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Background: Left ventricular global longitudinal strain (GLS) measured by speckle-tracking echocardiography (STE) has become a key marker of myocardial systolic function, yet normal reference values remain heterogeneous, and the magnitude of physiological sex differences is not fully defined. We performed a systematic review and meta-analysis to establish pooled GLS reference estimates in healthy individuals, quantify sex-related differences, and contextualize deformation findings relative to conventional systolic function. Methods: A systematic search of PubMed, Scopus, and EMBASE identified observational studies reporting GLS in healthy adults assessed by two-dimensional or three-dimensional STE. Random-effects meta-analysis using standardized mean differences (SMD) compared GLS between women and men. Descriptive pooled reference values were derived using weighted median and interquartile range (IQR) reconstruction from study-level distributions. Meta-regression analyses explored demographic, clinical, and methodological sources of heterogeneity. A complementary analysis evaluated sex-related differences in left ventricular ejection fraction (LVEF) within the same populations. Results: Thirty-two studies, including 19,157 healthy individuals, were analyzed. The pooled population had a weighted median age of 47.5 years and 53% female participants. Overall, GLS demonstrated a weighted median of 20.3% (IQR 17.8–22.5). Women showed higher GLS values than men (20.8% [18.4–23.1] vs. 19.4% [17.0–21.6]). Meta-analysis of 28 studies confirmed significantly greater GLS in females (SMD 0.487, 95% CI 0.409–0.565; p < 0.001), with consistent findings across imaging modalities and no subgroup interaction. Between-study heterogeneity was substantial (I2 = 82.7%), although effect direction was uniform. Meta-regression analyses identified no significant moderators, and sensitivity analyses confirmed stable estimates without publication bias. Segmental analysis demonstrated a physiological base-to-apex strain gradient. In contrast, LVEF was largely comparable between sexes, with no clinically meaningful difference (SMD 0.257, 95% CI 0.186–0.327; p < 0.001), indicating preserved global systolic performance despite differences in myocardial deformation. Conclusions: GLS demonstrates a consistent physiological range in healthy populations, with women exhibiting higher longitudinal deformation than men, independent of the imaging modality. These findings support the adoption of sex-specific GLS reference values and highlight the complementary roles of deformation and volumetric indices in improving the interpretation of myocardial function and reducing misclassification in clinical practice.

Background: Epicardial adipose tissue (EAT) is a metabolically active visceral fat depot increasingly associated with the development and progression of coronary artery disease (CAD). Transthoracic echocardiography is the most widely used modality for EAT assessment; however, substantial heterogeneity exists regarding the timing of measurement within the cardiac cycle, with EAT thickness variably assessed during systole or diastole. Whether these measurements provide equivalent information for identifying obstructive CAD remains unclear. This systematic review and meta-analysis evaluated the association between echocardiographically measured EAT thickness and angiographically confirmed obstructive CAD, with specific focus on systolic versus diastolic assessments. Methods: PubMed, Scopus, and EMBASE were systematically searched through December 2025 for observational studies comparing EAT thickness in patients with and without obstructive CAD confirmed by invasive coronary angiography. Random-effects models were used to pool standardized mean differences (SMDs) for systolic and diastolic EAT thickness. Heterogeneity was assessed using the I2 statistic, publication bias by funnel plots and Egger’s regression test, and robustness by meta-regression and leave-one-out sensitivity analyses. Results: Twenty-two studies including more than 6500 patients were analyzed. Both systolic and diastolic EAT thickness were significantly greater in patients with obstructive CAD than in non-CAD controls. Systolic EAT showed a large, pooled effect size (SMD 1.27; 95% CI 0.96–1.59; p < 0.001), while diastolic EAT demonstrated a similarly strong association (SMD 1.59; 95% CI 1.10–2.07; p < 0.001). Heterogeneity was substantial (I2 > 90%), but the direction of effect was consistent across all studies. Meta-regression analyses indicated that demographic, clinical, metabolic, geographic, and methodological characteristics, including ultrasound software/vendor category and timing of EAT measurement, did not significantly moderate the association between EAT thickness and obstructive CAD. No significant publication bias was detected, and sensitivity analyses confirmed the robustness of the results. Conclusions: Echocardiographically measured EAT thickness is strongly and consistently associated with obstructive CAD, irrespective of whether measurements are obtained during systole or diastole. Although both approaches show robust discriminatory capacity at the population level, differences in effect magnitude suggest that they may not be fully interchangeable. Moreover, in the absence of standardized and broadly applicable cut-off values, the interpretation and clinical management of EAT measurements as individual risk predictors require further investigation.

