What is the reason for and aim of the publication?
The first EACVI/ASE Consensus Document on Strain Imaging has been published in 2011. Since then, technology has evolved substantially and a huge amount of data has been generated that show the clinical utility of the technique. Nevertheless, there is a remaining uncertainty about when and how to use strain clinically with the consequence that strain is still underused in daily clinical practice.
The publication therefore aims to provide practical, evidence-based clinical guidance for applying strain echocardiography in specific scenarios and to help standardize clinical use and support interpretation (e.g., normal ranges, methodology). It also aims to drive technical development and highlights knowledge gaps where future research is needed.
What are the most important take-home messages?
- Strain (especially LV Global Longitudinal Strain, GLS) is clinically robust and adds value beyond EF.
- Strain should be routinely used in key clinical scenarios, including heart failure, cardio-oncology, ischemic heart disease, valvular disease and pulmonary hypertension.
- Three parameters in particular have been validated and are recommended for daily use: LVGLS as key parameter, RVFWLS for RV assessment, and LA reservoir strain, especially in the context of diastolic dysfunction.
- Vendor differences in strain have become smaller over the years. Nevertheless, inconsistencies remain regarding the use of endocardial and mid-/full-wall strain. The latter is recommended as it is more robust and has the larger evidence base.
- The use of regional strain assessment is limited but has added value in specific scenarios such as regional myocardial dysfunction and dyssynchrony.
What are challenges in practical implementation – and possible solutions?
Correct strain measurements depend on high-quality image acquisitions including stable, standardized views and regular rhythm. Tracking quality should be supervised by comparing the motion of the region of interest (ROI) with the motion of the underlying myocardium.
Although comparability of measurements by software from major vendors has clearly improved, differences in default settings (endocardial / mid-/full-wall) remain which limits the comparability of data. Care should be taken to always measure mid/full wall strain and report the parameter used.
There is still a lack of standardized cut-offs. The upcoming EACVI / ASE Recommendations for Chamber Quantification will provide for the first time normal values from a large meta-analysis.
Which issues still need to be tackled, that are not yet addressed by the paper?
There is still a lack of randomized trials using strain-guided management, a limited multicenter validation for many applications and there are sparse data in congenital heart disease as well as for atrial and right heart strain in many settings.
Advanced techniques, such as 3D strain and myocardial work analysis have limited reproducibility and need more standardization before routine clinical use.
What further developments on the topic are emerging?
Automated strain measurement algorithms and artificial intelligence (AI) will further improve reproducibility and may also be used for guiding image acquisition.
Myocardial work measurements (pressure-strain loops) can account for loading conditions and are particularly promising for investigating regional differences in myocardial function, but further validation and standardization is needed.
The ongoing efforts of the EACVI strain task force will contribute to further standardization and convergence of strain measurements among vendors.
AI-guided combination of deformation patterns from several heart chambers with integration of other parameters might allow better phenotyping of certain pathologies (e.g., HFpEF).
Clinical Applications of Strain Echocardiography
James D Thomas, et al. Clinical Applications of Strain Echocardiography: A Clinical Consensus Statement From the American Society of Echocardiography Developed in Collaboration With the European Association of Cardiovascular Imaging of the European Society of Cardiology, European Heart Journal - Cardiovascular Imaging, Volume 27, Issue 3, March 2026, Pages 335–368, https://doi.org/10.1093/ehjci/jeag006
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