As far as we are aware, this is the first report on CMR-FT at 3 T to study differences in myocardial deformation in CA with preserved and with mildly decreased LV systolic function in comparison with a group of healthy controls as a reference. We obtained several findings. Firstly, CMR-FT LV and RV deformation analysis showed significant and progressive decrease in GLS, GRS and GCS from healthy controls to CA-LVEFd with all of them significantly decreased in CA-LVEFp compared to healthy controls. Secondly, LV L-SDI, C-SDI and R-SDI, as well as LV and RV GLSR and LV GRSR showed significant differences among the groups, but only LV GLSR, GRSR and RV GRSR showed differences between healthy controls and CA-LVEFp, while neither dyssynchrony nor other strain rate parameters were significantly different in CA-LVEFp with respect to controls. Lastly, we also found that LVM and RWM were significantly increased in CA-LVEFp with respect to healthy controls.
There is increasing evidence that a reduction of LV strain and strain rate precedes the hemodynamic effects of LV impairment [
26,
27] and may add prognostic information in a number of conditions [
28]. Thus, we hypothesized that deformation analysis measured with CMR could detect preclinical involvement in CA with still preserved LVEF. Although CMR tagging is the gold-standard technique for deformation analysis, [
29‐
32] it is time-consuming and generally limited to the research arena requiring specific imaging protocols, sequences and dedicated post-processing software. CMR-FT is being increasingly used for deformation analysis since it does not suffer from the same limitations as echocardiography-based techniques while it can be done off-line in previously acquired standard cine sequences [
33] while enjoying short processing times [
34]. Equally, CMR-FT of the RV offers the potential for rapid and sensitive quantification of function.
Strain analysis
Strain is the most frequently used deformation index. Usually, 2D CMR-FT is used, as in this study, although 3D CMR-FT has been reported to be more reproducible [
35]. Still, the latter relies on the measurements done in the 2D short axis cine stack, so it is still affected by the through-plane motion of the heart. In our study CA-LVEF
p exhibited for all types of strain intermediate values between controls and CA-LVEF
d, and post-hoc analysis showed that LV GLS, GRS, GCS, and RV GRS and GLS were already decreased in CA-LVEF
p. Regarding LV strain parameters, there are no previous reports with which we could compare our results, but similar findings have been reported with STE in patients presenting with anthracycline induced cardiotoxicity, in whom a decrease of GLS [
12] and GCS [
36,
37] have been reported to precede significant changes in LVEF, and in alcohol induced cardiomyopathy, in which both GLS and GCS are reduced in subclinical myocardial dysfunction [
38]. Noteworthy, in our study GRS was also able to detect subclinical dysfunction despite the higher reported measurement variability of GRS, [
24,
39‐
41] which usually requires greater sample sizes than other strain parameters in order to detect differences. Regarding RV strain parameters, again there are no previous reports for comparison, but it has been shown with STE that RV strain analysis is able to detect early affection of RV function in patients under chemotherapy, which in a particular study was associated with reduced recovery of LVEF [
42].
We do not know the exact mechanism by which a decrease in global strain occurs in CA-LVEF
p. Actually, cocaine chronic cardiotoxicity has been considered to be a multifactorial process plus individual susceptibility, and it can be expected that this is the case in CA. Decreased LV volume has been reported to explain reduced GLS or GCS with preserved EF, [
43] but in our study no subject had LV volume below the normal range. We included in our analysis the presence of LGE, LVH and alcohol consumption as potential covariates. Interestingly, we observed decreased GLS along with increased LV mass in CA-LVEF
p, which is in accordance with previous observations of decreased longitudinal function in hypertrophied ventricles, [
44] but LVH failed to show a significant effect on strain parameters in the statistical analysis. With respect to presence of hypertension and alcohol consumption, both groups of CA had similar number of hypertensives and alcohol abusers, and similar severity of alcohol abuse, and in fact these variables failed to show a significant effect as covariates on strain parameters. Limited, short-lasting, subendocardial stress myocardial perfusion defects had been observed in 4 of the first 48 subjects of the cohort in which stress perfusion study was done, but this was not a covariate with significant effect on any strain parameter. Regarding LGE, this was of limited extension in our subjects and, though we observed a progressive decline in strain from the control group down to CA-LVEF
d with LGE, the presence of LGE was not a covariate with significant effect in any strain parameter. Again we cannot compare our results with those of others but it has been reported, in conditions such as hypertrophic cardiomyopathy, [
21] that strain and strain rate values are further decreased in those patients who exhibit LGE. We think that the very limited amount of LGE detected in our study can explain our findings. Interestingly, interstitial fibrosis might be present in the myocardium of CA which could affect strain measurements. Although we could not use the T1 mapping technique, we hypothesize that it would provide interesting data with regard to the myocardial interstitium in cocaine cardiotoxicity. Furthermore, T1 mapping along with strain analysis might provide a more comprehensive and accurate evaluation of this condition. We also assessed whether increased LV volumes occurred in CA-LVEF
p, since strain measures are still slightly affected by LV preload, [
45] but we found no significant LV dilatation in CA-LVEF
p compared with controls.