Takotsubo syndrome (TTS) often mimics anterior ST-elevation myocardial infarction (STEMI) caused by left anterior descending (LAD) occlusion, yet the two entities differ fundamentally in pathophysiology and mechanical behavior. Two-dimensional speckle-tracking echocardiography (2D-STE) enables detailed assessment of left ventricular (LV) deformation beyond conventional ejection fraction (LVEF). This meta-analysis compared global and regional LV strain patterns in TTS versus LAD-related anterior STEMI during the acute phase. A systematic search of PubMed, Embase, and Scopus through October 2025 identified observational case-control studies directly comparing TTS and angiographically confirmed anterior STEMI, with LV mechanics assessed by 2D-STE. Random-effects models were used to pool standardized mean differences (SMDs) for LVEF; global longitudinal strain (GLS); apical, mid-ventricular, and basal longitudinal strain (ALS, MLS, BLS); and global radial strain (GRS). Heterogeneity (I ), publication bias (funnel plots, Egger's test), meta-regression, and leave-one-out sensitivity analyses were performed. Six studies comprising 221 TTS and 290 anterior STEMI patients met the inclusion criteria. TTS patients were older, predominantly female, and had fewer metabolic risk factors, while LV size was comparable. LVEF was significantly lower in TTS (SMD -1.149; 95% CI -2.20 to -0.10; = 0.032), with stable findings across sensitivity analyses and no evidence of publication bias. GLS, ALS, MLS, and BLS showed only a non-significant trend toward greater impairment in TTS, and these comparisons were limited by marked inter-study heterogeneity. In contrast, GRS was significantly and consistently more reduced in TTS (SMD -1.284; 95% CI -1.59 to -0.98; < 0.001), indicating more profound global radial dysfunction. Meta-regression showed no significant influence of demographic factors or vendor-specific software on LVEF or GLS differences. Compared with LAD-related anterior STEMI, TTS is associated with more severely depressed LVEF and markedly impaired radial strain, while longitudinal strain differences remain inconclusive and suggest only a potential trend toward greater dysfunction, reflecting the limited and heterogeneous evidence. These findings are consistent with diffuse, stress-induced myocardial stunning in TTS and suggest that 2D-STE may aid differentiation between stress cardiomyopathy and ischemic infarction in the acute setting, although longitudinal strain parameters should be interpreted cautiously and regarded as hypothesis-generating.

Primary mitral regurgitation (PMR) is the most common mitral valve disorder in clinical practice. Although several prognostic indicators derived from resting transthoracic echocardiography (TTE) and exercise stress echocardiography (ESE) are available, patient outcomes remain highly variable, with substantial differences in complication rates and mortality. Identifying individuals at lower cardiovascular risk is therefore clinically relevant, as they represent a large proportion of cases. Current guidelines recommend an integrative approach—combining qualitative, semi-quantitative, and quantitative indices—to determine the timing of intervention, but they do not specifically address risk stratification in low-risk PMR populations. Recent studies have highlighted the potential prognostic value of chest wall configuration, assessed noninvasively using the Modified Haller Index (MHI). Defined as the ratio of latero-lateral thoracic diameter to the antero-posterior (A-P) sternum–spine distance, MHI appears to influence myocardial deformation indices obtained by speckle-tracking echocardiography (STE). Patients with PMR due to mitral valve prolapse (MVP) often show a reduced A-P thoracic diameter caused by sternal depression. Among these, those with an MHI > 2.5 or A-P diameter ≤ 13.5 cm display greater impairment in global and basal strain, particularly in longitudinal and circumferential directions. These abnormalities likely reflect extrinsic geometric constraints and cardiac displacement leading to apparent dyssynchrony rather than intrinsic myocardial dysfunction. A reduced A-P diameter was also independently associated with mitral annular disjunction (MAD) in MVP and emerged as a determinant of impaired strain in this subgroup. In a retrospective cohort of 424 symptomatic MVP patients with moderate MR undergoing ESE, positive tests and exercise-induced severe MR were uncommon. Importantly, an MHI > 2.5 or an A-P diameter ≤ 13.5 cm was associated with a favorable medium-term prognosis, with few adverse cardiovascular events. This narrative, non-systematic review, based on a structured but non-PRISMA literature search, summarizes current evidence on conventional and novel echocardiographic prognostic markers and their implications for risk stratification in PMR. As such, it carries inherent limitations, including potential selection bias, incomplete retrieval of unpublished or negative studies, and reliance on single-center observational data. The findings should therefore be interpreted cautiously and validated through larger, independent, multicenter investigations.

