- Open Access
- Open Peer Review
Global longitudinal strain is a more reproducible measure of left ventricular function than ejection fraction regardless of echocardiographic training
Cardiovascular Ultrasound volume 17, Article number: 18 (2019)
Left ventricular ejection fraction (LVEF) is an established method for evaluation of left ventricular (LV) systolic function. Global longitudinal strain (GLS) by speckle tracking echocardiography seems to be an important additive method for evaluation of LV function with improved reproducibility compared with LVEF. Our aim was to compare reproducibility of GLS and LVEF between an expert and trainee both as echocardiographic examiner and analyst.
Forty-seven patients with recent Acute Coronary Syndrome (ACS) underwent echocardiographic examination by both an expert echocardiographer and a trainee. Both echocardiographers, blinded for clinical data and each other’s findings, performed image analysis for evaluation of intra- and inter- observer variability. GLS was measured using speckle tracking echocardiography. LVEF was calculated by Simpson’s biplane method.
The trainee measured a GLS of − 19.4% (±3.5%) and expert − 18.7% (±3.2%) with an Intra class correlation coefficient (ICC) of 0.89 (0.74–0.95). LVEF by trainee was 50.3% (±8.2%) and by expert 53.6% (±8.6%), ICC coefficient was 0.63 (0.32–0.80). For GLS the systematic difference was 0.21% (− 4.58–2.64) vs. 4.08% (− 20.78–12.62) for LVEF.
GLS is a more reproducible method for evaluation of LV function than LVEF regardless of echocardiographic training.
Left ventricular ejection fraction (LVEF) is the established method for evaluation of LV systolic function and can be measured by a number of imaging modalities. LVEF by echocardiography has been regarded as a cornerstone in the prediction of outcome and is the most widely available method for evaluation of LV function. It is a vital measurement when determining whether patients benefit from an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) . In addition, LVEF is used to define systolic heart failure and has a great impact on the selection of medical treatment . Several echocardiographic methods have been used to measure LVEF but at present, the Simpson’s biplane method is most widely used . Determining LVEF by echocardiography is associated with a high level of inter-observer variability, which to a certain degree can be improved using contrast enhanced echocardiography and 3D echocardiography . Reliability of LVEF depends on image quality and in particular the ability to visualize the endocardial border. Studies have shown that LVEF measured by cardiovascular magnetic resonance imaging (CMR), radionuclide ventriculography and echocardiography is not easily interchangeable .
Strain by speckle tracking echocardiography is a technique that utilizes 2-dimensional gray scale images to evaluate both global and regional function of the left ventricle. Peak global longitudinal strain (GLS) may be used to measure systolic function. Previous studies have shown that GLS may both diagnose and exclude acute coronary heart disease better than LVEF [4,5,6]. In addition, GLS has better intra- and inter-observer reproducibility in post hoc analysis compared to LVEF [4, 7, 8]. Furthermore, GLS may be analyzed in a majority of patients with good feasibility  and may be measured as fast as LVEF [4, 10]. Since several studies have shown advantages of GLS compared to LVEF in the evaluation of LV function especially for mild systolic dysfunction , GLS is increasingly used in clinical practice. In ESC guidelines for management of acute coronary syndrome in patients presenting without persistent ST-segment elevation, echocardiography is recommended and strain is suggested as a tool to identify reduced regional function . GLS is also recommended used in early detection of cardiotoxicity during chemotherapy . However, it is not well studied how the level of echocardiographic training impact performance of GLS compared to LVEF. It is therefore of interest to study the effect of echocardiographic training on reproducibility of GLS and LVEF.
The aim of this study was to investigate reproducibility of LVEF by Simpson’s biplane and GLS by speckle tracking echocardiography when echocardiographers with different levels of expertise obtain images. Furthermore, we compared inter observer variability of GLS and LVEF between expert and trainee both in image acquisition, image analysis and cross analysis.
Material and methods
We invited 126 surviving patients from a previous study admitted with suspected non-ST elevation acute coronary syndrome (NSTE-ACS) [5, 14] to a five-year follow-up study with echocardiographic examination. Eleven patients declined further participation and 10 did not respond. Patients from this cohort were prospectively included to undergo a double echocardiographic examination by a trainee and an expert examiner, and 47 patients constitute the basis of the present study. The study was approved by the regional ethical committee.
