Strain Echocardiography GLS: Clinical Applications According to ASE/EACVI 2025
What the ASE/EACVI 2025 Consensus Changed
The ASE/EACVI 2025 document Clinical Applications of Strain Echocardiography is the first major joint clinical consensus on strain echocardiography since the 2011 document. Its key shift: strain is considered not as an additional research option but as a quantitative tool for clinical decisions in heart failure, cardio-oncology, ischemia, valvular defects, right ventricular pathology, left atrium, stress echocardiography, and congenital heart defects.
The main practical metric is the global longitudinal strain of the left ventricle, LV GLS. It reflects the longitudinal shortening of the myocardium, so it has a negative value in standard recordings. The less negative the GLS, the worse the longitudinal systolic deformation.
Norms and Thresholds for LV GLS
The consensus emphasizes: GLS depends on age, gender, hemodynamic load, image quality, frame rate, manufacturer algorithm, and software. Therefore, the result cannot be interpreted in isolation from the clinical context and methodology.
| Indicator | Practical Interpretation | Comment |
|---|---|---|
| LV GLS around −20% | Typical normal level | Guideline for well-recorded 2D speckle tracking |
| LV GLS ≤−18% | Usually normal | Consider gender, age, BP, HR, volume load |
| LV GLS from −16% to −18% | Borderline zone | Clinical correlation and comparison with previous studies needed |
| LV GLS less negative than −16% | Pathological | For example −15%, −14% and higher on the numerical scale |
| Relative worsening of GLS >15% from baseline | Significant dynamic decline | Especially important in serial monitoring and cardio-oncology |
In the conclusion, it is advisable to write both the actual negative value and the clinical interpretation. For dynamics, it is preferable to use the same ultrasound system, the same analysis package, and comparable load conditions.
When to Prescribe Strain Echocardiography
GLS is advisable when the LV ejection fraction is insufficiently sensitive or remains formally preserved, but there is a risk of early myocardial dysfunction. The most common indications: assessment of heart failure with preserved or moderately reduced EF, monitoring cardiotoxicity, clarifying risk in valvular defects, assessing ischemia and viability, quantitative characterization of cardiomyopathies.
- baseline echocardiography before potentially cardiotoxic therapy;
- serial monitoring with anthracyclines, HER2-targeted therapy, and other cardiotoxic regimens;
- dyspnea or signs of HF with preserved LV EF;
- aortic stenosis, mitral regurgitation, and other defects with borderline indications for intervention;
- suspicion of ischemic dysfunction with normal or near-normal EF;
- cardiomyopathies, including hypertrophic, dilated, infiltrative;
- assessment of the right ventricle and left atrium as part of an extended protocol.
Cardio-Oncology
In cardio-oncology, GLS is used for early detection of subclinical dysfunction before a drop in LV EF. The ASE/EACVI 2025 consensus supports a serial approach: baseline value before therapy, then comparable repeated measurements using the same method. A relative decrease in GLS >15% from baseline is considered a significant signal of worsening longitudinal function.
It is important not to replace clinical decision-making with a single number. Interpretation requires consideration of LV EF, symptoms, troponin, and natriuretic peptides, blood pressure, heart rate, and tracking quality. If GLS worsening is detected with poor imaging or another analysis program, the result should be confirmed.
Heart Failure and Cardiomyopathies
In heart failure, GLS helps identify hidden systolic function decline with preserved LV EF. This is especially useful in hypertrophy, diabetes, hypertension, obesity, chronic kidney disease, and infiltrative diseases. For cardiomyopathies, GLS adds quantitative information to EF, volumes, LV mass, diastolic function, and MRI data if performed.
In infiltrative processes and pronounced hypertrophy, not only the global indicator but also the regional deformation pattern is important. However, the consensus warns against automatic diagnosis based on the bull’s eye map without clinical verification.
Ischemic Disease and Stress Echocardiography
Strain can be used for quantitative assessment of regional and global function in suspected ischemia, post-myocardial infarction, and stress echocardiography protocols. The method's advantage is the objectification of segmental shortening changes, especially when visual wall motion assessment is difficult.
A fundamental limitation remains: strain should not replace expert visual assessment and clinical probability of CAD. In stress echocardiography, the result depends on image quality at peak load, frame rate, and correct endocardial tracking.
Valvular Defects
In valvular defects, GLS is useful as an early marker of myocardial decompensation when EF is still preserved. This is relevant in aortic stenosis, mitral regurgitation, and other chronic pressure or volume overloads. Less negative GLS with preserved EF may indicate reduced longitudinal reserve and a higher risk of adverse outcomes.
The decision for intervention should not be based solely on GLS. The indicator is considered along with symptoms, defect severity, chamber sizes, pulmonary artery pressure, LV EF, and other criteria of current valvular recommendations.
Right Ventricle and Left Atrium
The 2025 consensus separately considers strain of the right ventricle and left atrium. For the RV, the method is particularly attractive because the ventricle's geometry complicates assessment by a single ejection fraction. Free wall RV strain and global RV indicators are used in pulmonary hypertension, congenital defects, left heart diseases, and post-cardiac surgery.
Left atrial strain reflects reservoir, conduit, and pump function. It can complement the assessment of diastolic function, atrial fibrillation risk, and valvular defect consequences. However, for LA and RV, standardization is still less universal than for LV GLS, so local references and serial comparison are especially important.
How to Perform and Describe the Study
For LV GLS, standard apical views with good endocardial visualization, without foreshortening of the apex, are used. The analysis should include checking each segment: an automatic contour is not considered sufficient if tracking is visually incorrect. In atrial fibrillation, pronounced extrasystole, tachycardia, and poor acoustic window, reproducibility decreases.
The protocol should indicate: the speckle tracking method used, GLS value, analysis quality, presence of excluded segments, program or platform if necessary, and comparison with previous studies. For dynamics, it is preferable to output in percentage of relative change rather than just the absolute difference in GLS points.
Typical Interpretation Errors
- Comparing results obtained on different platforms without considering inter-manufacturer variability.
- Assessing GLS in a foreshortened apical view, which distorts longitudinal deformation.
- Ignoring blood pressure and load: afterload can worsen GLS without primary myocardial damage.
- Concluding cardiotoxicity based on one poor study without confirmation.
- Using only the absolute threshold instead of comparison with the baseline value.
Practical Algorithm
- Determine the clinical task: risk of cardiotoxicity, HF, valvular defect, ischemia, cardiomyopathy.
- Obtain quality apical images without foreshortening.
- Calculate LV GLS and check segment tracking.
- Compare the result with the normal guideline: ≤−18% is usually normal, −16…−18% is borderline, less negative than −16% is pathological.
- In repeat studies, assess relative change; worsening >15% is considered clinically significant.
- Formulate a conclusion in the context of LV EF, symptoms, biomarkers, and primary pathology.
Frequently asked questions
What is considered a normal LV GLS?
The practical guideline of the ASE/EACVI 2025 consensus: around −20% is typical for normal; ≤−18% is usually normal, from −16% to −18% is borderline, less negative than −16% is pathological. Load, image quality, and analysis program are always considered.
When is GLS mandatory in an echocardiography protocol?
It is most justified to include GLS in cardio-oncological monitoring, heart failure with preserved EF, cardiomyopathies, valvular defects with risk of hidden dysfunction, ischemia and stress echocardiography, as well as in extended RV and LA assessment.
What is more important: absolute GLS or dynamics?
For initial assessment, absolute GLS is important, but in follow-up, dynamics become decisive. A relative worsening of GLS >15% from the baseline value is considered significant, especially in cardiotoxicity monitoring.