Normal Values — STE-Derived Strain
LV Global Longitudinal Strain (LVGLS)
NormalMore negative than −18%
Borderline−16% to −18%
AbnormalLess negative than −16%
Mean (meta-analysis)−21% (SD 2.6%)
LLN (major vendors)−16%
GLS decreases progressively after age 60. Relatively stable up to age 60. Age and comorbidities (not race) are main determinants of variation.
RV Free Wall Longitudinal Strain (RVFWLS)
LLN — MenMore negative than −20%
LLN — WomenMore negative than −21%
Overall mean (WASE)−28.3% (SD 4.3%)
Men mean (WASE)−27.3% (SD 4.1%)
Women mean (WASE)−29.3% (SD 4.2%)
LLN overall (prior study)−18.2%
Normal values are sex-specific but do NOT change with age. Women have more negative (better) RVFWLS than men.
LA Reservoir Strain (LASr)
Normal range23% – 60%
Borderline abnormal23% – 30%
AbnormalLess than 23%
Mean (meta-analysis, n=2,542)~39%
LA conduit strain (LAScd)~23%
LA contractile strain (LASct)~17%
All 3 LA strain parameters decrease with age. Most published studies use R-R gating — this is the de facto preferred method.
Key Reporting and Measurement Standards
| Parameter | Standard / Recommendation |
|---|---|
| Preferred GLS timing | End-systolic LS (at aortic valve closure, AVC) — default. Peak systolic LS may be used if explicitly stated. |
| Preferred tracking method | Midwall / full-thickness tracking — now endorsed by ASE/EACVI. Most normative data use this approach. |
| Sign convention | Negative sign should be retained for GLS (e.g., "−18%"). If omitted, use term "global longitudinal shortening." |
| Regional strain | Not endorsed for routine clinical use — significant intervendor and test-retest variability. |
| Radial strain | Performed poorly in intervendor studies — NOT endorsed for clinical use. |
| 3D strain | Not advised for routine use — lower spatial/temporal resolution and unacceptable variability. |
| Layer-specific strain | Not endorsed — no demonstrated superiority over full-thickness strain. |
| Serial follow-up | Use same vendor and same software version. A relative change of 10–15% in GLS is clinically significant. |
| Frame rate | 50–90 fps for LV and LA strain; 60–90 fps for RV strain. |
| RV view | Apical RV-focused view — yields higher magnitude values than standard 4-chamber. Required for RVFWLS. |
| Dedicated software | Use dedicated RV and atrial strain software when available — better feasibility and reproducibility. |
| AF averaging | Average ≥3 consecutive cycles of similar RR length; avoid using a single cycle. |
Cardiotoxicity Surveillance Thresholds
Used for chemotherapy monitoring — these are relative change thresholds from individual patient baseline.
Significant relative GLS decline≥15% relative decrease
Actionable threshold (SUCCOUR trial)≥12% relative decrease
Preclinical cardiac dysfunction≥15% relative decrease (conservative)
Absolute exampleBaseline −20% → follow-up −17% = 15% relative change
ESC and ICOS guidelines recognize ≥15% relative GLS decrease as mild CTRCD. Cardioprotective therapy should be considered; chemotherapy should NOT be stopped for isolated GLS fall with preserved LVEF.
LA Strain & Filling Pressure Thresholds
LASr for elevated filling pressureLASr < 18%
LASr alternative thresholdLASr < 23% (single-center validation)
Gating methodR-R gating preferred (most published data)
ViewsApical 4-chamber ± 2-chamber
LASr < 18% identified as optimal cutoff for elevated PCWP in multicenter study of 322 patients. Provides additive value to conventional Doppler parameters and LAVi.