To standardize and increase quality of transthoracic echocardiographic examinations (TTE) both the European Association of Echocardiography (EAE) and American College of Cardiology (ACC)/American Heart Association (AHA) have published guidelines regarding echocardiographic and clinical competence [15, 16]. The defined expert in this study was a physician qualified as advanced or level 3-examiner with special interest in speckle tracking echocardiography. This implied a minimum of 12 months of training, 300 performed examinations and 750 interpreted examinations. The trainee was a physician qualified to basic or level 2 which required a minimum of 6 months of training, 150 examinations and 300 interpreted examinations.
Both examiners obtained echocardiographic examinations using a Vivid 7 Scanner (GE Ultrasound, Horten, Norway) with images and cineloops stored digitally. Both sets of echocardiographic examination were performed during the same consultation and the examiners were blinded for each other’s recordings and findings when examining the patients. Three consecutive cycles from three apical and three parasternal image planes were recorded using 2-dimensional gray scale echocardiography. Frame rates were between 55 and 95 frames/second.
Both examiners used the same commercially available software (EchoPAC version 112, GE Ultrasound) for post hoc analysis of echocardiographic recordings on a separate work station. The examiners were blinded for clinical data and echocardiographic findings before analyzing both sets of images. Closure of the aortic valve defined the end of systole and was determined by pulsed Doppler flow in the left ventricular outflow tract (LVOT). Peak systolic strain was defined as the maximum value of peak negative strain (myocardial shortening) or peak positive strain (myocardial lengthening) during systole. GLS by speckle tracking echocardiography was measured manually in a 18-segments LV model as the average segmental value based on three apical imaging planes. LVEF was calculated using Simpson’s biplane method. Image quality for both expert and trainee images was evaluated by the trainee echocardiographer. Image quality was rated poor when < 60% of endocardial border was visible in any standard apical image plane, fair when 60–74% was visualized and good when > 75% of the endocardium was visible. Left ventricular end diastolic diameter was measured perpendicular to the left ventricle in parasternal long axis image measuring the distance from the septal endocardium to the endocardium of posterior wall in the end diastole at the level of the tips of the mitral valve. E wave express early diastolic mitral inflow velocity measured by pulsed doppler. E’ represent early diastolic mitral annular velocity.
Continuous data are presented as mean ± SD or median (inter quartile range). Categorical data are presented as numbers (percentage). All statistical analyses were performed using SPSS 22.0 (SPSS Inc., Chicago, Illinois). Intra class correlation coefficients (ICC) were obtained using two-way mixed model with measures of absolute agreement to describe test reproducibility. ICC of LVEF and GLS were compared using Z-scores. Bland-Altman plots were created to demonstrate inter-observer agreement and were performed by Graphpad Prism ver. 6.05. Linear regression analysis of difference vs mean was used to identify proportional interrater bias. Fixed bias indicates a systemically difference in results between observers, expressed as mean difference analyzed by paired samples T-test.
The clinical data of the 47 patients are summarized in Table 1.
GLS and LVEF data in all assessment scenarios are displayed in Table 2. None of the image recordings for LVEF calculation or GLS measurement were rejected due to image quality. Single LV segments were excluded due to suboptimal image quality or poor tracking when performing GLS measurements. More than 95% of all segments were included in the analyses and there was no significant difference in feasibility between the analyses or examiners. Analyzing trainee images, trainee analyzed 17.3 (±1.2) segments versus expert 17.1 (±1.5), p = 0.45. In expert images the trainee analyzed 17.4 (±1.0) versus expert 17.6 (±1.1), p = 0.38. No images were rejected for LVEF calculation. Results from evaluation of image quality for both echocardiographers are reported in Table 3.
Reproducibility and systematic differences
Reproducibility was excellent in general for GLS regardless of level of training in both image acquisition and analysis. It was weakest when trainee and expert compared results after analyzing their own images with an ICC of 0.89 (0.74–0.95) (Table 2, scenario C and Fig. 3). The strongest reproducibility was seen when both analyzed the expert images where ICC was 0.94 (0.84–0.97) (Table 2, scenario A and Fig. 1).
