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Original research
Prognostic significance of longitudinal strain in dilated cardiomyopathy with recovered ejection fraction
  1. Marco Merlo1,
  2. Marco Masè1,
  3. Andrew Perry2,
  4. Eluisa La Franca3,
  5. Elena Deych2,
  6. Laura Ajello3,
  7. Diego Bellavia3,
  8. Andrea Boscutti1,
  9. Marco Gobbo1,
  10. Giuseppe Romano3,
  11. Davide Stolfo1,
  12. John Gorcsan2,
  13. Francesco Clemenza3,
  14. Gianfranco Sinagra1,
  15. Luigi Adamo4
  1. 1 Cardiology Unit, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
  2. 2 Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
  3. 3 Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
  4. 4 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr Luigi Adamo, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; ladamo2{at}


Objective Patients with non-ischaemic dilated cardiomyopathy (NICM) may experience a normalisation in left ventricular ejection fraction (LVEF). Although this correlates with improved prognosis, it does not correspond to a normalisation in the risk of death during follow-up. Currently, there are no tools to risk stratify this population. We tested the hypothesis that absolute global longitudinal strain (aGLS) is associated with mortality in patients with NICM and recovered ejection fraction (LVEF).

Methods We designed a retrospective, international, longitudinal cohort study enrolling patients with NICM with LVEF <40% improved to the normal range (>50%). We studied the relationship between aGLS measured at the time of the first recording of a normalised LVEF and all-cause mortality during follow-up. We considered aGLS >18% as normal and aGLS ≥16% as of potential prognostic value.

Results 206 patients met inclusion criteria. Median age was 53.5 years (IQR 44.3–62.8) and 56.6% were males. LVEF at diagnosis was 32.0% (IQR 24.0–38.8). LVEF at the time of recovery was 55.0% (IQR 51.7–60.0). aGLS at the time of LVEF recovery was 13.6%±3.9%. 166 (80%) and 141 (68%) patients had aGLS ≤18% and <16%, respectively. During a follow-up of 5.5±2.8 years, 35 patients (17%) died. aGLS at the time of first recording of a recovered LVEF correlated with mortality during follow-up (HR 0.90, 95% CI 0.91 to 0.99, p=0.048 in adjusted Cox model). No deaths were observed in patients with normal aGLS (>18%). In unadjusted Kaplan-Meier survival analysis, aGLS <16% was associated with higher mortality during follow-up (31 deaths (22%) in patients with GLS <16% vs 4 deaths (6.2%) in patients with GLS ≥16%, HR 3.2, 95% CI 1.1 to 9, p=0.03).

Conclusions In patients with NICM and normalised LVEF, an impaired aGLS at the time of LVEF recovery is frequent and associated with worse outcomes.

  • echocardiography
  • cardiomyopathy
  • dilated
  • heart failure
  • systolic

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors MM, LA: conceived the study, designed the study, analysed data, drafted the manuscript. ELF, DS: designed the study and revised the manuscript. MM, AP: collected data, analysed data, drafted the manuscript. AB, LA, DB, MG, GR: collected data, analysed data. ED: performed the statistical analysis of the data. JG, FC, GS: designed the study and revised the manuscript.

  • Funding LA was supported by NIH grant 1K08HL145108-01A1. No other funding supported the authors.

  • Competing interests None declared.

  • Patient and public involvement statement It was not possible to involve patients or the public in the design, conduct, reporting, or dissemination plans of our research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.