The impact of cardiovascular risk factors on global longitudinal strain over a decade in the general population: the copenhagen city heart study


Global longitudinal strain (GLS) declines throughout adult-life as the LV remodels and adapts. Information on the impact of cardiac risk factors such as male sex, obesity, smoking status, hypertension, hypercholesterolemia, and diabetes on GLS. over time has not yet been investigated. The present prospective longitudinal study included 689 participants of the 4th and 5th Copenhagen City Heart Study who had GLS measured at both timepoints. Mean age was 51 years and 45% were male. All participants underwent two echocardiographic examinations median 10.4 (IQR: 10.2, 10.9) years apart. Average decline in GLS during follow-up was -0.7%. High age, male sex, high body mass index, and mean arterial blood pressure (MAP) proved to be significantly associated with an accelerated decline in GLS. In a multivariable regression model including all the investigated cardiovascular risk factors, age (stand. β-coef. = −0.10, P = 0.005), male sex (stand. β-coef. = −0.16, P < 0.001), and MAP (stand. β-coef. = −0.07, P = 0.009) were independent predictors of an accelerated decline in GLS during a 10-year period. Finally, the investigated risk factors had different regional impact after the same multivariable adjustments. Male sex had a significant impact on changes in longitudinal strain at the apical, mid-wall and basal segments, meanwhile MAP and age only accelerated changes in the mid-wall and basal longitudinal strain. In the general population age, male sex, and MAP are independent predictors of an accelerated decline in GLS over a 10-year period. Furthermore, MAP, male sex and age had different regional impact.

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  1. 1.

    Moran AE, Forouzanfar MH, Roth GA, Mensah GA, Ezzati M, Murray CJL, Naghavi M (1980) Temporal trends in ischemic heart disease mortality in 21 world regions, to 2010: the Global Burden of Disease 2010 study. Circulation 129(2014):1483–1492.

    Article  Google Scholar 

  2. 2.

    Savarese G, Lund LH (2017) Global Public Health Burden of Heart Failure. Card. Fail. Rev. 3:7–11.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney M-T, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen M-L, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S, ESC Scientific Document Group ( 2016) European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur. Heart J. 37(2016):2315–2381.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Kannel WB, McGee DL (1979) Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham study. Diabetes Care 2:120–126

    CAS  Article  Google Scholar 

  5. 5.

    Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB (1998) Prediction of coronary heart disease using risk factor categories. Circulation 97:1837–1847

    CAS  Article  Google Scholar 

  6. 6.

    Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, González-Juanatey JR, Harjola V-P, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P, Filippatos G, McMurray JJV, Aboyans V, Achenbach S, Agewall S, Al-Attar N, Atherton JJ, Bauersachs J, John Camm A, Carerj S, Ceconi C, Coca A, Elliott P, Erol Ç, Ezekowitz J, Fernández-Golfín C, Fitzsimons D, Guazzi M, Guenoun M, Hasenfuss G, Hindricks G, Hoes AW, Iung B, Jaarsma T, Kirchhof P, Knuuti J, Kolh P, Konstantinides S, Lainscak M, Lancellotti P, Lip GYH, Maisano F, Mueller C, Petrie MC, Piepoli MF, Priori SG, Torbicki A, Tsutsui H, Veldhuisen V, Windecker DJS, Yancy C, Zamorano JL, Zamorano JL, Aboyans V, Achenbach S, Agewall S, Badimon L, Barón-Esquivias G, Baumgartner H, Bax JJ, Bueno H, Carerj S, Dean V, Erol Ç, Fitzsimons D, Gaemperli O, Kirchhof P, Kolh P, Lancellotti P, Lip GYH, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Roffi M, Torbicki A, Vaz Carneiro A, Windecker S, Sisakian HS, Isayev E, Kurlianskaya A, Mullens W, Tokmakova M, Agathangelou P, Melenovsky V, Wiggers H, Hassanein M, Uuetoa T, Lommi J, Kostovska ES, Juillière Y, Aladashvili A, Luchner A, Chrysohoou C, Nyolczas N, Thorgeirsson G, Marc Weinstein J, Di Lenarda A, Aidargaliyeva N, Bajraktari G, Beishenkulov M, Kamzola G, Abdel-Massih T, Celutkiene J, Noppe S, Cassar A, Vataman E, Abir-Khalil S, vanPol P, Mo R, Straburzynska-Migaj E, Fonseca C, Chioncel O, Shlyakhto E, Otasevic P, Goncalvesová E, Lainscak M, Díaz Molina B, Schaufelberger M, Suter T, Yilmaz MB, Voronkov L, Davies C (2016) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failureThe Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 37(2016):2129–2200.

    Article  PubMed  Google Scholar 

  7. 7.

    Conroy RM, Pyörälä K, Fitzgerald AP, Sans S, Menotti A, De Backer G, De Bacquer D, Ducimetière P, Jousilahti P, Keil U, Njølstad I, Oganov RG, Thomsen T, Tunstall-Pedoe H, Tverdal A, Wedel H, Whincup P, Wilhelmsen L, Graham IM (2003) SCORE project group, Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 24:987–1003

    CAS  Article  Google Scholar 

  8. 8.