Reproducibility was good for LVEF and was best when both examiners analyzed trainee images with an ICC of 0.76 (0.57–0.87) (Table 2, scenario B and Fig. 2). When the trainee analyzed both set of images the ICC was only 0.13 (− 0.45–0.49) (Table 2, scenario D and Fig. 4).
There was a significant difference in reproducibility between GLS and LVEF in favor of GLS as listed in Table 2 in all echocardiographer-analyst scenarios.
Furthermore, there was no proportional bias for GLS or LVEF, which indicate that the measurements agreed equally through the entire range of measurements. Fixed bias was present in all scenarios indicating a systematic difference in results of both GLS and LVEF (Fig. 1, 2, 3, 4, 5). There was a significant difference in fixed bias between GLS and LVEF when both examiners analyzed trainee images (Table 2, scenario B and Fig. 2) and when both examiners analyzed their own images (Table 2, scenario C and Fig. 3). In both scenarios, the fixed bias was higher in LVEF analysis.
When trainee comparing left ventricular end diastolic diameter in expert and trainee images ICC was 0.91 (0.85–0.95) with a systematic bias of − 0.43 mm. ICC of E/e’ was 0.92 (0.85–0.95) with a systematic bias of 0.25 (Fig. 6).
To our knowledge, this is one of very few studies to demonstrate that GLS is a more reproducible method for evaluation of LV systolic function than LVEF regardless of echocardiographic training. These findings support the emerging clinical use of GLS as an additional and incremental diagnostic tool in specific myocardial diseases.
A number of previous studies have compared the ability of GLS and LVEF to detect small reductions in LV function, particularly in ischemic heart disease [10, 14, 17,18,19]. In these studies, GLS and segmental strain had better ability than LVEF to predict infarct size and segmental viability in patients with myocardial infarction [18, 20], diagnose coronary artery occlusion in patients with NSTEMI [5, 21], exclude coronary artery disease in patients with chest pain , predict risk of ventricular arrhythmias  and predict mortality [4, 11]. The use of GLS in stress echocardiography increases diagnostic precision compared to LVEF and wall motion scoring, even for novice readers . Earlier studies have described inter- and intra-observer variability in LVEF  and GLS outperforming LVEF [4, 7]. In these studies, image readers were regarded as experts. However, despite several advantages of GLS compared to LVEF in clinical practice, LVEF is still the most used method for evaluation of LV systolic function. In order to use GLS in clinical practice it is important to know to how echocardiographic training may affect the analysis of GLS. We found that measurement of GLS by echocardiography in clinical practice is a highly reproducible method independent of echocardiographic training and significantly better reproducible than LVEF. There may be several reasons for this finding.
When measuring GLS and calculating LVEF there are numerous sources of error in both image acquisition and image analysis that may affect measurements and results. The sources of error include how each operator records and analyzes images offline. Level of echocardiographic training influence both image acquisition and image analysis and may potentially lead to high variability for both LVEF and GLS.
Obtaining images suitable for both LVEF and GLS analysis requires several technical considerations . In LVEF calculation, we need high-quality visualization of the endocardial border in both apical 4-chamber and 2-chamber views. The images should display LV cavity with minimum foreshortening. Timing of end systole and diastole is critical. End-diastole is defined as the first frame after mitral valve closure or the frame which LV dimension is the largest.  End-systole is defined as the frame after aortic valve closure or the frame in which the cardiac dimension or volume is smallest.  Error in these steps will lead to miscalculation of cavity volume and LVEF. As illustrated in Table 3, it seems that the expert echocardiographer generally was able to achieve better images for LVEF analysis. The differences in image quality and visibility of endocardial border may depend on factors as gain setting, focus depth and sector width. Small differences in cavity foreshortening and apical transducer rotation might introduce variability in volume calculation as well. Variability may increase with increasing LVEF due to larger variation in endocardial border between end diastole and end systole.
A major limitation of LVEF in patients with myocardial infarction is that the Simpson’s biplane method is based on an assumption of symmetric LV geometry. The presence of regional myocardial dysfunction as a result of myocardial infarction alters LV geometry.  As a consequence, the Simpson’s biplane method by echocardiography may partly fail to measure LVEF with precision, and level of echocardiographic experience may affect how LVEF is measured. Correlation between GLS and LVEF is reported higher in healthy subjects than in patients with myocardial infarction and heart failure.  Our study population is a heterogeneous group regarding ischemic myocardial pathology (Table 1) and degree of LV dysfunction (Table 4).
