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1/14/24, 10:59 PM Strain and Myocardial Work Index during Echo Exercise to Evaluate Myocardial Function in Athletes - PMC
J Cardiovasc Echogr. 2022 Apr-Jun; 32(2): 82–88. PMCID: PMC9558636

Published online 2022 Aug 17. doi: 10.4103/jcecho.jcecho_1_22: PMID: 36249438
10.4103/jcecho.jcecho_1_22
Strain and Myocardial Work Index during Echo Exercise to Evaluate Myocardial
Function in Athletes
Davide Domenico Borzì, Stefano Saladino, Valentina Losi,1 Denise Cristiana Faro,1 and Ines Paola Monte1
Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Catania,
Italy
1
Department of General Surgery and Medical-Surgery Specialties, University of Catania, Catania, Italy
Address for correspondence: Prof. Ines Paola Monte, Cardiology Unit, CAST Policlinic of University, Via S. Sofia
76, Catania, Italy. E-mail: inemonte@unict.it
Received 2022 Jan 4; Revised 2022 Feb 19; Accepted 2022 Mar 20.
Copyright : © 2022 Journal of Cardiovascular Echography
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-
NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-
commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Abstract
The aim of the study was to evaluate the application of global longitudinal strain (GLS) and my‐
ocardial work (MW) at rest and during exercise in healthy sedentary or trained participants, to
test their ability to improve echocardiographic information and to complement prescribing ex‐
ercise, cardiac screening, or rehabilitation programs.
Methods:
Thirty healthy males were divided into three groups of 10, sedentary (G1), resistance (G2) and
power (G3) athletes, underwent a standard clinical evaluation protocol and exercise stress
testing echocardiography.
Results:
During stress, all showed increased left ventricular ejection fraction and mitral annulus tissue
Doppler (E'). G1 showed a decrease in left atrial volume (LAVi) as opposed to an increase in
G3. E/E 'a decrease in G2, unlike the increase in G3. All groups showed increase of Strain (GLS
average AV, Longitudinal LS, Medio-Basal MB Apical AP), global constructive work (GCW), and
Global wasted work. G1 showed increase for global work efficiency, G2 and G3 for global work
index (GWI). G3 showed a greater variation of E/E', LAVi, GWI and GCW compared to G1 and
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9558636/?report=printable 1/16
G2, greater of GLS AV, LS-AP compared to G2. Only G3 showed differences for GLS AV versus
LS-AP. The relative regional strain ratio showed a greater value in G3 versus G1 at the end of
stress compared to rest.
Conclusions:
The new echocardiographic applications to study the physiological adaptation could open new
perspectives for the diagnostic and therapeutic development through the prescription of per‐
sonalized exercises and screening and follow-up of the early pathological changes of the
athlete's heart.
Keywords: Athletes’ heart, echocardiography, exercise echo, myocardial work, strain
Introduction
The morphological and functional changes observed in athletes' hearts (AH) define a condition
called AH. The European Association of Cardiovascular Imaging (EACVI), American College
Cardiology (ACC) and American Heart Association (AHA) suggested the correct interpretation
of imaging in the evaluation of athletes and new standards for electrocardiography (ECG) in‐
terpretation, fitness, and sports equipment.[1,2,3]
In 1975 Morganroth, using M-mode echocardiography, described cardiac adaptations to sports

