Heart and bipolar disorder: 'Hidden' contractility defects visible on echocardiography in young adults

A Taiwanese team (Taipei Medical University) published a paper in Biological Psychiatry, demonstrating that young adults with bipolar disorder (BD) show signs of subclinical systolic dysfunction of the heart at an early stage. The researchers compared 106 patients with BD and 54 healthy peers (20-45 years old) using advanced echocardiography - 2D speckle-tracking - and mapping according to the 17-segment AHA model. Even with preserved ejection fraction, patients with BD had worse key indicators: global longitudinal peak systolic strain (GLS) and "myocardial work" metrics (global work index, "constructive" and "lost" work). The disturbances affected segments corresponding to all three coronary basins. The authors call for earlier and more accurate assessment of the heart in people with BD, so as not to miss the path to heart failure.

Background of the study

Bipolar disorder (BD) is accompanied by a noticeable “cardiometabolic footprint”: patients are more likely to have obesity, hypertension, dyslipidemia, type 2 diabetes, and smoking, while affect fluctuations, chronic stress, and sleep disturbances increase sympathetic activation and inflammation. As a result, cardiovascular mortality in people with severe mental disorders is higher, and life expectancy is lower than in the population. At the same time, the contribution of drugs is ambiguous: some antipsychotics worsen weight gain and insulin resistance, and mood stabilizers require monitoring of the thyroid, kidneys, and electrolytes - all of which indirectly affect the heart.

Conventional echocardiography remains “normal” for a long time because the ejection fraction (EF) falls already at the late stages of myocardial dysfunction. Sensitive mechanical markers are needed for early detection of vulnerability. 2D speckle-tracking deformation analysis - primarily the global longitudinal strain (GLS) - detects “hidden” contractility failures with preserved EF (the less negative the GLS, the worse). Another layer is the “myocardial work” indicators (Global Work Index, Constructive/Wasted Work, Work Efficiency), which combine the deformation curve with noninvasively estimated LV pressure, so they are less dependent on the “load” and provide a more physiological picture of the contraction efficiency.

Until recently, most echocardiographic data on BD were from middle-aged and older patients with accumulated risk factors. The key question remained open: do young adults with BD have early, subclinical abnormalities in myocardial mechanics that anticipate heart failure and ischemic events? To answer this question, not only global indices are important, but also a regional map of 17 AHA segments, which allows us to link changes with coronary blood flow basins and microvascular dysfunction.

If such “subtle” markers are indeed worsened already at a young age, this changes the clinical tactics: cardiac risk in bipolar disorder should be proactively managed in a “psychiatrist-cardiologist” relationship, correction of blood pressure, lipids, body weight, physical activity and sleep should be started earlier; GLS and myocardial work should be considered as part of an extended screening in patients with risk factors or a long-term/severe course. This is a window of opportunity to catch reversible mechanisms before the fall in EF and clinical manifestations of heart failure.

Why is this important?

People with bipolar disorder have a 9-20 year lower life expectancy, and cardiovascular causes are a major contributor. Increased risks of MI and HF in severe mental illness are already known, but routine echocardiography is often “normal” until late stages. Subtle techniques such as strain and myocardial work pick up early mechanical failures of the ventricle, before ejection fraction has dropped. The new work shows that these “subtle” markers are already impaired in young adults with bipolar disorder, consistent with known epidemiological risks.

How was it carried out?

The study included 160 people: 106 with bipolar disorder and 54 without mental disorders. All of them underwent 2D speckle-tracking echocardiography according to the ASE/EACVI recommendations, GLS and four indices of myocardial work (Global Work Index, Global Constructive Work, Global Wasted Work, Global Work Efficiency) were calculated and compared globally and by 17 segments. The subgroup with preserved ejection fraction was analyzed separately. Result: bipolar disorder has worse GLS (Cohen's d≈1.08; p<0.001), lower global index and "constructive" work (d≈0.49 and 0.81), and higher "lost" work (d≈0.11; p=0.048). The pattern of damage is multisegmental - with the involvement of zones corresponding to the LAD, OB and RCA.

