Incremental Value of Global Longitudinal Strain in the Long-Term Prediction of Heart Failure among Patients with Coronary Artery Disease: Journal of the American Society of Echocardiography

K. Haji, T.H. Marwick, S. Stewart, M. Carrington, Y.-K. Chan, W. Chan, Q. Huynh, C. Neil, C. Wong

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3 Citations (Scopus)


Background: Heart failure (HF) remains a common complication for patients with coronary artery disease (CAD), especially after acute myocardial infarction. Although left ventricular ejection fraction (LVEF) is conventionally used to assess cardiac function for risk stratification, it has been shown in other settings to underestimate the risk of HF compared with global longitudinal strain (GLS). Moreover, most evidence pertains to early-onset HF. We sought the clinical and myocardial predictors for late-onset HF in patients with CAD. Methods: We analyzed echocardiograms (including GLS) in 334 patients with CAD (ages 65 ± 11 years, 77% male) who were enrolled in the Nurse-Led Intervention for Less Chronic Heart Failure trial, a prospective, randomized controlled trial that compared standard care with nurse-led intervention to prevent HF in individuals at risk of incident HF. Long-term (9 years) follow-up was obtained via data linkage. Analysis was performed using a competing-risk model. Results: Baseline LVEF values were normal or mildly impaired (LVEF ≥ 40%) in all subjects. After a median of 9 years of follow-up, 50 (15%) of the 334 patients had new HF admissions, and 68 (20%) died. In a competing-risk model, HF was associated with GLS (hazard ratio = 1.15 [1.05-1.25], P = .001), independent of estimated glomerular filtration rate (hazard ratio = 0.98 [0.97-0.99], P = .045), Charlson comorbidity score (hazard ratio = 1.64 [1.25-2.15], P < .001), or E/e’ (hazard ratio = 1.08 [1.02-1.14], P = .01). Global longitudinal strain—but not conventional echocardiographic measures—added incremental value to a clinical model based on age, gender, and Charlson score (area under the curve, 0.78-0.83, P = .01). Global longitudinal strain was still associated with HF development in patients taking baseline angiotensin convertase enzyme inhibitors (hazard ratio = 1.21 [1.11-1.31], P < .01) and baseline beta-blockers (1.17 [1.09, 1.26]; P < .01). Mortality was associated with older men, risk factors (hypertension or diabetes), and comorbidities (AF and chronic kidney disease). Conclusions: Global longitudinal strain is independently associated with risk of incident HF in patients admitted with CAD and provides incremental prognostic value to standard markers. Identifying an at-risk subgroup using GLS may be the focus of future randomized controlled trails to enable targeted therapeutic intervention. © 2021 American Society of Echocardiography
Original languageEnglish
Pages (from-to)187-195
Number of pages9
JournalJournal of the American Society of Echocardiography
Issue number2
Publication statusPublished - 2022


  • Aged
  • Coronary Artery Disease
  • Female
  • Heart Failure
  • Humans
  • Male
  • Middle Aged
  • Prognosis
  • Prospective Studies
  • Risk Factors
  • Stroke Volume
  • Ventricular Function, Left
  • beta adrenergic receptor blocking agent
  • dipeptidyl carboxypeptidase inhibitor
  • age
  • aged
  • Article
  • atrial fibrillation
  • cardiac patient
  • Charlson Comorbidity Index
  • chronic kidney failure
  • clinical feature
  • cohort analysis
  • comorbidity
  • controlled study
  • coronary artery disease
  • data analysis
  • diabetes mellitus
  • diagnostic value
  • disease association
  • disease severity
  • Doppler echocardiography
  • estimated glomerular filtration rate
  • female
  • follow up
  • gender
  • global longitudinal strain
  • hazard ratio
  • heart failure
  • heart left ventricle ejection time
  • human
  • hypertension
  • image analysis
  • intervention study
  • laboratory test
  • major clinical study
  • male
  • mortality
  • nurse
  • onset age
  • patient care
  • prediction
  • prognosis
  • prognostic value
  • radiological parameters
  • randomized controlled trial (topic)
  • receiver operating characteristic
  • risk factor
  • risk model
  • standard
  • statistical analysis
  • subgroup analysis
  • diagnostic imaging
  • heart left ventricle function
  • heart stroke volume
  • middle aged
  • prospective study
  • randomized controlled trial
  • Acute coronary syndrome
  • Ejection fraction
  • Heart failure
  • Myocardial strain


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