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Review
Hypertensive heart disease beyond left ventricular
hypertrophy: are we ready for echocardiographic
strain evaluation in everyday clinical practice?
Marijana Tadic a, Cesare Cuspidi b, Michele Bombelli c, and Guido Grassi c,d
Hypertension-induced left ventricular (LV) remodeling is a
well known entity that has usually been studied with
traditional echocardiographic techniques. In the last
decade echocardiographic methods are focused on
evaluation of heart mechanics. The strain assessment is
considered as part of comprehensive echocardiographic
examination. Nevertheless, LV strain and particularly
longitudinal strain was proofed as a significant
independent predictor of cardiovascular and total
morbidity and mortality, stronger than LV ejection fraction.
Considering the fact that hypertensive heart disease
represents one of the most important risk factors for the
development of heart failure with preserved ejection
fraction, one should be careful and accurate in identifying
subtle signs of cardiac dysfunction. The early detection of
cardiac dysfunction by conventional echocardiographic
methods is often not possible. The aim of the current
article is to overview the main principles of LV mechanics
and summarize the current knowledge and clinical
significance of LV strain in hypertensive patients.
Keywords: arterial hypertension, left ventricle, strain,
torsion, twist
Abbreviations: 2DE, two-dimensional echocardiography;
LV, left ventricle
INTRODUCTION
I
n the latest European guidelines for the management of
arterial hypertension echocardiographic examination
was recommended as class IIa and level B [1]. Routine
echocardiographic examination is not recommended in all
hypertensive patients, but only in order to confirm ECG
diagnosis of left ventricular (LV) hypertrophy or left atrial
dilatation [1]. On the other hand, echocardiographic exami-
nation represents the most available, widespread and afford-
able method of cardiac structure and function assessment.
The question in focus is should echocardiographic examina-
tion be performed in all hypertensive patients and which kind
of information modern echocardiography could provide us?
As the incidence of hypertensive patients with diagnosis
of heart failure with preserved ejection fraction is constantly
increasing [2], the interest for noninvasive techniques that
would discover subtle changes in LV function and mechan-
ics significantly increased.
Journal of Hypertension
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The purpose of this review is to summarize the current
knowledge regarding new echocardiographic methods that
could provide us valuable and comprehensive information
about early phase cardiac remodeling, which occurs
significantly before LV hypertrophy and symptomatic LV
dysfunction.
THE IMPLICATION OF LEFT
VENTRICULAR STRUCTURE ON
MECHANICS
There are many theories regarding LV anatomical structure.
However, widely accepted theory recognizes three LV
myocardial layers: endocardial, mid-myocardial and epicar-
dial. The prime orientation of the LV free wall myocytes
characterizes by increasing rotation in the epicardium–
endocardium direction. Therefore, subepicardial fibers
are lying at an angle about 608 to the horizontal plane
making a clockwise helix, the mid-wall fibres are practically
horizontal and they do not exist at the LV apex, whereas the
subendocardial myocytes with an angle of nearly þ608 form
the counterclockwise helix [3]. Both helixes are forming LV
free wall and interventricular septum; subepicardial clock-
wise helix is forming the right half of the septum, whereas
counterclockwise right-handed helix forms the left septal
half [3]. However, there is no sharp border between differ-
ent layers and helixes. Both epicardial and endocardial
layers consist of clockwise and counterclockwise helix
segments.
For LV function is even more important the angle
between different myocytes, layers and helices. The
mathematical model demonstrated that contraction of
Journal of Hypertension 2017, 35:000–000
a
Department of Internal Medicine and Cardiology, Charité – Universitätsmedizin
Berlin, Berlin, Germany, bClinical Research Unit, University of Milan-Bicocca and
Istituto Auxologico Italiano, Meda, cDepartment of Health Science, University
of Milano-Bicocca and dDepartment of Clinical Sciences and Community Health,
University of Milano and Fondazione Ospedale Maggiore Policlinico di Milano,
Milano, Italy
Correspondence to Marijana Tadic, MD, PhD, Department of Internal Medicine and
Cardiology, Charité – Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353
Berlin, Germany. E-mail: marijana_tadic@hotmail.com.
