Feasibility of subcostal vs. apical (four-chamber views) for global longitudinal strain in cancer patients

Ahmed Basuoni, Cardio-Oncology Unit, Sultan Qaboos Comprehensive Cancer Care and Research Centre, University Medical City, Muscat, Oman
Marwa Makhlouf, Cardio-Oncology Unit, Sultan Qaboos Comprehensive Cancer Care and Research Centre, University Medical City, Muscat, Oman
Hassan Alsayegh, Research Laboratories Department. Sultan Qaboos Comprehensive Cancer Care and Research Centre, University Medical City, Muscat, Oman
Sameera Khatri, Cardio-Oncology Unit, Sultan Qaboos Comprehensive Cancer Care and Research Centre, University Medical City, Muscat, Oman
Yasir Al-Malki, Cardio-Oncology Unit, Sultan Qaboos Comprehensive Cancer Care and Research Centre, University Medical City, Muscat, Oman
Noof Alkharousi, Cardio-Oncology Unit, Sultan Qaboos Comprehensive Cancer Care and Research Centre, University Medical City, Muscat, Oman
Waleed Dawelbeit, Cardio-Oncology Unit, Sultan Qaboos Comprehensive Cancer Care and Research Centre, University Medical City, Muscat, Oman

Global longitudinal strain (GLS) is a crucial echocardiographic parameter for early detection of subclinical left ventricular (LV) dysfunction in cancer patients receiving cardiotoxic therapies. However, standard apical views are often limited by patient factors such as obesity, chest wall deformities, radiation, or post-surgical reconstruction. This study evaluates the feasibility and reliability of the subcostal view for LV GLS assessment as an alternative imaging approach in cancer patients. A prospective cohort study was conducted at the Sultan Qaboos Comprehensive Cancer Care and Research Center between March and December 2024, involving 108 cancer patients (median age: 45 years, 88.9% female). Each patient contributed paired LV GLS measurements from subcostal and apical four-chamber views. Agreement between the two views was assessed, with −20% as the normal GLS cutoff. The agreement between LV longitudinal strain (LVLS) subcostal four-chamber view and LVLS apical four-chamber view readings was good, with an intraclass correlation coefficient (ICC: 0.634, p < 0.0001). The agreement between LV GLS subcostal four-chamber view and LV GLS apical four-chamber was excellent (ICC: 0.949, p < 0.0001). The subcostal view demonstrated 90.7% agreement with apical views in detecting abnormal GLS (< −20), with a Cohen’s Kappa of 0.754. Subcostal GLS was a strong predictor of apical GLS (area under the curve: 0.984), with an optimal threshold of −20.85 yielding 100% sensitivity and 92.31% specificity. The subcostal four-chamber view is a feasible and reliable alternative for LV GLS assessment in cancer patients.

Keywords: Global longitudinal strain. Subcostal view. Echocardiography. Cardio-oncology. Cardiotoxicity.