12. Ricotta JJ, Bryan FA, Bond MG, Kurtz A, O’Leary DH, Raines JK, BersonAS, Clouse ME, Calderon-Ortiz M, Toole JF. Multicenter validation study ofreal-time (B-mode) ultrasound, arteriography, and pathologic examination. JVasc Surg 1987;6:512–520.13. Ebrahim S, Papacosta O, Whincup P, Wannamethee G, Walker M, NicolaidesAN, Dhanjil S, Griffin M, Belcaro G, Rumley A, et al. Carotid plaque, intimamedia thickness, cardiovascular risk factors, and prevalent cardiovascular diseasein men and women: the Br Regional Heart Study. Stroke 1999;30:841–850.14. Li R, Duncan BB, Metcalf PA, Crouse JR III, Sharrett AR, Tyroler HA,Barnes R, Heiss G. B-mode-detected carotid artery plaque in a general popula-tion. Atherosclerosis Risk in Communities (ARIC) Study Investigators. Stroke1994;25:2377–2383.15. Jones DJ, Bromberger JT, Sutton-Tyrrell K, Matthews KA. Lifetime historyof depression and carotid atherosclerosis in middle-aged women. Arch GenPsychiatry 2003;60:153–160.

16. Horwath E, Johnson J, Klerman GL, Weissman MM. Depressive symptomsas relative risk and attributable risk factors for first-onset major depression. ArchGen Psychiatry 1992;49:817–823.17. Everson SA, Kaplan GA, Goldberg DE, Salonen R, Salonen JT. Hopelessnessand 4-year progression of carotid atherosclerosis. The Kuopio Ischemic HeartDisease Risk Factor Study. Arterioscler Thromb Vasc Biol 1997;17:1490–1495.18. Lesperance F, Frasure-Smith N, Talajic M, Bourassa MG. Five-year risk ofcardiac mortality in relation to initial severity and one-year changes in depressionsymptoms after myocardial infarction. Circulation 2002;105:1049–1053.19. Bush DE, Ziegelstein RC, Tayback M, Richter D, Stevens S, Zahalsky H,Fauerbach JA. Even minimal symptoms of depression increase mortality riskafter acute myocardial infarction. Am J Cardiol 2001;88:337–341.20. Kelley KW, Bluthe RM, Dantzer R, Zhou JH, Shen WH, Johnson RW,Broussard SR. Cytokine-induced sickness behavior. Brain Behav Immun2003;17(suppl):S112–S118.

A New Simple Method to Assess Global LeftVentricular Systolic Function Based on the Sum of

Regional Myocardial Velocities

Jesús Peteiro, MD, Juan Garcia-Lara, MD, Iris Garrido, MD, Lorenzo Monserrat, MD,Guillermo Aldama, MD, and Alfonso Castro-Beiras, MD

The relations between left ventricular (LV) functionand global tissue Doppler velocity, strain rate, andstrain were assessed in 99 studies. Significant corre-lations were found between the LV ejection fractionand global tissue Doppler velocity, strain, and strainrate (r � 0.50, r � 0.63, and r � 0.46, respectively,all p <0.001), suggesting that this global assessmentmay be useful in evaluating LV function. �2005 byExcerpta Medica Inc.

(Am J Cardiol 2005;95:550–552)

A lthough echocardiography is commonly used toassess the left ventricular (LV) ejection fraction

(EF), its main limitation is its intra- and interobservervariabilities.1 Tissue Doppler imaging (TDI) hasemerged as a useful technique to assess myocardialregional velocities. Again, the assessment of regionalvelocities may have significant intersubject variabil-ity, which depends mainly on the different placementof the sample.2,3 We hypothesized that the placementof a sample volume large enough to include the entireleft ventricle for the assessment of global myocardialvelocities would have less variability and that thisglobal value might correlate with LVEF and the ino-tropic state.

• • •The study group included 86 consecutive patients

(mean age 63 � 12 years; 54 men), after exclusions.Exclusion criteria were atrial fibrillation or atrial flut-ter and bad acoustic window. Previous myocardialinfarctions were reported in 27 patients (31%) andregional wall motion abnormalities in 31 patients

(36%). We performed 99 2-dimensional and tissueDoppler echocardiographic studies in the 86 patients(86 at rest and 13 under stress conditions with dobut-amine). In addition, noninvasive dP/dt was assessed asan index of contractility in 26 patients by the decay ofthe mitral regurgitation curve, as previously de-scribed.4 The mean LVEF in the studies was 0.58 �0.16 (range 0.16 to 0.87), and the mean LV wallmotion score index was 1.2 � 0.4 (range 1.0 to 2.3).