Received 7 August 2017 Revised 1 October 2017 Accepted 31 October 2017
J Hypertens 35:000–000 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000001632
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FIGURE 1 Multilayer structure of LV wall and main principle of longitudinal, cir-
cumferential and radial strain, LV basal and apical rotation.
longitudinal or circumferential fibers would result with
ejection fraction of approximately 15 and 28%, respectively
[4]. On the other hand, myocytes that make an angle of 608
with the horizontal plane generate ejection fractions higher
than 60% [4].
Myofibrils have the ability to stretch, shorten and
thicken. The combination of these movements in different
myocardial layers enables the stretching, shortening and
thickening of the LV, which could be measured in percent-
age of longitudinal, circumferential and radial strain [5].
Subendocardial and subepicardial layers are mainly
responsible for longitudinal strain; mid-myocardial layer
is mostly accountable for circumferential strain and thick-
ening of all fibers in all three layers is responsible for radial
strain. However, it should be emphasized that the distribu-
tion and angulation of myofibers in all layers contribute to
all kinds of strain (longitudinal, circumferential and radial).
In order to accumulate energy for efficient cardiac contrac-
tion two more cardiac motions are necessary: rotation and
twist [5].
The LV basal rotation occurs in clockwise direction,
whereas apical rotation represents more prominent motion
that occurs counterclockwise. LV twist is a result of interac-
tion between individual myofiber contraction and their 3D
architecture, and it represents the summation of absolute
values of LV basal and apical rotation [5]. Figure 1 shows the
multilayer structure of the LV wall and principle of longi-
tudinal, circumferential and radial strain, as well as LV basal
and apical rotation.
ECHOCARDIOGRAPHIC ASSESSMENT OF
LEFT VENTRICULAR FUNCTION
LV ejection fraction (LVEF) remains the gold standard for
evaluation of LV systolic function for decades. Two-dimen-
sional (2D) echocardiographic evaluation of LVEF is faced
with many limitations: foreshortening, geometry assump-
tion, moderate accuracy and reproducibility, average inter-
observer and intra-observer variability.
The first evaluation of LV diastolic function was per-
formed by pulsed Doppler, which was replaced by tissue
Doppler imaging that enables better and more accurate LV
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function assessment during the whole cardiac cycle (systole
and diastole). Most frequently used pulsed Doppler param-
eter (E/A) has very important disadvantages: significant
age-dependence, load-dependence and angle-depen-
dence, as well as dependence of sample volume position
(below or above mitral valve), relatively low reproducibil-
ity. Tissue Doppler imaging overcame some disadvantages
of pulsed Doppler, but it is faced with several important
limitations: angle-dependence and load-dependence, eval-
uation of only small portion of myocardium and significant
inter-observer variability.
The first strain technique was derived from tissue Dopp-
ler, which is the reason why tissue Doppler-based strain
was still angle-dependent and limited with significant noise
[5]. The appearance of speckle tracking imaging signifi-
cantly improved the quality and amount of information that
is obtained from myocardium.
Two-dimensional speckle tracking-derived strain is
angle-independent and significantly less load-dependent
and provides mechanical analysis of the whole thickness of
myocardium seen in one echocardiographic view. In this
way longitudinal, circumferential and radial strains were
obtained. Two-dimensional strain rates are strain-derived
parameters that provide the information about cardiac
mechanics during the whole cardiac cycle, similar as tissue
Doppler indices (early and late diastole and systole veloci-
ties).
Three-dimensional speckle tracking imaging went one
step further and provided information regarding mechanics
in the full thickness of myocardium. Additionally, this
method provides assessment of area strain that represents
a combination of longitudinal and circumferential strain
and excellent parameter of LV systolic function [6]. Table 1
represents the main advantages and disadvantages of LV
strain derived by tissue Doppler, 2D and 3D speckle track-
ing imaging.
The most important limitation of strain remains inter-
observer and inter-vendor variability, which is the lowest
for the longitudinal strain [7], but still worth mentioning.
However, even with this variability of global longitudinal
strain was superior in comparison with other conventional
echocardiographic parameters [7]. The variability is signifi-
cantly higher for global circumferential and the highest
for global radial strain. The recent study showed that LV
segmental longitudinal strain, in contrast to global LV
longitudinal strain, has significantly higher variability [8].
Intra-observer variability for 2D LV global longitudinal,
circumferential and radial strains ranged from 1.6 to
11.5%, whereas inter-observer variability ranged from 2.6
to 23% for coefficients of variation [9]. The same variability
coefficients for 3D LV global longitudinal, circumferential
and radial strains ranged from 5.0  4.3 to 10.1  8.5%, and
for inter-observer variability ranged from 6.9  6.1 to
17.0  16.2% for coefficients of variation [10].