activities according to two “extreme” models: left ventricular hypertrophy “concentric” power
athletes (PA), and “eccentric” Endurance athletes (EA).[4] Subsequently, several elaborations
showed a spectrum of morphostructural modifications more heterogeneous than the hypothe‐
sis of Morganroth in consideration of long-term cardiovascular adaptations induced by various
sports and age groups.[3,5]
Currently, the speckle tracking echocardiography (STE) and its derived parameters, such as
global longitudinal strain (GLS) and the myocardial work (MW), can further define the charac‐
teristics of AH.
The left ventricular GLS (LVGLS) has emerged in the last decade as a reliable tool for the study
of myocardial mechanics by adding information on cardiac performance compared with tradi‐
tional LV systolic function parameters, such as ejection fraction left ventricular ejection fraction
(LVEF).[6] Several studies have shown that a reduction in LVGLS is uncommon in AH, it cannot
be regarded a physiological adaptation to training and may be helpful to clarify the nature of
cardiovascular adaptations in specific circumstances.[7,8]
The MW can be considered an advancement of the GLS, able to study LV performance related
to changes in the effort, as it incorporates afterload and provides a measure of myocardial effi‐
ciency.[9,10,11,12] LV pressure-strain loop area and derived global MW indices correlate with
invasive measurements.[13]
“Exercise stress testing echocardiography” (ESTE) is a widely used method for simultaneous
assessment of myocardial function and hemodynamics during physiological stress. The LVGLS
evaluation during stress may provide an incremental value and enable further recognition of
early myocardial dysfunction,[14,15] but they are still few data on changes in GLS and MW
during exercise in healthy.[16]
Our hypothesis is that the new echocardiographic technologies, such as GLS and MW during
ESTE, can better assess the AH adaptations and provide more information than standard
echocardiography.
Materials and Methods
Study population
The study was conducted at the Echo-Lab of our Cardiology Unit. From January 2019 to
February 2020, healthy volunteers, students or graduates, practicing competitive or recre‐
ational sports, were consecutively enrolled. We evaluated 30 male participants, selected on the
basis of optimal echo images during stress, aged between 18 and 35 (26.9 ± 6.3 years), divided
into three groups: G1, 10 sedentary or practicing any kind of sport for <1 h/week (<4 h in the
last year). G2 and G3 groups were made up of athletes who had passed the medical examina‐
tion for the release of sports fitness for competitive activity and regularly enrolled in their re‐
spective national sports federations.
Athletes received sport-specific training protocols, were always doping-test negative, and did
not use anabolic steroids. The participants recruited from groups G2 and G3 practiced compet‐
itive activity for more than 24 months and in the past 12 months. G2 included 10 competitive
EA, mainly engaged in aerobic training (all cyclists) for at least 4 h a week (≥16 h/month in the
last year); G3 included 10 competitive PA practicing anaerobic sports (weightlifting and throw‐
ing) for at least 4 h/week (≥16 h/month in the past year). All participants have undergone
normal physical examination, blood test, standard ECG, and echocardiogram.
The study was conducted in accordance with the Helsinki Declaration. All participants provided
written informed consent before entering the study.
Exercise stress testing echocardiography
Exercise stress test The “Maximal Exercise-Stress Test” was performed on the “e-Bike EL
Ergometer,” using the Case system. The participants, in a semi-supine inclined left position,
started the exercise test with 2 min warm-up, followed by a 60W load increased by 30W every
2 min to target heart rate (HR). The pedaling speed was maintained at 60 rpm until muscle ex‐
haustion, with a subsequent 7 min recovery to 30W. The contraindicating symptoms included
chest discomfort, severe exhaustion, pain in lower limbs, pathological abnormalities in the elec‐
trocardiographic trace, or arterial blood pressure (ABP) increase ≥250/115 mmHg. The ABP
measurements were performed by a cuff connected to the ECG monitoring system during all
phases. During the test any cardiological signs and symptoms, increased ABP, ECG changes of
ischemia or arrhythmias, metabolic equivalents (METS), double product (DP = SBP × HR), and
increased workload (Watt), were detected. At the end of the test, all patients were asked to wait
30 min before being discharged.
Echocardiography A complete echocardiographic exam was performed by Vivid E95 (GE

