Purpose of the review Pregnancy induces cardiovascular adaptations, including increased cardiac output, blood volume, and heart rate, to support fetal development. These changes can sometimes unmask or exacerbate underlying myocardial dysfunction. Traditional echocardiographic measures, such as left ventricular ejection fraction (LVEF), often fail to detect subtle myocardial dysfunction. The purpose of this review is to evaluate the use of myocardial strain by echocardiography for early identification of myocardial impairment. Recent findings In pathological pregnancies, speckle-tracking echocardiography reveals subclinical myocardial dysfunction across various conditions. Women with gestational diabetes mellitus (GDM) exhibit significantly reduced LV global longitudinal strain (GLS), even in the absence of overt systolic dysfunction. They also have reduced right ventricular (RV) GLS, indicating biventricular dysfunction, and reduced left atrial (LA) reservoir and conduit strain, suggesting early diastolic dysfunction. Hypertensive disorders of pregnancy (HDP), such as preeclampsia and gestational hypertension, have been linked to lower GLS values reflecting early myocardial dysfunction before overt changes in LVEF. HDP also show reduced RV strain indices and altered LA mechanics. Additionally, women with peripartum cardiomyopathy (PPCM) exhibit markedly lower GLS, often below −15% (28). GLS at diagnosis has been shown to predict recovery outcomes, with lower strain values associated with prolonged hospitalization and higher rates of persistent cardiac dysfunction postpartum. PPCM also involves RV dysfunction and LA strain impairment correlating with unfavorable clinical outcomes. Lastly, obesity in pregnancy is associated with impaired myocardial deformation, including reduced LVGLS. Summary Strain echocardiography is a sensitive tool for early detection of myocardial dysfunction in pregnancies, aiding in risk stratification of women at increased risk of adverse cardiovascular outcomes. Key challenges exist including variability in reference ranges, operator dependency, and the need for cost-effective implementation in routine practice. Future research should focus on standardizing 2D strain imaging protocols and conducting longitudinal outcome studies. By bridging these gaps, strain imaging echocardiography can be used for earlier disease detection. Further research is needed to determine its role in optimizing risk stratification and improving cardiovascular health for both mother and offspring. Graphical abstract This figure shows representative comparative analysis of left ventricular global longitudinal strain (LVGLS) bullseye plots and time-to-strain curves, right ventricular global longitudinal strain (RVGLS) curves, and left atrial strain (LAS) curves in Peripartum Cardiomyopathy (left), Normal Pregnancy (center), and Chronic Hypertension (right). Center: Normal Pregnancy. Normal pregnancy demonstrates physiological adaptation to increased hemodynamic load. LVGLS: The bullseye plot shows a preserved and uniform strain distribution with a global longitudinal strain average of −21.0%. The time-to-peak longitudinal strain shows synchronized contraction across myocardial segments. LVGLS Time-to-Strain Curve: The curves demonstrate a tight, synchronous grouping with a peak systolic strain of −21.0%. RVGLS: The right ventricular global longitudinal strain is preserved, with a recorded value of −29.1% for the RV free wall and − 21.6% for the RV four-chamber longitudinal strain. LA Strain: Left atrial mechanics show robust function with a Reservoir Strain (LASr) of 41.8%, Conduit Strain (LAScd) of −38.4%, and Contractile Strain (LASct) of −3.4%. Left: Peripartum Cardiomyopathy (PPCM). PPCM illustrates severe, global biventricular and atrial impairment. LVGLS: The bullseye plot reveals a stark reduction in deformation, with a severely depressed global longitudinal strain average of −6.0%. LVGLS Time-to-Strain Curve: There is significant mechanical dyssynchrony and blunted systolic peaks, reflecting a profound loss of contractile function. RVGLS: Right ventricular function is markedly impaired, with an RV free wall strain of −12.2% and an RV four-chamber longitudinal strain of −9.3%. LA Strain: All phases of LA function are severely attenuated, showing a Reservoir Strain of only 7.9%, a Conduit Strain of −4.0%, and a Contractile Strain of −3.9%. Right: Chronic Hypertension. LVGLS: The bullseye plot shows an average global longitudinal strain of −19.1%, which is lower than the normal pregnancy control. There is evidence of regional variation, particularly in the basal segments. LVGLS Time-to-Strain Curve: The curves show a slightly reduced peak and increased dispersion compared to the normal pregnancy group, suggesting early mechanical remodeling. RVGLS: Right ventricular strain is mildly reduced compared to normal, with an RV free wall strain of −23.8% and an RV four chamber longitudinal strain of −27.0%. LA Strain: LA mechanics are impaired, particularly reservoir and conduit functions, with an LASr of 28.5%, an LAScd of −7.0%, and a compensatory increase in LASct to −21.5%.

