Prognostic Significance of Right Ventricular Global Longitudinal Strain in Acute Myocardial Infarction and Angiographic Correlation

doi:10.21203/rs.3.rs-1101353/v1

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Research Article

Prognostic Significance of Right Ventricular Global Longitudinal Strain in Acute Myocardial Infarction and Angiographic Correlation

https://doi.org/10.21203/rs.3.rs-1101353/v1

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OBJECTIVES

Objectives of this study were to evaluate right ventricular function using two dimensional speckle tracking echocardiography among patients who were admitted with acute myocardial infarction and treated with primary angioplasty, association between right ventricular strain global longitudinal strain and major adverse cardiovascular events and to analyse the angiographic results of all patients.

METHODS

This was a prospective observational study conducted in 200 consecutive patients admitted with acute inferior wall myocardial infarction and treated with primary angioplasty. Right ventricular global longitudinal strain was measured by two dimensional speckle tracking echocardiography and angiographic results of all patients were recorded. All patients were followed up till discharge / death. Categorical data were compared using Chi-square test or Fisher’s exact test. Logistic regression was done to find out the major adverse cardiovascular outcomes predictive by RVGLS. P < 0.05 was considered statistically significant.

RESULTS

200 patients were enrolled for the study of which were 102 (51%) patients and 98 (49 %) patients were males and females respectively. Patients with low RVGLS had higher incidence of left ventricular dysfunction(P=0..006) ,low TAPSE and S’(P<0.001) ,angiographic triple vessel disease(p<0.001),arrhythmias(p=0.02) ,right heart failure(P<0.001),target lesion revascularisation(P=0.029) and prolonged hospital stay(P<0.001).In multivariate analysis , arrhythmias (P=0.046 ,OR - 2.05, CI 0.93-8.10) ad target lesion revascularisation were the two major adverse cardiovascular events predictive by RVGLS.

CONCLUSION

RVGLS could be used a prognostic marker in patients admitted with acute inferior wall infarction, categorise the risk and might assist the interventionist in planning an earliest therapeutic strategy.

Cardiac & Cardiovascular Systems

Myocardial infarction

Right ventricular ischemia

Global Longitudinal strain

Arrhythmias

Complete heart block

Cardiogenic shock

Right ventricular ischemia due to acute inferior wall myocardial infarction is a major predictor of short and long adverse cardiovascular outcomes like arrhythmias, cardiogenic shock, heart failure and death ¹. The incidence of right ventricular involvement in acute inferior wall myocardial infarction varies from 30-50% ^2.Due to complex anatomy and asymmetric shape of the right ventricle earliest recognition of right ventricular dysfunction is challenging and conventional echocardiographic measures of right ventricular function assessment like fractional area change ,tricuspid annular plane systolic excursion are abnormal only after overt dysfunction sets in ³ . Longitudinal strain measured by speckle tracking echocardiography bridges this gap by detecting ventricular dysfunction at a subclinical stage and aids the clinician in planning an earliest interventional strategy and reduce in-hospital mortality ^{4, 5}.

This study was designed to evaluate right ventricular function using myocardial deformation techniques(two dimensional speckle tracking echocardiography ) in patients who were successfully treated for their first acute inferior wall myocardial infarction , to assess the accuracy of right ventricular global longitudinal strain in predicting major adverse cardiovascular events and to analyse the angiographic results of all patients.

This was a prospective observational study conducted in the Department of cardiology, Government TD Medical College and hospital, Alappuzha from 1-10-2019 to 1-11-2020. This study was conducted in accordance with the declaration of Helsinki and was approved by Institutional Ethics Committee (Reg no: ECR/ 122/Inst/KL/2013/RR-2016).

200 consecutive patients diagnosed with acute inferior wall myocardial infarction presenting within 12hrs of symptom onset, and had underwent primary angioplasty were included in the study. Patients with history of bundle branch block, prior history of myocardial infarction, percutaneous trans-luminal coronary angioplasty, acute stent thrombosis and patients with history of pulmonary hypertension (valvular heart disease, lung disease, and cardiomyopathy) renal, hepatic, hematological disorders and malignancy were excluded from the study.

