Additive Prognostic Value of Echocardiographic Global Longitudinal and Global Circumferential Strain to Electrocardiographic Criteria in Patients With Heart Failure Undergoing Cardiac Resynchronization Therapy

Circ Cardiovasc Imaging. 2016 Jun;9(6):e004241. doi: 10.1161/CIRCIMAGING.115.004241.


Background: Response to cardiac resynchronization therapy is most favorable in patients with heart failure with QRS duration ≥150 ms and left bundle branch block and less predictable in those with QRS width 120 to 149 ms or non-left bundle branch block.

Methods and results: We studied 205 patients with heart failure referred for cardiac resynchronization therapy with QRS ≥120 ms and ejection fraction ≤35%. We tested the hypothesis that contractile function using speckle-tracking echocardiographic global circumferential strain (GCS) from 2 short-axis views and global longitudinal strain (GLS) from 3 apical views add prognostic value to electrocardiographic criteria. There were 112 patients (55%) with GLS >-9% and 136 patients (66%) with GCS >-9%. During 4 years, 81 patients reached the combined primary end point (death, circulatory support, or transplant) and 120 reached the secondary end point (heart failure hospitalization or death). Both GLS >-9% and GCS >-9% were associated with increased risk of unfavorable events as follows: for the primary end point (hazard ratio=2.91; 95% confidence interval, 1.88-4.49; P<0.001) and (hazard ratio=3.73; 95% confidence interval, 2.39-5.82; P<0.001) for the secondary end point (hazard ratio=2.10; 95% confidence interval, 1.45-3.05; P<0.001) and (hazard ratio=3.25; 95% confidence interval, 2.23-4.75; P<0.001). In a prespecified subgroup of 120 patients with QRS 120 to 149 ms or non-left bundle branch block, significant associations of baseline GLS and GCS and outcomes remained: P=0.014 and P=0.002 for the primary end point and P=0.049 and P=0.001 for the secondary end point. Global strain measures had additive prognostic value to routine clinical or electrocardiographic parameters (P<0.001).

Conclusions: Baseline GCS and GLS were significantly associated with long-term outcome after cardiac resynchronization therapy and had additive prognostic value to routine clinical and electrocardiographic selection criteria for cardiac resynchronization therapy.

Keywords: cardiac resynchronization therapy; cardiomyopathy; echocardiography; heart failure; hospitalization; prognosis.

Publication types

  • Comparative Study

MeSH terms

  • Action Potentials
  • Aged
  • Arrhythmias, Cardiac / diagnostic imaging
  • Arrhythmias, Cardiac / mortality
  • Arrhythmias, Cardiac / physiopathology
  • Arrhythmias, Cardiac / therapy*
  • Biomechanical Phenomena
  • Cardiac Resynchronization Therapy* / adverse effects
  • Cardiac Resynchronization Therapy* / mortality
  • Echocardiography*
  • Electrocardiography*
  • Female
  • Heart Failure / diagnostic imaging*
  • Heart Failure / mortality
  • Heart Failure / physiopathology
  • Heart Failure / therapy*
  • Heart Rate
  • Heart Transplantation
  • Heart-Assist Devices
  • Humans
  • Kaplan-Meier Estimate
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Myocardial Contraction*
  • Patient Readmission
  • Pennsylvania
  • Predictive Value of Tests
  • Proportional Hazards Models
  • Prospective Studies
  • Retreatment
  • Risk Factors
  • Stroke Volume
  • Time Factors
  • Treatment Outcome
  • Ventricular Function, Left*