Echocardiographic strain in pregnancy: distinguishing physiological and pathological changes

期刊论文
发表日期：

2026年4月10日

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Atika Azhar,
Cynthia C. Taub

摘要

Purpose of the review

Pregnancy induces cardiovascular adaptations, including increased cardiac output, blood volume, and heart rate, to support fetal development. These changes can sometimes unmask or exacerbate underlying myocardial dysfunction. Traditional echocardiographic measures, such as left ventricular ejection fraction (LVEF), often fail to detect subtle myocardial dysfunction. The purpose of this review is to evaluate the use of myocardial strain by echocardiography for early identification of myocardial impairment.

Recent findings

In pathological pregnancies, speckle-tracking echocardiography reveals subclinical myocardial dysfunction across various conditions. Women with gestational diabetes mellitus (GDM) exhibit significantly reduced LV global longitudinal strain (GLS), even in the absence of overt systolic dysfunction. They also have reduced right ventricular (RV) GLS, indicating biventricular dysfunction, and reduced left atrial (LA) reservoir and conduit strain, suggesting early diastolic dysfunction. Hypertensive disorders of pregnancy (HDP), such as preeclampsia and gestational hypertension, have been linked to lower GLS values reflecting early myocardial dysfunction before overt changes in LVEF. HDP also show reduced RV strain indices and altered LA mechanics. Additionally, women with peripartum cardiomyopathy (PPCM) exhibit markedly lower GLS, often below −15% (28). GLS at diagnosis has been shown to predict recovery outcomes, with lower strain values associated with prolonged hospitalization and higher rates of persistent cardiac dysfunction postpartum. PPCM also involves RV dysfunction and LA strain impairment correlating with unfavorable clinical outcomes. Lastly, obesity in pregnancy is associated with impaired myocardial deformation, including reduced LVGLS.

Summary

Strain echocardiography is a sensitive tool for early detection of myocardial dysfunction in pregnancies, aiding in risk stratification of women at increased risk of adverse cardiovascular outcomes. Key challenges exist including variability in reference ranges, operator dependency, and the need for cost-effective implementation in routine practice. Future research should focus on standardizing 2D strain imaging protocols and conducting longitudinal outcome studies. By bridging these gaps, strain imaging echocardiography can be used for earlier disease detection. Further research is needed to determine its role in optimizing risk stratification and improving cardiovascular health for both mother and offspring.

Graphical abstract

This figure shows representative comparative analysis of left ventricular global longitudinal strain (LVGLS) bullseye plots and time-to-strain curves, right ventricular global longitudinal strain (RVGLS) curves, and left atrial strain (LAS) curves in Peripartum Cardiomyopathy (left), Normal Pregnancy (center), and Chronic Hypertension (right). Center: Normal Pregnancy. Normal pregnancy demonstrates physiological adaptation to increased hemodynamic load. LVGLS: The bullseye plot shows a preserved and uniform strain distribution with a global longitudinal strain average of −21.0%. The time-to-peak longitudinal strain shows synchronized contraction across myocardial segments. LVGLS Time-to-Strain Curve: The curves demonstrate a tight, synchronous grouping with a peak systolic strain of −21.0%. RVGLS: The right ventricular global longitudinal strain is preserved, with a recorded value of −29.1% for the RV free wall and − 21.6% for the RV four-chamber longitudinal strain. LA Strain: Left atrial mechanics show robust function with a Reservoir Strain (LASr) of 41.8%, Conduit Strain (LAScd) of −38.4%, and Contractile Strain (LASct) of −3.4%. Left: Peripartum Cardiomyopathy (PPCM). PPCM illustrates severe, global biventricular and atrial impairment. LVGLS: The bullseye plot reveals a stark reduction in deformation, with a severely depressed global longitudinal strain average of −6.0%. LVGLS Time-to-Strain Curve: There is significant mechanical dyssynchrony and blunted systolic peaks, reflecting a profound loss of contractile function. RVGLS: Right ventricular function is markedly impaired, with an RV free wall strain of −12.2% and an RV four-chamber longitudinal strain of −9.3%. LA Strain: All phases of LA function are severely attenuated, showing a Reservoir Strain of only 7.9%, a Conduit Strain of −4.0%, and a Contractile Strain of −3.9%. Right: Chronic Hypertension. LVGLS: The bullseye plot shows an average global longitudinal strain of −19.1%, which is lower than the normal pregnancy control. There is evidence of regional variation, particularly in the basal segments. LVGLS Time-to-Strain Curve: The curves show a slightly reduced peak and increased dispersion compared to the normal pregnancy group, suggesting early mechanical remodeling. RVGLS: Right ventricular strain is mildly reduced compared to normal, with an RV free wall strain of −23.8% and an RV four chamber longitudinal strain of −27.0%. LA Strain: LA mechanics are impaired, particularly reservoir and conduit functions, with an LASr of 28.5%, an LAScd of −7.0%, and a compensatory increase in LASct to −21.5%.