    D’Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, Kannel WB (2008) General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 117:743–753.

    Article  PubMed  Google Scholar 

  9. 9.

    Goff DC, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R, Greenland P, Lackland DT, Levy D, O’Donnell CJ, Robinson JG, Schwartz JS, Shero ST, Smith SC, Sorlie P, Stone NJ, Wilson PWF, Jordan HS, Nevo L, Wnek J, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, DeMets D, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen W-K, Smith SC, Tomaselli GF, A (2013) ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129(2014):S49–73.

    Article  PubMed  Google Scholar 

  10. 10.

    Nikitin NP, Loh PH, de Silva R, Witte KKA, Lukaschuk EI, Parker A, Farnsworth TA, Alamgir FM, Clark AL, Cleland JGF (2006) Left ventricular morphology, global and longitudinal function in normal older individuals: a cardiac magnetic resonance study. Int J Cardiol 108:76–83.

    Article  PubMed  Google Scholar 

  11. 11.

    Biering-Sørensen T, Biering-Sørensen SR, Olsen FJ, Sengeløv M, Jørgensen PG, Mogelvang R, Shah AM, Jensen JS (2017) Global Longitudinal Strain by Echocardiography Predicts Long-Term Risk of Cardiovascular Morbidity and Mortality in a Low-Risk General Population: The Copenhagen City Heart Study Cardiovasc. Imaging Circ.

    Article  Google Scholar 

  12. 12.

    Russo C, Jin Z, Elkind MSV, Rundek T, Homma S, Sacco RL, Di Tullio MR (2014) Prevalence and prognostic value of subclinical left ventricular systolic dysfunction by global longitudinal strain in a community-based cohort. Eur J Heart Fail 16:1301–1309.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Olsen FJ, Pedersen S, Jensen JS, Biering-Sørensen T (2016) Global longitudinal strain predicts incident atrial fibrillation and stroke occurrence after acute myocardial infarction. Medicine (Baltimore) 95:e5338.

    Article  Google Scholar 

  14. 14.

    Skaarup KG, Iversen A, Jørgensen PG, Olsen FJ, Grove GL, Jensen JS, Biering-Sørensen T (2018) Association between layer-specific global longitudinal strain and adverse outcomes following acute coronary syndrome. Eur Heart J Cardiovasc Imaging.

    Article  PubMed  Google Scholar 

  15. 15.

    Sengeløv M, Jørgensen PG, Jensen JS, Bruun NE, Olsen FJ, Fritz-Hansen T, Nochioka K, Biering-Sørensen T (2015) Global Longitudinal Strain Is a Superior Predictor of All-Cause Mortality in Heart Failure With Reduced Ejection Fraction. JACC Cardiovasc Imaging 8:1351–1359.

    Article  PubMed  Google Scholar 

  16. 16.

    Gosse P, Coulon P, Papaioannou G, Litalien J, Lemetayer P (2011) Impact of malignant arterial hypertension on the heart. J Hypertens 29:798–802.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Kuznetsova T, Herbots L, Richart T (2008) J D’hooge, L Thijs, RH Fagard, MC Herregods, JA Staessen, Left ventricular strain and strain rate in a general population. Eur. Heart J. 29:2014–2023.

    Article  PubMed  Google Scholar 

  18. 18.

    Ng ACT, Prevedello F, Dolci G, Roos CJ, Djaberi R, Bertini M, Ewe SH, Allman C, Leung DY, Marsan NA, Delgado V, Bax JJ (2018) Impact of Diabetes and Increasing Body Mass Index Category on Left Ventricular Systolic and Diastolic Function. J Am Soc Echocardiogr Off Publ Am Soc Echocardiogr 31:916–925.

    Article  Google Scholar 

  19. 19.

    Leng Z, Li R, Li Y, Wang L, Wang Y, Yang Y (2017) Myocardial layer-specific analysis in patients with heterozygous familial hypercholesterolemia using speckle tracking echocardiography. Echocardiogr Mt Kisco N 34:390–396.

    Article  Google Scholar 

  20. 20.

    Mogelvang R, Sogaard P, Pedersen SA, Olsen NT, Schnohr P, Jensen JS (2009) Tissue Doppler echocardiography in persons with hypertension, diabetes, or ischaemic heart disease: the Copenhagen City Heart Study. Eur Heart J 30:731–739.

    Article  PubMed  Google Scholar 

  21. 21.

    N.B. Schiller, P.M. Shah, M. Crawford, A. DeMaria, R. Devereux, H. Feigenbaum, H. Gutgesell, N. Reichek, D. Sahn, I. Schnittger, (1989) Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr Off Publ Am Soc Echocardiogr 2 (1989): 358–367.

  22. 22.

