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Torsional and longitudinal deformations are essential components of left ventricular (LV) performance. The purpose of our study was to investigate which of the 2D strain parameters could be a good predictor of cardiac events in patients with heart failure (HF).Methods: Echocardiography was performed simultaneously with N-terminal pro-brain natriuretic peptide (NTproBNP) determination in 106 consecutive hospitalized patients with HF, in sinus rhythm, after appropriate medical treatment. Patients with inadequate echocardiographic images, paced rhythm, significant primary valvular heart disease, coronary revascularization during follow-up, severe pulmonary disease, malignant neoplasia or renal failure, were not included in this group. Peak early diastolic transmitral velocity/peak early mitral annular diastolic velocity ratio (E/E') and peak systolic mitral annular velocity (S') were determined; the average of the velocities from the septal and lateral site of the mitral annulus was used. The parasternal apical and basal short-axis planes were recorded. LV twist (LVtw = the net difference between rotation angles at base and apex) and LV torsion (LVtor = LVtw normalized for LV diastolic longitudinal length) were measured by 2D-strain imaging. LV global longitudinal strain (LV[Latin Small Letter Open E]) was obtained by averaging longitudinal peak systolic strain of all 17 LV-segments from apical planes (four-, three- and two-chamber view). The primary study end-point was definite as cardiac death or hospital readmission due to HF worsening.Results: During the follow-up period (23±5 months) cardiac events occurred in 49 patients (46.2%): 10 cardiac deaths (9.4%) and 39 hospital readmissions (36.7%). The multivariate Cox regression analysis including LV ejection fraction, S', E/E', LVtor, LVtw, LV[Latin Small Letter Open E] and NTproBNP as candidate variables, identified LV[Latin Small Letter Open E] as the best independent predictor of cardiac events (HR = 1.42, 95%CI = 1.10 - 1.84, p=0.006) in the study population. The optimal LV[Latin Small Letter Open E] cut-off to predict cardiac events was -6.55% (72% sensitivity and 74% specificity). Of our patients, 50 (47.2%) presented LV[Latin Small Letter Open E] > -6.55% and 56 (52.8%) presented LV[Latin Small Letter Open E] ≤ -6.55%. Kaplan–Meier analysis showed that the cardiac event-free survival rate during follow-up was significantly higher in the group of patients with LV[Latin Small Letter Open E] ≤ -6.55% than in the rest with LV[Latin Small Letter Open E] > -6.55% (75% versus 30%, p=0.007, log-rank).Conclusions: In patients with HF, LV[Latin Small Letter Open E] could be a powerful predictor of cardiac events.