Clinical Indications for Strain — Consensus Endorsement
Based on Table 1 from Thomas et al., JASE 2025. +++ = Clinically endorsed ++ = May be appropriate — = Not currently endorsed
| Clinical Scenario | LVGLS | RVFWLS | LASr | LV Mechanical Dispersion | LV Myocardial Work |
|---|---|---|---|---|---|
| Acute & Chronic MI | +++ Dx & Prog | +++ Dx & Prog | ++ Prog | ++ Prog | — Insufficient evidence |
| Cardio-Oncology | +++ Dx & Prog | ++ Prog | ++ Prog | — | — |
| Valvular Heart Disease ≥ moderate | +++ Prog | +++ Prog | ++ Prog | — | — |
| Undifferentiated Cardiomyopathy | +++ Dx & Prog | +++ Dx & Prog | +++ Dx & Prog | ++ Prog | — |
| Acute & Chronic HF | +++ Dx & Prog | +++ Dx & Prog | +++ Dx & Prog | ++ Dx & Prog | — |
| Cardiac Resynchronization (CRT) | +++ Dx & Prog | +++ Dx & Prog | ++ Prog | — | — |
| Athlete's Heart | +++ Dx & Prog | +++ Dx & Prog | ++ Dx & Prog | ++ Dx & Prog | — |
| Pulmonary Hypertension | +++ Dx & Prog | +++ Dx & Prog | ++ Dx | — | — |
| Stress Echocardiography | ++ Dx & Prog | ++ Dx & Prog | ++ Dx | — | — |
| Adult Congenital Heart Disease | ++ Prog | ++ Dx & Prog | — | — | — |
When to Always Obtain Strain
HFrEF — LVGLS for prognostication; serial follow-up to predict LV recovery
Cardio-oncology — Baseline strain before anthracyclines; serially during chemotherapy
Increased LV mass — LVGLS with bull's-eye pattern to identify amyloidosis (apical sparing)
RV enlargement / TR ≥ moderate / PH — RVFWLS when technically feasible
Asymptomatic severe AS — LVGLS predicts adverse events; < −14.7% = 2.5× mortality risk
Severe primary MR — LVGLS should be supranormal (> −20%); if less negative, consider intervention
What Is NOT Endorsed
Regional / segmental strain quantification — too much intervendor and test-retest variability for routine use
Radial strain — poor performance in all intervendor studies
3D strain — lower resolution, unacceptable variability; investigational only
Layer-specific strain — no proven superiority over full-thickness strain
RV / LA mechanical dispersion — insufficient evidence at this time
Myocardial work indices (routine) — lacks standardization and clear cutoffs; investigational
RA strain (clinical) — not currently advised for routine practice
Strain by Clinical Condition
Heart Failure
Heart Failure — All Stages
| HF Stage / Type | Key Strain Recommendation | Threshold / Cutoff |
|---|---|---|
| Stage A (Risk factors, no structural disease) | GLS not advised for screening; may identify SBHF | Abnormal: < −16%; Borderline: −16 to −18% |
| Stage B (Asymptomatic LV dysfunction) | Abnormal or borderline GLS + other echo abnormalities = SBHF marker | GLS less negative than −16% + abnormal echo |
| HFrEF (LVEF < 40%) | LVGLS for prognostication; serial follow-up to predict LV recovery | GLS ≤ −6.95% = worse long-term outcomes; each 1% decrease = 15% increased mortality odds |
| HFpEF (LVEF ≥ 50%) | LVGLS aids diagnosis; worsening GLS & RVFWLS = adverse prognosis | Impaired GLS typically present even with normal EF |
| LVAD candidates | RVFWLS predicts RV failure post-implant — superior to TAPSE | RVFWLS cutoff varies by study; serial monitoring advised |
In HFpEF, RVFWLS is valuable for identifying early RV dysfunction in conjunction with elevated PA pressures, and for ongoing monitoring.
