Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology’s Department Of Cardiovascular Imaging – 2023

Correspondence: Sociedade Brasileira de Cardiologia – Av. Marechal Câmara, 360/330 – Centro – Rio de Janeiro, Brazil – Posta Code 20020-907. E-mail: diretrizes@cardiol.br

Presidents of the Department of Cardiovascular Imaging: Carlos Eduardo Rochitte (2020/2021) and André Luiz Cerqueira de Almeida (2022/2023)

Coordinating Editors: André Luiz Cerqueira de Almeida, Marcelo Dantas Tavares de Melo, Alex dos Santos Felix and David Costa de Souza Le Bihan

Co-Editors: Marcelo Luiz Campos Vieira and José Luiz Barros Pena

SBC Clinical Practice Guidelines Committee: Carisi Anne Polanczyk (Coordinator), Humberto Graner Moreira, Mário de Seixas Rocha, Jose Airton de Arruda, Pedro Gabriel Melo de Barros e Silva – Period 2022-2024

Santa Casa de Misericórdia de Feira de Santana, Feira de Santana, BA – Brazil

Universidade Federal da Paraíba, João Pessoa, PB – Brazil

Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP – Brazil

Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG – Brazil

Hospital Felicio Rocho, Belo Horizonte, MG – Brazil

Escola de Ecografia de Pernambuco (ECOPE), Recife, PE – Brazil

Beneficência Portuguesa de São Paulo, São Paulo, SP – Brazil

Instituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brazil

DF Star, Rede D’Or São Luiz, Brasília, DF – Brazil

Hospital Israelita Albert Einstein, São Paulo, SP – Brazil

Santa Casa de Feira de Santana, Feira de Santana, BA – Brazil

Instituto de Cardiologia e Transplantes do DF, Brasília, DF – Brazil

Diagnoson, Grupo Fleury, Salvador, BA – Brazil

Hospital da Bahia, Salvador, BA – Brazil

Escola Bahiana de Medicina e Saúde Pública, Salvador, BA – Brazil

Hospital do Coração (HCor), São Paulo, SP – Brazil

CardioEco Centro de Diagnóstico Cardiovascular e Ecocardiografia, Curitiba, PR – Brazil

UnitedHealth Group, Rio de Janeiro, RJ – Brazil

Faculdade de Medicina da Universidade Federal de Goiás, Goiânia, GO – Brazil

Hospital Pró-Cardiaco, Rio de Janeiro, RJ – Brazil

Hospital Universitário Antônio Pedro da Universidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brazil

Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF – Brazil

Clínica Cardio & Saúde, Curitiba, PR – Brazil

Heart & Mind Care Serviços Médicos (HMC), Manaus, AM – Brazil

Cardiologia Não Invasiva, Clínica CNI, Uberlândia, MG – Brazil

Diagnósticos da América SA (DASA), São Paulo, SP – Brazil

Hospital 9 de Julho, São Paulo, SP – Brazil

Universidade Federal do Paraná (UFPR), Curitiba, PR – Brazil

Departamento de Cardiologia Pediátrica (DCC/CP) da Sociedade Brasileira de Cardiologia (SBC), São Paulo, SP – Brazil

Sociedade Brasileira de Oncologia Pediátrica, São Paulo, SP – Brazil

Universidade Federal da Bahia (UFBA), Salvador, BA – Brazil

Instituto da Criança e do Adolescente do Hospital das Clinicas Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP – Brazil