Horten, Norway) equipped with a probe M5S, according to the standards of our laboratory
and the EACVI/ASE recommendations.[17] The image acquisitions were performed at rest and
at 85% of the expected maximum HR, using the dedicated software (EchoPAC AFI-Stress).
Before starting the test, we explained to the participants how to collaborate with a controlled
breathing during the acquisition phases of the Echo images.
Standard echo LV quantitative analysis M-2D-Doppler was performed according to the current
recommendations.[17,18] For this study were considered: LV diastolic diameter (LVIDd), mass
(LVMi) indexed for body surface area (BSA) using M-Mode; Left atrial volume (LAVi) indexed
for BSA and LVEF by the 2D-biplane method; peak velocity of the mitral flow, early (E), atrial
(A) and their ratio, by Pulsed Wave Doppler (PW); the average of the early diastolic (E') and
systolic (S') velocities by tissue Doppler imaging at septal and lateral mitral annulus, and the
ratio E/E'.
Advanced echo Images for the GLS calculation were acquired in the three standard apical
views, 60–70 fpm, and at least 7 cardiac cycles for each view to minimize unusable images to
maximum ESTE.[19]
The ESTE analyses were performed offline using the dedicated software (Echopac v. 2.02). We
calculated the GLS in a 17-segment bull's-eye model and strain of the single segments (LS) to
evaluate the regional mechanical [Figure 1a]. We considered the average systolic peak value of
the 12 middle-basal segments (LS-MB), the 5 apical (LS-AP), and the regional deformation ratio
between apex and base (LS-AP/LS-MB).[20,21]
The quantification of MW was performed using the same software package. It was measured
by areas Pressure strain loop (PSL), obtained from noninvasive pressure curves LV with ac‐
quired deformation with STE, as proposed by Russell et al.[10] The software has derived the
noninvasive-PSL after taking the GLS and integrated with the BP values and the time of valvular
events. GLS and SBP were synchronized by aligning the timing of the valve events, which have
been set from PW at mitral and aortic valve and then confirmed by 2DE evaluation of the long
axis apical view. MW was evaluated from mitral valve closure to mitral valve opening. A bull's
eye with the segmental and global work index (GWI) (the area within the curve total work
from mitral valve closure to mitral valve opening) values was also provided [Figure 1b]. We
also achieved global work (GW) global constructive work (GCW) work performed during
shortening in systole adding negative work during lengthening in isovolumetric relaxation),
global wasted work (GWW) negative work performed during lengthening in systole adding
work performed during shortening in isovolumetric relaxation; and efficiency (GWE) construc‐
tive work divided by the sum of constructive and wasted work).[21] All parameters were calcu‐
lated at rest (resting) and at peak exercise (stress).
Statistical analysis
Statistical analysis was performed using SPSS v. 26.0.(IBM SPSS v 26.0 New York, USA)
Continuous variables, reported as mean ± standard deviation, were compared by t-test. The
linear relationships between the deformation parameters and other continuous variables were
evaluated with the Pearson's correlation method. All significant variables on univariate analysis