Cardio-Oncology
Cardio-Oncology — Chemotherapy Monitoring
| Timing | Recommendation |
|---|---|
| Before anthracyclines | Obtain baseline LVGLS in ALL patients |
| Before other chemotherapy / radiotherapy | Baseline strain reasonable |
| Baseline strain < normal limits | Repeat echo with strain at mid-treatment |
| During anthracycline treatment | Obtain strain to identify subclinical cardiotoxicity |
| Childhood cancer survivors | Incorporate strain in all follow-up exams |
| Threshold | Interpretation | Action |
|---|---|---|
| Relative GLS decrease ≥ 12% | Clinically significant — consider cardioprotective therapy | Start cardioprotection regardless of LVEF change |
| Relative GLS decrease ≥ 15% | Mild CTRCD per ESC/ICOS guidelines (isolated strain fall) | Optimize risk factors; do NOT stop chemotherapy if LVEF preserved |
| Relative GLS decrease ≥ 10% | Sensitivity 78%, specificity 79% for predicting LVEF decline | Close monitoring; consider cardioprotection |
Valvular Heart Disease
Valvular Heart Disease — Strain Cutoffs
| Valve Lesion | Key Strain Finding | Threshold / Clinical Implication |
|---|---|---|
| Aortic Stenosis (AS) | LVGLS — prognostic in asymptomatic patients | GLS < −14.7% → 2.5× increased mortality risk in severe asymptomatic AS. Apical-sparing pattern → screen for coexisting amyloidosis (99mTc scintigraphy). |
| Aortic Regurgitation (AR) | LVGLS predicts disease progression and surgical outcomes | GLS −18% best cutoff for disease progression; −14% predicts poor outcome post-AVR. LVGLS worsens continuously — no single cutoff; trend matters. |
| Mitral Regurgitation (primary MR) | LVGLS should be supranormal — preload augmented | GLS less negative than −20% = adverse prognosis; consider intervention. BNP + GLS provide synergistic risk stratification. |
| Mitral Regurgitation (secondary MR) | LVGLS useful for monitoring; less clear cutoff | No well-established cutoff to guide timing of intervention in secondary MR. |
| Mitral Stenosis (MS) | LVGLS reduced — primarily preload-mediated | ~85% of severe MS have GLS in lowest quartile; reduced preload is main driver, not intrinsic contractile dysfunction. |
| Tricuspid Regurgitation (TR) | RVFWLS prognostic before intervention | RVFWLS < −23% → better outcomes post-surgery. < −24% cutoff also validated for 5-year mortality risk after isolated TR surgery. |
⚠️ Key concept: Because LVGLS is a continuous parameter, in valvular disease absolute cutoffs are less meaningful than recognizing that as strain magnitude decreases, prognosis worsens continuously. In AR, TR, and primary MR (augmented preload, reduced volumetric afterload), LVGLS should be supranormal — less negative values reflect contractile dysfunction.
RV Strain
RV Strain — Clinical Applications
| Condition | RVFWLS Finding | Clinical Significance |
|---|---|---|
| Pulmonary Hypertension / PAH | Significantly worse than no-PH; correlates with invasive PA pressure, BNP, 6MWD | Serial RVFWLS monitors treatment response; improvement correlates with improving PVR |
| HF (HFrEF & HFpEF) | Strong outcome predictor independent of LVEF and LVGLS | RVFWLS predicts RV failure after LVAD implantation; superior to TAPSE |
| STEMI / Ischemic CM | RVFWLS prognostic; independently associated with adverse outcomes | Incremental value over clinical, infarct size, and LV parameters |
| ARVC | Type I: normal; Type II: delayed onset/reduced peak; Type III: systolic stretching with postsystolic shortening | Detects subclinical regional RV dysfunction before conventional echo; RV mechanical dispersion stratifies arrhythmic risk |
| Systemic Sclerosis | Occult regional and global RV dysfunction detectable regardless of RVSP | Useful for screening subclinical RV disease in scleroderma |
| Significant TR | RVFWLS < −23% suggestive of poorer outcomes | Pre-operative risk stratification before TR intervention |
RV-PA Coupling: RVFWLS/PASP ratio validated as noninvasive coupling index against invasive Ees/Ea. Independently prognostic in PAH, severe TR, HFpEF, and secondary MR (COAPT trial). Endorsed as an alternative/complement to TAPSE/PASP.
