 2D Speckle tracking echocardiography in the assessment of cardiac function 1.2.1 Concept of strain and strain rate 1.2.1.1 Strain Strain (S) describes the deformation of an object normalized to its original shape and size 1.2.1.2 Strain rate 1.2.2 2D Speckle tracking echocardiography 1.2.2.1 Speckle formation 1.2.2.2 Speckle tracking 1.2.2.3 Assessment of strain and strain rate by speckle tracking 1.2.3 Application of speckle tracking echocardiography for assessment of cardiac function 1.2.3.1 Longitudinal strain Longitudinal strain represents myocardial deformation directed from the base to the apex During systole, ventricular myocardial fibers shorten with a translational movement from the base to the apex, so that it has negative value 1.2.3.2 Circumferential strain Describe the shortening of the nuclei along the circumference of the heart and achieved on the short axial view 1.2.3.3 Radiation strain Describe the deformation of the myocardium in the radial direction (towards the center of the heart chambers) 1.2.3.4 Twisting and Torsion 1.2.4 Clinical applications of speckle tracking echocardiography 1.2.5 Factors that may influence strain value 1.2.6 Advantages and disadvantages of speckle tracking echocardiography 1.3 Several studies using speckle tracking echocardiography in patients with myocardial infaection 1.3.1 International studies Cimino S et al studied 20 STEMI patients showed that GLS closely correlated with both EF and WMSI by Cardiac megnetic resonance (CMR) (r= -0.86; p = 0.001 and r = 0.8; p = 0.001) and significant correlated with both EF and WMSI by speckle traking echocardiography (r= -0.65; p = 0.001 and r = 0.53; p = 0.013) Yang Y studied 387 STEMI patients were treated by PCI and monitored within months The results showed that MACE was 24.8 Zaliaduonute-Peksiene D et al studied 82 STEMI patients and motitored within months The result showed that LVR was 34.1% GLS was an independent predictor of LVR after acute myocardial infarction with cut off point was -1.6 (sensitivity: 78% and specificity: 73%) Ersbөll M et al studied 548 patients with acute myocardial infarction Echocardiography was done within 48 hours of admission The results showed that GLS of patients with Killip class > was significantly impaired compared with patients with (Killip class 1) (−14.6 ± 3.3% vs −10.1 ± 3.5%, P < 0.0001) 1.3.2 Vietnamese studies Trinh Viet Ha et al studied 125 patients with acute coronary syndrom without ST elevation myocardial infarction by 2D speckle tracking echocardiography The results showed that GLS before and after PCI within 48 hours and after 30 days gradualy improved respectively: -16.94 ± 3.37 % ; -17.31 ± 3.22 %; -18.59 ± 3.34 % GLS could predict MACE within months with AUC = 0.945 (95%CI: 0.896 – 0.985) p < 0.001 In multivariates Cox model, GLS was independent predictor with HR = 1.72 (95%CI: 1.12 – 2.89) p < 0.05 Chapter SUBJECTS AND METHOD 2.1 Studying subjects: - Patient group: 118 STEMI patients at first time were treated by primary PCI at Cardiovascular Institude – Bach Mai hospital from january 2016 to March 2019 - Control group: 60 normal people 2.1.1 Patient group 2.1.1.1 Selection creteria - Patients were diagnosised STEMI according to The third universal definition of myocardial infarction with ST elevation - Were underwent coronary angiography and intervention - Agree to participate in the study - Got enough data at time of asessment 2.1.1.2 Exclusion creteria - History of MI, serious disease, severse valvular disease, cardiomyopathy, history of left bundle branch block, atrial fibrilation - Complication of PCI, was being taken inotropic drugs - The echocardiogram is unsatisfactory for evaluation 2.1.2 Control group 2.1.2.1 Selection creteria - Normal people with no cardiovascular disease volunteer to participate in the study The subjects were similar in age and sex with the disease group 2.1.2.2 Exclusion creteria - Disagree to participate in the study - The echocardiogram is unsatisfactory for evaluation 2.2 Methodology 2.2.1 Study design - A coss-sectional descriptive and prospective cohort sudy 2.2.2 Study sample and the way to select subjects 2.2.2.1 Study sample * Patient group - Apply the formula for calculating sample size to a ratio - Lacalzada studied 97 STEMI patients who were treated by PCI and followed up at least months The result showed that MACE was 