PRIMARY OBJECTIVE of the study was to evaluate right ventricular function using myocardial deformation techniques (two dimensional speckle tracking echocardiography) among patients who were successfully treated for their first acute inferior wall myocardial infarction.

The secondary objectives of this study were:

1. To assess right ventricular global longitudinal strain in predicting major adverse cardiovascular events like heart failure, arrhythmias, recurrent angina, arrhythmia,

re-infarction, target lesion revascularisation and prolonged hospital stay and death

2. To analyse the angiographic results of all patients

Demographic data, history of comorbid illnesses were collected with the help of a structured questionnaire. Right ventricular global longitudinal strain was measured by two dimensional speckle tracking echocardiography (GE VIVID E9- ECHOPAC software e) after primary angioplasty and coronary angiographic results of all patients were recorded. Informed consent was obtained from all individual participants included in the study. All patients were followed up till discharge / death.

DEFINTIONS AND CUT-OFF VALUES:

LOW RV GLS - Patients with values > -20% were considered to have low right ventricular global longitudinal strain.

MAJOR ADVERSE CARDIOVASCULAR EVENTS (MACE):

Major adverse cardiovascular events analysed in this study were

• Brady arrhythmias (complete heart block, Mobitz type 1 &2 atrioventricular blocks, junctional bradycardia)

• Tachyarhythmias (ventricular tachyaarhytmias, ectopic atrial tachycardia, atrial fibrillation and junctional tachycardia)

• Heart failure – symptoms like dyspnea, orthopnea and clinical evidence of raised jugular venous pressure, S3 and bibasal crepitations.

• Re-infarction–patient developing clinical, biochemical and electrocardiographic features suggestive of myocardial infarction after revascularisation during the course of admission in the hospital

• Recurrent angina – Patients developing symptoms suggestive of typical angina following revascularisation during the course of admission in the hospital

• Target lesion revascularisation – Patients who underwent repeat intervention after revascularisation in the culprit lesion due to recurrent symptoms and electrocardiographic features of re-infarction

• Duration of hospital stay (prolonged hospital stay defined as hospital stay more than 5 days.

• Death

SAMPLE SIZE:

Due to gross variation in the prevalence of right ventricular infarction in inferior wall myocardial infarction conducted in various studies and due to COVID-19 pandemic , all patients admitted with acute inferior wall infarction in department of cardiology, Government TD medical college and hospital, Alappuzha from October 2019 - September 2020 were included in the study.

STATISTICS:

All the data collected were coded and keyed in Microsoft Excel sheet were re-checked and analysed using SPSS Statistics V22.

• Quantitative variables were summarised using mean and standard deviation or median and interquartile range (IQR), depending on the normality of distribution.

• Categorical variables were represented using frequency and percentage.

• Categorical data were compared using Chi-square test or Fisher’s exact test.

• Logistic regression was done to find out the major adverse cardiovascular outcomes predictive by RVGLS. P < 0.05 was considered statistically significant.

200 patients were enrolled for the study of which were 102 (51%) patients and 98 (49 %) patients were males and females respectively. The baseline characteristics of the study population are summarised in table 1

Table 1: Baseline characteristics of study subjects (N=200)

ECHOCARDIOGRAPHIC CHARACTERISTICS:

Mild left ventricular dysfunction (Left ventricular ejection fraction 40% to 49%) was found in 32 (16%) patients. The mean RV free wall GLS of our study population is 16.50±3.84. 112 (56%) patients had low right ventricular global longitudinal strain (RV GLS <-20 %).

Triple vessel disease involving the, RCA, LCX and LAD was found in 22.5% (n=45) of the study population. The echocardiographic and angiographic characteristics of the study population are summarised in table 2

Table 2: Echocardiographic and angiographic characteristics

COMPLICATIONS:

Atrioventricular Blocks were the most common complication observed in 33.5% of the study population. 24 patients (12%) had complete heart block at presentation and 3 patients (1.5%) developed Mobitz type 2 atrioventricular block (figure 1).

Figure 1: ARRHYTHMIAS

42 patients (21%), 32 patients (17.5 %) and 21patients (14%) developed recurrent angina, re-infarction and target lesion revascularisation respectively. Prolonged hospital stay (more than 4 days) was seen in 30.5% (n=61) of the study population (figure 28) 10 %( n=20) of the total study population died due to complications (figure 2).