LA Strain
LA Strain — Clinical Applications
| Application | Key LASr Finding | Evidence Level |
|---|---|---|
| Elevated LV filling pressure | LASr < 18% = elevated PCWP (multicenter, n=322); LASr < 23% (single-center) | Endorsed — additive to E/e′ and LAVi |
| HFpEF diagnosis | Impaired LASr commonly present; powerful independent prognostic marker | Endorsed |
| New-onset AF prediction | Impaired LASr in at-risk patients; RA strain more predictive of AF recurrence | May be appropriate — not routinely advised |
| AF recurrence after cardioversion / ablation | LASr predicts recurrence and LA reverse remodeling; no vendor-specific cutoffs yet | May be appropriate |
| Cryptogenic stroke | LASr predicts paroxysmal AF over 3-year Holter monitoring | May be appropriate in select patients |
| RA strain (RASr) | Normal RASr ~44%; RA contractile ~17%; RA conduit ~18% | NOT currently advised for routine practice — further evidence needed |
Ischemic Heart Disease
Ischemic Heart Disease
| Application | Recommendation | Key Cutoffs |
|---|---|---|
| Non-STEMI ACS (no RWMA) | GLS / SLS patterns may detect significant CAD when RWMA absent | Cutoffs −17.4% to −19.7% (sensitivity 51–81%, specificity 58–81%) |
| STEMI | Strain has no clear added value — ECG alone mandates intervention | — |
| Early phase post-PCI for AMI | LVGLS or SLS for predicting recovery, adverse remodeling, and outcomes | Proposed cutoffs −10% to −15% for adverse remodeling prediction |
| Long-term risk after AMI | Each 1% reduction in LVGLS → 34% increase in hazard ratio for adverse outcomes | Cutoffs −9.3% to −15.1% across studies |
| Dobutamine stress echo (viability) | LVGLS increase with low-dose dobutamine → functional recovery | Qualitative assessment; no firm cutoffs endorsed |
| Exercise / dobutamine stress | Postsystolic shortening (strain curve shape) preferred over quantitative peak strain | No universal cutoff for stress strain; curve shape analysis preferred |
⚠️ Postsystolic shortening is the hallmark of ischemia on strain curves — a sensitive but non-specific marker. STE has insufficient temporal resolution for reliable strain rate measurement at high heart rates. TDI-based strain rate may be more reliable in stress settings.
Special Populations
💊 Hypertension, Diabetes, Obesity (Stage A/B HF)▶
- Impaired LVGLS in hypertension, diabetes, and obesity is prognostically important — associated with incident HF
- Hypertensive pattern: predominant basal-to-midsegment strain impairment
- Abnormal or borderline GLS + other echo abnormalities = Stage B HF marker
- GLS not currently advised for screening of Stage A HF — no evidence it alters outcomes
- Useful for recognition and monitoring of Stage B HF treatment
🏃 Athletes — Athlete's Heart vs Cardiomyopathy▶
Key concept: GLS is usually preserved in competitive athletes; if less negative than low-normal range for age/sex, suspect underlying cardiomyopathy.