It should be emphasized that strain could provide valu-
able information about both systolic and diastolic functions.
It is widely accepted that LV longitudinal function repre-
sents excellent parameter of LV systolic function because of
its high correlation with LV ejection fraction [6–11]. Inves-
tigations even showed that LV global longitudinal strain
represented a better predictor of cardiovascular and total
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TABLE 1. Strengths and limitations of the various modalities in LV strain assessment
TDI
Technical aspects
Availability þþ
Costs þ þþ
Typical scan duration (minutes) 3 3
Typical analysis duration (minutes) 15–20
Safety þþþ
Imaging window dependence þ þþ
Temporal resolution þþþ
Spatial resolution þþþ
Angle dependency þþþ
Strain rate assessment þþþ
Variability þþþ
Clinical utility þ þþþ
Major limitations Deformation evaluation in one dimension
Strain derived from tissue Doppler velocities
Assessment of only regional strain
Time consuming (only for research)
(þ) Low; (þþ) moderate; (þþþ) high; (-) not associated.
morbidity and mortality in general population, as well as in
patients with heart failure or other cardiovascular condi-
tions [12–14]. However, LV multidirectional strain is also
associated with LV diastolic function indices such as E/e0
and E/A ratios [15–17], which enables information regard-
ing LV filling pressure and Hayashi et al. even reported that
the ratio between E (early LV filling velocity) and longitu-
dinal strain might be more accurate than E/e for evaluation
of LV filling pressure [17]. Furthermore, strain rates (early
and late diastolic and systolic) represent strain equivalent
for tissue Doppler-derived parameters and correspond well
with indices of LV diastolic function. The limitation is still
relatively high inter-observer and intra-observer variability,
as well as inter-vendor variability.
Cardiac magnetic resonance (CMR) remains the gold
standard for evaluation of LV function and strain because
of its high spatial and temporal resolution. However,
because of relatively low availability, high costs, long scan
duration and long analysis, it is not suitable for evaluation of
LV mechanics in hypertensive population without comor-
bidities that would demand this sophisticated method.
Furthermore, CMR is not used for evaluation of LV diastolic
function.
Nowadays, cost-effectiveness ratio represents an impor-
tant precondition for wide clinical usage of some technique.
Comparing CMR and echocardiographic strain assessment,
it is obvious that the latter technique is significantly more
available with considerably better cost-effectiveness ratio
than CMR. There are no data that compare cost-effective-
ness between conventional echocardiographic parameters
and strain. However, echocardiographic machines from
practically all vendors are equipped with software for strain
assessment or have possibility for its installation, which is
an affordable investment.
LONGITUDINAL STRAIN IN ARTERIAL
HYPERTENSION
Of all available strain parameters, LV global longitudinal
strain certainly has the major importance and the largest
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Arterial hypertension and strain
Two-dimensional speckle Three-dimensional
tracking imaging speckle tracking imaging
þþ þ
þþþ
1
3–5 3–5
þþþ þþþ
þþþ
þþ þ
þþ þ
- -
þþþ
þ þþ
þþ
Strain assessment in only one plane Stable cardiac rhythm
Low temporal resolution
Low availability
clinical utility. Recent studies showed that LV global lon-
gitudinal strain represents a good predictor of cardiovascu-
lar and total morbidity and mortality in hypertensive
population [18] or in the large group of patients with large
prevalence of different cardiovascular risk factors of which
arterial hypertension was present in more than 40% [12,19].
Kuznetsova et al. [19] succeeded to show that layer-specific
longitudinal strains (endocardal, midcardial and epicardial)
were independent predictors of cardiovascular, coronary
and cardiac events. Interestingly, authors used sex-specific
cut-off values for LV longitudinal strain that has not been yet
proposed by guidelines. Strain analysis is not completely
load-independent, age-independent, sex-independent and
race-independent [5], however, it shows higher consistency
than other conventional echocardiographic parameters.
Table 2 summarizes findings regarding the predictive
value of LV global longitudinal and circumferential strains.
Studies included in this table are the only follow-up inves-
tigations in the hypertensive patients or in the global
population with a significant percentage of hypertensive
patients published in PubMed and Medline. Data regarding
predictive value of LV radial strain in hypertensive patients
were not found.