What does this mean in practice?

The main conclusion: even in young patients with bipolar disorder and “normal EF,” the heart does not work perfectly - there are signs of reduced contractility and ineffective “work” of the myocardium. This is a window of opportunity for prevention and early correction of risk factors (body weight, lipids, blood pressure), revision of cardiotropic therapy, as well as closer cooperation between psychiatrists and cardiologists. Independent media emphasize: such metrics should be considered as part of cardio-screening for bipolar disorder in order to catch vulnerability before the clinical presentation of heart failure.

What's new compared to previous studies

Previously, echocardiographic signals in BAR were more often found in people after middle age or with obvious risk factors; often only global indicators were assessed. Here:

• Young cohort (20-45 years) with already measurable mechanism-shifts, despite preserved EF.
• Regional analysis on a 17-segment map linking mechanics to coronary perfusion (three basins).
• The emphasis on myocardial work is an integral indicator that takes into account not only deformation, but also pressure load, which makes the conclusions physiologically more meaningful than GLS alone.

Possible mechanisms (authors' hypotheses and context)

Why does the myocardium "slip" in BAR? Several lines converge: endothelial dysfunction, microvascular disorders, inflammation and metabolic shifts (including lipid), as well as the effect of drugs and episodes of affect on vegetative and hemodynamics. The regional picture, coinciding with the zones of three arteries, suggests the role of the coronary microcirculatory bed and the mismatch of perfusion to the load. Studies are needed that link microvascular tests and strain/work in BAR.

Who and when should undergo “thin” echocardiography?

The authors do not make direct clinical recommendations, but reasonable approaches emerge from the data and context:

• Who should be treated first: young adults with bipolar disorder and comorbid risk factors (hypertension, dyslipidemia, obesity, smoking), patients with a long-term course or repeated affective episodes.
• What to look at: in addition to standard echocardiography - GLS and myocardial work (GWI, GCW, GWW, GWE) globally and by segment.
• Why: to start cardiac prevention earlier and individualize therapy; repeated measurements - to assess the dynamics during treatment of bipolar disorder and to correct risk factors.

Limitations and what's next

This is a single-center, cross-sectional study; not all possible influences (bipolar phases, duration, treatment regimens) are equally represented. It is not possible to assert causality: bipolar → heart or common risk factors → heart and bipolar → heart. Longitudinal studies are needed, head-to-head comparisons with coronary microvascular function and verification whether cardiometabolic interventions (diet, activity, treatment of hypertension/dyslipidemia) improve GLS/myocardial function in bipolar → and whether they reduce the risk of HF. Nevertheless, the fact of multisegmental abnormalities in young adults with bipolar → heart disease is confirmed and should change the clinical optics.

Short lists - so as not to lose the essence

Key numbers and effects:

• n=160 (BAR 106; control 54; 20-45 years).
• Worse GLS (d≈1.08; p<0.001); lower GWI (d≈0.49; p=0.019) and GCW (d≈0.81; p<0.001); higher than GWW (d≈0.11; p=0.048).
• Disturbances in all major coronary basins; EF is preserved.

Practical conclusions for the psychiatrist-cardiologist team:

• Add GLS + myocardial work to the cardiac assessment in BD, especially in patients with risk factors.
• Strengthen multidisciplinary management: correction of blood pressure, lipids, body weight - in parallel with the treatment of bipolar disorder.
• Plan for follow-up: Repeated “fine” echometry can provide clues as to where interventions are working.

Study source: Hsiao CY. et al. Impaired Global and Regional Peak Systolic Strain and Myocardial Work in Young Adults With Bipolar Disorder. Biological Psychiatry. Online ahead of print July 5, 2025; doi:10.1016/j.biopsych.2025.06.021.