Hospital Evangélico, Cachoeiro de Itapemirim, ES – Brazil

Instituto do Coração de Marília (ICM), Marília, SP – Brazil

Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo, SP – Brazil

Hospital Aliança Rede D’Or São Luiz, Salvador, BA – Brazil

Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ – Brazil

Grupo Fleury, São Paulo, SP – Brazil

Hospital Cardio Pulmonar Rede D’or São Luiz, Salvador, BA – Brazil

Universidade Federal do Ceará, Fortaleza, CE – Brazil

Universidade Federal do Vale do São Francisco (UNIVASF), Petrolina, PE – Brazil

Hospital Nossa Senhora da Conceição, Tubarão, SC – Brazil

Universidade do Sul de Santa Catarina (UNISUL), Tubarão, SC – Brazil

EcoHaertel - Hospital Mae de Deus, Porto Alegre, RS – Brazil

Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS – Brazil

Universidade Federal de São Paulo (UNIFESP), São Paulo, SP – Brazil

Quanta Diagnóstico por Imagem, Curitiba, PR – Brazil

Hospital Santa Izabel Salvador, BA – Brazil

Santa Casa da Bahia, Salvador, BA – Brazil

Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ – Brazil

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology’s Department Of Cardiovascular Imaging – 2023
The report below lists declarations of interest as reported to the SBC by the experts during the period of the development of these statement, 2022/2023.
Expert	Type of relationship with industry
Adenalva Lima de Souza Beck	Nothing to be declared
Alex Felix	Nothing to be declared
Ana Clara Rodrigues	Nothing to be declared
Ana Cristina Camarozano	Nothing to be declared
Anderson da Costa Armstrong	Financial declaration A - Economically relevant payments of any kind made to (i) you, (ii) your spouse/partner or any other person living with you, (iii) any legal person in which any of these is either a direct or indirect controlling owner, business partner, shareholder or participant; any payments received for lectures, lessons, training instruction, compensation, fees paid for participation in advisory boards, investigative boards or other committees, etc. From the brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - Amyloidosis: Anylam. Other relationships Funding of continuing medical education activities, including travel, accommodation and registration in conferences and courses, from the brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - Health area; CARDIOVASF.
André Luiz Cerqueira de Almeida	Financial declaration A - Economically relevant payments of any kind made to (i) you, (ii) your spouse/partner or any other person living with you, (iii) any legal person in which any of these is either a direct or indirect controlling owner, business partner, shareholder or participant; any payments received for lectures, lessons, training instruction, compensation, fees paid for participation in advisory boards, investigative boards or other committees, etc. From the brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - Boston Scientific: Speaker.
Andressa Mussi Soares	Financial declaration A - Economically relevant payments of any kind made to (i) you, (ii) your spouse/partner or any other person living with you, (iii) any legal person in which any of these is either a direct or indirect controlling owner, business partner, shareholder or participant; any payments received for lectures, lessons, training instruction, compensation, fees paid for participation in advisory boards, investigative boards or other committees, etc. From the brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - Bayer: Anticoagulation and heart failure; Pfizer: Anticoagulation and amyloidosis; Jannsen: Leukemia. Other relationships Funding of continuing medical education activities, including travel, accommodation and registration in conferences and courses, from the brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - Bayer: Heart failure.
Arnaldo Rabischoffsky	Nothing to be declared
Aurélio Carvalho Pinheiro	Nothing to be declared
Bruna Morhy Borges Leal Assunção	Nothing to be declared
Camila Rocon	Nothing to be declared
Carlos Eduardo Suaide Silva	Nothing to be declared
Carlos Eduardo Rochitte	Nothing to be declared
Cecilia Beatriz Bittencourt Viana Cruz	Nothing to be declared
Cintia Galhardo Tressino	Nothing to be declared
Claudia Gianini Monaco	Nothing to be declared
Claudia R. Pinheiro de Castro Grau	Nothing to be declared
Cláudio Henrique Fischer	Nothing to be declared
Daniel de Andrade Hygidio	Nothing to be declared
Daniela do Carmo Rassi Frota	Nothing to be declared
David Costa de Souza Le Bihan	Financial declaration A - Economically relevant payments of any kind made to (i) you, (ii) your spouse/partner or any other person living with you, (iii) any legal person in which any of these is either a direct or indirect controlling owner, business partner, shareholder or participant; any payments received for lectures, lessons, training instruction, compensation, fees paid for participation in advisory boards, investigative boards or other committees, etc. From the brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - Edwards Lifescience; Abbott; GE Healthcare; Philips.
Eliza de Almeida Gripp	Nothing to be declared
Fábio Luis de Jesus Soares	Nothing to be declared
Fabio Villaça Guimarães Filho	Nothing to be declared
Gabriela Nunes Leal	Nothing to be declared
Henry Abensur	Nothing to be declared
Isabel Cristina Britto Guimarães	Nothing to be declared
Jeane Mike Tsutsui	Other relationships Any economically relevant equity interest in companies in the healthcare or education industry or in any companies competing with or supplying to SBC: - Health area: Grupo Fleury.
Jorge Andion Torreão	Other relationships Any economically relevant equity interest in companies in the healthcare or education industry or in any companies competing with or supplying to SBC: - Partner of an education company in the health sector.
Jorge Eduardo Assef	Nothing to be declared
José Luiz Barros Pena	Nothing to be declared
Jose Maria Del Castillo	Nothing to be declared
Marcelo Dantas Tavares de Melo	Nothing to be declared
Marcelo Goulart Paiva	Nothing to be declared
Marcelo Haertel Miglioranza	Nothing to be declared
Marcelo Luiz Campos Vieira	Nothing to be declared
Márcio Silva Miguel Lima	Nothing to be declared
Marco Stephan Lofrano Alves	Nothing to be declared
Maria Eduarda Menezes de Siqueira	Nothing to be declared
Maria Estefânia Bosco Otto	Nothing to be declared
Maria Rosa Dantas	Nothing to be declared
Maria Veronica Camara dos Santos	Nothing to be declared
Marly Maria Uellendahl Lopes	Nothing to be declared
Rafael Bonafim Piveta	Other relationships Any economically relevant equity interest in companies in the healthcare or education industry or in any companies competing with or supplying to SBC: - Partner at WavesMed (digital platform for continuing education/updates).
Rafael Modesto Fernandes	Nothing to be declared
Renato de Aguiar Hortegal	Nothing to be declared
Roberto Magalhães Saraiva	Nothing to be declared
Rodrigo Bellio de Mattos Barretto	Financial declaration A - Economically relevant payments of any kind made to (i) you, (ii) your spouse/partner or any other person living with you, (iii) any legal person in which any of these is either a direct or indirect controlling owner, business partner, shareholder or participant; any payments received for lectures, lessons, training instruction, compensation, fees paid for participation in advisory boards, investigative boards or other committees, etc. From the brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - GE; Abbot; Edwards.
Rodrigo Julio Cerci	Nothing to be declared
Salustiano Pereira de Araujo	Nothing to be declared
Samira Saady Morhy	Nothing to be declared
Sanderson Antonio Cauduro	Nothing to be declared
Sandra Marques e Silva	Other relationships Funding of continuing medical education activities, including travel, accommodation and registration in conferences and courses, from the brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - Pfizer: Amyloidosis; Sanofi, Pint Pharma, Takeda and Chiesi: Fabry.
Sandra Nívea dos Reis Saraiva Falcão	Nothing to be declared
Silvio Henrique Barberato	Nothing to be declared
Thais Harada Campos Espirito Santo	Nothing to be declared
Tonnison de Oliveira Silva	Nothing to be declared
Vera Maria Cury Salemi	Nothing to be declared
Viviane Tiemi Hotta	Financial declaration B - Research funding under your direct/personal responsibility (directed to the department or institution) from the Brazilian or international pharmaceutical, orthosis, prosthesis, equipment and implants industry: - Pfizer: Amyloidosis.

