Highlight
HERZCHECK is the first large-scale, multicenter cross-sectional study to implement a fully mobile, telemedically supervised, contrast-free cardiac magnetic resonance imaging (MRI) screening algorithm for subclinical preheart failure (pre-HF) in rural and underresourced regions. The study revealed a high prevalence (22.7%) of subclinical pre-HF among at-risk individuals aged 40–69 with cardiovascular risk factors. Importantly, global longitudinal strain (GLS)-based screening identified subclinical pre-HF approximately 6.7 years earlier than symptom-based diagnosis under standard care, offering a critical window for targeted preventive interventions.
Study Background
Heart failure (HF) remains a global public health challenge, associated with significant morbidity, mortality, and healthcare costs. The burden is especially pronounced in rural and underresourced areas, where access to specialized cardiac diagnostics and care is limited. Early detection of HF, particularly at the subclinical preheart failure stage, offers an opportunity to implement interventions that can delay or prevent progression to symptomatic HF. However, current screening algorithms are lacking, partly due to the challenge of conducting cost-effective, standardized, and widely accessible cardiac assessments in resource-constrained settings.
Global longitudinal strain (GLS) measured via cardiac imaging has emerged as a sensitive marker of myocardial dysfunction preceding overt HF. Cardiovascular magnetic resonance imaging is the gold standard modality for cardiac function assessment, but often unavailable in mobile or rural settings due to infrastructure requirements and cost. Telemedicine offers potential for remote supervision and standardized interpretation, which can overcome barriers in underresourced regions.
Study Design
The HERZCHECK study was a prospective, cross-sectional cohort trial conducted between June 2021 and April 2023 at 12 rural and underresourced sites across Germany. The study enrolled 4666 asymptomatic participants aged 40–69 years who possessed at least one cardiovascular risk factor: obesity, smoking, arterial hypertension, diabetes, hypercholesterolemia, or chronic kidney disease. Of these, 4509 participants with complete datasets underwent telemedically supervised, contrast-free, short cardiac MRI scans performed within fully mobile screening units.
Subclinical preheart failure was defined by a predetermined cutoff of global longitudinal strain (GLS) ≥ -15%, a threshold allowing early detection of myocardial dysfunction before symptoms arise. For comparative analysis, an entropy-balanced, matched control cohort was constructed from claims data (n=8420), representing individuals diagnosed with HF under standard care pathways based on symptom development and clinical diagnosis.
Key Findings
The prevalence of subclinical preheart failure in this community-based, at-risk population was 22.7% (95% confidence interval 21.5%–23.9%), illustrating a substantial burden of early myocardial dysfunction. Screening via GLS detected these subclinical abnormalities on average 6.7 years (approximately 7 years) before the first symptomatic HF diagnosis under the standard care model.
This lead time represents a crucial opportunity for earlier preventive strategies to mitigate progression to symptomatic HF, such as optimized management of risk factors, lifestyle modification, and potentially tailored pharmacologic interventions. Importantly, the use of mobile, telemedically supervised MRI overcame traditional infrastructure limitations, permitting standardized, reproducible cardiac assessments directly in the community setting without contrast administration, thus improving feasibility and patient safety.
Further analyses within HERZCHECK reported no major safety concerns or adverse events related to the mobile cardiac MRI procedure. The telemedicine approach also facilitated remote expert supervision for image acquisition and interpretation, ensuring high-quality data despite geographically dispersed sites.
Expert Commentary
The HERZCHECK study addresses a critical gap in cardiology—the early identification of preclinical myocardial dysfunction in populations underserved by traditional healthcare infrastructures. As noted by experts in the field, early detection of subclinical HF aligns with emerging guideline recommendations advocating for proactive risk reduction and personalized intervention to halt disease progression.
While promising, some limitations warrant consideration. The study was conducted in Germany, and its generalizability to other regions and healthcare systems may require adaptation. The reliance on GLS alone, although sensitive, should ideally be complemented by biomarker or clinical risk stratification to refine screening specificity. Additionally, longitudinal follow-up data assessing intervention efficacy based on HERZCHECK screening results remain pending.
Nonetheless, mechanistically, detecting myocardial strain abnormalities reflects subclinical myocardial fibrosis and impaired contractility, consistent with well-characterized HF pathophysiology. Telemedicine-enhanced mobile CMR thus represents an innovative avenue combining cutting-edge imaging and digital health technologies to enhance early cardiac care delivery outside of hospital settings.
Conclusion
The HERZCHECK study demonstrated the feasibility and clinical utility of a telemedically supervised, mobile cardiac MRI screening protocol to detect subclinical preheart failure in at-risk populations residing in rural and underresourced areas. With a high prevalence of early myocardial dysfunction and the capability to identify disease nearly seven years before symptom onset, this approach provides a transformative opportunity for timely preventive cardiology.
Broader implementation of such screening programs could reduce the burden of symptomatic heart failure, optimize healthcare resource utilization, and improve long-term cardiovascular outcomes. Future research should focus on integrating multimodal biomarkers, validating cost-effectiveness, and establishing standardized intervention pathways based on early detection results.
Funding and Clinical Trials Registration
The HERZCHECK study was registered under ClinicalTrials.gov with the identifier NCT05122793. Details regarding funding sources were not explicitly provided in the abstract.
References
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