- Strength-based sports: Increased LV wall thickness with preserved LVGLS — distinguish from HCM and infiltrative disease
- Endurance sports: Increased LV chamber volume with preserved LVGLS — distinguish from eccentric cardiomyopathies
- RV: RV dilation common in endurance athletes; RVFWLS relatively preserved vs age-matched general population. Contrast with ARVC and HCM where RVFWLS is frequently abnormal
- LA: LA strain NOT advised to differentiate athlete remodeling from cardiomyopathy/atriopathy — insufficient evidence
- ARVC differentiation: RVFWLS may provide incremental information when RV chamber parameters are abnormal
🧬 Hypertrophic Cardiomyopathy (HCM)▶
- Neutral-variant HCM: Relatively impaired septal function with relatively preserved apical strain
- Apical HCM: Apical strain impairment; apical aneurysm variant shows apical dyskinesis
- RVFWLS frequently abnormal in HCM — incremental to chamber measurements
- LA strain: LASr impaired in HCM; higher in competitive athletes than HCM patients
- Follow-up: Serial LVGLS and RVFWLS monitoring advised in HCM
💊 Cardiac Amyloidosis▶
Apical-sparing pattern of longitudinal strain is the hallmark:
- Mean of apical segments > 2× the mean of the rest of the heart = amyloidosis pattern
- Pattern seen in both light-chain (AL) and transthyretin (ATTR) amyloidosis
- When apical-sparing pattern is observed: perform nuclear scintigraphy (99mTc-HDP, 99mTc-PYP, or 99mTc-DPD) to confirm ATTR
- Caution: ESRD can mimic apical-sparing pattern on strain
- Also seen in low-flow AS — when apical-sparing noted in AS, screen for coexisting amyloidosis
- GLS should always be obtained and reported in patients with increased LV mass
💓 Cardiac Resynchronization Therapy (CRT)▶
- Visual assessment of septal flash and apical rocking may be sufficient to select candidates — potentially more accurate than current guideline criteria alone
- Strain curve shape analysis characterizes LBBB-induced dyssynchrony:
- Early: Slight notch in septal strain when lateral wall contracts
- Progressive: More pronounced septal notching
- Advanced: Systolic septal stretching during lateral wall contraction
- LVMD may help identify patients needing defibrillator therapy in CRT populations; not suited for detecting dyssynchrony amenable to CRT
- Myocardial work indices (lateral-to-septal work difference) show promise for CRT response prediction — not yet endorsed for routine use
- Beware: Pseudonormal septal strain pattern when lateral wall is dysfunctional (infarcted)
🫀 Childhood Cancer Survivors▶
- Significant reductions in LVGLS and LV global radial strain even with preserved LVEF after high-dose anthracyclines ± mediastinal radiation
- RVFWLS detects subclinical RV abnormalities
- Subclinical LV dysfunction identified in 1/3 of survivors with normal LVEF (St. Jude Lifetime Cohort, n=1,820)
- Combined LVEF + LVGLS + LV diastolic function assessment is supported in adult survivors of childhood cancer
- Strain should be incorporated in all follow-up echocardiographic exams in this population
♻️ Post-MI / Convalescent▶
- LVGLS and SLS patterns may diagnose significant CAD in non-STEMI even without RWMA
- Postsystolic shortening and early systolic stretching are characteristic ischemic strain patterns
- Ischemic memory: postsystolic shortening may persist even after resolution of ischemia
- LVMD elevated after MI → associated with ventricular arrhythmias and sudden cardiac death risk. Optimal cutoffs vary; hazard ratio 1.19 per 10ms increase in LVMD
- RVFWLS independently predicts all-cause mortality post-AMI, incremental to LVEF, E/e′, and MR
🌀 Atrial Fibrillation▶
- Strain measurement in AF: average ≥3 consecutive cycles with approximately equal RR length; avoid single-cycle measurements
- P-P gating cannot be used in AF — R-R gating required
- LASr detects impaired reservoir function before atrial dilatation develops
- LA fibrosis increases LA stiffness and worsens reservoir and contractile function — detectable by strain
- LASr and RA strain (RASr) predict AF recurrence after cardioversion and catheter ablation; no vendor-specific cutoffs yet proposed for ablation recurrence
- RA strain may be more predictive of AF recurrence than LA strain
🫀 Congenital Heart Disease (CHD)▶
- Tetralogy of Fallot (repaired): RVFWLS quantifies RV function and predicts outcomes; serial monitoring advised. LVGLS (ventricular interaction) also associates with adverse outcomes
- Systemic RV (TGA atrial switch, ccTGA, Fontan): Use RV GLS (not RVFWLS) — septal contribution is critical to systemic output. Serial RV GLS advised
- PH in CHD / Eisenmenger: RVFWLS has prognostic significance; LVGLS also contributory
- Ebstein's anomaly: LVGLS < −18% superior to LVEF for transplant-free survival prediction
- No accepted normative RV strain values for systemic RV, post-TOF repair, or Ebstein's — use with caution
- LA/RA strain in CHD: emerging area; no robust evidence to support clinical use at this time
Technical Pitfalls & Clinical Advice
Based on Table 2, Thomas et al. JASE 2025. Addressing these pitfalls is essential for accurate and reproducible strain measurements.