were included in multivariate regression step by step, after excluding those that showed
collinearity (Pearson r > 0.6). A P < 0.05 indicates statistical significance and goodness of
adapted model expressed with the statistical R-squared.
The echocardiogram was always performed by the IM operator. The offline analysis of the cap‐
tured images is always by the DB operator. The image quality was optimal, and no LV segment
was excluded from the analysis. The reproducibility (intra/inter-observer variability) of LV de‐
formation of our laboratory was previously reported.[22]
Results
We found a good intraclass correlation (r = 0.790, P < 0.0001) for strain component (intra-ob‐
server 0.978; inter-observer 0.957).
Study population
All participants were male, matched by age (G1: 27 ± 6; G2:28 ± 5; G3: 27 ± 5 y). G3 showed
higher BSA than G2 (2 ± 0.1 vs. 19 ± 0.1 sqm P < 0.030) and DBP values at rest than G1 (72 ± 9
vs. 62 ± 6 mmHg P < 0.013). At the end of the stress, G2 reached higher levels of METS than G1
and G3 (12 ± 2.4 vs. 9.4 ± 1.4 P < 0.009 and vs. 9.9 ± 1.2 P < 0.026 ml/kg/min) and Watts (225
± 49 vs. 182 ± 22 P < 0.022 and vs. 195 ± 32 W). G3 showed a greater increase in SBP than the
other groups (74 ± 19 vs. 63 ± 28 and vs. 57 ± 13 Δ %, P < 0.036 G3 vs. G2).
Echo findings
Standard echo Resting
G2 and G3 showed only LVEF greater than G1 [Table 1].
Stress
Compared to rest, G1 showed an increase in LVEF and E', a decrease in LAVi; G2 an increase in
LVEF and E', a decrease in E/E'; G3 showed an increase in LVEF, E/E', E' and LAVi. The increase
in LVEF and LAVi in G2 and G3 was greater than G1. The increase in the E/E' and LAVi in G3
was greater than G2 [Table 2].
Advanced echo Resting
Only LS-MB in G3 was greater than G1.
Stress
Compared to rest, GLS-AV, LS-MB, LS-AP, GCW, GWW had increased in all groups. In G1, GWE
also increased, and in G2 and G3, GWI. In G2 the increase in GWI was greater than in G1. In G3
the increase in LS AP, GWI and GCW was greater than in G1, and that of E/E', LAVi and GWW
greater than in G2; GWE in G3 was smaller than in G2.
Changes (Δ%) of echo findings in stress to resting
G3 showed a higher Δ% E/E', LAVi, GWI and GCW than G1 and G2, and a higher Δ%GLS-AV, LS-
AP compared to G2. In the analysis of relative regional strain between groups, changes of Δ%
of the regional LS [Figure 2a] showed differences only in G3: GLS-AV vs. Δ%LS-AP (P < 0.007),
with Δ%GLS-AV < Δ%LS-AP; Δ%GLS-AV vs. Δ%LS-MB (P < 0.004) with Δ%GLS-AV > Δ%LS-MB;
Δ%LS-AP vs. Δ%LS-MB (P < 0.002) with Δ% LS-AP > %ΔLS-MB [Table 3]. In the analysis be‐
tween groups of the relative regional strain ratio, G3 showed a higher value than G1 [Figure 2b
]; while, in the analysis within groups, from rest to stress of the relative regional strain ratio,
only G3 group showed an increase.
Pearson's correlations
Resting: G1 showed a positive correlation of GWI and GCW with SBP, negative of GWI with GLS-
AV and LS-AP, and of GWE with LS-AP. G2 showed a positive correlation of GWI and GCW with
SBP, of GCW with LAVi, negative of both with GLS-AV, of GWI with LS-MB.
Stress: G2 showed a positive correlation of GCW with SBP and LAVi. G3 showed GWW posi‐
tively with LS-AP and negatively with LAVi; GWE positively with LAVi and negatively with LS-AP.
Discussion
New advanced echocardiographic applications expand the observation on adaptations during