20.6 So we chose p = 0.2, d = 0.08 So n = 96 - In this study, ours sample size was 118 patients * Control group: We chose 60 normal people 2.2.2.2 The way to select subjects * Patient group - Patients were selected in the study if they met the above selection criterias We took conssecutively 118 patients Each patient was monitored within months at the following times: after day, after days, after month, after months and after months * Control group: Normal people who volunteered to the study 2.2.3 Time duration and place of the study 2.2.3.1 Time duration of the study: from january 2016 to March 2019 2.2.3.2 Place of the study: Cardiovascular Institude – Bach Mai hospital 2.2.4 Steps to conduct research - Step 1: Create medical records according to the research form - Step 2: Clinical exam - Step 3: Record the results of blood tests, electrocardiograms, PCI in the patient's medical records - Step 4: Treatment according to ESC guidelines 2012, 2017 - Step 5:, The patients were had blood tests and echocardiographies within 24 hours and days after PCI - Step 6: The patients were had blood tests and echocardiographies after month, months, months Record cardiovascular events - Step 7: Collecting and processing research data 2.2.5 Step to conduct 2D speckle traking echocardiography - Step 1: Image acquisition: Record motion images in 3chamber, 4-chamber, and 2-chamber long-axis order for at least consecutive cycles - Step 2: Image analysis: Motion images were analyzed by AFI software available on the ultrasound machine The software divides the left ventricle into segments Images 2.5-8 Longitudinal strain in 3-chamber, 4-chamber, and 2-chamber long-axis and GLS 2.2.6 Data processing The data were processed and analyzed using the program Stata 14.1 11 Table 3.12 Changes in GLS by group early and late PCI GLS after PCI (%) Time from chest pain to PCI ≥ 12 hours < 12 hours n day (n = 118) days (n = 118) month (n = 118) months months (n = 112) (n = 108) (1) (2) (3) (4) (5) 52 52 52 50 48 X ± SD -12.07 ± 3.19 -12.33 ± 2.85 -13.59 ± 2.74 -14.18 ± 2.59 -14.51 ± 2.44 p n p(1-2) = 0.03 p(2-3)< 0.001 p(3-4) = 0.27 p(4-5) = 0.52 66 66 66 X ± SD -11.78 ± 3.37 -12.16 ± 3.09 -13.18 ± 2.97 p p 62 60 -14.04 ± 2.53 -14.49 ± 2.40 p(1-2)< 0.001 p(2-3)< 0.001 p(3-4) = 0.08 p(4-5) = 0.3 0.64 0.77 0.44 0.79 0.96 Table 3.14 Change in GLS according to Killip class GLS Sau can thiệp (%) Killip class Killp I n X ±SD day (n = 118) (1) days n = 118 (2) month (n = 118) (3) months (n = 112) (4) months (n = 108) (5) 89 89 89 87 85 -12.44 ± 3.21 -12.68 ± 2.94 -13.85 ± 2.77 Killip II, III p p n X ±SD -14.46 ± 2.51-14.76 ± 2.44 p(1-2) < 0.01 p(2-3)< 0.001 p(3-4) = 0.13 p(4-5) = 0.43 29 29 29 25 23 -10.28 ± 3.01 -10.86 ± 2.70 -11.86 ± 2.69 -12.85 ± 2.30 -13.50 ± 2.00 p p(1-2)< 0.01 p(2-3)< 0.001 p(3-4) = 0.15 < 0.01 < 0.01 < 0.001 < 0.01 p(4-5) = 0.3 < 0.05 12 Table 3.15 GLS changes according to the culprit artery group GLS after PCI (%) culprit artery LAD n day (n = 118) (1) days (n = 118) (2) month (n = 118) (3) months (n = 112) (4) months (n = 108) (5) 69 69 69 65 62 X ±SD -10.68 ± 2.81 -11.17 ± 2.56 -12.42 ± 2.47 -13.25 ± 2.36 -13.60 ± 2.32 p LCX n p(1-2)< 0.001 p(2-3)< 0.001 p(3-4)=0.05 11 11 11 11 p(4-5) = 0.4 10 X ±SD -12.61 ± 2.46 -12.79 ± 2.28 -13.85 ± 2.35 -14.19 ± 2.43 -15.04 ± 1.56 p RCA n p(1-2) = 0.2 p(2-3)< 0.001 p(3-4) = 0.02 p(4-5) = 0.36 38 38 38 36 36 X ±SD -13.93 ± 3.29 -14.00 ± 3,02 -14.91 ± 3.02 -15.61 ± 2.24 -15.88 ± 2.04 p p p(1-2) = 0.54 p(2-3)< 0.001 p(3-4) = 0.26 p(4-5)< 0.01 < 0.001* < 0.001* < 0.001* < 0.001* < 0.001* Kruskal-Wallis test Table 3.19 Changes GLS by TMP group GLS after PCI (%) TMP group TMP < III TMP III n day (n = 118) days (n = 118) month (n = 118) months (n = 112) months (n = 108) (1) (2) (3) (4) (5) 69 69 69 68 65 X ±SD -12.59 ± 3.20 -12.84 ± 2,86 -13.92 ± 2.68 p(1-2) < 0.01 p(2-3)< 0.001 p n 49 49 49 -14.50 ± 2.40-14.95 ± 2.25 p(3-4) = 0.19 p(4-5) = 0.26 44 43 X ±SD -10.95 ± 3.19 -11.38 ± 2.94 -12.57 ± 2.96 -13.49 ± 2.67 -13.80 ± 2.50 p(1-2)< 0.001 p(2-3)< 0.001 p(3-4) = 0.12 p(4-5) = 0.57 p p < 0.01 < 0.01 0.01 0.04 0.01 13 Table 3.21 Changes GLS by EF group GLS after PCI (%) EF EF < 40% n day (n = 118) (1) days (n = 118) (2) month (n = 118) (3) months (n = 112) (4) months (n = 108) (5) 23 23 23 17 16 X ±SD -8.56 ± 2.12 -9.38 ± 1.96 -10.33 ± 2.13 -11.64 ± 1.74 -12.03 ± 1.43 p 40% ≤ EF< 50% n p(1-2)