Heart Failure May Be Predicated by Subtle Impairment, Researchers Say

March 19, 2021
Maggie L. Shaw

Reduced left ventricular ejection fraction, longitudinal strain, and circumferential strain have possibly been linked to development of heart failure among elderly individuals.

As part of the ongoing community-based Atherosclerosis Risk in Communities study, a subgroup of patients without heart failure (HF) underwent 2-dimensional and strain echocardiography to measure their left ventricular ejection fraction (LVEF), longitudinal strain (LS), and circumferential strain (CS) during their fifth study visit.

Investigators found that impairments in these 3 measures of systolic function, as taken at this visit, could be at-risk indicators for developing incident adjudicated HF and HF with reduced ejection fraction (HFrEF).

“Limited data exist regarding the association of subtle subclinical systolic dysfunction and incident HF in late life,” the authors said. “We wanted to assess the independent associations of subclinical impairments in systolic performance with incident HF in late life.”

Their study appeared in a recent issue of JAMA Cardiology.

For visits taking place between January 1, 2011, to December 31, 2013, data on 4960 study participants were analyzed from June 1, 2018, to February 28, 2020. The median (interquartile range [IQR]) follow-up was 5.5 (IQR, 5.0-5.8) years; the mean (SD) patient age, 75.5 (5) years; and most were female (59.0%) or Black (19.0%). A cohort of 374 low-risk patients (no cardiovascular disease or risk factors) was used as the reference group.

Of the 71.6% of the study cohort who had all 3 measures—LVEF, LS, CS—few had an LVEF below 50% (1.5%). However, close to 30% had 1 or more measures of systolic impairment comprising LVEF below 60%, LS below 16.0%, and CS below 23.7%, and each was shown to be an independent risk factor for HF.

The mean (SD) LVEF, LS, and CS were 65.7%, 18.1%, and 28.0%, respectively, and lower values were more common among men and Black study participants vs women and White participants. As especially strong association was seen per SD worsening in LVEF among men than women: men had an HR per SD of 1.51 (95% CI, 1.34-1.70) vs 1.25 (95% CI, 1.07-1.45; P = .01) in women

Overall, there was a 41% greater chance of incident HF for every SD decrease in LVEF (HR, 1.41; 95% CI, 1.29-1.55), while there was a 159% greater chance for having an LVEF below 60% (HR, 2.59; 95% CI, 1.99-3.37).

Both continuous and dichotomized LS and CS were linked to incident HF among elderly patients:

  • Continuous LS was associated with a 37% greater chance of HF (95% CI, 1.22-1.53)
  • Dichotomized LS was associated with a 93% greater chance of HF (95% CI, 1.46-2.55)
  • Continuous CS was associated with a 39% greater chance of HF (95% CI, 1.22-1.57)
  • Dichotomized CS was associated with a 130% greater chance of HF (95% CI, 1.64-3.22)

When risk comparisons were done based on guideline-based limits vs ARIC limits, the risk for incident HF or death as gauged by LVEF impairment was greater with the former, although fewer patients were classified as impaired:

  • Risk of HF or death: HR of 2.99 (95% CI, 2.19-4.09) vs HR of 1.88 (95% CI, 1.58-2.25), respectively
  • Impaired patients: 2.1% vs 13.9%, respectively

In addition, the authors noted, “the population-attributable risk associated with LVEF less than 60% was 11% compared with 5% using guideline-based limits.”

“These findings suggest that among elderly people living in the community, worse LVEF, LS, and CS are independently associated with incident HF and with incident HFrEF in particular, the authors concluded. “Relatively subtle impairments of systolic function, detected based on LVEF or strain, appear to be associated with development of HF in late life and are likely substantially undetected by current routine assessments of LV function.”

Their findings hold value, they note, because although the associated impairments seen with LVEF, LS, and CS are independent of one another, their cumulative risk points to the prognostic value of subtle impairments in systolic function at predicting HF risk.


Jensen AMR, Zierath R, Claggett B, et al. Association of left ventricular systolic function with incident heart failure in late life. JAMA Cardiol. Published online March 17, 2021. doi:10.1001/jamacardio.2021.0131