We measured LV end-diastolic volume, LV end-systolic volume, the LVEF by the biplane Simpson’srule,5 and the wall motion score index in every study.Color TDI was performed in the apical 4- and 2-cham-ber views. The angle and depth were set to include theentire LV cavity in each view. The mean frame ratewas 114 � 20 frames/s (range 77 to 134). The samplewas digitized when the LV cavity achieved its maxi-mal dimension. The region of interest was set toenclose the external myocardial border and the mitralannulus to include all the myocardial signals but ex-cluding the mitral valve (Figure 1). Accordingly, theresults of the sample include the mean of all myocar-dial velocities and also signals from the LV cavity.Two-dimensional and tissue Doppler echocardio-graphic images were stored on an optical disc foroff-line analysis. The means of the peak systolic tissueDoppler velocity, peak systolic strain rate, and peaksystolic strain (percent) obtained in the 4- and 2-cham-ber apical views were measured offline from the re-corded color tissue Doppler images to correlate withthe LVEF and dP/dt. The formula used to calculatedP/dt was dP/dt (mm Hg) � 32/time (seconds) fromthe velocity of 1 to 3 m/s achieved in the mitralregurgitation Doppler curve.4

Intra- and interobserver variabilities were calcu-lated by assessing the same 2-dimensional and TDImeasurements in 18 randomized studies 4 weeks afterthe first study. Variability is given as a percentage of

From the Unit of Echocardiography and Department of Cardiology,Juan Canalejo Hospital, A Coruña, Spain. Dr. Peteiro’s address is:P/Ronda 5-4° izda, 15011 A Coruña, Spain. E-mail: pete@canalejo.org. Manuscript received August 24, 2004; revised manu-script received and accepted October 13, 2004.

550 ©2005 by Excerpta Medica Inc. All rights reserved. 0002-9149/05/$–see front matterThe American Journal of Cardiology Vol. 95 February 15, 2005 doi:10.1016/j.amjcard.2004.10.033

error in each measurement and calculated as the dif-ference between the 2 assessments corrected by themean value of the 2 assessments.

The relation between TDI mea-surements and the LVEF and dP/dtwas assessed by linear regressionanalysis. Values of r are given. A pvalue �0.05 was considered signifi-cant. Receiver-operator characteris-tic curves were built to define thecut-off values more accurately to dis-criminate a normal from an abnormalLVEF. The values of area under thecurve (AUC) and 95% confidenceintervals (CIs) are given.

The mean time to measure globalsystolic myocardial velocity, strainrate, and strain was 172 � 32 sec-onds, whereas it was 93 � 15 sec-onds for the assessment of the LVEFby the biplane Simpson’s rule (p�0.01). Inter- and intraobservervariabilities for the assessment of theLVEF, tissue Doppler velocity,strain rate, and strain were not differ-ent (Table 1).

Correlations between the LVEFand systolic tissue Doppler velocity,

strain rate, and strain were r � 0.50, r � 0.63, and r �0.46, respectively (all p �0.001, SEE 0.14, 0.12, and0.14, respectively; Figure 2). In patients with regionalwall motion abnormalities, correlations were not dif-ferent (r � 0.56, r � 0.54, and r � 0.63 between theLVEF and tissue Doppler velocity, strain rate, andstrain, respectively; p �0.001). Global systolic tissueDoppler velocity, strain rate, and strain were alsocorrelated with wall motion score index (r � 0.53, r �0.53, and r � 0.46, respectively; all p �0.001, SEE0.32, 0.32, and 0.33, respectively). Correlations be-tween noninvasive measurement of dP/dt and tissueDoppler velocity, strain rate, and strain were r � 0.69(p �0.001), r � 0.65 (p �0.001), and r � 0.53 (p�0.01) (SEE 0.66, 0.14, and 3.20, respectively; Fig-ure 3). However, the correlation between dP/dt and theLVEF was poorer (r � 0.39, p � 0.05).

The best differentiation of a normal LVEF (�50%)from an abnormal LVEF (�50%) was provided by asystolic tissue Doppler velocity �1.8 cm/s (sensitivity75%, specificity 82%; AUC 0.81, 95% CI 0.70 to0.92), strain rate ��0.45/s (sensitivity 82%, specific-ity 75%; AUC 0.84, 95% CI 0.75 to 0.93), and strain��7.5% (sensitivity 70%, specificity 71%; AUC0.76, 95% CI 0.66 to 0.86).

