ORIGINAL INVESTIGATION Speckle Strain Echocardiography Predicts Outcome in Patients with Heart Failure with both Depressed and Preserved Left Ventricular Ejection Fraction Mark R. Stampehl, M.D.,* Douglas L. Mann, M.D.,† John S. Nguyen, M.D.,* Francisco Cota, M.D.,* Cristina Colmenares, M.D.,* and Hisham Dokainish, M.D., F.R.C.P.C., F.A.C.C., F.A.S.E.‡ *Section of Cardiology, Department of Medicine, Division of Cardiology, Baylor College of Medicine, Houston, Texas; †Department of Medicine, Washington University, St. Louis, Missouri; and ‡Department of Medicine, McMaster University, Hamilton, Canada Background: While speckle imaging has been shown to predict outcome in patients with heart failure (HF), it remains unclear whether speckle strain predicts outcome in patients with HF with preserved ejection fraction (HFPEF). Methods: Four hundred twenty patients with HF by Framingham criteria and either: left ventricular (LV) EF <50%, or elevated LV filling pressure by comprehensive echo Doppler study in the setting of left ventricular ejection fraction (LVEF) ≥50%, were enrolled. Speckle tracking was used to measure strain and strain rate in multiple vectors. The primary endpoint was HF hospitalization or cardiovascular death. Results: Follow-up was completed in 380/420 patients (90%). The mean age was 55.7  0.8 years, 191/380 (50%) were male, 319/380 (84%) were hypertensive, 183/380 (48%) were diabetic, and 152/380 (40%) had known coronary artery disease. At a mean follow-up of 369  30 days, 107/380 patients (28%) reached the primary endpoint: 97 HF rehospitalizations and 10 cardiac deaths. The best univariate predictors of outcome were global longitudinal peak strain (GLPS) (v 2 = 25.6, P < 0.001), mitral DT (v 2 = 16.8, P < 0.001), LVEF (v 2 = 16.7, P < 0.0001), longitu- dinal early diastolic strain (v 2 = 8.7, P = 0.003), and circumferential peak strain (v 2 = 7.9, P = 0.005). On multivariate analysis, GLPS (P < 0.0001), LVEF (P = 0.0002), and mitral DT (P = 0.005) were inde- pendent predictors of outcome. In the 100 HF patients with preserved LVEF, there were 17 events. Patients with GPLS ≤15 had significantly better event-free survival than patients with GPLS >15 (v 2 = 4.1, P = 0.04), whereas LVEF did not predict event-free survival. Conclusion: Speckle strain echo- cardiography is an important predictor of outcome in HF patients with both depressed and preserved LVEF. (Echocardiography 2014;00:1–8) Key words: speckle tracking echocardiography, strain imaging, heart failure, outcome Heart failure (HF) with depressed and preserved left ventricular ejection fraction (LVEF) is a common and increasing problem and results in significant morbidity and mortality rates. 1–6 HF outcomes can be predicted by clinical vari- ables, biomarkers, and two-dimensional (2D), Doppler and tissue Doppler echocardiographic variables. 7–9 A novel echocardiographic modal- ity, speckle tracking, can measure myocardial deformation (strain), and the rate of deformation (strain rate). 10 Advantages of speckle imaging over Doppler in assessing myocardial mechanics include angle independence, freedom from tethering, and ability to measure strain and strain rate in multiple vectors (longitudinal, circumfer- ential, twist). 11 Speckle strain indices have been used to map out myocardial mechanics in health and cardiac disease. 12–14 Recent work has dem- onstrated that these novel speckle strain variables can predict HF rehospitalization and cardiovascu- lar death, although these data are relatively few and the prognostic role of these variables in patients with HF with preserved ejection fraction (HFPEF) (preserved EF) remains unclear. 15–18 Therefore, we sought to determine the prognos- tic importance of systolic and diastolic strain in patients with congestive heart failure (CHF), hypothesizing that, given evidence of systolic dysfunction in patients with preserved LVEF and cardiac disease, 19 these strain variables would independently predict outcome in patients with HF and both preserved and depressed LVEF. In Address for correspondence and reprint requests: Hisham Dokainish, M.D., F.R.C.P.C., F.A.C.C., F.A.S.E., Department of Medicine, Section of Cardiology, McMaster University Health Sciences Centre, 237 Barton Street E., CVSRI #C3-111, Hamil- ton, Ontario, L8L 2X2, Canada. Fax: 905-577-1424; E-mail: hisham.dokainish@phri.ca 1 © 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12613 Echocardiography