Prognostic implications of ventricular strain in heart failure with preserved ejection fraction: a 2D speckle-tracking echocardiography study

Background Two-dimensional speckle-tracking echocardiography (2D-STE) has been widely used to assess subclinical myocardial dysfunction, primarily focusing on left ventricular (LV) longitudinal systolic function in heart failure with preserved ejection fraction (HFpEF). However, data remains limited on the prognostic value of both left ventricular (LV) and right ventricular (RV) strain parameters, particularly diastolic strain components. Aim To evaluate the prognostic relationship between LV and RV systolic and diastolic strain parameters and clinical outcomes in patients with HFpEF. Methods Of 2,201 screened HFpEF patients, 688 consecutive eligible patients were retrospectively enrolled. 2D-STE strain parameters were assessed from transthoracic echocardiographic (2D-TTE) images. Patients were prospectively followed for cardiovascular (CVS) events, including hospitalization for acute heart failure, cardiovascular-related death, heart transplantation and the need for ventricular assist device (VAD) implantation 2D-STE analysis was used to measure peak LV (longitudinal, radial, and circumferential) and RV (longitudinal and radial) strain. Long-term outcomes were assessed for all-cause cardiovascular events and recurrent hospitalizations. Results Among 688 patients (mean age 58 ± 4 years, 58% male), 264 patients reached the combined endpoint over a mean follow-up of 1.5 ± 0.6 years. Both LV and RV strain parameters were significantly impaired compared to normal reference values (p < 0.0001), with RV strain impairment being more pronounced than LV strain impairment. The strongest predictors of cardiovascular events were RV Free Wall systolic and diastolic strain (AUC: 0.86 and 0.77), global RV systolic and diastolic strain (AUC: 0.77 and 0.70) and global LV longitudinal systolic and diastolic strain (AUC: 0.78 and 0.75). The degree of myocardial dysfunction correlated most strongly with RV strain impairment (free wall > global strain), followed by LV strain impairment. Greater myocardial strain impairments were observed in patients with: Higher left atrial volume index (LAVI), NYHA functional class ≥ II, more severe diastolic dysfunction, lower LA, LV, and RV strain values and reduced tricuspid annular plane systolic excursion (TAPSE) (p < 0.001) RV free wall strain impairment and to a lesser extent, LV strain impairment were independent predictors of survival after multiple statistical adjustments. Conclusion In HFpEF patients, RV strain parameters outperform LV strain as prognostic markers, with RV free wall strain providing the strongest risk stratification. Given their superior prognostic value, RV and LV strain assessments should be integrated into routine clinical screening to enhance risk stratification and patient management.