• • •We evaluated a simple method to analyze global

LV function by measuring the sum of intramyocardialvelocities. We found adequate correlations with theLVEF and wall motion score index and also with anoninvasive index of contractility. This method isrelatively simple and not time consuming. The time todigitize the entire myocardium and calculate globalmyocardial velocities, strain rate, and strain was ap-proximately 1 minute more as a mean than that re-quired to measure the LVEF by the biplane Simpson’smethod. One of the problems of measuring intramyo-

FIGURE 1. Digitization for the assessment of tissue Doppler velocity, strain rate, andstrain was performed when the LV cavity achieved its maximal dimension. The regionof interest was set to enclose the external myocardial border but exclude the mitralvalve (left). A smooth and easily assessable strain rate curve is depicted with thismethod (right).

FIGURE 2. Plot of the correlation obtained between global strainrate (SR) and the LVEF.

TABLE 1 Variability in the Assessment of the LVEF and GlobalTissue Doppler Velocity, Strain Rate, and Strain

Variability LVEFs-TDV(cm)

Strain Rate(L/s)

Strain(%)

Intraobserver (%) 8 � 7 7 � 9 7 � 13 18 � 45Interobserver (%) 5 � 5 5 � 11 3 � 2 13 � 13

s-TDV � systolic tissue Doppler velocity

BRIEF REPORTS 551

cardial velocities and strain is the intra- and interob-server variabilities because of the difficulty of mea-suring 2 times in exactly the same point of themyocardium.2,3 This variability is much less when theentire myocardium is included, as we propose, as asimple measurement of global LV function. Regard-ing the measurement of strain rate curves in a local-ized site of the myocardium, curves are usually noisy,and it is difficult to ascertain the true value. However,with the method we propose, noise does not exist, anda smooth strain rate curve is depicted (Figure 1).Tissue Doppler velocity measuring the mitral annulus

systolic descent has been used as a relatively simplemethod to measure global LV function. However, thismethod requires measurements in several locations ofthe mitral annulus,6,7 in contrast with the simplicity ofour method. In a recent study, global myocardial strainwithout including intracavitary signals was correlatedadequately with wall motion score index.8 A cut-offstrain value of �21% had 92% sensitivity and 89%specificity for the detection of an abnormal wall mo-tion score index. However, this method required acomputerized system that is not commercially avail-able, and the investigators did not compare it with analternative quantitative method such as the LVEF. Incomparison with that approach, our method is simplerand may have obvious clinical applications, such asthe assessment of changes in the inotropic state duringstress echocardiography or pharmacologic therapy.

1. ACC/AHA practice guidelines. ACC/AHA guidelines for clinical applicationof echocardiography. Circulation 1997;95:1686–1744.2. Vinereau D, Khokhar A, Fraser AG. Reproducibility of pulsed wave tissueDoppler echocardiography. J Am Soc Echocardiogr 1999;12:492–499.3. Fraser AG, Payne N, Madler CF, Janerot-Sjoberg B, Lind B, Grocott-MasonRM, Ionescu AA, Florescu N, Wilkenshoff U, Lancellotti P, et al. Feasibility andreproducibility of off-line tissue Doppler measurement of regional myocardialfunction during dobutamine stress echocardiography. Eur J Echocardiogr 2003;4:43–53.4. Bargiggia GS, Bertucci C, Recusani F, Raisaro A, de Servi S, Valdes-CruzLM, Sahn DJ, Tronconi L. A new method for estimating left ventricular dP/dt bycontinuous wave Doppler-echocardiography. Validation studies at cardiac cath-eterization. Circulation 1989;80:1287–1292.5. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H,Gutgesell H, Reichek N, Sahn D, Schnittger I, et al. Recommendations forquantification of the left ventricle by two dimensional echocardiography. J AmSoc Echocardiogr 1989;2:358–367.6. Gulati VK, Katz WE, Follansbee WP, Gorcsan J III. Mitral annulus descentvelocity by tissue Doppler echocardiography as an index of left ventricularfunction. Am J Cardiol 1996;77:979–984.7. Vinereau D, Khokhar A, Tweddel AC, Cinteza M, Fraser AG. Estimation ofglobal left ventricular function from the velocity of longitudinal shortening.Echocardiography 2002;19:177–185.8. Reisner SA, Lysyansky P, Agmon Y, Mutlak D, Lessick J, Friedman Z. Globallongitudinal strain: a novel index of left ventricular systolic function. J Am SocEchocardiogr 2004;17:630–633.

FIGURE 3. Plot of the correlation obtained between global strainrate (SR) and dP/dt.

552 THE AMERICAN JOURNAL OF CARDIOLOGY� VOL. 95 FEBRUARY 15, 2005