GLS does not rely on geometric assumptions but measures myocardial function with precision as we have demonstrated previously [5, 10, 14, 17, 21]. Strain by speckle tracking measure directly segmental myocardial deformation of the LV in a 16-segment model. Average deformation of LV is expressed as GLS. LVEF describes LV systolic function indirectly on the basis of changes in calculated LV volume during the systole. In addition, GLS may be more sensitive than LVEF to changes in long-axis shortening, which makes GLS useful in evaluation of LV function where LVEF is preserved [27, 28]. After the region of interest (ROI) is set in strain measurement, speckle tracking is performed automatically by the respective software.
Image acquisition for strain analysis by speckle tracking has different sources of error . Recognition and elimination of acoustic phenomena as reverberation and acoustic shadowing is important. Tracking of these phenomena will result in underestimation of true deformation [29, 30]. Since strain by speckle tracking is essentially angle independent, this can to a certain degree be eliminated by adjusting probe position. The software performs automated speckle tracking frame by frame which imply that the frame rate needs to be optimized. A frame rate between 40 and 80 frames per second (FPS) is often recommended [29, 30]. Low frame rate and tachycardia may result in undersampling where systolic events are missed, resulting in underestimation of true deformation .
Images suitable for strain analysis may be easier to obtain than images for endocardial tracing. Manual tracing of the endocardium in two image planes may be performed with significant variability between observers due to differences in defining the endocardial border in both end diastole and end systole even in high quality images. Variability is influenced by differences in image acquisition. Since GLS on the other hand is a direct and objective measurement of myocardial deformation and function, this may reduce variability between echocardiographers.
Our findings demonstrate that GLS is a more reproducible parameter regardless of echocardiographic training and image quality compared to LVEF. Level of training is probably more important for LVEF calculation. Our results are similar to a study of Medvedkovsky et al. who addressed the same issue but with another vendor and software  and of Negishi et al. . The findings in this study supports the use of GLS in clinical practice as an important supplement in describing LV function with low variability between observers even among echocardiographic trainees.
At present, there is no industrial standard for strain analysis among different echocardiographic machine vendors. GLS may at the present time therefore vary between vendors and measured results may not be interchangeable. Identical equipment should be used comparing examinations. In the future, it is likely that there will be an industry standard for strain regardless of vendor and GLS may then be measured and compared with any echocardiographic machine . At present there are limited software available that allows automated LVEF measurement that could reduce inter observer reproducibility.
The present study demonstrates that GLS is a more reproducible method for evaluation of LV function than LVEF regardless of echocardiographic training.
Availability of data and materials
The datasets during and/or analyzed during the current study is available from the corresponding author on reasonable request.
American College of Cardiology
Angiotensin converting enzyme
Acute coronary syndrome
American Heart Association
Angiotensin receptor blocker
Cardiovascular magnetic resonance imaging
Cardiac resynchronization therapy
European Association of Echocardiography
End diastolic diameter
European society of cardiology
Frames per seconds
Global longitudinal strain
Intra class correlation coefficient
Left ventricular ejection fraction
Left ventricular outflow tract
Non-ST elevation acute coronary syndrome
New Yok Heart Association
Region of interest
Transthoracic echocardiographic examination
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, Gonzalez-Juanatey JR, Harjola VP, Jankowska EA, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the 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. 2016;37(27):2129–200.
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440–63.
Hoffmann R, Barletta G, von Bardeleben S, Vanoverschelde JL, Kasprzak J, Greis C, Becher H. Analysis of left ventricular volumes and function: a multicenter comparison of cardiac magnetic resonance imaging, cine ventriculography, and unenhanced and contrast-enhanced two-dimensional and three-dimensional echocardiography. J Am Soc Echocardiogr. 2014;27(3):292–301.
Stanton T, Leano R, Marwick TH. Prediction of all-cause mortality from global longitudinal speckle strain: comparison with ejection fraction and wall motion scoring. Circ Cardiovasc Imaging. 2009;2(5):356–64.