•Good quality cardiac electrocardiographic monitoring
•Obtain 3-, 4-, and 2-chamber acoustic windows with a frame rate between 40-80 frames per second.
•Mark aortic valve closure.
•Mark topographic definitions to determine the region of interest in the 3-, 4- and 2-chamber windows.
•Accept or discard the myocardial segments tracked in each window and make adjustments if necessary.
•Evaluate the curves and interpret the results of the polar map.
•Properly record the hemodynamic conditions under which GLS was measured.

Relevant Strain Information	Description
Vital signs	Blood pressure and heart rate ¹⁶
Strain type	Longitudinal, circumferential, and radial
Absolute strain value	For describing chamber function
Cardiac chamber	LV, RV, or LA
Polar map pattern (Figure 2.2)	Any typical patterns, such as amyloidosis or hypertrophic cardiomyopathy ⁴⁰
Variation (%) in sequential exams	Proven use in cardio-oncology. ∆%= baseline strain examination (current/baseline)²¹
Equipment and software version	Normal strain values vary according to equipment brand and version³⁷

Chamber/strain type	Normality value (absolute value)	Application in clinical practice
LV Longitudinal (negative) Radial (positive) Circumferential (negative)	18%^35,39 20%³⁵ 40%³⁵ 20%	++++ + +
RV Longitudinal free wall (negative)	20%^35,36	+++
LA (varies with age, positive) Reservoir (most common) Conduit Pump	39%^38,39 23%³⁸ 17%^38,41	+++ + +

Time between chemotherapy drug infusion and echocardiography (pre- or post-)
Heart rate Blood pressure Volume status (description of the diameter and variation of the inferior vena cava)
Comparison with baseline, especially left ventricular ejection fraction and GLS: if there is a relative decrease, report the percentage)
Equipment/software used for GLS analysis

Strain indications in ischemic heart disease
Assessing segmental and global change
Differentiating subendocardial and transmural infarcts (longitudinal, radial, and circumferential change)
Determining the culprit artery according to “bulls eye” mapping
Assessing improvement in global and segmental strain after myocardial revascularization
Improving detection of coronary artery disease
Predicting outcomes and remodeling after acute mysocardial infarction
Predicting outcomes, such as hospitalization for heart failure and all-cause mortality
Identifying patients at risk of arrhythmia

