title: Global Longitudinal Strain Is a Superior Predictor of All-Cause Mortality in Heart Failure With Reduced Ejection Fraction.
abstract: OBJECTIVE
  The purpose of this study was to investigate the prognostic value of global longitudinal strain (GLS) in heart failure with reduced ejection fraction (HFrEF) patients in relation to all-cause mortality.
  
  
  BACKGROUND
  Measurement of myocardial deformation by 2-dimensional speckle tracking echocardiography, specifically GLS, may be superior to conventional echocardiographic parameters, including left ventricular ejection fraction, in predicting all-cause mortality in HFrEF patients.
  
  
  METHODS
  Transthoracic echocardiographic examinations were retrieved for 1,065 HFrEF patients admitted to a heart failure clinic. The echocardiographic images were analyzed, and conventional and novel echocardiographic parameters were obtained.
  
  
  RESULTS
  Many of the conventional echocardiographic parameters proved to be predictors of mortality. However, GLS remained an independent predictor of mortality in the multivariable model after adjusting for age, sex, body mass index, total cholesterol, mean arterial pressure, heart rate, ischemic cardiomyopathy, percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, noninsulin dependent diabetes mellitus, and conventional echocardiographic parameters (hazard ratio [HR]: 1.15; 95% confidence interval [CI]: 1.04 to 1.27; p = 0.008, per 1% decrease). No other echocardiographic parameter remained an independent predictor after adjusting for these variables. Furthermore, GLS had the highest C-statistics of all the echocardiographic parameters and added incremental prognostic value with a significant increase in the net reclassification improvement (p = 0.009). Atrial fibrillation (AF) modified the relationship between GLS and mortality (p value for interaction = 0.036); HR: 1.08 (95% CI: 0.97 to 1.19), p = 0.150 and HR: 1.22 (95% CI: 1.15 to 1.29), p < 0.001, per 1% decrease in GLS for patients with and without AF, respectively. Sex also modified the relationship between GLS and mortality (p value for interaction = 0.047); HR: 1.23 (95% CI: 1.16 to 1.30), p < 0.001 and HR: 1.09 (95% CI: 0.99 to 1.20), p = 0.083, per 1% decrease in GLS for men and women, respectively.
  
  
  CONCLUSIONS
  GLS is an independent predictor of all-cause mortality in HFrEF patients, especially in male patients without AF. Furthermore, GLS was a superior prognosticator compared with all other echocardiographic parameters.
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark. Electronic address: jlm392@alumni.ku.dk.
authors.forename: Morten
authors.initials: M
authors.lastname: Sengeløv
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Peter Godsk
authors.initials: PG
authors.lastname: Jørgensen
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Jan Skov
authors.initials: JS
authors.lastname: Jensen
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Clinical Institute, Aalborg University, Aalborg, Denmark.
authors.forename: Niels Eske
authors.initials: NE
authors.lastname: Bruun
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Flemming Javier
authors.initials: FJ
authors.lastname: Olsen
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Thomas
authors.initials: T
authors.lastname: Fritz-Hansen
authors.affiliation: Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Kotaro
authors.initials: K
authors.lastname: Nochioka
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Tor
authors.initials: T
authors.lastname: Biering-Sørensen
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D002303:Cardiac Output, Low / Q000000981:diagnostic imaging*; D002423:Cause of Death; D015331:Cohort Studies; D016208:Databases, Factual; D003718:Denmark; D004452:Echocardiography / Q000379:methods*; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000401:mortality* / Q000503:physiopathology; D006801:Humans; D007091:Image Processing, Computer-Assisted; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D013318:Stroke Volume / Q000502:physiology; D016019:Survival Analysis; D018617:Ultrasonography, Doppler, Pulsed / Q000379:methods
keywords: GLS; echocardiography; prognosis; risk stratification; speckle tracking; systolic function