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Review
. 2025 Jun 16;12(6):229.
doi: 10.3390/jcdd12060229.

Early Echocardiographic Markers in Heart Failure with Preserved Ejection Fraction

Annamaria Tavernese  1   2 , Vincenzo Rizza  3 , Valeria Cammalleri  2 , Rocco Mollace  4   5 , Cristina Carresi  6 , Giorgio Antonelli  1   2 , Nino Cocco  2 , Luca D'Antonio  2 , Martina Gelfusa  2 , Francesco Piccirillo  2 , Annunziata Nusca  1   2 , Gian Paolo Ussia  1   2
Affiliations
Review

Early Echocardiographic Markers in Heart Failure with Preserved Ejection Fraction

Annamaria Tavernese et al. J Cardiovasc Dev Dis. .

Abstract

Heart failure with preserved ejection fraction (HFpEF) represents nearly half of all heart failure cases and remains diagnostically challenging due to its heterogeneous pathophysiology and often subtle myocardial dysfunction. Conventional echocardiographic parameters, such as left ventricular ejection fraction (LVEF) and the left atrial volume index (LAVI), frequently fail to detect early functional changes. Advanced echocardiographic techniques have emerged as valuable tools for early diagnosis and risk stratification. Global Longitudinal Strain (GLS) allows for the identification of subclinical systolic dysfunction, even with preserved LVEF. Left Atrial Strain (LAS), particularly reservoir and pump strain, provides sensitive markers of diastolic function and elevated filling pressures, offering additional diagnostic and prognostic insights. Myocardial Work (MW), through non-invasive pressure-strain loops, enables load-independent assessment of contractility, while Right Ventricular Free Wall Longitudinal Strain (RVFWLS) captures early right heart involvement, often present in advanced HFpEF. The integration of these advanced parameters can enhance diagnostic precision and guide personalized treatment strategies. This review highlights the current evidence and clinical applications of strain-based imaging in HFpEF, underscoring the importance of a multiparametric, pathophysiology-oriented approach in heart failure evaluation.

Keywords: diastolic dysfunction; echocardiographic biomarkers; global longitudinal strain (GLS); heart failure with preserved ejection fraction (HFpEF); left atrial strain (LAS); myocardial work (MW); right ventricular free wall longitudinal strain (RVFWLS); shear wave imaging (SWI); speckle-tracking echocardiography (STE); subclinical myocardial dysfunction.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
LV GLS (assessed using speckle-tracking echocardiography) of a patient affected by dilated cardiomyopathy with borderline low ejection fraction (LVEF 51%) but significantly impaired longitudinal contraction of basal septum, basal lateral, and mid-basal inferior walls. GLS = Global Longitudinal Strain; LV = Left Ventricle; LVEF = Left Ventricular Ejection Fraction.
Figure 2
Figure 2
LV Myocardial Work (MW) indices calculated combining LV GLS and peak arterial pressure evaluated with a cuff manometer. FR = Frame Rate; BP = Blood Pressure; GCW = Global Constructive Work; GLS = Global Longitudinal Strain; GS = Global Strain; GWE = Global Work Efficiency; GWI = Global Work Index; GWW = Global Wasted Work; HR = Heart Rate; LV = Left Ventricle; PSD = Peak Strain Dispersion.
Figure 3
Figure 3
Right Ventricular Free Wall Longitudinal Strain (assessed using speckle-tracking echocardiography). RVFWLS = Right Ventricular Free Wall Longitudinal Strain; RV4CLS = Right Ventricular 4-Chamber Longitudinal Strain.
Figure 4
Figure 4
LA strain components. ED = End Diastole; LA = Left Atrium; LAScd = Left Atrial Recoil Strain; LASct = Left Atrial Pump Strain; LASr = Left Atrial Reservoir Strain.
See this image and copyright information in PMC

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