Clinical scenario	Concept
Ischemia detection^189,276-280	•Regional LS detects endocardial ischemia. •CS can help differentiate transmural and non-transmural infarctions. •Increased time to peak LS can help detect ischemia. •Post-systolic shortening (sensitive but not specific for detecting ischemia). •Systolic RLS (lower dependence on load and heart rate than strain). •Diastolic strain parameters.
Feasibility assessment^281-285	•LS and RLS increase the accuracy of viability detection in MI patients treated with TCA and low doses of dobutamine. •LS is the best predictor of functional improvement after CABG. •Lack of response to dobutamine accurately predicts lack of improvement after CABG. •Differentiation between stunned and hibernating myocardium (lower LS and RLS and post-systolic shortening).
Aortic stenosis^286,287	•GLS in the evaluation of low-flow/low-gradient aortic stenosis. •Patients with GLS > 10% after dobutamine use have longer survival. •Stress GLS is more accurate than resting GLS.
Hypertensive cardiomyopathy²⁸⁸	•LS and RS deficits are more evident during stress than rest in the initial phases, allowing prevention measures.
Diabetic cardiomyopathy^289,290	•Lower RLS in middle and basal segments during DSE. •Early decreased myocardial velocities in asymptomatic patients with insulin resistance during DSE.
Cardiomyopathies^132,291-293	•Lower systolic functional reserve detected in LS and RS after stress. •No improvement in diastolic function parameters. •Increased time-to-peak in HCM with important dyssynchrony. •Low RVLS values in arrhythmogenic dysplasia do not significantly improve with stress.
Athlete’s heart^294,295	•Slightly lower LS values with preserved or supranormal myocardial reserve. •Stress GLS helps differentiate athlete’s heart from cardiomyopathy.

Age in years	Peak systolic GLS	Peak strain in apical 4-chamber view	Peak circumferential systolic global strain	Peak circumferential systolic strain at the papillary muscle level	Peak radial global systolic strain	Peak radial systolic strain at the papillary muscle level
0-1	18.7% (20.8, 16.7)	19.4% (22.2, 16.6)	_____	18.2% (22.6, 13.7)	_____	44.4% (36.6, 52.1)
2-9	21.7% (23.0, 20.5)	21.0% (21.8, 20.2)	24.5% (27.2, 21.7)	20.3% (21.4, 19.1)	48.0% (33.3, 62.8)	50.8% (47.4, 54.1)
10-13	20% (20.8, 19.1)	20.5% (21.7, 19.2)	21.9% (26.5, 17.4)	21.5% (23.1, 19.8)	43.7% (33.0, 54.5)	52.1% (48.5, 55.8)
14-21	19.9 (20.6, 19.2)	19.9% (21.2, 18.6)	16.4% (23.3, 9.6)	16.4% (23.3, 9.6)	44.0% (41.6, 46.4)	46.4% (39.7, 53.1)
Overall	20.2% (20.8, 19.6)	20.4% (21.1, 19.8)	22.3% (19.9, 24.6)	20.4% (21.1, 19.8)	45.2% (38.8, 51.7)	49.4% (47.2, 51.6)

	31 days- 24 months	2-5 years	5-11 years	11-18 years
GLS RV %	25.4 (3.9)	25.9 (4.0)	25.8 (4.7)	25.4 (4.1)

Measure	31 days- 24 months	2-5 years	5-11 years	11-18 years
LA strain (R)%	52.8 (10.1)	55.7 (10.7)	58.1 (10)	57.6 (10.5)
LA strain (C)%	14.2 (6.6)	12.7 (6.1)	14.0 (6.7)	15.1 (7.0)
RA strain (R)%	47.1 (9.6)	49.6 (10.2)	51.6 (10.7)	52.0 (10.6)
RA strain (C)%	11.5 (6.0)	11.9 (5.9)	11.8 (6.3)	12.8 (5.8)

	Authors	Parameter	Cut-off	Findings	Sn/Sp
Idiopathic pulmonary hypertension	Muntean et al.³⁰²	mid-segment FW RV strain	18.5%	Predictor of clinical worsening	Sn: 91.7%, Sp: 30.8% AUC=0.88, SD 0.06
Ebstein's anomaly	Kühn et al.³⁰³	RVGLS (6 segments)	20.15%	Diagnosis of RV dysfunction (EF < 50% in MRI)	Sn: 77% Sp: 46%
Systemic RV (PO TGA Senning/Mustard)	Lipczyńska et al.³⁰⁴	RVGLS (6 segments)	14.2%	Diagnosis of RV Dysfunction (EF< 45% in MRI)	Sn: 83%, Sp: 90% AUC= 0.882
Systemic RV (CTGA)	Kowalik et al.³⁰⁵	RVGLS (6 segments)		Diagnosis of RV dysfunction (EF < 45% in MRI)	Sn: 77.3% Sp: 72.7%
PO AOLCA	Castaldi et al.³⁰⁶	LV peak segmental strain	14.8%	Predictor of fibrosis in MRI	Sn: 92.5% Sp: 93.7%
Univentricular physiology (PO Fontan)	Park et al.³⁰⁷	Circumferential strain rate	-1.0s^-1	Predictor of hospital stay >14 days after TCC anastomosis	Sn: 72% Sp: 60%