Figure 2: COMPLICATIONS

Association of RV GLS with baseline characteristics:

21 patients (52.5% ) in the age group of 60-70 years and 29 patients (64.4%) above 70 years had a low RV GLS .The difference observed in the incidence of abnormal RV GLS between the various subgroups of age were not statistically significant (p=0.589).

The difference observed in RV GLS among individuals with risk factors like hypertension , diabetes , thyroid disorders ,CVA , smoking ,alcoholism were not statistically significant ( Table 3)

Association of wall involved with RV GLS:

About 58.7% (n=61) of the individuals with inferior, right ventricular and posterior wall myocardial infarction (IW+RV+PW) had low RV GLS that was statistically significant (p<0.001). (Table 4)

Association of angiographic lesions with RV GLS:

Patients with triple vessel disease had relatively higher incidence of low RV GLS the difference observed in RV GLS between the three different angiographic profiles were statistically significant (p<0.001) (Table 4)

Association of complications with RV GLS:

The difference observed in RV GLS among patients who developed complications like arrhythmias, heart failure, target lesion revascularisation and prolonged hospital stay were found to be statistically significant. (Table 4)

The difference observed in RV GLS between patients who developed recurrent angina, re-infarction and death did not differ significantly from patients who had no complications.

In multivariate analysis, RVGLS was predictive of two complications namely target lesion revascularisation and arrhythmias (Table 5)

The ROC curve for RV GLS to predict major adverse cardiovascular events was to the left of the reference line (> 45 degree diagonal of the ROC space) (figure 3) indicating good sensitivity and likelihood ratio to predict major adverse cardiovascular events

The AUC (Area under the curve) for RV GLS was 0.915 which indicates that RV GLS has good accuracy to predict major adverse cardiovascular events (Table 6)

From our study, the optimal cut off score for RV GLS in predicting major adverse cardiovascular outcomes was -14.8 %with a sensitivity of 0.813 and specificity of 0.868.

Patients with low RV GLS had significantly higher incidence of major adverse cardiovascular events like arrhythmias , ventricular failure , target lesion revascularisation and prolonged hospital stay, angiographic triple vessel disease , low TAPSE and S’ . In multivariate analysis RVGLS was found to be predictive of hemodynamically significant arrhythmias and target lesion revascularisation. (Table 5).

The difference observed in RV GLS among the baseline characteristics like age, sex, diabetes mellitus, systemic hypertension, thyroid illness, stroke, smoking and alcoholism were not statistically significant. There was no significant association between RV GLS and re-infarction, recurrent angina and mortality.

The study population comprised nearly equal proportion of males and females with two third (62.5%) of the individuals over 50 years. Risk factors for cardiopulmonary disease like diabetes, hypertension, and hypercholesterolemia were present in more than 50% of the study population. Though 60% of diabetics and 70% of hypertensive were found to have low GLS, the difference observed was not statistically significant (diabetes à P=0.061, hypertension àP=0.107). The traditional risk factors for developing coronary artery disease independently as well as synergistically could alter measures of right ventricular function assessment by speckle tracking that might have implications in predicting the prognosis of these patients. The normal values of RV GLS differs according to the age, sex and demographics, the usual range being for women (−26.7 ± 3.1) , for men (−24.7 ± 2.6 ).

The mean RV GLS of the study population ranges from -13% to -20% , with very low values of RV GLS observed in patients with cardiogenic shock complicated by complicated by complete heart block (70%) and ventricular tachycardia (66%)(P=0.02). Patients with inferior ,right ventricular and posterior infarction had low RV GLS , probably due to larger proportion of myocardium involved and the possibility of tethering effect on adjacent walls of myocardium(P<0.001).

