Clinical Investigations
Normal Values and Indexing
Age-, Sex-, and Race-Based Normal Values for Left Ventricular Circumferential Strain from the World Alliance Societies of Echocardiography Study

https://doi.org/10.1016/j.echo.2022.12.018Get rights and content

Highlights

  • •

    A total of 1,572 healthy adult subjects were studied.

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    Normal values of 2D regional circumferential strain and GCS were established.

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    Age, sex, and race affect circumferential strain measurements.

Background

Left ventricular (LV) circumferential strain has received less attention than longitudinal deformation, which has recently become part of routine clinical practice. Among other reasons, this is because of the lack of established normal values. Accordingly, the aim of this study was to establish normative values for LV circumferential strain and determine sex-, age-, and race-related differences in a large cohort of healthy adults.

Methods

Complete two-dimensional transthoracic echocardiograms were obtained in 1,572 healthy subjects (51% men), enrolled in the World Alliance Societies of Echocardiography Normal Values Study. Subjects were divided into three age groups (<35, 35-55, and >55 years) and stratified by sex and by race. Vendor-independent semiautomated speckle-tracking software was used to determine LV regional circumferential strain and global circumferential strain (GCS) values. Limits of normal for each measurement were defined as 95% of the corresponding sex and age group falling between the 2.5th and 97.5th percentiles. Intergroup differences were analyzed using unpaired t tests.

Results

Circumferential strain showed a gradient, with lower magnitude at the mitral valve level, increasing progressively toward the apex. Compared with men, women had statistically higher magnitudes of regional and global strain. Older age was associated with a stepwise increase in GCS despite an unaffected ejection fraction, a decrease in LV volume, and relatively stable global longitudinal strain in men, with a small gradual decrease in women. Asian subjects demonstrated significantly higher GCS magnitudes than whites of both sexes and blacks among women only. In contrast, no significant differences in GCS were found between white and black subjects of either sex. Importantly, despite statistical significance of these differences across sex, age, and race, circumferential strain values were similar in all groups, with variations of the order of magnitude of 1% to 2%. Notably, no differences in GCS were found among brands of imaging equipment.

Conclusion

This study established normal values of LV regional circumferential strain and GCS and identified sex-, age-, and race-related differences when present.

Section snippets

Study Design and Population

The World Alliance Societies of Echocardiography (WASE) Normal Values Study is a multicenter, international, observational, prospective, cross-sectional study of normal values of echocardiographic parameters.21 Briefly, the study involved healthy adult individuals from 19 centers in 15 countries on six continents. Each institution enrolled 100 volunteers. Individuals were screened from September 2016 to January 2019. Subjects >18 years of age and without histories or clinical evidence of heart,

Results

Baseline clinical and demographic characteristics of the study population are summarized in Table 1. As expected, significantly higher body mass index, weight, and blood pressure were observed in men, while women had higher heart rates. Of note, 28 subjects (<1.8% of the study population) had systolic blood pressure > 140 mm Hg at the time of imaging.

Discussion

In this WASE Normal Values Study, we report age-, sex-, and race-related normative values and normality thresholds for regional circumferential strain and GCS in a large group of healthy adults. To our knowledge, this is the first study to include a multiethnic cohort and one of the largest to report normal regional circumferential strain and GCS values obtained using vendor-independent analysis software. The key findings of this study are as follows: (1) normal circumferential strain gradually

Conclusion

In this study, we established normal values of LV circumferential strain at both regional and global levels and identified sex-, age-, and race-related differences when present. Because of the large size and the multiracial nature of the WASE cohort, and the standardized methodology, these normal values are likely to be more representative than those previously reported from smaller, ethnically homogeneous cohorts. These data may facilitate eventual integration of rotational deformation

Additional WASE Investigators

Aldo D. Prado, Centro Privado de Cardiologia, Tucumán, Argentina; Eduardo Filipini, Universidad Nacional de la Plata, Buenos Aires, Argentina; Agatha Kwon and Samantha Hoschke-Edwards, Heart Care Partners, Queensland, Australia; Tania Regina Afonso, Albert Einstein Hospital, Sao Paulo, Brazil; Babitha Thampinathan and Maala Sooriyakanthan, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Mei Zhang, Yingbin Wang, and Yu Zhang, Qilu Hospital of Shandong University,

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    Dr. Singulane has received a grant from the Brazilian Society of Cardiology, Department of Cardiovascular Imaging. Mr. Schreckenberg, Mr. Blankenhagen and Mr. Hitschrich are employees of TomTec Imaging Systems.

    Gerard P. Aurigemma, MD, FASE, served as guest editor for this report.

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    2022 by the American Society of Echocardiography.