{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,9]],"date-time":"2026-08-09T16:43:17Z","timestamp":1786293797462,"version":"build-2736575974"},"reference-count":16,"publisher":"Wiley","issue":"5","license":[{"start":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T00:00:00Z","timestamp":1778544000000},"content-version":"vor","delay-in-days":11,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T00:00:00Z","timestamp":1777593600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Echocardiography"],"published-print":{"date-parts":[[2026,5]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The Charlson Comorbidity Index (CCI) is a validated mortality predictor in heart failure, but its utility in tracking subclinical left ventricular (LV) mechanics remains unclear. We evaluated the relationship between cumulative comorbidity burden, assessed by a modified CCI (mCCI), and LV mechanics using layer\u2010specific speckle tracking echocardiography and non\u2010invasive myocardial work (MW) analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Seventy\u2010one stable outpatients with preserved LVEF (\u226550%) and no overt heart failure or significant coronary artery disease were stratified by mCCI scores (adapted by excluding CAD and including hypertension): Group 1 (Low, 0\u20131), Group 2 (Intermediate, 2\u20133), Group 3 (High, \u22654). All underwent comprehensive echocardiography, layer\u2010specific strain, and pressure\u2010strain loop\u2010derived MW analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      While LVEF and epicardial GLS (Epi\u2010GLS) were preserved across groups, Group 3 showed significantly impaired endocardial GLS (Endo\u2010GLS) versus Group 1 (\u221219.7 \u00b1 2.9%\u00a0vs. \u221222.4 \u00b1 2.0%,\n                      <jats:italic>p<\/jats:italic>\n                      = 0.003), with a stepwise decrease in the transmural strain gradient (Endo\/Epi ratio;\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001). Global Wasted Work (GWW) (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.006) and Peak Systolic Dispersion (PSD) (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.002) increased progressively, while Global Work Efficiency (GWE) was reduced in the high\u2010risk group. On multivariate regression, mCCI independently predicted Endo\u2010GLS (\n                      <jats:italic>\u03b2<\/jats:italic>\n                      = 0.236,\n                      <jats:italic>p<\/jats:italic>\n                      = 0.021) and was the sole independent predictor of GWE (\n                      <jats:italic>\u03b2<\/jats:italic>\n                      = \u22120.394,\n                      <jats:italic>p<\/jats:italic>\n                      = 0.002), irrespective of age and systolic blood pressure. During a median 6\u2010month follow\u2010up, Group 3 had a higher composite event rate than Groups 1 and 2 (44.4%\u00a0vs. 7.4% and 11.1%; log\u2010rank\n                      <jats:italic>p<\/jats:italic>\n                      = 0.001).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>An increased comorbidity burden, assessed by the mCCI, is independently associated with subclinical myocardial dysfunction\u2014selective subendocardial impairment, increased wasted work, and mechanical inefficiency\u2014suggesting the mCCI may flag early mechanical uncoupling in preserved LVEF. Although these abnormalities correlated with adverse outcomes, their modest discriminative value (AUC 0.60\u20130.62) underscores the hypothesis\u2010generating nature of these findings, warranting validation in larger prospective cohorts.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/echo.70498","type":"journal-article","created":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T12:24:28Z","timestamp":1778588668000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Subclinical Myocardial Impairment Tracking the Comorbidity Burden: A Layer\u2010Specific Strain and Myocardial Work Analysis in Patients With Preserved Ejection Fraction"],"prefix":"10.1111","volume":"43","author":[{"given":"\u00d6zdemir","family":"Kuzucu","sequence":"first","affiliation":[{"name":"Department of Cardiology University of Health Sciences \u0130zmir Bayrakl\u0131 State Hospital  Izmir Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5863-8822","authenticated-orcid":false,"given":"Nazile Bilgin","family":"Do\u011fan","sequence":"additional","affiliation":[{"name":"Department of Cardiology University of Health Sciences \u0130zmir Bayrakl\u0131 State Hospital  Izmir Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-3068-7573","authenticated-orcid":false,"given":"Nuri Eren","family":"\u00d6get","sequence":"additional","affiliation":[{"name":"Department of Cardiology University of Health Sciences \u0130zmir Bayrakl\u0131 State Hospital  Izmir Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5087-2574","authenticated-orcid":false,"given":"Bar\u0131\u015f","family":"\u00dcnal","sequence":"additional","affiliation":[{"name":"Department of Cardiology University of Health Sciences \u0130zmir Bayrakl\u0131 State Hospital  Izmir Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,5,12]]},"reference":[{"key":"e_1_2_8_2_1","doi-asserted-by":"publisher","DOI":"10.1038\/nrcardio.2017.65"},{"key":"e_1_2_8_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2013.02.092"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.116.021884"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/0021\u20109681(87)90171\u20108"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCIMAGING.109.862334"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.echo.2012.10.008"},{"key":"e_1_2_8_8_1","doi-asserted-by":"publisher","DOI":"10.1002\/ejhf.2315"},{"key":"e_1_2_8_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.echo.2019.03.011"},{"key":"e_1_2_8_10_1","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehs016"},{"key":"e_1_2_8_11_1","doi-asserted-by":"publisher","DOI":"10.1053\/euje.2000.0031"},{"key":"e_1_2_8_12_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jtcvs.2007.10.088"},{"issue":"7","key":"e_1_2_8_13_1","first-page":"1478","article-title":"Subendocardial Texture Analysis for the Detection of Microvascular Ischemia","volume":"14","author":"Sorbets E.","year":"2021","journal-title":"JACC Cardiovasc Imaging"},{"key":"e_1_2_8_14_1","doi-asserted-by":"publisher","DOI":"10.1093\/ehjimp\/qyag007"},{"key":"e_1_2_8_15_1","doi-asserted-by":"publisher","DOI":"10.1093\/ehjci\/jev078"},{"key":"e_1_2_8_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcmg.2009.11.012"},{"issue":"10","key":"e_1_2_8_17_1","first-page":"1083","article-title":"Imaging Predictors of Response to Cardiac Resynchronization Therapy: Left Ventricular Work Asymmetry vs. Septal Flash","volume":"21","author":"Aalen J. 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