Incremental Value of Apical Longitudinal Strain in Predicting High-Risk Apical Aneurysms in Patients with Hypertrophic Cardiomyopathy

Background: Apical aneurysms have long been considered a critical risk marker for poor clinical outcomes in hypertrophic cardiomyopathy (HCM) individuals. This study aims to identify apical features associated with adverse outcomes and explore their incremental predictive value beyond the traditional sudden cardiac death (SCD) risk score model. Methods: From December 2019 to November 2024, 2318 HCM patients were diagnosed at Tongji Hospital. Ultimately, 65 HCM patients with apical aneurysms were included in the analysis, each having undergone conventional and contrast echocardiography, as well as speckle tracking echocardiography (STE). Results: With a median follow-up of 26 months, composite events occurred in 25 (38%) patients, while none occurred in 40 (62%). Multivariate Cox regression revealed that abnormal apical longitudinal strain average (LS-avg) significantly increased composite event risk (HR: 1.23; 95% CI: 1.02–1.48). For patients with a 5-year SCD risk score < 4% or aneurysm diameter < 20 mm, survival differed significantly between apical LS-avg ≥ −6.6% and <−6.6% (p < 0.05). Correct reclassification was 10.8% (7/65) for reduced 5-year SCD risk scores and 15.4% (10/65) for smaller aneurysms. Incorporating apical LS-avg into 5-year SCD risk score or aneurysm diameter assessment improved risk assessment (NRI: 67.7% and 66.2% for adverse event prediction). A likelihood ratio test showed that apical LS-avg enhanced prognostic accuracy in patients, with lower 5-year SCD risk scores and smaller aneurysms (all p < 0.001). Conclusions: Apical LS-avg may be associated with an increased risk of adverse cardiovascular events in HCM individuals who had apical aneurysms. On the basis of the conventional 5-year SCD risk score and aneurysm size, apical LS-avg may have the potential to be used to individually identify the high-risk group of this patient cohort, particularly among those with a 5-year SCD risk score < 4% and an aneurysm diameter < 20 mm.