Background: Left ventricular (LV) mechanics assessed by speckle-tracking echocardiography provides sensitive markers of cardiac adaptation to exercise. Different training modalities—endurance, high-intensity interval training (HIIT), and acute exercise tests—impose distinct hemodynamic loads, yet their comparative effects on LV deformation remain unclear. Importantly, acute and chronic endurance exposures may elicit divergent myocardial responses that must be interpreted separately. Methods: A systematic search of PubMed, Scopus, and EMBASE (through September 2025) identified studies evaluating LV mechanics in response to endurance, HIIT, or acute exercise among healthy or recreationally active individuals. Echocardiographic parameters of strain and torsion were extracted, and methodological quality was appraised using the NIH Quality Assessment Tool. Results: Twenty-three studies (859 participants) met inclusion criteria. Acute prolonged endurance exercise—particularly marathon and ultra-endurance events—was associated with transient, fully reversible reductions in global longitudinal, circumferential, and radial strain and torsion, despite preserved ejection fraction, reflecting short-term myocardial fatigue rather than maladaptive remodeling. In contrast, chronic endurance training maintained or improved LV mechanics without evidence of dysfunction, while HIIT interventions consistently enhanced LV systolic strain and rotational indices across diverse age groups and sexes, reflecting improved contractile efficiency and physiological remodeling. Acute exercise produced heterogeneous, load-dependent strain responses, with isometric stress increasing regional strain and maximal exertion inducing temporary global reductions. Between-study heterogeneity was moderate, methodological quality generally good, and small-study effects varied by modality, being most evident in endurance studies, borderline for HIIT, and limited for acute tests due to sample size. Conclusions: Acute endurance exercise produces transient, reversible LV deformation changes, whereas chronic endurance training preserves mechanical efficiency. HIIT reliably enhances systolic strain and torsional mechanics, and acute exercise elicits variable but physiologically meaningful responses. These findings clarify that transient post-race strain reductions reflect physiological fatigue, not chronic maladaptation, and underscore the modality-specific nature of myocardial adaptation to exercise.

Background: Mitral valve prolapse (MVP) is the most common valvular abnormality in the general population and has been linked to mitral regurgitation, arrhythmias, and sudden cardiac death. Its prevalence and prognostic significance in athletes remain uncertain, raising important questions for pre-participation screening, eligibility for competition, and long-term follow-up. Methods: We systematically searched PubMed, Scopus, and EMBASE databases from inception through August 2025 for original studies reporting MVP prevalence in athletes, diagnosed by echocardiography or pathological assessment. Data on study characteristics, diagnostic definitions, prevalence, arrhythmias, and outcomes were independently extracted by three reviewers. Methodological quality was appraised using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: Twelve studies published between 1987 and 2024 met inclusion criteria, enrolling 19,463 athletes from diverse sports and competitive levels. A total of 407 MVP cases were identified, corresponding to a crude pooled prevalence of 2.4%. Prevalence estimates varied substantially (0.2–20%), reflecting heterogeneity in study populations and diagnostic definitions. When all studies were pooled using a random-effects model, the overall prevalence was 2.0% (95% CI 1.2–2.8%). A sensitivity analysis restricted to contemporary, unselected athletic cohorts yielded a prevalence of 1.1% (95% CI 0.4–1.9%), closely aligning with population-based estimates. Ventricular arrhythmias were more frequent than supraventricular arrhythmias, particularly in association with bileaflet prolapse, leaflet thickening, or significant mitral regurgitation. Most athletes were asymptomatic, and only one prospective study provided long-term follow-up, confirming a generally benign prognosis, though rare adverse events (atrial fibrillation, valve surgery) were documented. Conclusions: MVP is relatively uncommon in athletes and occurs at rates similar to the general population. In most cases, prognosis is favorable and should not preclude sports participation. Nonetheless, recognition of high-risk phenotypes with arrhythmogenic potential highlights the need for individualized evaluation and tailored surveillance strategies in sports cardiology practice.