The relationship between peak oxygen consumption –
functional capacity and global longitudinal strain in hyper-
tensive population [20] could be significant in the follow-up
of hypertensive patients and possibly those with heart
failure with preserved ejection fraction. Interestingly, the
similar findings were reported in the patients with high–
normal blood pressure [21], which only confirms the signif-
icance of evaluation of LV longitudinal strain even in
patients with prehypertension and especially in those with
additional risk factors such as obesity, diabetes, dyslipidemia,
and so on.
Recently published investigations, for the first time
reported the beneficial effect of pharmacotherapy on LV
global longitudinal strain in hypertensive patients followed
6 and 12 months, respectively, after introduction of antihy-
pertensive therapy [22,23]. The authors reported significant
improvement of LV global longitudinal strain, as well as
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TABLE 2. The predictive value of LV longitudinal and circumferential strain

Sample size and individuals
Reference included in the study
LV longitudinal strain
Biering-Sørensen 1296 participants in a general
et al. [12] population (mean age 57  16
years, 42% men, 38%
hypertension, 9% diabetes, 5%
ishemic heart disease)
Saito et al. [18] 388 asymptomatic nonischemic
patients with hypertension who
had abnormal LV geometry
(mean age 66 years, 47% men,
21% diabetes, 25% atrial
fibrillation)
Kuznetsova et al. [19] 791 participants in a general
population (mean age 51 years,
48% men, 41% hypertension,
4% diabetes)
Lee et al. [33] 95 hypertensive patients (mean age
65.5  12.0 years, 60% men).
LV circumferential strain
Choi et al. [39] 1768 asymptomatic individuals
(mean age 65 years, 53% men,
47% hypertension)
Follow-up
Method period Main findings
2D STI 11 years Lower GLS was associated with a higher risk of incident heart
failure, acute myocardial infarction, or cardiovascular death
independently of age, sex, heart rate, hypertension, SBP,
left ventricular ejection fraction, left ventricular mass index,
left ventricular dimension, deceleration time, left atrium
dimension, and pro B-type natriuretic peptide. GLS is a
stronger predictor in men than in women
2D STI 4 years GLS and its reduction (>16%) are related with major adverse
cardiac events in asymptomatic hypertensive heart disease.
A risk score that used age more than 70, atrial fibrillation,
concentric hypertrophy, and baseline GLS 16% was very
useful for predicting risk of major adverse cardiac events
2D STI 7.9 years Decreased global GLS (>18.8% in women and > 17.4% in
men) increased risk for cardiovascular (128%, P<0.001) and
cardiac (94%, P<0.001) events. The risk for cardiovascular
events increased with higher number of left ventricular
impairments (low GLS, diastolic dysfunction, and
hypertrophy)
Layers-specific longitudinal strains (endocardial, mid-
myocardial and epicardial) are independent predictors of
cardiovascular, cardiac and coronary events
2D STI 7.3  2.0 years Epicardial longitudinal strain (>17.6%) was the only
independent prognostic factor in regularly treated
hypertensive patients
CMR 5.5  1.3 years Circumferential strain predicted incident heart failure
independent of age, diabetes status, hypertension,
myocardial infarction, left ventricular mass index, and left
ventricular ejection fraction. Circumferential strain was also
significantly associated to the composite atherosclerotic
cardiovascular events, but its relationship was decreased
after including left ventricular mass index in the model

2D STI, two-dimensional speckle tracking imaging; CMR, cardiac magnetic resonance; GLS, global longitudinal strain; LV, left ventricular.

parameters of LV diastolic function, and in this way showed
that mild deterioration of LV function is reversible with
appropriate and timely introduced therapy. However, the
reduction in longitudinal strain with antihypertensive treat-
ment was mostly mediated via reduction of afterload and
did not occur independently of peripheral BP values. The
evidence on BP-independent strain improvement after
antihypertensive treatment (e.g. via remodeling) is still
lacking.
LV hypertrophy has been considered as one of the most
responsible factors for deterioration of LV multidirectional
strain in arterial hypertension [15,24]. Our study group
showed that geometry pattern had significant impact on
LV longitudinal strain [25]. Global longitudinal strain grad-
ually decreased from hypertensive patients with normal LV
geometry and concentric remodeling, across hypertensive
individuals with eccentric nondilated LV hypertrophy, to
the patients with concentric and dilated LV hypertrophy
patterns [25]. Galderisi et al. [6] showed that young hyper-
tensive patients with normal LV mass index also had sig-
nificantly lower 3D longitudinal, area and radial strain than
normotensives. However, LV mass was still significantly
higher, although in normal range, in hypertensive patients
than in controls.