⚠️ Foreshortening of Apical Windows
Effect on StrainErroneously increases apical segmental strain values. Example: foreshortened GLS −20.8% vs optimal GLS −16.8% — clinically significant difference.
Clinical AdviceAvoid using foreshortened LV images for strain quantification. Ensure the true apex is visualized during acquisition before applying speckle tracking.
⚠️ Poor Visualization / Endocardial Tracking
Effect on StrainPoor endocardial/myocardial tracking. Software may smooth out poor tracking without alerting the user — a major pitfall of STE.
Clinical AdviceDo not incorporate segments with poor image quality into global strain calculations. If more than 3 segments are uninterpretable, do not report LVGLS.
⚠️ Excessively Large Myocardial ROI
Effect on StrainUnderestimates strain values. Including the pericardium artificially lowers strain magnitude.
Clinical AdviceEnsure that only the full myocardial wall is included in the ROI. Avoid including pericardial tissue.
⚠️ Excessively Small Myocardial ROI
Effect on StrainOverestimates strain values. In hypertrophic hearts, too-thin ROI reflects a subendocardial layer rather than full thickness. Example: too-thin ROI GLS −12.1% vs optimal −10.5%.
Clinical AdviceParticularly important in hypertrophic hearts — ensure inclusion of the full myocardial wall. ROI width should encompass the full wall thickness.
⚠️ Local Abnormalities in Chamber Geometry
Effect on StrainSeptal bulge or focal thickening causes radial strain to dominate, potentially resulting in net positive systolic strain from apical views.
Clinical AdviceDraw ROI in a straight, longitudinal direction, avoiding significant local bulges. If the thickening extends across more than one full segment, include the thickened region within the ROI.
⚠️ Inaccurate End-Diastole / End-Systole Definition
Effect on StrainEither increases or decreases strain depending on where segmental curve peaks/troughs start and end in the cardiac cycle. Affects both end-systolic and peak-systolic measurements.
Clinical AdviceEnd-diastole (zero strain) should correspond to MVC. End-systole should correspond to AVC. Manually adjust timing by direct observation of mitral/aortic valve events or spectral Doppler if automated timing is incorrect.
⚠️ Atrial Fibrillation — Single Cycle Measurement
Effect on StrainOver- or underestimation of strain values depending on the preceding filling phase (RR length).
Clinical AdviceConsider averaging several cycles, or measure the third of three consecutive cycles with approximately the same RR length.
⚠️ Ventricular Ectopic Beats
Effect on StrainOver- or underestimation of strain values depending on the preceding filling phase.
Clinical AdviceAvoid performing strain analysis on immediate post-ectopic beats.
⚠️ Conventional 4-Chamber View for RVFWLS
Effect on StrainUnderestimation of RVFWLS. The RV free wall segments most distant from the IVS undergo greatest longitudinal deformation and are best captured in the RV-focused view. Example: conventional 4Ch RVLS −18.8% vs RV-focused −21.9%.
Clinical AdviceAlways use the apical RV-focused four-chamber view for RVFWLS quantification. Lateral approach, scanning bed with apical cutout recommended for optimal positioning.
General Technical Best Practices
| Parameter | Best Practice |
|---|---|
| Frame rate — LV/LA | 50–90 fps |
| Frame rate — RV | 60–90 fps |
| Frame rate — Stress echo | >100 fps recommended (standard STE often inadequate at high HR) |
| Dedicated software | Use dedicated RV and atrial tracking software over LV-software adaptation — better feasibility and reproducibility |
| Serial comparison | Same vendor AND same software version for serial patient follow-up. Different vendors now acceptable "with care" given convergence. |
| End-systolic strain | Default reporting parameter — report at AVC, not peak systolic, unless explicitly stated |
| Sign convention | Keep negative sign for GLS. If omitting sign, use term "global longitudinal shortening." |
| Compare tracking to motion | During postprocessing, always verify that the speckle-tracking result matches the underlying myocardial motion — software may smooth areas of failed tracking |
2025 Updates — What Changed from 2011
New Normal Value Thresholds
LVGLS — Three-zone system (new):
Normal >−18% / Borderline −16 to −18% / Abnormal <−16%. Based on comprehensive meta-analysis of 23,208 adults (Morris et al., 2025).