Grenne B, Eek C, Sjoli B, Dahlslett T, Uchto M, Hol PK, Skulstad H, Smiseth OA, Edvardsen T, Brunvand H. Acute coronary occlusion in non-ST-elevation acute coronary syndrome: outcome and early identification by strain echocardiography. Heart. 2010;96(19):1550–6.
Dahlslett T, Karlsen S, Grenne B, Eek C, Sjoli B, Skulstad H, Smiseth OA, Edvardsen T, Brunvand H. Early assessment of strain echocardiography can accurately exclude significant coronary artery stenosis in suspected non-ST-segment elevation acute coronary syndrome. J Am Soc Echocardiogr. 2014;27(5):512–9.
Kalam K, Otahal P, Marwick TH. Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction. Heart. 2014;100(21):1673–80.
Negishi T, Negishi K, Thavendiranathan P, Cho GY, Popescu BA, Vinereanu D, Kurosawa K, Penicka M, Marwick TH, Investigators S. Effect of experience and training on the concordance and precision of strain measurements. JACC Cardiovasc Imaging. 2017;10(5):518–22.
Marwick TH, Leano RL, Brown J, Sun JP, Hoffmann R, Lysyansky P, Becker M, Thomas JD. Myocardial strain measurement with 2-dimensional speckle-tracking echocardiography: definition of normal range. JACC Cardiovasc Imaging. 2009;2(1):80–4.
Sjoli B, Grenne B, Smiseth OA, Edvardsen T, Brunvand H. The advantage of global strain compared to left ventricular ejection fraction to predict outcome after acute myocardial infarction. Echocardiography. 2011;28(5):556–63.
Ersboll M, Valeur N, Mogensen UM, Andersen MJ, Moller JE, Velazquez EJ, Hassager C, Sogaard P, Kober L. Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction. J Am Coll Cardiol. 2013;61(23):2365–73.
Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the Management of Acute Coronary Syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267–315.
Zamorano JL, Lancellotti P, Rodriguez Munoz D, Aboyans V, Asteggiano R, Galderisi M, Habib G, Lenihan DJ, Lip GYH, Lyon AR, et al. 2016 ESC position paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for practice guidelines: the task force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(36):2768–801.
Grenne B, Eek C, Sjoli B, Skulstad H, Aakhus S, Smiseth OA, Edvardsen T, Brunvand H. Changes of myocardial function in patients with non-ST-elevation acute coronary syndrome awaiting coronary angiography. Am J Cardiol. 2010;105(9):1212–8.
Quinones MA. American College of Cardiology/American Heart Association clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians--American Society of internal medicine task force on clinical competence. Circulation. 2003;107(7):1068–89.
Popescu BA, Andrade MJ, Badano LP, Fox KF, Flachskampf FA, Lancellotti P, Varga A, Sicari R, Evangelista A, Nihoyannopoulos P, et al. European Association of Echocardiography recommendations for training, competence, and quality improvement in echocardiography. J Am Soc Echocardiogr. 2009;10(8):893–905.
Sjoli B, Orn S, Grenne B, Ihlen H, Edvardsen T, Brunvand H. Diagnostic capability and reproducibility of strain by Doppler and by speckle tracking in patients with acute myocardial infarction. JACC Cardiovasc Imaging. 2009;2(1):24–33.
Sjoli B, Orn S, Grenne B, Vartdal T, Smiseth OA, Edvardsen T, Brunvand H. Comparison of left ventricular ejection fraction and left ventricular global strain as determinants of infarct size in patients with acute myocardial infarction. J Am Soc Echocardiogr. 2009;22(11):1232–8.
Biering-Sorensen T, Hoffmann S, Mogelvang R, Zeeberg Iversen A, Galatius S, Fritz-Hansen T, Bech J, Jensen JS. Myocardial strain analysis by 2-dimensional speckle tracking echocardiography improves diagnostics of coronary artery stenosis in stable angina pectoris. Circ Cardiovasc Imaging. 2014;7(1):58–65.
Mollema SA, Delgado V, Bertini M, Antoni ML, Boersma E, Holman ER, Stokkel MP, van der Wall EE, Schalij MJ, Bax JJ. Viability assessment with global left ventricular longitudinal strain predicts recovery of left ventricular function after acute myocardial infarction. Circ Cardiovasc Imaging. 2010;3(1):15–23.