The association between blood pressure values and LV
longitudinal strain in arterial hypertension was confirmed in
many previous studies [6,15,23]. This association was dem-
onstrated in patients with high-normal blood pressure [26],
white-coat hypertension [27], masked hypertension [28],
night-time hypertension [29] and hypertensive patients with
different 24-h blood pressure patterns (dippers and non-
dippers) [30,31]. Figure 2 demonstrates the assessment of
LV global and layer-specific longitudinal strain in normo-
tensive, prehypertensive and hypertensive individuals.
Arterial hypertension has impact on all myocardial
layers. Kim et al. [32] showed that all endocardial, mid-
cardial and epicardial longitudinal strains were lower in
hypertensive patients than in controls. Our results showed
that mostly endocardial and mid-myocardial layers are
affected by white-coat, masked and sustained hypertension
[27,28], Lee et al. [33] interestingly showed that only epicar-
dial longitudinal strain has predictive value in hypertensive
population, whereas Kuznetsova et al. [19] reported that
longitudinal strains of all three myocardial layers were
important predictors in this population of patients.
One should not forget that any additional risk factor,
such as diabetes, overweight or obesity, dyslipidemia,
smoking, or renal failure significantly contributes to deteri-
oration of LV longitudinal mechanics [34–36]. Additional
risk factors have not additive, but unfortunately cumulative
effect.
CIRCUMFERENTIAL STRAIN IN
ARTERIAL HYPERTENSION
The recent article showed that all strain parameters corre-
lated well to LV ejection fraction [37]. However, the stron-
gest correlation with LV ejection fraction demonstrated

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Arterial hypertension and strain

FIGURE 2 The assessment of LV global and layer-specific longitudinal strain in normotensive, prehypertensive and hypertensive individuals. The gradual reduction in LV
longitudinal strain from normotensive to hypertensive individuals should be noticed. (a and b) Global and layer-specific longitudinal strain in normotensive controls; (c and d)
global and layer-specific longitudinal strain in prehypertensive controls and (e and f) global and layer-specific longitudinal strain in hypertensive patient.

global circumferential strain (r ¼ 0.82, P < 0.001) and
longitudinal strain (r ¼ 0.76, P < 0.001) [37]. Similar find-
ings were found in study that used magnetic resonance for
assessment of LV ejection fraction and strains [38]. Further-
more, longitudinal and circumferential strains obtained by
echocardiography and CMR closely correlated with ejection
fraction assessed by magnetic resonance (r ¼ 0.85 and
r ¼ 0.95, respectively, P < 0.001).
The Multi-Ethnic Study of Atherosclerosis showed that
LV circumferential strain represents robust, and indepen-
dent predictor for heart failure occurrence in asymptomatic
individuals without evidence of prior cardiovascular dis-
ease [39].
The findings regarding LV circumferential strain in
hypertensive population are not concurrent. Some authors
found significantly lower values of LV circumferential strain
[24,37–41], whereas others disagreed [6,42–44]. Most of the
circumferential changes found in hypertensive patients
were ascribed to LV hypertrophy. However, our findings
in prehypertensive and white-coat hypertensive patients
showed that LV hypertrophy is not crucial for deterioration
of circumferential strain [26,27]. On the other hand,
researches also demonstrated that LV geometry and partic-
ularly concentric and concentric-dilated LV hypertrophy
patterns are responsible for worsening of LV circumferen-
tial mechanics [25,41].
Layer assessment of circumferential function showed
that hypertension impacts circumferential strain in the same
direction as longitudinal strain: from endocardium to epi-
cardium. Huang et al. [45] showed that only endocardial

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Tadic et al.
FIGURE 3 The evaluation of LV global and multilayer circumferential strain in control and hypertensive individuals. The gradual reduction in LV circumferential strain from
normotensive to hypertensive individuals should be noted. (a and b) Global and layer-specific circumferential strain in normotensive controls; (c and d) global and layer-specific
longitudinal strain in hypertensive individuals.
circumferential strain was reduced in hypertensive patients,
whereas mid-myocardial and epicardial were similar with
controls. Our research group showed that white-coat and
masked hypertension affected both LV endocardial and
mid-myocardial circumferential strain, but not epicardial
strain [27,28]. Figure 3 shows the evaluation of LV global
and multilayer circumferential strain in controls and
hypertensive patients.
