Background <p>Previous studies have reported that left atrial (LA) and left ventricular (LV) strain at rest can predict exercise-induced elevated LV filling pressure. However, head to head comparison of LA and LV strain is very limited. The purpose of this study was to compare the peak atrial longitudinal stain (PALS) and LV global longitudinal strain (GLS) in the prediction of exercise-induced elevated LV filling pressure.</p> Methods <p>From January 2018 to December 2022, 286 consecutive patients underwent treadmill stress echocardiography. Patients with atrial fibrillation, septal E/e’ ≥ 15 at rest, and LV ejection fraction &lt; 50% were excluded from the study. Patients lacking PALS or GLS and those with exercise-induced LV wall motion abnormality were also excluded. Finally, 204 patients were enrolled to the analysis. All patients underwent symptom-limited treadmill stress echocardiography, and exercise-induced elevated LV filling pressure was defined as post-exercise septal E/e’ ≥ 15.</p> Results <p>Forty eight of the 204 patients had post-exercise septal E/e’ ≥ 15. Receiver operator characteristic curve analysis revealed the best cutoff value of 23.8% for PALS (sensitivity 67%, specificity 66%, respectively) and -17.7% for GLS (sensitivity 85%, specificity 65%, respectively) to predict post-exercise septal E/e’ ≥ 15. Univariate logistic analysis demonstrated that higher age, impaired PALS, impaired GLS, and raised septal E/e’ at rest were associated with post-exercise septal E/e’ ≥ 15. However, multivariate logistic analysis revealed that age, GLS, and E/e’ were independent predictors of post-exercise septal E/e’ ≥ 15, but PALS was not.</p> Conclusions <p>Both impaired PALS and GLS at rest can predict post-exercise septal E/e’ ≥ 15.0 modestly. However, multivariate logistic analysis has demonstrated that impaired GLS, not PALS, was an independent predictor of exercise-induced elevated LV filling pressure estimated by post-exercise septal E/e’ ≥ 15.</p>