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Myocardial Strain in the Assessment of Patients With Heart FailureA Review

Educational Objective
To describe the uses of speckle-tracking echocardiography strain imaging for the diagnosis and management of heart failure syndromes.
1 Credit CME

Importance  The cornerstones of imaging in heart failure (HF) are the measurement of systolic and diastolic function and left ventricular (LV) filling pressure.

Observations  Ejection fraction and the assessment of LV filling pressure and diastolic dysfunction using the ratio of early transmitral flow and LV relaxation (E/e′) are conventional imaging markers of LV function. Despite their extensive use in HF guidelines, both have significant detractions, especially in an era when HF with preserved ejection fraction is becoming the dominant presentation. In contrast, strain imaging has provided a new window into myocardial mechanics. Myocardial strain is now well validated, robust, and can easily be performed on most modern echocardiography machines. This Review summarizes the evidence in 9 situations across the stages of HF where LV global longitudinal strain and other strain parameters may provide information on risk prediction, diagnosis, assessment of treatment response, and follow-up.

Conclusions and Relevance  The evolution of myocardial deformation imaging from research tool to clinical practice will provide clinicians with a useful additional imaging parameter to facilitate the assessment and risk evaluation of patients with HF.

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Article Information

Accepted for Publication: December 27, 2018.

Corresponding Author: Thomas H. Marwick, MBBS, PhD, MPH, Baker Heart and Diabetes Institute, PO Box 6492, Melbourne, VIC 3004, Australia (

Published Online: February 27, 2019. doi:10.1001/jamacardio.2019.0052

Author Contributions: Dr Marwick had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Drafting of the manuscript: Marwick.

Critical revision of the manuscript for important intellectual content: Shah, Thomas.

Administrative, technical, or material support: Marwick, Thomas.

Conflict of Interest Disclosures: Dr Marwick has received research support from the National Health and Medical Research Council (grants 1119955, 1080582, 1059738, and 1149692) and General Electric Medical Systems for an ongoing research study on the use of strain for the assessment of cardiotoxicity. Dr Shah has received funding from the National Institutes of Health (grants R01 HL127028, R01 HL107577, and R01 HL140731), Actelion Pharmaceuticals, AstraZeneca, Corvia Medical, and Novartis as well as consulting fees from Actelion Pharmaceuticals, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cardiora, Eisai, Ironwood Pharmaceuticals, Merck & Co, Novartis, Pfizer, Sanofi, and United Therapeutics. Dr Thomas has received consulting fees and honoraria from General Electric, Edwards Lifesciences, Abbott Laboratories, and Bay Labs, and his spouse is employed by Bay Labs.

Disclaimer: Dr Shah is an associate editor of JAMA Cardiology. He was not involved in the editorial evaluation or decision to accept this article for publication.

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