Skip to main content

Advertisement

SpringerLink
Log in

3D echocardiographic global longitudinal strain can identify patients with mildly-to-moderately reduced ejection fraction at higher cardiovascular risk

  • Original Paper
  • Published:
The International Journal of Cardiovascular Imaging Aims and scope Submit manuscript

Abstract

Severely reduced left ventricular (LV) ejection fraction (EF) derived from 2D echocardiographic (2DE) images is associated with increased mortality and used to guide therapeutic choices. Global longitudinal strain (GLS) is more sensitive than LVEF to detect abnormal LV function, and accordingly may help identify patients with mildly-to-moderately reduced LVEF who are at a similarly high cardiovascular (CV) risk. We hypothesized that 3D echocardiographic (3DE) measurements of EF and GLS, which are more reliable and reproducible, may have even better predictive value than the 2DE indices, and compared their ability to identify such patients. We retrospectively studied 104 inpatients with 2DE-derived LVEF of 30–50% who underwent transthoracic echocardiography during 2006–2010 period, had good quality images, and were followed-up through 2016. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Kaplan–Meier survival curves were generated for two subgroups defined by the median of each parameter as the cutoff. Of the 104 patients, 32 died of CV related causes. Cox regression revealed that 3D GLS was the only variable associated with CV mortality. Kaplan–Meier curves showed that 2D LVEF, 2D GLS and 3D EF were unable to differentiate patients at higher CV mortality risk, but 3D GLS was the only parameter to do so. Because 3D GLS is able to identify patients with mildly-to-moderately reduced LVEF who are at higher CV mortality risk, its incorporation into clinical decisions may improve survival of those who would benefit from therapeutic interventions not indicated according to the current guidelines.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

2DE:

Two-dimensional echocardiographic

3DE:

Three-dimensional echocardiographic

BSA:

Body surface area

CV:

Cardiovascular

EF:

Ejection fraction

GLS:

Global longitudinal strain

LV:

Left ventricular

STE:

Speckle tracking echocardiography

References

  1. Nelson GR, Cohn PF, Gorlin R (1975) Prognosis in medically-treated coronary artery disease: influence of ejection fraction compared to other parameters. Circulation 52:408–412

    Article  CAS  PubMed  Google Scholar 

  2. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL, Brown MW, Andrews ML, Multicenter Automatic Defibrillator Implantation Trial III (2002) Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 346:877–883

    Article  PubMed  Google Scholar 

  3. Curtis JP, Sokol SI, Wang Y, Rathore SS, Ko DT, Jadbabaie F, Portnay EL, Marshalko SJ, Radford MJ, Krumholz HM (2003) The association of left ventricular ejection fraction, mortality, and cause of death in stable outpatients with heart failure. J Am Coll Cardiol 42:736–742

    Article  PubMed  Google Scholar 

  4. Solomon SD, Anavekar N, Skali H, McMurray JJ, Swedberg K, Yusuf S, Granger CB, Michelson EL, Wang D, Pocock S, Pfeffer MA, Candesartan in Heart Failure Reduction in Mortality I (2005) Influence of ejection fraction on cardiovascular outcomes in a broad spectrum of heart failure patients. Circulation 112:3738–3744

    Article  PubMed  Google Scholar 

  5. Buxton AE, Lee KL, Hafley GE, Pires LA, Fisher JD, Gold MR, Josephson ME, Lehmann MH, Prystowsky EN, Investigators M (2007) Limitations of ejection fraction for prediction of sudden death risk in patients with coronary artery disease: lessons from the MUSTT study. J Am Coll Cardiol 50:1150–1157

    Article  PubMed  Google Scholar 

  6. Kalam K, Otahal P, Marwick TH (2014) Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction. Heart 100:1673–1680

    Article  PubMed  Google Scholar 

  7. Morris DA, Otani K, Bekfani T, Takigiku K, Izumi C, Yuda S, Sakata K, Ohte N, Tanabe K, Friedrich K, Kuhnle Y, Nakatani S, Otsuji Y, Haverkamp W, Boldt LH, Takeuchi M (2014) Multidirectional global left ventricular systolic function in normal subjects and patients with hypertension: multicenter evaluation. J Am Soc Echocardiogr 27:493–500

