What is the management approach for patients with abnormal left ventricular longitudinal strain?

Management of Patients with Abnormal Left Ventricular Longitudinal Strain

Overview

Abnormal left ventricular longitudinal strain (LVGLS) requires targeted medical therapy and close monitoring as it predicts future deterioration in cardiac function and adverse outcomes even when ejection fraction appears normal.

Left ventricular global longitudinal strain (LVGLS) is a sensitive marker of subclinical, early myocardial dysfunction that can detect cardiac abnormalities before changes in ejection fraction become apparent. It provides incremental prognostic information beyond traditional measures and should guide management decisions.

Diagnostic Assessment

• Normal LVGLS values: >18% (in absolute terms)
• Abnormal LVGLS values: ≤16-18% (in absolute terms)
• Significance: An abnormal GLS has a sensitivity of 88% for predicting a decrease in LVEF >5% during follow-up 1

Management Algorithm

Step 1: Optimize Guideline-Directed Medical Therapy (GDMT)

For patients with abnormal LVGLS and reduced LVEF (<50%):

• First-line medications:

  • ACE inhibitors or ARBs (or preferably ARNI)
  • Beta-blockers (carvedilol or long-acting metoprolol)
  • Mineralocorticoid receptor antagonists (MRAs)
  • SGLT2 inhibitors

• For African American patients: Consider adding isosorbide dinitrate/hydralazine 2

For patients with abnormal LVGLS but preserved LVEF (HFpEF):

• First-line medications:
  • Diuretics for symptom relief in volume-overloaded patients
  • SGLT2 inhibitors
  • Blood pressure control according to hypertension guidelines 2

Step 2: Address Specific Underlying Conditions

• Hypertension: Aggressive control is essential as hypertension is associated with higher risk of deterioration in LVEF in patients with abnormal LVGLS 3
• Coronary artery disease: Consider revascularization in patients with CAD and symptoms or myocardial ischemia 2
• Atrial fibrillation: Manage according to guidelines with either rhythm or rate control strategy 2
• Valvular heart disease: Consider early intervention, particularly in aortic stenosis where abnormal LVGLS may indicate subclinical LV damage 2

Step 3: Monitoring and Follow-up

• Echocardiography: Repeat at 3-6 month intervals to assess for changes in LVGLS and LVEF
• Medication adjustment: Titrate GDMT to maximum tolerated doses
• Biomarker monitoring: Consider BNP/NT-proBNP to track disease progression

Special Considerations

Patients with Recovered LVEF but Abnormal LVGLS

These patients remain at high risk for recurrent heart failure:

• Continue full GDMT: Even if LVEF has normalized, abnormal LVGLS predicts future deterioration 1
• Close monitoring: More frequent follow-up is warranted
• Risk stratification: An abnormal GLS (≤16%) has 88% sensitivity for predicting LVEF deterioration 1

Patients with Secondary Mitral Regurgitation and Abnormal LVGLS

• Consider transcatheter edge-to-edge repair: Improvement in LVGLS at 6 months post-procedure is associated with reduced mortality and heart failure hospitalizations 4
• Optimize GDMT: Even without intervention, improvement in LVGLS with medical therapy alone is associated with better outcomes 4

Congenital Heart Disease Patients with Abnormal LVGLS

• Aggressive GDMT: Use of renin-angiotensin-aldosterone system antagonists is associated with lower risk of cardiovascular events 3
• Hypertension control: Critical for preventing deterioration in LVEF 3

Prognostic Implications

Abnormal LVGLS is independently associated with:

• Higher risk of death or heart failure hospitalization (HR 0.55 for those with improvement) 4
• Higher risk of death alone (HR 0.48 for those with improvement) 4
• Higher risk of heart failure hospitalization (HR 0.50 for those with improvement) 4

Common Pitfalls to Avoid

1. Relying solely on LVEF: LVGLS can detect subclinical dysfunction even when LVEF is normal
2. Premature discontinuation of GDMT: Patients with recovered LVEF but abnormal LVGLS need continued therapy
3. Inadequate follow-up: Patients with abnormal LVGLS require closer monitoring
4. Overlooking hypertension control: Critical for preventing deterioration in patients with abnormal LVGLS
5. Neglecting right ventricular function: Assessment of RV function is mandatory during follow-up 2

By implementing this management approach for patients with abnormal LVGLS, clinicians can potentially prevent progression to overt heart failure and improve long-term outcomes.