Title : Echocardiographic evaluation of takayasu arteritis including speckle tracking echocardiography and aortic stiffness
Abstract:
Introduction: Cardiac involvement with overt Left Ventricular (LV) dysfunction and congestive heart failure are known in Takayasu’s Arteritis (TA). Subclinical LV dysfunction can also occur despite a normal global LV Ejection Fraction (LVEF). Speckle-Tracking Echocardiography (STE) and Strain imaging are valuable in identifying such subclinical myocardial dysfunction. Aortic stiffness, a measure of arterial elasticity, is also emerging as a marker for cardiovascular risk in systemic inflammatory diseases.
Objectives: To assess LV, RV and LA strain and aortic stiffness in Indian patients with TA and correlate these with disease activity.
Methods: 100 patients of Takayasu Arteritis>18 years (mean age 29.8 years+10.04: range 18-52 years), 70% females, were enrolled. Echocardiographic imaging was performed in all including LV, RV and LA strain analysis along with calculation of aortic stiffness. Twenty-five (25) age and sex-matched, non-hypertensive healthy controls were also recruited.
Results: The mean duration of illness 6.34 years was+4.41 years (range 1-30 years) and the clinical presentation included constitutional symptoms in 48%, hypertension in 44% patients and limb claudication in 35% patients. The predominant angiographic type was Numano V in 42% patients followed by Type III in 20%. In comparison to controls, patients had significantly higher left atrial size (34.53 ±4.01 mm vs 32.66±mm, p=0.036), left ventricular end-diastolic diameter (LVEDd: 44.92±3.27 mm vs 43.98±3.8 mm, p=0.216), left ventricular end-systolic diameter (LVESd: 29.23±3.54 mm vs 28.92±3.2 mm, p=0.690), left ventricular interventricular septum thickness (LV-IVS: 11.09±1.22 mm vs 10.8±1.5 mm, p=0.312), left ventricular posterior wall thickness (LV-PW: 11.14±1.35 mm vs 10.6±1.42 mm, p=0.079) and left ventricular mass indexed (71.6±7.6 vs 68.5 ± 6.8 gm/m2, p=0.065). Although normal, the mean LVEF was significantly lower in patients (54.91±3.99 vs 59.6±4.7%, p=0.0001) vs controls, while 6% patients had LVEF<50%. Valvular regurgitation was observed in 47% patients (majority: 80% had mild regurgitation, 42% had TR, 38% had MR, and 20% had AR).
Patients of TA had significantly lower mean GLS (-16.09±2.16% vs -18.9+3.50, p=0.0001), peak atrial longitudinal strain (PALS: 25.03±2.04% vs 27.1+4.14 % p= 0.0001) and RV-FWS (23.42 ± 2.72% vs 25.2+2.98%, p=0.736). The % of patients with LV GLS>−16% was 32%, while the % of those with PALS<-25% and RVGLS>-23% was 26% and 14% respectively. The mean aortic stiffness was higher in patients with TA (8.39±2.45 vs 7.44+/-0.64 m/sec) as compared to controls, and 17% patients with TA had high Aortic stiffness (>12 m/sec). Those with LVGLS > -16% had longer duration of symptoms (7.02±4.2 years vs 5.66 ± 3.2 years, p=0.05), higher mean ITAS score (4.96±2.9 s 4.44+2.1) and higher ESR and CRP values. The prevalence of impaired RV strain was also significantly more in these patients (28% vs 7%, p=0.0003), while the frequency of those with impaired PALS was higher (29% vs 18%, p=0.1) but not significant.
Patients of TA with abnormal Aortic stiffness had significantly higher mean ITAS-2010 scores (5.58±5.06 vs 3.62±3.2, p=0.044), active disease (ITAS-2010>2, 64% vs 40%, p<0.01), and higher ESR and CRP values. These patients also had more prevalence of abnormal RV-FWS (41% vs 9%, p=0.0001) and decreased atrial reservoir function (abnormal PALS in 41% vs 24%, p=0.034).
Conclusion: Despite overall normal global LVEF, in patients with TA, LVGLS, RVGLS and atrial reservoir function were significantly lower while Aortic stiffness was significantly higher. Overall, 32%, 26% and 14% had impaired LVGLS, RVFWS and PALS. Patients of TA with impaired LVGLS and abnormal Aortic stiffness had higher ITAS score, more active disease and higher ESR and CRP than those with normal parameters. These patients also had significantly higher prevalence of concomitantly impaired RV strain and atrial reservoir function. Our study provides important insights into the prevalence of impaired bi-ventricular strain, atrial reservoir function and measures of aortic stiffness in Indian patients with Takayasu’s arteritis.
