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What’s to Gain from Myocardial Strain?

Echocardiography guidelines from the ASE and other societies are now recommending the inclusion of strain imaging as a powerful complement to traditional function parameters. [1] Strain has seen a lot of adoption over recent years, because it adds diagnostic information to echo exams, in particular global longitudinal strain (GLS) to detect heart failure (HF), including HF with preserved ejection fraction (HFpEF). [2]

Until recently, however, health professionals have been hesitant to adopt strain as a routine clinical practice. They have legitimate reasons for their reservations, including the additional time it takes not only to measure strain, but also train staff in the new procedures. Most concerning has been the high variability in measurements across vendors, software versions, and operators. 

New advancements in technology are now overcoming these limitations, and alongside the recommendations from professional bodies, using strain is becoming increasingly important for regular clinical practice.  

Related read: Q+A: The Value of Strain for Echocardiography


The Opportunity for Using Strain in Cardio-oncology

Strain echo can be especially valuable in cardio-oncology to support early detection of cardiotoxicity during chemotherapy. Clinicians can use strain to understand what is happening in a patient’s heart before a decline in left ventricular function occurs. This can allow pre-treatment risk stratification, early dysfunction identification, recovery prediction, and surveillance and treatment of subclinical left ventricular damage.

In the Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy: A Report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging, it is stated that “Global longitudinal Strain is the optimal parameter of deformation for the early detection of subclinical LV dysfunction.” [3] For these patients, it has been shown that monitoring global longitudinal Strain can be a sensitive prognostic marker of sub-clinical changes in LV function caused by cardiotoxicity.


Why Strain an Important Addition to Ejection Fraction?

Unlike ejection fraction, strain echo isn’t limited when measuring contractability. GLS, for example, supports increased reliability when assessing global systolic function in conditions such as undifferentiated left ventricular hypertrophy, cardiac amyloidosis, pericardial disease, ischemic heart disease, and aortic stenosis. 

This can be helpful when looking for earlier prognostic indicators of cardiac disease and assessing the prognosis of patients with these conditions.

Several studies have not only proven that GLS can be very important in predicting adverse cardiovascular outcomes in various patient populations independent of LVEF, but also that new advances in technology can improve intra- and inter-observer reproducibility in post hoc analysis, and it can be measured just as fast as EF. [4]

GLS should be analyzed as part of a routine echo, as recommended in the “The American Society of Echocardiography Recommendations for Cardiac Chamber Quantification in Adults,”and more recently in the “2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure.” [5] [6]

Indices of myocardial deformation, such as global longitudinal strain, may identify subclinical LV systolic dysfunction, which has been associated with greater risk of developing HF or recurrent HF hospitalizations.[7]gradient-line-3


Despite evidence supporting strain’s inclusion in echo reporting and risk stratification, its aforementioned pitfalls have slowed its implementation across healthcare modalities. However, new technology has eliminated these pitfalls, as will be illustrated below. 



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. It can automate strain parameters in addition to EF, and send reports through a secure cloud to assist with clinical decision-making. It has been validated to provide accurate values which are vendor-agnostic, trained to not only contour and measure as well as an expert sonographer, but go beyond this and also predict a patient’s known outcome. This leads to accurate results that can be applied to any vendor, anywhere in the world, all while avoiding variability between users and methods.

Related read: WASE I: Echocardiography Predicts Death in Patients with Acute COVID-19 Infection: The World Alliance Societies of Echocardiography (WASE-COVID) Study.


Strain Imaging Is Possible With Minimal Cost and Time

While most echocardiography equipment vendors offer strain modules specific to their machines, the price tags can be prohibitive. Clinical sites will need to not only upgrade their machines, but also spend significant time training staff (or possibly hiring new staff). Even more expensive are the costs associated with using obsolete tech, which can be far larger and more insidious than the upfront cost of any upgrade. These costs can quickly add up before a single strain analysis is performed. 

Cloud AI technology is rapidly evolving and taking shape in echocardiography. This modern technology presents a new way forward that is integral to delivering a better provider and patient experience, while improving operations and reducing costs. It is easier and more cost effective to onboard than on-premise software solutions, and it can also be set up easily, with no upfront cost or equipment investment. Updates are fully managed and deployed by the cloud vendor to any type of location, regardless of the tech in place, as part of the service. As this type of technology requires no special training, healthcare professionals can begin including strain in their measurements almost immediately. 

Ultromics’ cloud AI technology measures echo exams as part of a fully managed service, automating Strain, EF, and Volumes, with minimal cost and effort. This showcases a more immediate return with a smaller initial capital investment. Healthcare professionals can implement strain for their patients faster, and without variability. 

In addition, some degree of financial relief has arrived with the new add-on CPT code for Strain imaging, published by the Centers for Medicare & Medicaid Services for use from Jan. 1, 2020. The release of this code shows support from professional bodies in using Strain as a best practice.

Strain has been shown to be a valuable measurement for risk stratification, and with guidelines recommending its regular use, practices are beginning to onboard it more regularly.
With the new possibilities of strain imaging technology overcoming variability and cost limitations, more practices can realize the full potential of strain alongside traditional measurements.

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  1. Non-Invasive Imaging in Coronary Syndromes: Recommendations of The European Association of Cardiovascular Imaging and the American Society of Echocardiography, in Collaboration with The American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance
  2. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
  3. EXPERT CONSENSUS STATEMENT| VOLUME 27, ISSUE 9, P911-939, SEPTEMBER 01, 2014 PDF [3 MB] Figures Save Share Reprints Request Expert Consensus for Multimodality Imaging Evaluation of Adult Patients during and after Cancer Therapy: A Report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
  4. ​​Fully automated quantification of contrast and non-contrast echocardiograms eliminates inter-operator variability.
  5. The American Society of Echocardiography Recommendations for Cardiac Chamber Quantification in Adults
  6. 2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure
  7. Prognostic implications of left ventricular strain by speckle-tracking echocardiography in the general population: a meta-analysis