title: Incremental prognostic value of echocardiographic strain and its association with mortality in cancer patients.
abstract: BACKGROUND
  Left ventricular global longitudinal systolic strain (GLS) has been shown to be superior to ejection fraction in detecting subclinical dysfunction in patients with cancer and predicting mortality in patients with cardiovascular disease. Cancer-related fatigue is common in the later stages of neoplastic malignancies and may be indicative of nonovert heart failure. The aim of this study was to determine whether reduced strain by echocardiography was associated with all-cause mortality in a cancer cohort.
  
  
  METHODS
  In this retrospective study, 120 patients with cancer undergoing or scheduled to undergo chemotherapy and with normal ejection fractions (>50%) underwent assessments of GLS. GLS was derived by averaging all speckle-tracking strain segments of the left ventricle.
  
  
  RESULTS
  Over an average follow-up period of 21.6 ± 13.9 months, 57 of 120 patients died. Univariate predictors of all-cause mortality (P < .10) were Eastern Cooperative Oncology Group performance status, male sex, hematologic malignancy, β-blocker use, and GLS. Multivariate analysis of all significant univariate variables showed that Eastern Cooperative Oncology Group performance status (hazard ratio, 2.12; 95% confidence interval, 1.54-2.92; P < .001), male sex (hazard ratio, 1.93; 95% confidence interval, 1.14-3.27; P = .014), and GLS (hazard ratio, 0.89; 95% confidence interval, 0.81-0.97; P = .012) were significantly and independently associated with mortality. Stepwise analysis of the multivariate associations showed an increase in the global χ(2) value after adding GLS (P = .011) to significant clinical variables.
  
  
  CONCLUSIONS
  Eastern Cooperative Oncology Group performance status, male sex, and GLS were significantly associated with all-cause mortality in patients with cancer with normal ejection fractions receiving chemotherapy. Adding GLS to significant clinical variables provided incremental prognostic information.
authors.affiliation: Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana. Electronic address: isaac.b.rhea@gmail.com.
authors.forename: Isaac B
authors.initials: IB
authors.lastname: Rhea
authors.affiliation: Division of Cardiology, Community Health Network, Indianapolis, Indiana.
authors.forename: Sarada
authors.initials: S
authors.lastname: Uppuluri
authors.affiliation: Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: Stephen
authors.initials: S
authors.lastname: Sawada
authors.affiliation: Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: Bryan P
authors.initials: BP
authors.lastname: Schneider
authors.affiliation: Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana.
authors.forename: Harvey
authors.initials: H
authors.lastname: Feigenbaum
mesh_terms: D015897:Comorbidity; D004452:Echocardiography / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015994:Incidence; D007196:Indiana / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000000981:diagnostic imaging* / Q000401:mortality*; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D017678:Sex Distribution; D013318:Stroke Volume; D016019:Survival Analysis; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000401:mortality*
keywords: Echocardiography; Mortality; Neoplasia; Prognosis; Speckle-tracking imaging; Strain