Left ventricular dysfunction is very rare in inferior wall myocardial infarction. The possible mechanisms are the shift of interventricular septum due to right ventricular ischemia altering the left ventricular geometry, reduce the left ventricular preload and eventually reduce measures of left ventricular function ⁶. 25(78.1%) patients with left ventricular dysfunction and 21.9% of the patients will left ventricular dysfunction had normal RV GLS (P=0.006)

Conventional parameters of right ventricular function assessment like TAPSE, S’ are significantly limited by factors like tethering and angle dependency⁷. Volumetric assessment of RV function (RV FAC -fractional area change) is highly operator dependent and requires proper visualisation of endocardial borders^8.9. RV strain assessment overcomes the above mentioned limitations⁷ although the effect of translational motion of the heart cannot be excluded. 112 patients (84.2%) with low TAPSE, and 83 patients (93.3%) with low S’ had low GLS with statistical difference (p<0.001).

Among 45 patients (ventricular tachycardia, Mobitz type 2 AV block and complete heart block) 32 patients (16%) with low RV GLS, developed hemodynamic compromise with cardiogenic shock and required inotropic support. The plausible explanation for higher incidence of arrhythmias and need for inotropic support in patients with low RV GLS could be mechanical and electrical heterogeneity of right ventricular myocardium which serves as a substrate for development for arrhythmias^10,11,12 .

Though the incidence of reinfarction, recurrent angina and death were proportionately higher in individuals with low RV GLS the difference observed was not statistically significant. The incidence of re-infarction and recurrent angina depends on factors like patient delay, system delay, previous infarction, comorbid illnesses, procedural characteristics like slow flow, edge dissection and the thrombus burden at the time of angioplasty. The incidence of target lesion revascularisation and the duration of hospital stay was higher in individuals with lower right ventricular global longitudinal strain and the difference observed was statistically significant (P=0.029).

COMPARISON OF RV GLS CUT OFF VALUES WITH PREVIOUS STUDIES:

In the study done by Park et al ¹³, in a total of 282 consecutive inferior STEMI patients treated with primary PCI on follow-up for , 54 month), 59 patients (21%) had 1 or more major adverse cardiovascular event (MACE) (43 deaths, 7 nonfatal MI, 4 target vessel revascularization, and 6 heart failure admission).The best cut off value of GLSRV for the prediction of major adverse cardiovascular events was 15.5% ( p<0.001) with a sensitivity of 73% and a specificity of 65% .

Jurcut et al ¹⁴, concluded that the cut off values for right ventricular global longitudinal strain to predict early mortality in patients with acute inferior wall infarction with right ventricular infarction was. RV GLS ≤ –14% with a sensitivity of 88.9% and a specificity of 62.5% (AUC: 0.817, P = 0.002)

From our study , the optimal cut off score for RV GLS in predicting major adverse cardiovascular outcomes was -14.8 % (( AUC = 0.915 , a 95 % confidence interval 0.876-0.954 , p<0.001) with a sensitivity of 81.3 % and specificity of 86.8 %.

Inferior wall infarction results in cardiogenic shock more frequently than anterior wall infarction due to right ventricular involvement¹⁵ , Bezold -jarish reflex¹⁶ , mechanical complications like acute severe mitral regurgitation ¹⁷and arrhythmias like complete heart block ¹¹and ventricular tachycardia. Hemodynamically significant right ventricular impairment occurs in nearly 10% of the patients and establishing patency of the infarct related artery restores right ventricular function within 48-72hrs ¹⁸.

Conventional measures of right ventricular function like (right ventricular fractional area change (RV FAC), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler velocity of lateral tricuspid annulus(S’) could identify RV dysfunction only in a proportion of patients and a majority of the patients with normal values of RV FAC, TAPSE and S’ have been found to have right ventricular dysfunction ^{19, 20}. Additionally, TAPSE and tricuspid S’ velocity represents the degree of displacement of basal segment of RV free wall whereas RVGLS is a measure of global right ventricular systolic function ⁷.

The clinical application of RVGLS highlighted in our study has been demonstrated in representative figure4 and figure5. Patient1 presented with inferior+right+posterior wall acute myocardial infarction. The conventional measures of assessment of right ventricular function namely TAPSE (figure4a) and S’ (figure4b) were normal with values of 20mm and 0.12 m/s respectively. However, RVGLS was very low with a value of 13.2% (figure4c,4d). The patient had angiographic triple vessel disease with a 90% discrete stenosis of the mid RCA(figure5a) , bifurcation lesion of LAD-D1(medina 1,1,1) figure5c) and a diffusely diseased LCX (figure5b). The patient underwent primary angioplasty of the right coronary artery (figure5d) and was planned for elective angioplasty of the left anterior descending artery later.

