Adding Strain Measure to LVEF Better Predicts Later HF

Debra L. Beck

March 25, 2021

A new analysis that combined measures of left ventricular ejection fraction (LVEF) and LV strain suggests that the current approach of measuring just LVEF underestimates the prevalence of prognosticly important impairments of systolic function in late life.

Besides LVEF, the researchers measured longitudinal strain (LS), and circumferential strain (CS), both of which detect abnormalities in age-related ventricular deformation and reserve that are seen even when LVEF is normal.

"What we saw was that whether we modeled it dichotomized or continuously, left ventricular ejection fraction, longitudinal strain, and circumferential strain were all independently associated with the development of heart failure during follow-up, independent of clinical risk factors, but also of each other," said Amil Shah, MD, MPH, Brigham and Women's Hospital, Boston.

"So, for example, even if you hold ejection fraction constant, but longitudinal strain gets worse, that's still predictive of future risk of heart failure," he added.

Still not known, he stressed, is the clinical significance of these findings. "We need to understand whether these subtle changes that we're seeing are actually leading to heart failure and whether we can intervene to ameliorate the risk in some way. We don't have data for that yet."

Shah and colleagues, including first author Anne Marie Reimer Jensen, BS, also from the Brigham, published these new findings in JAMA Cardiology on March 17, using data on 4960 older adults enrolled in the Atherosclerosis Risk in Communities (ARIC) study.

The researchers also found that using an LVEF cutoff of 0.60% offered better discrimination of the risk for HF than the guideline standards of 0.52% for men and 0.54% for women.

The adjusted hazard ratio (HR) per SD decrease in LVEF was 1.41, and for LVEF less than 60% the HR was 2.59 (P < .05 for both).

Similar findings were observed for continuous LS (HR, 1.37), dichotomized LS (HR, 1.93), continuous CS (HR, 1.39), and dichotomized CS (HR, 2.30).

The population-attributable risk associated with an LVEF below 60% was 11%, compared with 5% using guideline-based limits, a finding the researchers replicated in 908 participants in the Copenhagen City Heart Study.

"Adjunctive assessment of strain may add to the detection of an arc toward LV dysfunction and prompt earlier interventions to prevent clinical HF," write Clyde Yancy, MD, MSc, Northwestern University, Chicago, and Gregg C. Fonarow, MD, University of California, Los Angeles, in an Editor's Note.

Their comments are aligned with recent efforts to update the classification scheme used in heart failure to, among other things, acknowledge the existence of a pre-heart failure stage, wherein prevention efforts might arrest a decline in LV function.

Many imaging laboratories are already routinely including measures of global LS and CS, said Shah.

He added, however, that although it's "very feasible" to measure LS reliably, the reliability for CS is lower and there are "vendor differences" in how strain is calculated.

For this analysis, the researchers conducted a time-to-event analysis of ARIC participants free from heart failure who, for the first time since the study began in 1987, underwent a comprehensive protocolized echocardiography examination at their fifth study visit (January 2011 to December 2013).

Lower 10th percentile limits were determined in 374 participants free of cardiovascular disease or risk factors.

Brigham and Women's is not an ARIC clinical site but serves as the dedicated echocardiography core laboratory for the study. A second echocardiographic follow-up of these patients has been completed and is now being analyzed, Shah said.

The ARIC study is funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. Shah reports receiving research support from Novartis and Philips Ultrasound through Brigham and Women's Hospital outside the submitted work. Yancy reports spousal employment with Abbott Labs. Fonarow reports receiving personal fees from a number of pharmaceutical and device companies.

JAMA Cardiol. Published online March 17, 2021. Abstract, Editorial

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