RVFWLS — Sex-specific LLN:
Men −20%; Women −21%. Endorsed for clinical use. Normal values are sex-specific but do NOT change with age.
LASr — Clinically endorsed thresholds:
Normal 23–60%; Borderline 23–30%; LASr <18% = elevated filling pressure (optimal cutoff, multicenter validation).
Technical Updates
Midwall/full-thickness tracking endorsed:
Now the preferred approach. Most normative and clinical data use this method. Vendors encouraged to standardize accordingly.
Intervendor convergence confirmed:
Third intervendor study (2025) showed gratifying convergence of strain measurements. Most vendors now support midwall/full-wall strain.
Dedicated RV/LA software:
Use dedicated software over LV-software adaptation — comparable values but significantly better feasibility and reproducibility (Mirea et al., 2022).
AI algorithms — conditional endorsement:
May be used clinically after demonstrating agreement with existing algorithms and regulatory approval. Rapid advancement expected.
New Clinical Endorsements (not in 2011)
LASr for filling pressure estimation — LASr <18% endorsed as optimal cutoff for elevated PCWP
RVFWLS/PASP coupling ratio — validated noninvasive RV-PA coupling index; prognostic in PAH, TR, HFpEF, secondary MR
Amyloidosis pattern (apical sparing) — mean apex >2× mean rest of heart → trigger nuclear scintigraphy
Cardio-oncology protocol standardized — 12% relative GLS decline = actionable (SUCCOUR trial); 15% = mild CTRCD (ESC/ICOS)
Asymptomatic severe AS — GLS <−14.7% = 2.5× mortality risk (EACVI meta-analysis, 8 studies)
Valvular disease — supranormal GLS concept — in AR, TR, primary MR, GLS should be >−20%; if less negative = contractile dysfunction despite normal EF
CRT dyssynchrony staging — four-stage LBBB-induced remodeling classification by strain curve shape
Still NOT Endorsed (confirmed in 2025)
Radial strain — poor intervendor performance; not endorsed
3D strain (routine) — lower resolution, variability; investigational
Layer-specific strain — no superiority demonstrated
Segmental strain cutoffs — too much test-retest and intervendor variability
Myocardial work indices (routine) — insufficient standardization; cutoff overlap with normal
RA strain (clinical use) — emerging; no robust evidence yet
SAHF screening by GLS — no evidence GLS-guided screening alters outcomes in asymptomatic Stage A HF
Future Directions (Emerging — Not Yet Endorsed)
| Technology | Current Status | Limiting Factor |
|---|---|---|
| 3D Speckle-Tracking Strain | Investigational; full-volume 3D strain software improving | Lower temporal/spatial resolution; intervendor variability unacceptable for routine use |
| Multilayer Strain | Not endorsed — no added value demonstrated | Thin walls limit layer differentiation; interdependence of layer-specific GLS |
| Myocardial Work (PSL) | Promising for load-correction; CRT response; ischemia detection | Lack of standardization; cutoff overlap; valve timing sensitivity |
| AI-Based Strain | Several commercially cleared algorithms (FDA); deep learning correlation with experts r=0.91 | Requires agreement with existing algorithms and regulatory approval per jurisdiction |
| Ultrafast / Plane-Wave STE | Research — frame rates ≥500 fps for strain rate measurement | Not yet clinically endorsed |
| RV Myocardial Work | Cannot be clinically advised — LV PSL algorithms applied off-label to RV geometry | Consequences of LV algorithm applied to RV geometry not established |
⚠️ Clinical Disclaimer: This reference is based on the 2025 ASE/EACVI Strain Consensus Statement. Strain measurements are vendor-dependent — always use the same vendor for serial follow-up. Not a substitute for individual clinical judgment or complete guideline review.