Eek C, Grenne B, Brunvand H, Aakhus S, Endresen K, Smiseth OA, Edvardsen T, Skulstad H. Strain echocardiography predicts acute coronary occlusion in patients with non-ST-segment elevation acute coronary syndrome. Eur J Echocardiogr. 2010;11(6):501–8.
Haugaa KH, Grenne BL, Eek CH, Ersboll M, Valeur N, Svendsen JH, Florian A, Sjoli B, Brunvand H, Kober L, et al. Strain echocardiography improves risk prediction of ventricular arrhythmias after myocardial infarction. JACC Cardiovasc Imaging. 2013;6(8):841–50.
Yamada A, Luis SA, Sathianathan D, Khandheria BK, Cafaro J, Hamilton-Craig CR, Platts DG, Haseler L, Burstow D, Chan J. Reproducibility of regional and global longitudinal strains derived from two-dimensional speckle-tracking and doppler tissue imaging between expert and novice readers during quantitative dobutamine stress echocardiography. J Am Soc Echocardiog. 2014;27(8):880–7.
Otterstad JE, Froeland G, St John Sutton M, Holme I. Accuracy and reproducibility of biplane two-dimensional echocardiographic measurements of left ventricular dimensions and function. Eur Heart J. 1997;18(3):507–13.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1–39 e14.
Delgado V, Mollema SA, Ypenburg C, Tops LF, van der Wall EE, Schalij MJ, Bax JJ. Relation between global left ventricular longitudinal strain assessed with novel automated function imaging and biplane left ventricular ejection fraction in patients with coronary artery disease. J Am Soc Echocardiogr. 2008;21(11):1244–50.
Gjesdal O, Helle-Valle T, Hopp E, Lunde K, Vartdal T, Aakhus S, Smith HJ, Ihlen H, Edvardsen T. Noninvasive separation of large, medium, and small myocardial infarcts in survivors of reperfused ST-elevation myocardial infarction: a comprehensive tissue Doppler and speckle-tracking echocardiography study. Circ Cardiovasc Imaging. 2008;1(3):189–96 182 p following 196.
Cho GY, Marwick TH, Kim HS, Kim MK, Hong KS, Oh DJ. Global 2-dimensional strain as a new prognosticator in patients with heart failure. J Am Coll Cardiol. 2009;54(7):618–24.
Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G, Galderisi M, Marwick T, Nagueh SF, Sengupta PP, et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr. 2011;24(3):277–313.
Teske AJ, De Boeck BW, Melman PG, Sieswerda GT, Doevendans PA, Cramer MJ. Echocardiographic quantification of myocardial function using tissue deformation imaging, a guide to image acquisition and analysis using tissue Doppler and speckle tracking. Cardiovasc Ultrasound. 2007;5:27.
Medvedofsky D, Kebed K, Laffin L, Stone J, Addetia K, Lang RM, Mor-Avi V. Reproducibility and experience dependence of echocardiographic indices of left ventricular function: side-by-side comparison of global longitudinal strain and ejection fraction. Echocardiography. 2017;34(3):365–70.
Voigt JU, Pedrizzetti G, Lysyansky P, Marwick TH, Houle H, Baumann R, Pedri S, Ito Y, Abe Y, Metz S, et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/industry task force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging. 2015;16(1):1–11.
SK: Conception and design, analysis and interpretation of data, drafting and final approval of manuscript. TD, BG: Conception and design, analysis and interpretation of data, critical revision and final approval of manuscript. BS, OS, TE, HB: Conception and design, critical revision and final approval of manuscript.
This study is funded by Norwegian Extra Foundation for Health and Rehabilitation and Sørlandet Hospital, Arendal, Norway.
Ethics approval and consent to participate
This study is approved by the Regional committees for medical and health research ethics in South-Eastern Norway Regional Health Authority.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Karlsen, S., Dahlslett, T., Grenne, B. et al. Global longitudinal strain is a more reproducible measure of left ventricular function than ejection fraction regardless of echocardiographic training. Cardiovasc Ultrasound 17, 18 (2019) doi:10.1186/s12947-019-0168-9
- Global longitudinal strain
- Left ventricular ejection fraction
- Echocardiographic training