peak exercise phases. EA perform isotonic exercise, characterized by normal or reduced pe‐
ripheral vascular resistance and increased cardiac output, reflecting the high aerobic involve‐
ment of large muscle groups.[22,23] The power sports are characterized by isometric exercise,
increased peripheral vascular endurance during training, and greater global afterload imposed
on the ventricle, which results in concentric rather than eccentric chambers' remodeling.
Our data agree with this pathophysiological background. Our athletes showed LVMi average
values greater than the sedentary, but LVIDd slightly less well in G3. The conventional parame‐
ters of cardiac function remain normal and did not differ between the groups, while the car‐
diac deformation characteristics differ between trained athletes aerobic and anaerobic. The
wide variations in blood pressure during the workout could alter the vascular structure with
deterioration of the elastic fibers of the vessels.[23] The resulting increase in vascular stiffness
could therefore have a negative impact on the LV deformational properties and ventricular-ar‐
terial coupling. Furthermore, since the use/abuse of anabolic drugs affects a significant impair‐
ment of LVGLS as a result of the pro-fibrotic load,[24,25,26] special attention should be paid to
the hidden use of illicit drugs.
Our study showed that, at peak of stress, various forms of training lead to specific cardiac
adaptation patterns: PA (G3) show changes in SBP and %SBP more than the EA (G2).[27,28]
According to Rowland,[28] we have no significant differences between G1 and G2 groups for
E' and E/E' at rest and stress. E/E' during stress and its variation Δ% compared to rest, reveal
an opposite trend between G1 and G2, these tend to have lower values (improvement) than
G3, which tends to increase (worsen), although none showed pathological values.
Furthermore, we found LAVi values during stress lower than the rest phase in G2 and higher
in G3. With increased LV stiffness or noncompliance, the left atrium (LA) pressure rises to
maintain adequate LV filling, and the higher atrial wall tension leads to chamber dilation and
the stretch of the atrial myocardium.[28] In pathological hypertrophy, the compensatory LA
contraction is impaired, as a result of both increased workloads imposed on the LA my‐
ocardium and of intrinsic LA dysfunction. Since LA function reflects and influences LV diastolic
filling, its reduction may contribute to a decrease in LV preload and stroke volume, according
to the Frank–Starling mechanism.[29] Sengupta in 24 recreational athletes noted LA dilation
immediately after half marathon persisting 72 h after completion, and has suggested a preser‐
vation of LVEF but subclinical LV diastolic dysfunction.[30]
The global and regional strain values found at rest are similar to those observed by other stud‐
ies.[19] In G1 and G2, the contribution provided by the MB and AP regions during Stress is no
different and LS-AP is always greater in both the groups. In G2 there is a homogeneous contri‐
bution from all myocardial regions, while in G1 AP is greater (in both cases no statistical rele‐
vance). In G3, we obtained significant differences between myocardial regions. This data is also
confirmed by the analysis of the regional deformation ratio that only in G3 shows differences
between the various ventricular regions with a greater apical component than the MB region.
Only G3 showed a different trend compared to G2 and a significant increase in LS-AP from rest
to stress, probably due to the different modes of cardiac adaptation to stress.
For all groups the same maximum effort was considered for the acquisition of stress images
(85% theoretical HR for age). The HR is also similar for all groups. However, the SBP values
reached at the peak are different, higher in G3 than G1 and G2, as a result of adaptations to the
increase in peripheral resistance. These higher values would be supported by the greater con‐
tribution of the ventricular apex during systole. Conversely, the lower contribution of the mid‐
dle and basal region and the increase of E/E' and LAVi could express an early diastolic dys‐
function, similar to what evidenced by Sengupta in young runners immediately after the race.
[30]
The resting MW parameters observed in our study are comparable with those obtained in
other studies.[21] In the stress phase, G2 and G3 show GWI values greater than G1. This may
be related to the fact that it represents the overall work within the PSL.[10,11] GWE is reduced
in all groups, but higher in G2 than in G3. This parameter is expresses the contractile efficiency
of the myocardium as a percentage of constructive work compared to all the work done by the
myocardium, and is not influenced by the BSP values. As GWW and GCW are parameters de‐
pendent on GLS and SBP, the basic information is provided to us by GWE, it follows that, al‐
though in G3 GCW and GWW are higher, in terms of efficiency G2 shows higher values. This
behavior could be linked to the same observations on diastolic function: a higher value of
GWW could be due to adaptation to pressure levels, with a consequent increase in the GCW re‐
