Key Points:
- Individuals in rural areas have a particularly high prevalence of both clinical and subclinical heart failure (HF).
- Early detection of individuals at risk of progression to symptomatic HF may reduce occurrence and healthcare burden.
- Global longitudinal strain (GLS) is a recommended parameter to identify individuals at risk.
- In HERZCHECK, a GLS-based screening strategy was utilized to detect subclinical heart failure in rural areas.
- HERZCHECK demonstrated that subclinical HF affects approximately one-fourth of the rural at-risk population and GLS-based risk screening identified these individuals approximately 7 years earlier than standard of care.
Diagnosed cases of both symptomatic and asymptomatic heart failure (HF) are increasing around the world. This population is associated with substantial healthcare costs and increased rates of adverse cardiovascular events. The prevalence is particularly high in structurally weak, low-income regions. The early detection of subclinical cardiac dysfunction may reduce the incidence and socioeconomic burden of HF. The AHA/ACC/HFSA Guideline for the Management of Heart Failure recommends global longitudinal strain (GLS) as a parameter to diagnose structural heart failure and GLS is a predictor of risk for development of Stage B HF. In a featured clinical research presentation at the 2025 American College of Cardiology Scientific Sessions on Sunday, March 30, Dr. Sebastian Kelle on behalf of the HERZCHECK investigators reviewed the findings from HERZCHECK: “Mobile CMR to Improve Subclinical Heart Failure Detection in Rural Areas”. HERZCHECK is a monocentric, controlled, randomized clinical trial with blinded evaluation of endpoints which sought to assess GLS-based screening to improve early detection of subclinical heart failure in rural areas.
The HERZCHECK trial is a prospective, randomized controlled trial employing a prospective randomized open blinded endpoint design. The study targets asymptomatic adults aged 40–69 years without a history of HF, but with at least one of the following cardiovascular risk factors: hypertension, hypercholesterolemia, obesity, smoking/tobacco consumption, chronic diabetes mellitus, or chronic kidney disease. Participants undergo a comprehensive screening examination including a questionnaire-based medical history, laboratory testing, and CMR at baseline. Based on CMR-derived global longitudinal strain (GLS), participants are classified as stratum A (GLS < −15%), B (GLS ≥ −15% to < −11%), or C (GLS ≥ −11%), with strata B and C being defined as asymptomatic pre-HF. Ten percent of participants in stratum A and all of stratum B and C are subsequently randomized into two groups, receiving either conventional or innovative medical reports, the latter including information on GLS, guideline-based recommendations, and access to a lifestyle intervention app for cardiovascular prevention. Additionally, treating physicians of participants in the innovative group are granted access to an expert center for telemedical inquiries. Follow-up assessments are performed over 12 months to evaluate changes in GLS, as well as adverse cardiac events and quality of life.
Asymptomatic patients (40-69 years) with at least one cardiovascular risk factor underwent telemedically-supervised cardiac magnetic resonance (CMR) in mobile screening units at 12 sites. Subclinical HF was diagnosed using a previously defined cutoff of GLS ≥ -15%. An entropy-balanced historical control cohort was used to determine how much earlier patients were identified via the GLS-based screening compared with standard of care. Within two years, 4,509 patients underwent CMR and were included in the analysis. Sex was equally distributed (56% female), 46% of participants had ≥3 cardiac risk factors, and notably, 44% of participants had obesity. The prevalence of subclinical HF was 22.7% (95% CI [21.5%-23.9%]). Independent predictors of impaired GLS were male sex (OR 4.178; 95% CI [3.575-4.893]; p<0.001), obesity (OR 1.489; 95% CI [1.280-1.733]; p<0.001), diabetes (OR 1.714; 95% CI [1.441-2.038]; p<0.001), and smoking (OR 1.394; 95% CI [1.192-1.632]; p<0.001). Participants identified as having subclinical HF had significantly more HF hospitalization events at one year. Comparing patients diagnosed with subclinical HF to the entropy-balanced historical control cohort (n=8,420), the GLS-based screening routine identified patients 6.65 years earlier than standard of care.
When concluding his discussion at the ACC conference, Dr. Kelle stated: “The progression of subclinical heart failure significantly affects the patient, their family, the economy, and healthcare providers…This trial demonstrated the feasibility and added diagnostic value of CMR testing as part of future potential screening mechanisms for heart failure in rural areas.”