	Right ventricle	Left ventricle
Structure	Inlet, trabecular region, infundibulum.	No infundibulum and limited trabeculation.
Form	Multiple muscle bands Triangular in the coronal plane Crescent in the transverse plane	Elliptical
Predominant myocardial fiber orientation	Subepicardium: circumferential Subendocardium: longitudinal	Subepicardium: oblique Mesocardium: circumferential Subendocardium: longitudinal
Arrangement of fibers in the free wall	Transverse predominance	Olique predominance
Arrangement of fibers in the IVS	Obliquely, extending to the outflow tract	Obliquely
Contribution of IVS thickening in the transverse axis and shortening in the longitudinal axis in systole	+++	+++
Contraction pattern	Mainly longitudinal from base to apex	Subepicardium and Subendocardium: longitudinal shortening in opposite directions. Mesocardium: circumferential direction
Mass (g/m²)	26 (SD, 5)	87 (SD,12)
Wall thickness (mm)	2-5	7-11

•Pulmonary hypertension (including patients with acute or chronic pulmonary embolism)
•Heart failure with reduced or preserved ejection fraction
•Acute myocardial infarction
•Cardiomyopathies (ADRV, HCM, DCM)
•Valvular heart disease (mitral stenosis, functional tricuspid regurgitation)
•Candidates for ventricular assist device implantation
•Heart transplant

Parameter	Definition
Apical rotation (º)	Peak counterclockwise systolic rotation of the apical LV region (measured in degrees)
Apical rotation rate (º/s)	Peak counterclockwise apical rotation speed (measured in degrees/second)
Basal rotation (º)	Peak clockwise systolic rotation of the basal region of the LV (measured in degrees)
Basal rotation rate (º/s)	Peak basal clockwise rotation velocity (measured in degrees/second)
LV twist (º)	Peak difference of LV apex and base systolic rotation (measured in degrees)
LV torsion (º/cm)	Normalized twist: ratio of the twist angle and the distance between the base and apex in systole (measured in degrees/centimeter)
Twist rate (º/s)	Peak LV twist speed (measured in degrees/second)

Parameter	Definition
Apical reverse rotation (º)	Peak clockwise diastolic rotation of the apical LV region (measured in degrees)
Apical reverse rotation rate (º/s)	Peak velocity of clockwise apical reverse rotation (measured in degrees/second)
Basal reverse rotation (º)	Peak diastolic counterclockwise rotation of the basal region of the LV (measured in degrees)
Basal reverse rotation rate (º/s)	Peak basal rotation speed (measured in degrees/second)
Untwist (º)	Difference in peak reverse diastolic rotation of the apex and base of the LV (measured in degrees)
Untwist Rate (º/s)	Peak LV untwist speed (measured in degrees/second)

Cardiovascular disease	LV twist	Findings
Ischemic cardiomyopathy	Decreased	Twist decreases depending on the location and extent of ischemia.
Dilated cardiomyopathy	Decreased	Twist decreases proportionally to decreased ejection fraction
Hypertrophic cardiomyopathy	Increased	Twist increases especially if the LV outflow tract is obstructed
Aortic stenosis	Increased	Increased twist in cases of increased LV afterload.

	Strain	Myocardial work
AFI use	yes	yes
Measure	AVO-AVC	IVCT + ET + IVRT
Integrated with blood pressure	no	yes
Value	%	mmHg%
Incorporates postload	no	yes
Measures efficiency	no	yes
Estimates myocardial oxygen consumption	no	yes

Type	HFpEF	HCM	Normal
Reservoir	16.3 ± 5.8	22.1 ± 5.5	29.1 ± 5.3
Conduit	11.9 ± 4.0	10.4 ± 3.9	21.3 ± 5.1
Pump	4.5 ± 2.9	11.7 ± 4.0	7.8 ± 2.5

[1] Correspondence: Sociedade Brasileira de Cardiologia – Av. Marechal Câmara, 360/330 – Centro – Rio de Janeiro, Brazil – Posta Code 20020-907. E-mail: diretrizes@cardiol.br