CLINICAL APPLICATIONS OF RVGLS :

In a study done by Hamada et al ²¹, 618 patients with acute decompensated heart failure, there were 34.8% cardiac events during a median follow-up of 427 days. In multivariate analysis impaired RVGLS (≥−13.1%; hazard ratio, 1.51; 95% CI, 1.12–2.04; P=0.01) were independently associated with cardiac events

RV dysfunction (incidence 9%-44%) is a poor prognostic factor in patients undergoing left ventricular assist devices and RVGLS <9.6% was found to be an independent predictor of adverse cardiovascular outcomes and in-hospital mortality.²²

In patients with ischemic cardiomyopathy lower RVGLS (≥ −15.4%) was associated with lower one-year event-free survival (93.0% vs. 67.2%, p = 0.030).²³

From various studies conducted in patients presenting with inferior wall myocardial infarction, impaired RVGLS(≥−19.7% ) have been found to be predictive of proximal RCA culprit lesions²⁴ , complications like atrioventricular blocks , cardiogenic shock (RVGLS >-15.9%)²⁵ , (RVGLS ≥ −15.5%) was associated with significantly lower rates of survival and event-free survival⁵

Among patients presenting with inferior wall infarction and treated with primary angioplasty, RVGLS was superior to the conventional echocardiographic parameters in predicting recovery and late remodelling of the right ventricle that is associated with the occurrence of future cardiovascular events like recurrent heart failure, recurrent infarction due to stent thrombosis .²⁶

In patients presenting with NSTEMI, RVGLS was significantly associated with poor cardiovascular outcomes and hemodynamically significant arrhythmias²⁷

Abnormally low RV GLS may represent a dysynchrony in the right ventricle resulting in mechanical and electrical heterogeneity setting a milieu for development for recurrent arrhythmias and heart failure²⁸. In the current study, statistical significant association of RV GLS were observed with parameters like ejection fraction, TAPSE, S’, multivessel disease, arrhythmias and, target lesion revascularisation and duration of hospital stay.

Since strain imaging by speckle tracking analysis the contraction of the myocardium in three orthogonal planes (longitudinal, radial and circumferential), longitudinal strain can detect subclinical dysfunction at an early stage when the conventional parameters may be normal and obviating the limitations of conventional measures ²⁹.

Right ventricular global longitudinal strain measurement in acute coronary syndromes is an important predictor of complications like malignant ventricular arrhythmias, heart failure, reinfarction ³⁰that would help in risk stratifying the patients and plan an earliest appropriate interventional strategy.

The severity of acute myocardial infarction have been conventionally categorised based on clinical evaluation (KILLIP class) 31, electrocardiogram (Scarlovsky Birnbaum grading – myocardium at risk)³² and echocardiogram (TAPSE, S’) ^33.Since right ventricular global longitudinal strain could identify right ventricular dysfunction at a subclinical stage RV GLS might be used in addition to the above conventional methods to risk stratify patients admitted with acute myocardial infarction, prevent the progression of salvageable myocardium to infarction and necrosis and could serve as an independent prognostic marker in predicting major adverse cardiovascular events and in hospital outcomes.

STEMI - ST elevation myocardial infarction

MI - Myocardial infarction

RV GLS - Right ventricular global longitudinal strain

TAPSE - Tricuspid annular plane systolic excursion

FAC - Fractional Area Change

S’ - Tricuspid annulus tissue doppler velocity

TLR - Target lesion revascularisation

TDI - Tissue doppler imaging

VSR - Ventricular septal rupture

VT/VF - Ventricular tachycardia/ fibrillation

CHB - Complete heart block

AF - Atrial fibrillation

RCA - Right coronary artery

LCX - Left circumflex artery

2D TTE - Two dimensional transthoracic echocardiography

STE - Speckle tracking echocardiography

LAD - Left anterior descending artery

CAG - Coronary angiogram

CVA - Cerebrovascular accident

IW - Inferior wall

PW - Posterior wall

RV - Right ventricle

LV - Left ventricle

ROC - Receiver operator characteristic

AUC - Area under curve

LIMITATIONS OF THE STUDY

This was a single centred prospective observational study with a small sample size.

