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The Value of Strain in Echocardiography: What the Guidelines Say

  • | By Ultromics
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Myocardial strain echocardiography has emerged as a valuable predictor of heart failure and other adverse cardiac outcomes. Recognized for its value in early disease detection and heightened sensitivity over left ventricular ejection fraction (LVEF), guidelines emphasize the importance of adding strain to regular reporting practices. [1]

With this in mind, we’ve consolidated everything guidelines have suggested for strain into quick summaries that you can reference.

We’ll show you why strain is important, what the most recent guidelines say, and how to easily start implementing strain into your regular reporting practices.


Strain in echocardiography cover



For more details on these guidelines, download our free guide. 

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Why Cardiac Strain Matters 


Global longitudinal strain (GLS) has been shown to be more sensitive than left ventricular ejection fraction (LVEF) as a measure of systolic function. GLS is increasingly being used to identify subclinical left ventricular dysfunction in a variety of myocardial diseases. [1,2] 

This can make diagnosing and risk-assessing cardiac dysfunction in patients with clinical and pre-clinical cardiovascular diseases more accurate than ever before. Improved accuracy leads to earlier diagnoses and management even before visual changes and symptoms occur. [1]

This is why guidelines emphasize the importance of adding GLS to echocardiography, ensuring these measurements can be performed with minimal variability and in a timely manner.


What the Guidelines Are Saying About Strain: An Important Measure of Cardiac Function



2022 AHA/ACC/HFSA Guideline for the management of heart failure
GLS is recommended for identifying subclinical left ventricular systolic dysfunction, which has been associated with a higher risk of heart failure and recurrent heart failure hospitalizations.[3]

2022 ASE/ASNC/SCMR/SCCT Guidelines for multimodality imaging of patients with hypertrophic cardiomyopathy
Strain can indicate a range of abnormalities, even in patients with normal wall motion and ejection fraction. It predicts event-free survival in HCM patients with normal ejection fraction, and it’s paramount in patients with increased LV wall thickness. [4]

2022 EACVI/ASE Guidelines for non-invasive imaging in coronary syndromes
These guidelines suggest including LVEF and GLS in routine echocardiograms before hospital discharge, and baseline assessment of resting LV function should be performed in all patients with suspected coronary artery disease. [2]

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
GLS can detect cardiac dysfunction at an earlier stage. [5]

2021 BSE and BCOS Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab
GLS, LVEF, and volumes are a recommended dataset for a cardio-oncology protocol. GLS is shown to be superior to LVEF in patients receiving trastuzumab and has been suggested that it is more reproducible with appropriate training. [6]

2020 ASE/SCCT/SCMR Recommendations on the Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes
Strain echocardiography is an important tool to complement routine two-dimensional imaging in the assessment of ventricular morphology among competitive athletes. Left ventricular GLS values higher than -15% should raise consideration of pathology. [7]

2019 ASE Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults
GLS is recommended to evaluate ventricular function as part of the standard examination. The most useful clinical data is longitudinal strain derived from apical imaging planes. [8]

2015 ASE/EACVI Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults
GLS should be analyzed as part of a routine echo, offering incremental prognostic data over LVEF in a variety of cardiac conditions. [9]

2014 ASE/EACVI Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy[10]
Guidelines suggest GLS as the optimal parameter for early detection of subclinical LV dysfunction. Measurements during chemotherapy should be compared with baseline values where a relative percentage decrease of > 15% is likely to be of clinical significance. GLS assessment is recommended every 3 months.


Get more details about these findings with our free digital brochure: Value of Strain – What the Guidelines Say 


A New Standard for Heart Failure Detection

GLS has emerged as an essential indicator of cardiovascular health, but adding this measurement to routine echocardiograms takes extra time and expertise.

This can be a major roadblock for healthcare providers that are already feeling the pressure of increased heart failure patients and a reduced talent pool. 

To support the addition of GLS to echocardiography, we need to drastically change the way we measure and assess heart failure risk.

Thankfully, all providers, regardless of their care setting, can now make precise, accurate, and timely diagnoses of heart failure with Ultromics’ AI technology.

The cloud-based platform, EchoGo, offers a simple, secure and seamless way to augment your existing technology and workflow with fully automated, advanced echo analysis including critical advanced measures recommended by guidelines.


See EchoGo’s speed and accuracy for yourself with a free online demo:

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  1. Smiseth, OA, et al. European Heart Journal. 2015;37:1196–1207
  2. Edvardsen T, et al. J Am Soc Echocardiogr. 2022;35:329-354
  3. Heidenreich PA, et al. Circulation. 2022;145:263-421
  4. Nagueh SF, et al. J Am Soc Echocardiogr. 2022;35:533-569
  5. McDonagh TA, et al. European Heart Journal. 2021; 42:3599-3726
  6. Dobson R, et al. J Am Coll Cardiol CardioOnc. 2021;3:1–16
  7. Baggash AI, et al. J Am Soc Echocardiogr. 2020;33:523-549
  8. Mitchell C, et al. J Am Soc Echocardiogr. 2019;32:1-64
  9. Lang RM, et al. J Am Soc Echocardiogr. 2015;28:1-39
  10. Plana CJ, et al. J Am Soc Echocardiogr 2014;27:911-39

Strain Analysis Can Be Performed with Zero Variability

A major concern for the clinical usability of strain has been the variance in normal values between vendor solutions, and the inter-observer variability from varying levels of experience. This is where Ultromics’ AI cloud-based platform comes into play.