    Article  PubMed  Google Scholar 

  8. Ali MT, Yucel E, Bouras S, Wang L, Fei HW, Halpern EF, Scherrer-Crosbie M (2016) Myocardial strain is associated with adverse clinical cardiac events in patients treated with anthracyclines. J Am Soc Echocardiogr 29(522–527):e3

    Google Scholar 

  9. Nahum J, Bensaid A, Dussault C, Macron L, Clemence D, Bouhemad B, Monin JL, Rande JL, Gueret P, Lim P (2010) Impact of longitudinal myocardial deformation on the prognosis of chronic heart failure patients. Circ Cardiovasc Imaging 3:249–256

    Article  PubMed  Google Scholar 

  10. Motoki H, Borowski AG, Shrestha K, Troughton RW, Tang WH, Thomas JD, Klein AL (2012) Incremental prognostic value of assessing left ventricular myocardial mechanics in patients with chronic systolic heart failure. J Am Coll Cardiol 60:2074–2081

    Article  PubMed  Google Scholar 

  11. Ersboll M, Valeur N, Mogensen UM, Andersen MJ, Moller JE, Velazquez EJ, Hassager C, Sogaard P, Kober L (2013) Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction. J Am Coll Cardiol 61:2365–2373

    Article  PubMed  Google Scholar 

  12. Krishnasamy R, Isbel NM, Hawley CM, Pascoe EM, Burrage M, Leano R, Haluska BA, Marwick TH, Stanton T (2015) Left ventricular global longitudinal strain (GLS) is a superior predictor of all-cause and cardiovascular mortality when compared to ejection fraction in advanced chronic kidney disease. PLoS ONE 10:e0127044

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Nagata Y, Takeuchi M, Wu VC, Izumo M, Suzuki K, Sato K, Seo Y, Akashi YJ, Aonuma K, Otsuji Y (2015) Prognostic value of LV deformation parameters using 2D and 3D speckle-tracking echocardiography in asymptomatic patients with severe aortic stenosis and preserved LV ejection fraction. JACC Cardiovasc Imaging 8:235–245

    Article  PubMed  Google Scholar 

  14. Sengelov M, Jorgensen PG, Jensen JS, Bruun NE, Olsen FJ, Fritz-Hansen T, Nochioka K, Biering-Sorensen T (2015) Global longitudinal strain Is a superior predictor of all-cause mortality in heart failure with reduced ejection fraction. JACC Cardiovasc Imaging 8:1351–1359

    Article  PubMed  Google Scholar 

  15. Biering-Sorensen T, Biering-Sorensen SR, Olsen FJ, Sengelov M, Jorgensen PG, Mogelvang R, Shah AM, Jensen JS (2017) Global longitudinal strain by echocardiography predicts long-term risk of cardiovascular morbidity and mortality in a low-risk general population: the Copenhagen City Heart Study. Circ Cardiovasc Imaging 10:e005521

    PubMed  PubMed Central  Google Scholar 

  16. Dorosz JL, Lezotte DC, Weitzenkamp DA, Allen LA, Salcedo EE (2012) Performance of 3-dimensional echocardiography in measuring left ventricular volumes and ejection fraction: a systematic review and meta-analysis. J Am Coll Cardiol 59:1799–1808

    Article  PubMed  PubMed Central  Google Scholar 

  17. Maffessanti F, Nesser HJ, Weinert L, Steringer-Mascherbauer R, Niel J, Gorissen W, Sugeng L, Lang RM, Mor-Avi V (2009) Quantitative evaluation of regional left ventricular function using three-dimensional speckle tracking echocardiography in patients with and without heart disease. Am J Cardiol 104:1755–1762

    Article  PubMed  Google Scholar 

  18. Stanton T, Jenkins C, Haluska BA, Marwick TH (2014) Association of outcome with left ventricular parameters measured by two-dimensional and three-dimensional echocardiography in patients at high cardiovascular risk. J Am Soc Echocardiogr 27:65–73