    Frederiksen CA, Juhl-Olsen P, Hermansen JF, Andersen NH, Sloth E (2015) Clinical utility of semi-automated estimation of ejection fraction at the point-of-care. Heart Lung Vessels 7:208–216

    PubMed  Google Scholar 

  23. 23.

    Cheng S, Larson MG, McCabe EL, Osypiuk E, Lehman BT, Stanchev P, Aragam J, Benjamin EJ, Solomon SD, Vasan RS (2013) Age- and sex-based reference limits and clinical correlates of myocardial strain and synchrony: the Framingham Heart Study. Circ Cardiovasc Imaging 6:692–699.

    Article  PubMed  Google Scholar 

  24. 24.

    Kajstura J, Cheng W, Sarangarajan R, Li P, Li B, Nitahara JA, Chapnick S, Reiss K, Olivetti G, Anversa P (1996) Necrotic and apoptotic myocyte cell death in the aging heart of Fischer 344 rats. Am J Physiol 271:H1215–1228.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Tan YT, Wenzelburger F, Lee E, Heatlie G, Leyva F, Patel K, Frenneaux M, Sanderson JE (2009) The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion. J Am Coll Cardiol 54:36–46.

    Article  PubMed  Google Scholar 

  26. 26.

    Xiao RP, Tomhave ED, Wang DJ, Ji X, Boluyt MO, Cheng H, Lakatta EG, Koch WJ (1998) Age-associated reductions in cardiac beta1- and beta2-adrenergic responses without changes in inhibitory G proteins or receptor kinases. J Clin Invest 101:1273–1282.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Lundorff IJ, Sengeløv M (2018) P Godsk Jørgensen, S Pedersen, D Modin, N Eske Bruun, T Fritz-Hansen, J Skov Jensen, T Biering-Sørensen (2018) Echocardiographic Predictors of Mortality in Women With Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Imaging 11:008031.

    Article  Google Scholar 

  28. 28.

    Olivetti G, Giordano G, Corradi D, Melissari M, Lagrasta C, Gambert SR, Anversa P (1995) Gender differences and aging: effects on the human heart. J Am Coll Cardiol 26:1068–1079.

    CAS  Article  Google Scholar 

  29. 29.

    Ishizu T, Seo Y, Kameda Y, Kawamura R, Kimura T, Shimojo N, Xu D, Murakoshi N, Aonuma K (2014) Left ventricular strain and transmural distribution of structural remodeling in hypertensive heart disease. Hypertens Dallas Tex 1979(63):500–506.

    CAS  Article  Google Scholar 

  30. 30.

    Poulsen SH, Andersen NH, Heickendorff L, Mogensen CE (2005) Relation between plasma amino-terminal propeptide of procollagen type III and left ventricular longitudinal strain in essential hypertension. Heart Br Card Soc 91:624–629.

    CAS  Article  Google Scholar 

  31. 31.

    Cikes M, Sutherland GR, Anderson LJ, Bijnens BH (2010) The role of echocardiographic deformation imaging in hypertrophic myopathies. Nat Rev Cardiol 7:384–396.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Frohlich ED, Apstein C, Chobanian AV, Devereux RB, Dustan HP, Dzau V, Fauad-Tarazi F, Horan MJ, Marcus M, Massie B (1992) The heart in hypertension. N Engl J Med 327:998–1008.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Liu D, Hu K, Nordbeck P, Ertl G, Störk S, Weidemann F (2016) Longitudinal strain bull’s eye plot patterns in patients with cardiomyopathy and concentric left ventricular hypertrophy. Eur J Med Res 21:21.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Diaz T, Pencina MJ, Benjamin EJ, Aragam J, Fuller DL, Pencina KM, Levy D, Vasan RS (2009) Prevalence, clinical correlates, and prognosis of discrete upper septal thickening on echocardiography: the Framingham Heart Study. Echocardiogr Mt Kisco N 26:247–253.

    Article  Google Scholar 

  35. 35.

    Grossman W, Jones D, McLaurin LP (1975) Wall stress and patterns of hypertrophy in the human left ventricle. J Clin Invest 56:56–64.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Shah AM, Claggett B, Sweitzer NK, Shah SJ, Anand IS, Liu L, Pitt B, Pfeffer MA, Solomon SD (2015) Prognostic Importance of Impaired Systolic Function in Heart Failure With Preserved Ejection Fraction and the Impact of Spironolactone. Circulation 132:402–414.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

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Correspondence to Kristoffer Grundtvig Skaarup.

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TBS is a steering committee member of the Amgen financed GALACTIC-HF trial. In addition, he is a member of an advisory board in Sanofi Pasteur and Amgen and has received speaker honorarium from Sanofi Pasteur and Novartis. PGJ reports lecture fee from Novo Nordisk.

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Skaarup, K.G., Lassen, M.C.H., Marott, J.L. et al. The impact of cardiovascular risk factors on global longitudinal strain over a decade in the general population: the copenhagen city heart study. Int J Cardiovasc Imaging (2020).

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  • General population
  • Echocardiography
  • Global longitudinal strain
  • Risk factors