Considering the fact that long follow-up studies are not
available, we could only hypothesize that longitudinal
function deteriorates prior circumferential function
impairment, which is a probable mechanism of maintaining
LV ejection fraction in hypertensive patients for a long time.
This could also be the rational reason for development of
heart failure with preserved ejection fraction in hyper-
tensive individuals.
Szelényi et al. [44] showed that the pathological process
in the hypertensive patients probably begins from the
longitudinally arranged subendocardial myofibres, which
consequently decreases LV longitudinal systolic function.
The mid-myocardial myocytes responsible mostly for
circumferential and radial mechanics remained preserved
for a longer time, which enables the maintenance of
normal LV ejection fraction. Our investigations demon-
strated that circumferential strain is also deteriorated in
different subgroups of hypertensive patients [25–30], but
possibly this reduction is still lower than for longitudinal
strain resulting with similar ejection fraction preservation
over time.
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One should also not forget the cumulative negative
effect of different cardiovascular risk factors on LV circum-
ferential strain, similarly as on longitudinal strain, as we
reported in patients with the metabolic syndrome, obesity
or diabetes [35,36,46].
RADIAL STRAIN IN ARTERIAL
HYPERTENSION
LV radial strain represents the percentage of LV thickening
during systole and although it is the easiest for explanation,
it is the most difficult for interpretation primarily because of
high inter-observer and intra-observer variability and even
higher inter-vendor variability. This inconsistency makes
radial strain impractical for everyday clinical usage. How-
ever, investigations showed that it might be a useful param-
eter in the assessment of subclinical LV damage.
There are several important limitations of radial strain.
Radial strain does not correlate that well as longitudinal
strain with ultrasonomicrometry, a gold standard for LV
deformation assessment that could not be used in human
population because of its invasive nature [47,48]. This
variance is the result of inability of echocardiographic beam
to be perpendicular on the major part of LV in short-axis
view. Additional problem is the large amplitude of cardiac
motions in transversal plane during cardiac cycle, which
makes the tracking of myocardium more difficult.
The association between arterial hypertension and
LV radial strain is less investigated than the relationship
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Arterial hypertension and strain

FIGURE 4 The assessment of LV global radial strain in control and hypertensive individuals. The reduction in LV radial strain from normotensive to hypertensive individuals
should be noticed. (a) Global radial strain in normotensive controls; (b) global radial strain in hypertensive patient.

between hypertension and longitudinal and circumferential
strain. The majority of authors found significantly decreased
LV radial strain in hypertensive patients [6,20,24,25,43]. In
our studies, even when we could not detect radial mechanic
changes in prehypertension or white-coat hypertension by
2D speckle tracking, we succeeded with 3D strain [26,27].
Huang et al. [37] recently reported that LV radial strain
gradually decreased with reduction of LV ejection fraction
in hypertensive population. Figure 4 reveals the assessment
of LV global radial strain in control and hypertensive
individuals.
The deterioration of LV radial strain is usually attributed
to LV hypertrophy. However, studies showed that hyper-
tensive patients (young hypertensive patients or prehyper-
tensive patients) even in circumstances of normal LV mass
had lower values of LV radial strain.
TWIST AND TORSION IN ARTERIAL
HYPERTENSION
LV twist and untwist represent complex cardiac motions
that resulted from the dynamic interaction between clock-
wise and counterclockwise epicardial and endocardial
myocytes. LV twist is caused by the opposed LV basal
and apical rotation and it is calculated as the mathematical
difference between apical and basal rotation, whereas
torsion is calculated as the ratio between twisting and
the LV length in end-diastole. LV twist represents parameter
of systolic and diastolic function at the same time [49,50],
whereas untwist is mostly related with LV diastolic function
because it promotes blood suction during early diastole.