    Article  PubMed  Google Scholar 

  19. Medvedofsky D, Maffessanti F, Weinert L, Tehrani DM, Narang A, Addetia K, Mediratta A, Besser SA, Maor E, Patel AR, Spencer KT, Mor-Avi V, Lang RM (2017) 2D and 3D echocardiography-derived indices of left ventricular function and shape: relationship with mortality. JACC Cardiovasc Imaging 11:1569–1579

    Article  PubMed  PubMed Central  Google Scholar 

  20. Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, Lancellotti P, LeFevre M, Miller F Jr, Otto CM (2017) Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 30:372–392

    Article  PubMed  Google Scholar 

  21. Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, Hahn RT, Han Y, Hung J, Lang RM, Little SH, Shah DJ, Shernan S, Thavendiranathan P, Thomas JD, Weissman NJ (2017) Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 30:303–371

    Article  PubMed  Google Scholar 

  22. Goldenberg I, Kutyifa V, Klein HU, Cannom DS, Brown MW, Dan A, Daubert JP, Estes NA 3rd, Foster E, Greenberg H, Kautzner J, Klempfner R, Kuniss M, Merkely B, Pfeffer MA, Quesada A, Viskin S, McNitt S, Polonsky B, Ghanem A, Solomon SD, Wilber D, Zareba W, Moss AJ (2014) Survival with cardiac-resynchronization therapy in mild heart failure. N Engl J Med 370:1694–1701

    Article  CAS  PubMed  Google Scholar 

  23. Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP, Estes NA 3rd, Foster E, Greenberg H, Higgins SL, Pfeffer MA, Solomon SD, Wilber D, Zareba W, Investigators M-CT (2009) Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med 361:1329–1338

    Article  PubMed  Google Scholar 

  24. Zareba W, Klein H, Cygankiewicz I, Hall WJ, McNitt S, Brown M, Cannom D, Daubert JP, Eldar M, Gold MR, Goldberger JJ, Goldenberg I, Lichstein E, Pitschner H, Rashtian M, Solomon S, Viskin S, Wang P, Moss AJ, Investigators M-C (2011) Effectiveness of cardiac resynchronization therapy by QRS Morphology in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT). Circulation 123:1061–1072

    Article  PubMed  Google Scholar 

  25. Armenian SH, Lacchetti C, Barac A, Carver J, Constine LS, Denduluri N, Dent S, Douglas PS, Durand JB, Ewer M, Fabian C, Hudson M, Jessup M, Jones LW, Ky B, Mayer EL, Moslehi J, Oeffinger K, Ray K, Ruddy K, Lenihan D (2017) Prevention and monitoring of cardiac dysfunction in survivors of adult cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 35:893–911

    Article  PubMed  Google Scholar 

  26. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C (2017) 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 136:e137–e161

    Article  PubMed  Google Scholar 

  27. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL (2013) 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 128:1810–1852

    Article  PubMed  Google Scholar 

  28. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28(1–39):e14

    Google Scholar 

  29. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Tracy CM, Epstein AE, Darbar D, DiMarco JP, Dunbar SB, Estes NA 3rd, Ferguson TB Jr, Hammill SC, Karasik PE, Link MS, Marine JE, Schoenfeld MH, Shanker AJ, Silka MJ, Stevenson LW, Stevenson WG, Varosy PD, College American, American Heart Association Task Force on Practice G, Heart Rhythm S (2012) ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2013(61):e6–e75

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA

    Diego Medvedofsky, Roberto M. Lang, Lynn Weinert, David M. Tehrani, Akhil Narang & Victor Mor-Avi

Authors
  1. Diego Medvedofsky
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Roberto M. Lang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lynn Weinert
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David M. Tehrani
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Akhil Narang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Victor Mor-Avi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Victor Mor-Avi.

Ethics declarations

Conflict of interest

AN was supported by funding from the NIH T32 Training Grant (#(5T32HL7381). The remaining authors have no relevant financial disclosures or conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

The study was approved by the Institutional Review Board with a waiver of consent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Medvedofsky, D., Lang, R.M., Weinert, L. et al. 3D echocardiographic global longitudinal strain can identify patients with mildly-to-moderately reduced ejection fraction at higher cardiovascular risk. Int J Cardiovasc Imaging 35, 1573–1579 (2019). https://doi.org/10.1007/s10554-019-01589-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10554-019-01589-7

Keywords

Search

Navigation