Global Circumferential and Radial Strain Among Patients With Immune Checkpoint Inhibitor Myocarditis

Thiago Quinaglia, Carlos Gongora, Magid Awadalla, Malek Z.O. Hassan, Amna Zafar, Zsofia D. Drobni, Syed S. Mahmood, Lili Zhang, Otavio R. Coelho-Filho, Giselle A. Suero-Abreu, Muhammad A. Rizvi, Gagan Sahni, Anant Mandawat, Eduardo Zatarain-Nicolás, Michael Mahmoudi, Ryan Sullivan, Sarju Ganatra, Lucie M. Heinzerling, Franck Thuny, Stephane EderhyHannah K. Gilman, Supraja Sama, Sofia Nikolaidou, Ana González Mansilla, Antonio Calles, Marcella Cabral, Francisco Fernández-Avilés, Juan José Gavira, Nahikari Salterain González, Manuel García de Yébenes Castro, Ana Barac, Jonathan Afilalo, Daniel A. Zlotoff, Leyre Zubiri, Kerry L. Reynolds, Richard Devereux, Judy Hung, Michael H. Picard, Eric H. Yang, Dipti Gupta, Caroline Michel, Alexander R. Lyon, Carol L. Chen, Anju Nohria, Michael G. Fradley, Paaladinesh Thavendiranathan, Tomas G. Neilan

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Background: Global circumferential strain (GCS) and global radial strain (GRS) are reduced with cytotoxic chemotherapy. There are limited data on the effect of immune checkpoint inhibitor (ICI) myocarditis on GCS and GRS. Objectives: This study aimed to detail the role of GCS and GRS in ICI myocarditis. Methods: In this retrospective study, GCS and GRS from 75 cases of patients with ICI myocarditis and 50 ICI-treated patients without myocarditis (controls) were compared. Pre-ICI GCS and GRS were available for 12 cases and 50 controls. Measurements were performed in a core laboratory blinded to group and time. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiogenic shock, cardiac arrest, complete heart block, and cardiac death. Results: Cases and controls were similar in age (66 ± 15 years vs 63 ± 12 years; P = 0.20), sex (male: 73% vs 61%; P = 0.20) and cancer type (P = 0.08). Pre-ICI GCS and GRS were also similar (GCS: 22.6% ± 3.4% vs 23.5% ± 3.8%; P = 0.14; GRS: 45.5% ± 6.2% vs 43.6% ± 8.8%; P = 0.24). Overall, 56% (n = 42) of patients with myocarditis presented with preserved left ventricular ejection fraction (LVEF). GCS and GRS were lower in myocarditis compared with on-ICI controls (GCS: 17.5% ± 4.2% vs 23.6% ± 3.0%; P < 0.001; GRS: 28.6% ± 6.7% vs 47.0% ± 7.4%; P < 0.001). Over a median follow-up of 30 days, 28 cardiovascular events occurred. A GCS (HR: 4.9 [95% CI: 1.6-15.0]; P = 0.005) and GRS (HR: 3.9 [95% CI: 1.4-10.8]; P = 0.008) below the median was associated with an increased event rate. In receiver-operating characteristic (ROC) curves, GCS (AUC: 0.80 [95% CI: 0.70-0.91]) and GRS (AUC: 0.76 [95% CI: 0.64-0.88]) showed better performance than cardiac troponin T (cTnT) (AUC: 0.70 [95% CI: 0.58-0.82]), LVEF (AUC: 0.69 [95% CI: 0.56-0.81]), and age (AUC: 0.54 [95% CI: 0.40-0.68]). Net reclassification index and integrated discrimination improvement demonstrated incremental prognostic utility of GRS over LVEF (P = 0.04) and GCS over cTnT (P = 0.002). Conclusions: GCS and GRS are lower in ICI myocarditis, and the magnitude of reduction has prognostic significance.

Original languageEnglish (US)
Pages (from-to)1883-1896
Number of pages14
JournalJACC: Cardiovascular Imaging
Issue number11
StatePublished - Nov 2022


  • cardiovascular risk stratification
  • immune checkpoint inhibitors
  • myocarditis
  • strain modalities survival analysis

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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