: Pregnancy induces substantial cardiovascular remodeling, yet whether maternal cardiac adaptation differs across ethnic groups remains unclear. Body size, ventricular geometry, and thoracoabdominal configuration may modulate key functional indices such as left ventricular ejection fraction (LVEF) and global longitudinal strain (LV-GLS). This systematic review compared echocardiographic characteristics between Asian and Western healthy pregnant women in late gestation and explored physiological mechanisms underlying observed differences. : A comprehensive search of PubMed, Scopus, and EMBASE identified studies reporting transthoracic echocardiography in healthy singleton third-trimester pregnancies across Asian and Western populations. Extracted variables included anthropometry, ventricular dimensions and volumes, LVEF, and LV-GLS. Pooled estimates were calculated using inverse-variance weighting, with heterogeneity quantified using the I statistic. Study quality was assessed with the NIH Case-Control Quality Assessment Tool. Comparative forest plots visualized population differences. Twenty studies involving 1431 participants (578 Asian and 853 Western women) met inclusion criteria. Asian women consistently exhibited smaller ventricular chambers, higher LVEF, and more favorable LV-GLS. Importantly, these differences persisted after indexing LV-GLS to BSA, indicating that body-size normalization attenuates-but does not eliminate-population differences in myocardial deformation. Western women demonstrated slightly attenuated GLS despite preserved LVEF, plausibly attributable to larger cardiac size, higher wall stress, greater diaphragmatic elevation, and increased extrinsic thoracic compression. Between-study heterogeneity was substantial (I > 95%) due to variation in imaging platforms, strain software, and population characteristics. Methodological quality was fair, with frequent lack of sample-size justification and incomplete confounder adjustment. : Healthy Asian pregnant women display a hyperdynamic systolic phenotype, whereas Western women show a physiologically appropriate, load-related attenuation of LV-GLS with preserved LVEF. These findings highlight the need for ethnicity-associated and anatomy-aware echocardiographic reference values and support incorporating thoracic geometric indices, such as the modified Haller Index, into strain interpretation during pregnancy.

Background: Since the 1990s, numerous investigations have assessed the diagnostic effectiveness—specifically sensitivity, specificity, and accuracy—of exercise stress testing (EST), stress echocardiography (SE), stress myocardial single-photon emission computed tomography (SPECT), and stress cardiac magnetic resonance imaging (CMR). However, the outcomes of these studies have often been inconsistent and inconclusive. To provide a clearer comparison, we conducted systematic reviews and meta-analyses aimed at quantitatively evaluating and comparing the aggregated diagnostic performance of these four commonly used techniques for detecting coronary artery disease (CAD). Methods: A comprehensive search of PubMed, Scopus, Embase, Cochrane Library, and Web of Science was conducted to identify cohort studies evaluating the diagnostic accuracy of EST, SE, stress myocardial SPECT, and stress CMR in symptomatic patients with suspected or confirmed CAD. The main goal was to compare their diagnostic value by pooling sensitivity and specificity results. Each study’s data were extracted in terms of true positives, false positives, true negatives, and false negatives. Results: A total of 104 studies, comprising 16,824 symptomatic individuals with either suspected or known CAD, met the inclusion criteria. The pooled sensitivities for CAD detection were 0.66 (95% CI: 0.59–0.72, p < 0.001) for EST, 0.81 (95% CI: 0.79–0.83, p < 0.001) for SE, 0.82 (95% CI: 0.78–0.85, p < 0.001) for stress myocardial SPECT, and 0.83 (95% CI: 0.81–0.85, p < 0.001) for stress CMR. Corresponding specificities were 0.61 (95% CI: 0.55–0.67, p < 0.001), 0.85 (95% CI: 0.82–0.87, p < 0.001), 0.74 (95% CI: 0.70–0.78, p < 0.001), and 0.89 (95% CI: 0.86–0.92, p < 0.001), respectively. Considerable heterogeneity was observed across the studies, as reflected by I2 values ranging from 82.5% to 92.5%. Egger’s generalized test revealed statistically significant publication bias (p < 0.05 for all methods), likely due to the influence of smaller studies reporting more favorable results. Despite this, sensitivity analyses supported the overall robustness and reliability of the pooled findings. Conclusions: Among the diagnostic tools assessed, EST demonstrated the lowest accuracy for detecting obstructive CAD, whereas stress CMR exhibited the highest. Although stress myocardial SPECT showed strong sensitivity, its specificity was comparatively limited. SE emerged as the most balanced option, offering good diagnostic accuracy combined with advantages such as broad availability, cost-effectiveness, and the absence of ionizing radiation.

