Time-aligned segmental strain as a diagnostic marker for obstructive coronary artery disease in patients with chronic chest pain

Abstract Background Myocardial strain curves provide valuable insights into coronary artery disease (CAD) beyond conventional peak strain measurements. This study aimed to evaluate the diagnostic utility of time-aligned segmental strain and strain rate (S/SR) curves to identify obstructive CAD in consecutive chest pain patients. Methods A total of 510 chest-pain patients referred to coronary computed tomography angiography (CCTA) were included. Segmental strain curves were time-aligned using aortic valve closure (AVC) and cardiac cycle length as reference points. Average S/SR curves were generated for 18 myocardial segments, establishing reference curves from a group of 314 chronic chest-pain patients without CAD (No-CAD). Deviations were defined based on thresholds of peak S/SR or average S/SR curve deviation over systole and the first half of diastole. Results Significant differences were observed between groups, particularly between the revascularized MI, CABG, or 3-vessel CAD groups compared to the No-CAD group (p<0.05). ROC curve analysis demonstrated excellent diagnostic performance for CABG patients (AUC up to 0.933), while the detection rate for PCI was limited (AUC < 0.7). Global longitudinal strain rate in early diastole (GLSR E) and segmental peak SR E showed the highest diagnostic accuracy. These findings confirm that time-aligned strain analysis improves the detection of significant CAD but remains limited for identifying patients with mild disease. Conclusion Time-aligned segmental strain analysis improved detection of high-grade disease requiring CABG but could not distinguish single-vessel from non-obstructive CAD. Pathological strain patterns became significant only in advanced CAD, indicating that segmental resting strain analysis has clinical utility primarily for identifying advanced CAD.