Speckle tracking-derived LV twist correlates well with
CMR-derived twist [51]. The largest limitation of speckle

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FIGURE 5 The calculation of LV basal and apical rotation and twist in control and patient with long-lasting hypertension. The gradual increase in LV rotation and twist
from control to hypertensive individuals should be noticed. (a) Normotensive control; (b) hypertensive patient.
tracking-derived twist is determination of the true LV apex,
which is not easy to detect with echocardiography, unlike
magnetic resonance that could easily define any part of
the heart.
There is no agreement regarding the influence of arterial
hypertension on LV twist. Some investigators, including our
study group, found increased LV twist in hypertensive
patients [25,26,30,50,52]. Shin et al. [53] reported the inverse
relationship between LV longitudinal strain and LV twist, as
well as good correlation with ventriculoatrial coupling in
hypertensive population. The authors demonstrated that LV
twist and ventriculoatrial coupling were increased during
the well compensated phase of arterial hypertension and
reduced progressively as LV systolic function worsened in
more advance stage of hypertension [53]. This decrement in
LV twist was also revealed in the hypertensive population
with decreased LV ejection fraction [48]. Deteriorated LV
untwisting is related with elevated arterial stiffness and
coronary microcirculatory dysfunction, as well as decreased
exercise capacity and neurohumoral activation (increased
pro-BNP) in hypertensive patients [54].
Investigations also showed the association between LV
geometry and LV twisting in hypertensive patients. Namely,
Cameli et al. [52] showed that LV twist and untwist gradually
increased from eccentric geometry, throughout concentric
remodeling to concentric LV hypertrophy. Our findings
showed that only hypertensive individuals with dilated
and concentric-dilated LV hypertrophy had significantly
higher LV twist than patients with normal geometry [25].
Mizuguchi et al. did not find statistical difference between
hypertensive individuals with different LV geometry pat-
terns, however, there was a tendency of LV twist and
untwist increase from normal LV geometry, across eccen-
tric, to concentric LV hypertrophy [24].
Increased twist and untwist might be a very useful
compensatory mechanism for maintaining LV systolic func-
tion and LV diastolic filling in the condition of reduced
longitudinal strain in the initial stage of hypertensive heart
disease. However, in the later stage these compensatory
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mechanisms weaken and LV twist becomes reduced.
Figure 5 demonstrates the calculation of LV basal and apical
rotation and twist in control and patient with long-lasting
hypertension.
LEFT VENTRICULAR MECHANICS IN
OTHER CARDIOVASCULAR DISEASES
The importance of LV mechanics evaluation and particu-
larly longitudinal strain has been assessed in many cardio-
vascular conditions such as diabetes, ischemic heart
disease, heart failure with preserved and reduced LVEF,
and valvular heart disease [55–58]. The investigations
showed significantly reduced LV longitudinal strain in these
conditions and revealed its predictive value in cardiovas-
cular and overall morbidity and mortality [59–62]. In most
of these investigations LV longitudinal strain was proved to
be a better predictor of morbidity and mortality than LVEF.
CONCLUSION
Arterial hypertension is a well known cardiovascular risk
factor that is related with increased cardiovascular and total
morbidity and mortality. Hypertensive heart disease is an
old entity, which after all needs reassessment in terms of
criteria and methods of evaluation. New echocardiographic
techniques allow the detection of subclinical and subtle
cardiac changes and could be successfully used in the
follow-up of hypertensive patients and evaluation of effi-
cacy of therapy. LV longitudinal strain has the greatest
importance because of its simple assessment, low costs,
high predictive value, high sensitivity and specificity, as
well as reasonable low variability. On account of all these
advantages, LV longitudinal strain represents a better
parameter for detection of hypertensive heart remodeling
than conventional echocardiographic parameters used
nowadays. The modern approach to the hypertensive
patients should involve an echocardiographic examination
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JH-D-17-00804
with LV longitudinal strain assessment, which is particularly
important in patients with increased cardiovascular risk.
ACKNOWLEDGEMENTS
Conflicts of interest
There are no conflicts of interest.
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Reviewer’s Summary Evaluations
Reviewer 2
This paper nicely summarizes the actual state of the art in
echocardiography to define the ‘‘strain’’ imposed on the
different layers of the ventricular wall. The authors make
clear that the instruments actually used by cardiologists
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indeed have the necessary software on board and that no
supplementary costs should be made. They illustrate the
higher capacity of the technique to better define the dam-
age on the ventricular wall caused by hypertension, espe-
cially in an early stage. The remaining question is to define
the golden standard to which the techniques available ’ad
hoc’ can be compared.
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