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What’s to gain from myocardial strain?

Strain imaging is a powerful complement to conventional echocardiography. It has been shown to be extremely helpful in the early detection of myocardial dysfunction across a wide range of cardiovascular syndromes. In fact, its effectiveness has been so evident that guidelines from the ASE and other societies have recommended the inclusion of strain imaging in routine clinical practice. [1] 

The Centers for Medicare and Medicaid Services established a myocardial strain Current Procedural Terminology (CPT) add-on code +93356®, acknowledging strain imaging as a clinically useful diagnostic service. This was the first new echo technology to achieve CPT editorial panel category 1 status in a decade. [8]

Several studies have found that strain is more reproducible than other left ventricular measures such as ejection fraction (EF). New advancements in technology are making it easier than ever to include strain alongside traditional echocardiographic parameters.

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


Why is Strain an Important Addition to Ejection Fraction?


Unlike ejection fraction, strain echo isn’t limited when measuring contractability. Global longitudinal strain (GLS), for example, supports increased reliability when assessing global systolic function in conditions such as undifferentiated left ventricular hypertrophy, heart failure, 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 left ventricular ejection fraction (LVEF), but also that new advances in technology can improve intra- and inter-observer reproducibility. [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]



Using Strain to Assess Heart Failure


Strain echocardiography is a recommended additional imaging parameter to facilitate the assessment and risk evaluation of patients with heart failure (HF), especially in an era when HF with preserved ejection fraction is becoming the dominant presentation. 

With GLS being shown to detect cardiac dysfunction at an earlier stage, the 2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure recommend strain echocardiography for evaluation of patients with suspected heart failure, including indices of myocardial deformation through GLS. They recommend GLS for identifying subclinical left ventricular systolic dysfunction, which has been associated with a higher risk of heart failure and recurrent heart failure hospitalizations. [10,11]

Read more: The Value of Strain in Echocardiography: What the Guidelines Say


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Strain Can Be Measured with Zero Variability


Cardiovascular disease is still a leading cause for mortality worldwide. It’s rising in prevalence, making precision detection and risk stratification a cornerstone in clinical practice.

Although data and guidelines have demonstrated the superiority of myocardial strain, treatment decision broadly relies on left ventricular ejection fraction assessment. This is because available methods for measuring strain are still limited, time consuming, and variable. However, the landscape is changing, and this change is being driven by artificial intelligence.

EchoGo Core provides a fully automated approach to measure strain, help clinicians detect disease earlier, save time, enhance diagnostic confidence, and ultimately enable a more precise diagnosis. EchoGo Core has been proven to produce precise and accurate analysis – with zero variability – that is predictive of cardiac outcomes, outperforming traditional semi-automated or manual analysis. [4,12]

Related read: Human vs Artificial Intelligence-Based Echocardiography Analysis as Predictor of Outcomes (WASE-COVID)


Starting or Scaling Strain is Easy With Minimal Cost and Training


Healthcare providers are embracing the benefits of cloud and software as a service (SaaS) solutions to adopt strain at scale, speed operations, and drive innovation toward value-based care delivery.

While most echocardiography equipment vendors offer strain modules specific to their machines, the price tags can be prohibitive. Clinical sites also spend significant time training staff (or possibly hiring new staff). 

Thanks to the flexibility of pay-as-you-go cloud-based services and solutions, all providers can quickly start or scale up strain and deploy these critical measures recommended by guidelines. 

Myocardial strain can be automated as part of a cloud service, without the need for special training and initial hardware or software investment. 

With the new possibilities of measuring strain easily — including overcoming variability, time, and cost limitations - more practices are realizing the full potential of strain.



    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
    8. American Society of Echocardiography CPT Code
    9. Smiseth, OA, et al. European Heart Journal. 2015;37:1196–1207
    10. Heidenreich PA, et al. Circulation. 2022;145:263-421
    11. McDonagh TA, et al. European Heart Journal. 2021; 42:3599-3726
    12. Asch J, et al, J Am Soc Echocardiogr. 2022;35:1-55  Human vs Artificial Intelligence-Based Echocardiography Analysis as Predictor of Outcomes: An analysis from the World Alliance Societies of Echocardiography COVID

Guideline update

Myocardial strain echocardiography has emerged as a valuable predictor of heart failure and other adverse cardiac outcomes.