The study population comprising mostly patients with cardiopulmonary risk factors could have resulted in higher incidence of complications (multivessel disease , heart failure and reinfarction).The study population had wide range of variation in absolute values of right ventricular global longitudinal strain and the cut-off values for RV GLS predictive of adverse outcomes were derived from a sample of 200 patients that may not be representative of a larger cohort in a tertiary care setting .

FUNDING:

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

COMPETING INTERESTS:

The authors have no relevant financial or non-financial interests to disclose.

CONTRIBUTIONS:

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Dr. KAPIL RAJENDRAN. The scientific concepts of this manuscript was contributed by Dr.BAIJU RAJAN. The first draft of the manuscript was written by Dr.SIVAPRASAD KUNJUKRISHNAPILLA and Dr.MOHANAN KS and all authors commented on previous versions of the manuscript. The final proof reading and statistics were contributed by Dr.PRAVEEN VELAPPAN and Dr.ABDUL SALAM respectively. All authors read and approved the final manuscript

We thank Dr.BAIJU RAJAN in helping with the scientific aspects of this manuscript , Dr.SIVAPRASAD K in formulating the study protocol, Dr.MOHANAN KS in final proof reading ,Dr.PRAVEEN VELAPPAN in review of literature and Dr.ABDUL SALAM in helping with the statistics.

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Table 1 : Baseline characteristics of study subjects (N=200)

Age-no (%)
30-40 years	29(14.5)
41-50 years	46(23.0)
51-60 years	40(20.0)
61-70 years	40(20.0)
> 70 years	45(22.5)
Sex-no (%)
Male	102(51.0)
Female	98(49.0)
Type 2 diabetes mellitus-no (%)
Yes	117(58.5)
No	83(41.5)
Smoking-no (%)
Yes	46(23.0)
No	154(77.0)
Alcohol-no (%)
Yes	62(31.0)
No	138(69.0)
Systemic hypertension-no (%)
Yes	115(57.5)
No	85(42.5)
Thyroid disorder-no (%)
Yes	72(36.0)
No	128(64.0)
CVA-no (%)
Yes	57(28.5)
No	143(71.5)

CVA – cerebrovascular accident

Table 2 : Echocardiographic and angiographic characteristics

	Wall involved- no (%)
	IW		39(19.5)
	IW+RV		57(28.5)
	IW+RV+PW		104(52.0)
	Ejection fraction-no (%)
	Mild dysfunction		32(16.0)
	Normal		168(84.0)
	Right ventricular global longitudinal strain
	Low		112(56.0)
	Normal		88(44.0)
	TAPSE-no (%)
	Abnormal		133(66.5)
	Normal		67(33.5)
S’-no (%)
Abnormal		89(44.5)
Normal		111(55.5)
CAG-vessels involved-no (%)
LCX		26(13.0)
LCX+RAMUS		1(0.5)
RCA		76(38.0)
RCA+LAD		18(9.0)
RCA+LCX		33(16.5)
RCA+LCX+LAD		45(22.5)
RCA+RAMUS		1(0.5)

IW- inferior wall RV -right ventricle PW-posterior wall TAPSE -Tricuspid Annular plane systolic excursion S’- lateral tricuspid annulus tissue doppler CAG-coronary angiogram LCX- left circumflex artery LAD- left anterior descending artery RCA-right coronary artery