quired to support high working values produced not useful for the systole (GWW).
In our study, the workload on the bicycle ergometer was the means to bring the heart to high
HR, in order to observe the adaptations of different type of athlete's hearts during effort. The
greater workloads sustained by the G2 (cyclists) compared to the G3 (body builder) can be ex‐
plained by the type of training supported by G2; in fact, specific training for a specific athletic
gesture (pedaling) leads to improve athletic performance despite a lower muscle mass, as
strength does not depend only on muscle mass. The force is also a nervous phenomenon as
specific training improves athletic performance thanks to the ability of the nervous system to
recruit specific muscle units more efficiently and equipped with a specific enzymatic pool for
that specific type of work.
These results highlight the GLS and MW analysis utility, compared to conventional echocardio‐
graphic parameters, to identify functional adaptations. The GLS and MW analysis during ESTE
is a novelty in the field of AH study. Our data show a different diastolic function behavior of the
power group compared to resistance and control group, and a correlation with the deforma‐
tion of LV.
Limitations
We need to recognize the limitations of this study.
This is a unicentric study with a small sample and needs a broader application to be able to
draw extensive conclusions. Nevertheless, it satisfies our goal of verifying the applicability of
the method during stress.
The accentuation of breathing during exercise is a limit to the correct acquisition of images.
However, an adequate preparation of the patient before the execution of the test can favor its
success.
Conclusions
The heart adaptations observed in athletes, depending on the type of sport, can be detected
early with the new techniques. The use of GLS and MW could open new perspectives for the
development of personalized diagnostic-therapeutic protocols for the different “types of AH,”
for the early screening of pathological alterations, as well as for personalized rehabilitation
programs in heart diseases. Despite the interesting results observed, further multicenter stud‐
ies with larger samples are needed to confirm and take advantage of our findings.
Ethical clearance
The study was conducted in accordance with the Helsinki Declaration. All participants provided
written informed consent before entering the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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and exercise in athletes: Potential trigger for developing atrial dysfunction? Scand J Med Sci Sports. 2016;26:1444–54.
[PubMed: 26752626]
30. Sengupta S, Jain R, Burkule N, Olet S, Khandheria BK. Myocardial Work Index: A Novel Method for Assessment of
Myocardial Function in South Asian Recreational Athletes. J Patient Cent Res Rev. 2020;7:147–56. [PMCID:
PMC7197886] [PubMed: 32377548]
Figures and Tables
Figure 1
A bull's eye with the Global Longitudinal Strain (1a-red map) and Global Work Index (1b-green map). GLS = Global
Longitudinal Strain Average of all segments. PSD = peak strain dispersion. BP = Blood pressure. GWI: Global Work
Index; GWE: Global Work Efficiency. HR APLAX = HR at apical long axis view
Table 1
Echo findings at rest
G1 G2 G3 P between groups
Standard
LVEF (%) 60±3.5 64.1±3.2 63.3±4.7 0.0138* 0.0368#
SVi (ml/mq) 32.97±9.5 34.24±9.4 32.22±6.1
E/E’ (m/s) 7.32±1.04 7.19±2.02 6.69±1.52
E’ (m/s) 0.11±0.02 0.13±0.04 0.11±0.003
S’ (m/s) 0.08±0.01 0.08±0.02 0.08±0.01
RWT (cm) 0.34±0.09 0.09 0.39±0.06 0.38±0.06
LVMi (ml/mq) 71.1±15.3 15.3 84.2±20.7 76.7±9.1
LVIDd (cm) 4.91±0.4 0.43 4.85±0.5 4.81±0.4
LAVi (ml/mq) 16.5±3.8 17.8±5.3 17.8±2.6
Advanced
GLS-AV (%) −19.5±1.3 −19.8±1.5 −18.6±1.17 0.020#
LS-MB (%) −18.1±1.1 −17.9±1.9 −16.9±0.8
LS-AP (%) −22.0±3.2 −24.0±2.1 −22.7±2.9
GWI (mmHg %) 1633±235 1846±332 1720±159
GCW (mmHg %) 1970±269 268.71 2201±370 1983±217
GWW (mmHg %) 69±41 77±41 87±40
GWE (mmHg %) 96±2 96±2 95±2
*G2 versus G1, # G3 versus G1, § G3 versus G2. LV=Left ventricular, LVEF=LV ejection fraction, LVMi=LV mass index by
body surface area, LVIDd=LV internal diastolic diameter, SVi=Stroke Volume index by body surface area, LAVi=Left
Atrial Volume indexed by body surface area, RWT=Relative Wall Thickness, S’=Peak velocity of systolic mitral annular
motion as determined by pulsed wave Doppler, E/E’=Ratio between early flow velocity at mitral valve (E) and tissue
velocity wave (E’) at mitral annulus, GLS-AV=Global longitudinal strain-average, LS=Longitudinal strain, LS-AP=LS api‐
cal segments, LSMB=LS strain medio-basal segments, MD=Mechanical dispersion, GCW=Global constructive work,
GW=Global work, GWE=GW efficiency, GWI=GW index, GWW=Global wasted work, G1=Sedentary, G2=Resistance,
G3=Power
Table 2
Echo findings at stress
G1 G2 G3 Between
groups
Stress Stress Stress
versus rest versus rest versus rest
Standard
LVEF (%) 71±5.7 0.001 78±4.4 0.0001 76±3.1 0.0001 0.014*
SVi (ml/mq) 30.33±3.1 37.38±11.8 34.5±6.2 0.037#
E/E’ (m/s) 6.35±2.91 5.88±1.92 0.043 7.91±2.08 0.055 0.037§
E’ (m/s) 0.20±0.05 <0.001 0.16±0.05 0.036 0.17±0.05 0.007 0.05
LAVi 14.1±2.3 17.5±5.1 24.0±6.1 0.006 0.044*

