Chronic heart failure has been divided into 4 stages that range from pre-heart failure (PHF), a state of high risk of developing myocardial dysfunction, to advanced chronic heart failure {CHF). The primary risk factors of PHF are: Western diet, tobacco use, alcoholism, chronic mental disorders that are known to predispose to biological risk factors (obesity, hypertension, myocardial infarction and cardiomyopathy). Both types of risk factors can damage the myocytes, leading to cardiac hypertrophy and alterations in the size and shape of cardiomyocytes to condition from physiological subcellular remodeling to pathological or deformation, definable as PHF. Oxidative stress, development of intracellular Ca2+ overload, activeation of proteases and phospholipases, mitochondrial dysfunction, and alterations in cardiac gene expression result in changes in the biochemical composition, molecular structure, and function of different subcellular organelles with pathological subcellular remodeling or myocardial deformation. The subcellular remodeling may be intimately involved in the transition of cardiac hypertrophy or cardiac deformation to heart failure. CHF may be associated with increase in ACE in the tissues with increase in brain RAAS activity in association with cardiac hypertrophy. The observed changes in the shape and size of cardiomyocytes are considered cardiac remodeling, which are known to explain cardiac dysfunction in heart failure but may be physiological. These physio-pathological markers of PHF could be examined via imaging for the diagnosis of global longitudinal strain (GLS) and other myocardial strains. In clinical practice, GLS and area strain have been shown to be more reproducible and more useful compared to circumferential and radial strains. They have been demonstrated to be as accurate as sonomicrometry and magnetic resonance imaging (MRI) in several conditions related to health and diseases. There is a gap in the knowledge that heart failure with preserved ejection fraction (HFpEF), which also includes PHF, can be effectively treated by current therapy. 2D and 3D speckle tracking echocardiography have been used to quantify regional alterations of longitudinal strain and area strain through their polar projection, which allows a further evaluation of both the site and extent of myocardial damage that may be important in clinical decision-making. 2D and 3D speckle tracking echocardiography parameters indicating myocardial deformation (stage B heart failure) are reduction in left ventricular(LV) longitudinal strain, LV circumferential strain, circumferential peak systolic strain rate (SR), circumferential peak early diastolic SR, right ventricular longitudinal strain, and longitudinal peak systolic SR. The degree of abnormality may depend on quality of machine. The analysis of strain increases sensitivity in detecting subclinical cardiac failure in cardiomyopathies, cancer chemotherapy and acute coronary syndromes (ACS). Strain is frequently attenuated in these conditions and can be utilized for the evaluation of disease progression and the effect of therapeutic interventions.