Table 3: Association of baseline characteristics with RV GLS

Variable	Right ventricular global longitudinal strain		P value
Variable	Low	Normal	P value
Age
30-40 years	16(55.2)	13(44.8)	0.589
41-50 years	27(58.7)	19(41.3)
51-60 years	19(47.5)	21(52.5)
61-70 years	21(52.5)	19(47.5)
>70 years	29(64.4)	16(35.6)
Sex
Male	59(57.8)	43(42.2)	0.592
Female	53(54.1)	45(45.9)	0.592
Type 2 diabetes mellitus
Yes	72(61.5)	45(38.5)	0.061
No	40(48.2)	43(51.8)	0.061
Smoking
Yes	23(50.0)	23(50.0)	0.350
No	89(57.8)	65(42.2)	0.350
Alcohol
Yes	35(56.5)	27(43.5)	0.931
No	77(55.8)	61(44.2)	0.931
Systemic hypertension
Yes	70(60.9)	45(39.1)	0.107
No	42(49.4)	43(50.6)	0.107
Thyroid disorder
Yes	40(55.6)	32(44.4)	0.924
No	72(56.2)	56(43.8)	0.924
CVA
Yes	37(64.9)	20(35.1)	0.109
No	75(52.4)	68(47.6)	0.109

CVA – cerebrovascular accident

Table 4: Association of conventional echocardiographic parameters , angiographic profile and complications with RVGLS

Variable	Right ventricular global longitudinal strain		P value
Variable	Low	Normal	P value
Wall involved
IW	9(23.1)	30(76.9)	<0.001*
IW+RV	42(73.7)	15(26.3)
IW+RV+PW	61(58.7)	43(41.3)
Ejection fraction
Mild dysfunction	25(78.1)	7(21.9)	0.006*
Normal	87(51.8)	81(48.2)	0.006*
TAPSE
Abnormal	112(84.2)	21(15.8)	<0.001*
Normal	14(7)	186(93)	<0.001*
S’
Abnormal	83(93.3)	6(6.7)	<0.001*
Normal	24(21.6)	87(78.4)	<0.001*
CAG-vessels involved
LCX	13(50.0)	13(50.0)	<0.001*
LCX+RAMUS	0(0.0)	1(100)
RCA	27(35.5)	49(64.5)
RCA+LAD	12(66.7)	6(33.3)
RCA+LCX	24(72.7)	9(27.3)
RCA+LCX+LAD	36(80.0)	9(20.0)
RCA+RAMUS	0(0.0)	1(100)
Arrhythmia
VT	12(66.7)	6(33.3)	0.02^*
CHB	17(70.8)	7(29.2)
Junctional bradycardia	10(58.9)	7(41.1)
First degree heart block	8(50)	8(50)
Mobitz type 1 heart block	10(90.9)	1(9.1)
Mobitz type 2 heart block	3(100)	0(0.0)
AF	7(77.8)	2(22.2)
Sinus bradycardia	24(66.7)	12(33.3)

Right Heart failure
Yes	52(76.5)	16(23.5)	<0.001*
No	60(45.5)	72(54.5)	<0.001*
Reinfarction
Yes	23(65.7)	12(34.3)	0.202
No	89(53.9)	76(46.1)	0.202
Recurrent angina
Yes	29(69.0)	13(31.0)	0.055
No	83(52.5)	75(47.5)	0.055
Target lesion revascularisation
Yes	14(66.7)	7(33.3)	0.029*
No	91(50.8)	88(40.2)	0.029*
Hospital stay
Prolonged	48(78.7)	13(21.3)	<0.001*
Not prolonged	64(46.0)	75(54.0)	<0.001*
Death
Yes	15(75.0)	5(25.0)	0.071
No	97(53.9)	83(46.1)	0.071

Table 5: Factors associated with right ventricular global longitudinal strain-multivariate analysis-logistic regression

	P value	OR
	P value	OR
Wall involved-IW+RV+PW	0.994	1.07(0.87-1.74)
Ejection fraction-mild dysfunction	0.165	4.48(0.88-8.94
CAG-vessel involved-RCA+LCX+LAD	0.252	2.15(0.58-8.01)
Heart failure	0.839	1.29(0.65-1.45)
arrhythmias	0.046	2.05(0.93-8.10)
Re-infarction	0.755	1(0.96-1.05)
Target lesion revascularisation*	0.035	3.64(1.35-11.53)
Prolonged hospital stay	0.984	1.02(0.79-1.38)

Table 6: Area under the curve

Area under the curve	95 % CI	P value
0.915	0.876-954	<0.001*

*statistically significant

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Prognostic Significance of Right Ventricular Global Longitudinal Strain in Acute Myocardial Infarction and Angiographic Correlation

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