(ml/mq) 0.001#
0.025§
Advanced
GLS-AV (%) −23.4±1.3 0.0001 −23.6±1 0.0001 −23.7±1.2 0.0001
LS-MB (%) −20.9±2.1 0.002 −21±1.3 0.0009 −20.2±1.1 0.0001
LS-AP (%) −28.8±3.3 0.0017 −30.1±4.6 0.0004 −32.1±3.4 0.0001 0.050#
GWI (mmHg 1907±429 2378±668 0.0185 2475±454 0.0002 0.038*

%) 0.010#
GCW (mmHg 3318±542 0.0001 3508±1081 0.0009 4037±474 0.0001 0.005#

%)
GWW 184±114 0.0046 157±70 0.0028 239±123 0.0072 0.040§

(mmHg %)
GWE (mmHg 94±4 0.0413 96±2 93±3 0.035§

%)
*G2 versus G1, # G3 versus G1, § G3 versus G2. LV=Left ventricular, LVEF=LV ejection fraction, SVi=Stroke volume index
by body surface area, LAVi=Left atrial volume indexed by body surface area, E/E’=Ratio between early flow velocity at
mitral valve (E) and tissue velocity wave (E’) at mitral annulus, GLS-AV=Global longitudinal strain-average,
LS=Longitudinal strain, LS-AP=LS apical segments, LS-MB=LS medio-basal segments, GCW=Global constructive work,
GW=Global work, GWE=GW efficiency, GW=GW index, GWW=Global wasted work
Table 3
Changes (Δ%) stress to resting
G1 G2 G3 P
Standard
SVi (ml/mq) 0.14±32.45 9.36±18.28 11.63±36.39
E/E’ (m/s) −12.96±39.37 −16.92±18.56 20.43±28.89 0.044#

0.003§
E’ (m/s) 83.40±59.78 41.87±51.44 52.57±49
LVEF (%) 19.62±14.15 21.32±8.92 20.68±10.54
LAVi (ml/mq) −11.19±19.67 5.32±35.03 35.31±29.88 <0.001#

0.054§
Advanced
GLS AV (%) 20.39±9.14 19.66±8.2 27.77±8.72 0.046§
LS MB (%) 16.01±12.52 17.24±12.69 19.75±7.39
LS AP (%) 22.36±15.32 18.46±11.05 28.93±9.46 0.029§
GWI (mmHg %) 17.88±26.4 29.8±34.38 43.91±21.56 0.026#
GCW (mmHg %) 71.58±39.55 57.73±36.33 104.81±24.94 0.037#

0.003§
GWW (mmHg %) 184.09±151.15 136.2±95.46 253.59±286.21
GWE (mmHg %) −2.4±3.16 −0.5±1.71 −1.74±3.73
#
G3 versus G1, § G3 versus G2. SVi=Stroke volume index by body surface area, LV=Left ventricular, LVEF=LV ejection
fraction, E/E’=Ratio between early flow velocity at mitral valve (E) and tissue velocity wave (E’) at mitral annulus,
E’=Peak velocity of early diastolic mitral annular motion as determined by pulsed wave doppler, LAVi=Left atrial vol‐
ume indexed by body surface area, GLS-AV=Global longitudinal strain-average, LS=Longitudinal strain, LS MB=LS
medio-basal segments, LS AP=LS apical segments, GW=Global work, GWI=GW index, GWE=GW efficiency, GCW=Global
constructive work, GWW=Global wasted work
Figure 2
Changes (Δ%) of Echo findings in Stress to Resting. Analysis of relative regional strain within each group (2a) and
analysis between groups of the relative regional strain ratio (2b). GLSAV: Global Longitudinal Strain Average; LSMB:
Longitudinal Strain Medio-Basal; LSAP: Longitudinal Strain Apical

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1/14/24, 10:59 PM Strain and Myocardial Work Index during Echo Exercise to Evaluate Myocardial Function in Athletes - PMC

J Cardiovasc Echogr. 2022 Apr-Jun; 32(2): 82–88. PMCID: PMC9558636

Copyright : © 2022 Journal of Cardiovascular Echography

Keywords: Athletes’ heart, echocardiography, exercise echo, myocardial work, strain

In 1975 Morganroth, using M-mode echocardiography, described cardiac adaptations to sports

Materials and Methods

Exercise stress testing echocardiography

Echocardiography A complete echocardiographic exam was performed by Vivid E95 (GE

Standard echo Resting

G2 and G3 showed only LVEF greater than G1 [Table 1].

