Global longitudinal strain in stress test of asymptomatic severe aortic stenosis: a focused meta-analysis
DOI:
https://doi.org/10.18502/cbj.v6i1.22784Keywords:
Asymptomatic diseases, exercise test, global longitudinal strain, myocardial contraction, echocardiography, stress echocardiography, ventricular function, risk stratificationAbstract
Objectives: In asymptomatic severe aortic stenosis (AS) with preserved ejection fraction, subclinical myocardial dysfunction often precedes symptoms by years. Left ventricular ejection fraction (LVEF) is not a determining factor of this early impairment. Global longitudinal strain (GLS) can detect subtle impairment earlier, but its behaviour during exercise stress testing in this context has not been thoroughly assessed. We examined whether GLS at rest and during exercise can distinguish patients with abnormal stress test responses from those with normal responses, and whether exercise‑derived strain adds information beyond resting measurements.
Methods: The researchers conducted a comprehensive review of studies published up to August 21, 2025, using databases including PubMed, Scopus, and Web of Science. They included studies reporting Global Longitudinal Strain (GLS) in asymptomatic patients with severe aortic stenosis (AS) who had a left ventricular ejection fraction (LVEF) of 55% or greater. The studies compared responses to normal versus abnormal exercise stress tests. Two reviewers independently extracted the data. The researchers used the Newcastle-Ottawa Scale to assess study quality. A meta-analysis was performed using random-effects models with Hedges’ g to calculate standardized mean differences, conducted in STATA-MP version 17.
Results: Four studies involving 887 patients were included in the analysis. Resting GLS was worse in patients with abnormal stress responses (SMD -0.37; 95% CI -0.51 to -0.22; p<0.001), with no heterogeneity across studies (I²=0%). During exercise, the difference more than doubled (SMD -0.86; 95% CI -1.40 to -0.32; p=0.002), though substantial heterogeneity was present (I²=82%). Delta GLS showed a non-significant trend (SMD -0.34; p=0.22), also with high heterogeneity (I²=84%), likely related to differences in imaging timing across studies. All studies scored 6–8 on the Newcastle-Ottawa Scale.
Conclusions: GLS identifies subclinical myocardial dysfunction in this population. The exercise signal is stronger than the resting signal but requires standardisation before clinical application. Prospective studies with pre-specified GLS thresholds are needed.