Malnutrition and systemic inflammation are increasingly recognized as important determinants of prognosis in patients with heart failure. Several immunonutritional indices, including the Prognostic Nutritional Index (PNI), the Controlling Nutritional Status (CONUT) score, and the C-reactive protein-albumin-lymphocyte (CALLy) index, have been proposed as markers of nutritional and inflammatory status. However, their prognostic value in elderly patients with heart failure with preserved ejection fraction (HFpEF) remains incompletely defined. This study aimed to evaluate the prognostic significance of these immunonutritional indices in elderly patients with HFpEF over a long-term follow-up period. This retrospective observational study included 200 elderly patients hospitalized with HFpEF (mean age 86.6 ± 6.5 years). Clinical, laboratory, and echocardiographic parameters were collected at admission. Nutritional status was assessed using PNI, CONUT score, and CALLy index. Patients were followed for mortality during long-term follow-up. Survival analyses were performed using Cox regression models, receiver operating characteristic (ROC) curves, and Kaplan-Meier analysis. Median follow-up was 3.8 years (IQR 2.1-5.9). During follow-up, 123 patients (61.5%) died, while 77 patients (38.5%) were alive at the end of observation. In univariate analysis, PNI, CONUT score, left ventricular ejection fraction (LVEF), and the tricuspid annular plane systolic excursion to systolic pulmonary artery pressure (TAPSE/sPAP) ratio were significantly associated with mortality. In multivariate analysis, the CONUT score, LVEF, and the TAPSE/sPAP ratio remained independent predictors of mortality. ROC analysis showed strong prognostic performance for the TAPSE/sPAP ratio (AUC 0.932), CONUT score (AUC 0.925), and LVEF (AUC 0.897). Optimal cut-off values for mortality prediction were CONUT ≥ 6, LVEF ≥ 65%, and TAPSE/sPAP ≤ 0.55 mm/mmHg. Kaplan-Meier analysis confirmed significantly reduced survival among patients with higher CONUT scores, higher LVEF, and an impaired TAPSE/sPAP ratio. In elderly patients with HFpEF, nutritional status and cardiopulmonary functional parameters are important determinants of long-term prognosis. The CONUT score emerged as the most informative immunonutritional index, while echocardiographic parameters reflecting ventricular function and right ventricular-pulmonary arterial coupling provided additional prognostic information. Integrating nutritional assessment with echocardiographic evaluation may improve risk stratification in elderly patients with HFpEF.

Background: Immune checkpoint inhibitors (ICIs) improve cancer outcomes but may cause cardiovascular toxicity, including early subclinical myocardial injury. Conventional echocardiography has limited sensitivity, whereas speckle-tracking echocardiography (STE) allows for early detection of myocardial deformation. Data on short-term ICI-related effects on biventricular mechanics are limited, and atrial function remains poorly characterized. This study evaluated the early impact of ICI therapy on biventricular and biatrial mechanics using STE in patients with advanced cancer. Methods: In this prospective, single-center study, 28 consecutive patients with advanced cancer undergoing ICI therapy were followed for 3 months. Clinical, laboratory, electrocardiographic, and echocardiographic assessments were performed at baseline, 1 month, and 3 months. STE was used to assess left ventricular global longitudinal strain (LV-GLS) and circumferential strain; right ventricular GLS (RV-GLS); and left and right atrial reservoir, conduit, and contractile strain parameters. Subclinical LV dysfunction was defined as a relative LV-GLS reduction >15%. Logistic and Cox regression analyses identified predictors of strain impairment and adverse clinical events. Results: Conventional echocardiographic parameters, including left ventricular ejection fraction, remained stable. In contrast, LV-GLS declined progressively from 20.7 ± 2.1% to 17.6 ± 2.7% at 3 months (p = 0.002), with subclinical LV dysfunction observed in 85.7% of patients. RV-GLS also deteriorated despite preserved TAPSE. Both left and right atrial strain and strain-rate parameters showed an early and marked decline, accompanied by increased left atrial stiffness despite unchanged atrial volumes. Older age and higher neutrophil-to-lymphocyte ratio (NLR) were associated with LV-GLS impairment. Over a mean follow-up of 5.4 ± 3 months, baseline LV-GLS independently predicted adverse clinical events and mortality. Optimal cut-off values were 67 years for age, 4 for NLR, and 19.5% for LV-GLS. Conclusions: Short-term ICI therapy is associated with early, diffuse subclinical myocardial dysfunction involving both ventricles and atria, detectable only by STE. Comprehensive biventricular and biatrial strain assessment may enhance early cardio-oncology surveillance and risk stratification in ICI-treated patients.