Prognostic Role of Left Ventricular Global Longitudinal Strain in Predicting Outcomes in Heart Failure with Preserved Ejection Fraction (HFPEF)

Abstract

Background: Heart failure with preserved ejection fraction is a growing phenotype of chronic heart failure that carries significant cardiovascular morbidity, recurrent clinical decompensation, and increased mortality. Although left ventricular ejection fraction remains preserved in HFpEF, subtle abnormalities in myocardial mechanics may still be present. LGE has emerged in recent years as an advanced echocardiographic tool that can assess early myocardial dysfunction beyond that of a standard evaluation of systolic function, using global longitudinal strain.

Objective: To assess the prognostic value of LGE in predicting cardiovascular adverse outcomes in patients with heart failure with preserved ejection fraction.

Methods: This study was conducted as a prospective observational study in Buffalo General Hospital, Buffalo, USA, from February 2024 to February 2025. Patients were consecutively recruited, and 200 patients with a HFpEF diagnosis were included. Measurement of left ventricular global longitudinal strain was done by comprehensive transthoracic echocardiography with 2D speckle-tracking imaging. Based on predefined strain thresholds, participants were classified into impaired and preserved LV-GLS groups. Clinical follow-up was used to record adverse cardiovascular events such as disease progression, re-hospitalization, arrhythmias, intensive care admissions, major adverse cardiovascular events, and cardiovascular death.

Results: Abnormal values of LV-GLS were found in 104 patients, and preserved myocardial strain was found in 96 patients. Impaired strain was associated with a higher prevalence of hypertension, diabetes mellitus, obesity, atrial fibrillation, and higher NT-proBNP levels. Echocardiographic assessment also showed that left atrial volume index, pulmonary artery systolic pressure, E/e′ ratio, and left ventricular mass index were significantly higher in the group with abnormal myocardial strain. The impaired LV-GLS group had more cardiovascular complications during follow-up evaluation. Impaired LV-GLS was shown to be an independent predictor of adverse cardiovascular events. LV-GLS also showed good discriminatory power in the identification of major cardiovascular events by receiver operating characteristic analysis.

Conclusion: Reduced left ventricular global longitudinal strain is strongly associated with adverse clinical progression in patients with HFpEF. Myocardial deformation imaging might offer valuable prognostic data additional to the traditional echocardiographic parameters and help in earlier cardiovascular risk stratification and monitoring tailored to the patient.