Finally, we speculate that the presence of reduced strain values in CA-LVEF
p might have independent prognostic importance, similarly to other conditions, [
46] though our study was not designed to assess outcomes. Future studies will show the prognostic value of abnormal strain measurements and whether they normalize after cocaine cessation.
Dyssynchrony index
Segmental strain analysis with CMR-FT is a useful method for assessment of regional myocardial deformation [
35]. We had previously observed in our cohort of CA a variable degree of dyssynchrony of contraction on visual assessment. Therefore, in this study we intended to assess left ventricular dyssynchrony with CMR-FT by measuring SDI, defined as the standard deviation of the calculated time-to-peak percentages of all segments with respect to the duration of the cardiac cycle [
25]. CMR-FT derived SDI has demonstrated good agreement with dyssynchrony measured with STE [
47] and has been used in conditions such as heart failure and congenital heart disease [
25,
48]. Also, LV dyssynchrony may be a sign of impaired LV function in CA similarly to other conditions [
25].
Though we observed significant differences among the groups for L-SDI, R-SDI and C-SDI, with the healthy control group showing the lowest values and CA-LVEF
d exhibiting the highest, neither of these parameters could exhibit significant differences between controls and CA-LVEF
p. We obtained a C-SDI of 8.0 ± 3.4% in the control group, higher than previously published ranges, [
25] though differences in design and methodology as well as the sample size, could explain the differences. We cannot compare our findings in CA with other reports, but equivalent results have been shown in alcohol induced cardiomyopathy with realtime 3D echocardiography, with increased SDI in addicts compared to controls [
49].
Strain rate
Significant differences were found for LV and RV GLSR and GRSR among the groups, and post-hoc analysis showed for both LV GLSR and LV GRSR, and for RV GRSR, significant differences between controls and CA-LVEF
p, and between controls and CA-LVEF
d. Usually, in CMR-FT analysis integral variables such as displacement and strain are more reliable than the differential ones, including strain rate. In particular, temporal resolution is such that rapid myocardial events like isovolumic time intervals are not reliable. Strain rate measurements are noisier and less reproducible than strain parameters, and more affected by temporal resolution, thus results must be interpreted with caution. Actually, CMR-FT has lower temporal resolution compared to STE, which explains why CMR-FT strain values tend to be lower [
50] and strain rate parameters less robust. As for strain and dyssynchrony, neither alcohol consumption nor the presence of LVH or LGE were found to have a significant effect on these parameters.
Ventricular dimensions and function
We observed significant differences in all LV and RV dimensions and function parameters mainly due to differences between controls and CA-LVEFd. LVH was present in nearly one third of both groups of CA but it was in mild all cases, though both LV mass and relative wall mass, which is calculated as mass divided by the end-diastolic volume, were significantly increased in CA-LVEFp compared to controls. Equally, LV dilatation was seen marginally in CA-LVEFp and in 19% of CA-LVEFd, but again was mild in all cases. Thus, LV mass and dimensions were just mildly affected in our cohort of asymptomatic CA, and LVH was not found to have a significant statistical effect on deformation parameters. We hypothesize that several factors not fully understood, might interact causing the decreased strain we have found in these subjects.
Clinical implications of deformation analysis in CA
Regarding the clinical use of CMR-FT in cocaine cardiotoxicity, we consider that this technique cannot be promoted in CA before several questions are answered, as was the case with other pathologies such as chemotherapy induced cardiotoxicity. First, the prognostic significance of strain measurement in cocaine addicts should be established. Also, decision on which single parameter to use, and with which cut-off values, should be made. Finally, strong evidence should be available before any changes in medical management can be discussed. At the moment we can only suggest to use strain parameters, because of their known robustness, and among them global longitudinal strain would be our measurement of choice, similar to other pathologies. Still, data on prognostic value is mandatory before we can promote this technique in clinical practice and, at current, no data is available in order to change this subject’s medical management further than strongly recommend cessation of cocaine and a closer follow-up, with otherwise treatment according to current guidelines.