Advanced echo Resting

Only LS-MB in G3 was greater than G1.

Changes (Δ%) of echo findings in stress to resting

New advanced echocardiographic applications expand the observation on adaptations during

We need to recognize the limitations of this study.

Financial support and sponsorship

There are no conflicts of interest.

Figures and Tables

Echo findings at rest

LVEF (%) 60±3.5 64.1±3.2 63.3±4.7 0.0138* 0.0368#

SVi (ml/mq) 32.97±9.5 34.24±9.4 32.22±6.1

E/E’ (m/s) 7.32±1.04 7.19±2.02 6.69±1.52

E’ (m/s) 0.11±0.02 0.13±0.04 0.11±0.003

S’ (m/s) 0.08±0.01 0.08±0.02 0.08±0.01

RWT (cm) 0.34±0.09 0.09 0.39±0.06 0.38±0.06

LVMi (ml/mq) 71.1±15.3 15.3 84.2±20.7 76.7±9.1

LVIDd (cm) 4.91±0.4 0.43 4.85±0.5 4.81±0.4

LAVi (ml/mq) 16.5±3.8 17.8±5.3 17.8±2.6

GLS-AV (%) −19.5±1.3 −19.8±1.5 −18.6±1.17 0.020#

LS-MB (%) −18.1±1.1 −17.9±1.9 −16.9±0.8

LS-AP (%) −22.0±3.2 −24.0±2.1 −22.7±2.9

GWI (mmHg %) 1633±235 1846±332 1720±159

GCW (mmHg %) 1970±269 268.71 2201±370 1983±217

GWW (mmHg %) 69±41 77±41 87±40

GWE (mmHg %) 96±2 96±2 95±2

Echo findings at stress

LVEF (%) 71±5.7 0.001 78±4.4 0.0001 76±3.1 0.0001 0.014*

SVi (ml/mq) 30.33±3.1 37.38±11.8 34.5±6.2 0.037#

E/E’ (m/s) 6.35±2.91 5.88±1.92 0.043 7.91±2.08 0.055 0.037§

E’ (m/s) 0.20±0.05 <0.001 0.16±0.05 0.036 0.17±0.05 0.007 0.05

LAVi 14.1±2.3 17.5±5.1 24.0±6.1 0.006 0.044*

GLS-AV (%) −23.4±1.3 0.0001 −23.6±1 0.0001 −23.7±1.2 0.0001

LS-MB (%) −20.9±2.1 0.002 −21±1.3 0.0009 −20.2±1.1 0.0001

LS-AP (%) −28.8±3.3 0.0017 −30.1±4.6 0.0004 −32.1±3.4 0.0001 0.050#

GWI (mmHg 1907±429 2378±668 0.0185 2475±454 0.0002 0.038*

GCW (mmHg 3318±542 0.0001 3508±1081 0.0009 4037±474 0.0001 0.005#

GWW 184±114 0.0046 157±70 0.0028 239±123 0.0072 0.040§

GWE (mmHg 94±4 0.0413 96±2 93±3 0.035§

Changes (Δ%) stress to resting

SVi (ml/mq) 0.14±32.45 9.36±18.28 11.63±36.39

E/E’ (m/s) −12.96±39.37 −16.92±18.56 20.43±28.89 0.044#

E’ (m/s) 83.40±59.78 41.87±51.44 52.57±49

LVEF (%) 19.62±14.15 21.32±8.92 20.68±10.54

LAVi (ml/mq) −11.19±19.67 5.32±35.03 35.31±29.88 <0.001#

GLS AV (%) 20.39±9.14 19.66±8.2 27.77±8.72 0.046§

LS MB (%) 16.01±12.52 17.24±12.69 19.75±7.39

LS AP (%) 22.36±15.32 18.46±11.05 28.93±9.46 0.029§

GWI (mmHg %) 17.88±26.4 29.8±34.38 43.91±21.56 0.026#

GCW (mmHg %) 71.58±39.55 57.73±36.33 104.81±24.94 0.037#