Diagnostic Accuracy of Tissue Doppler Index E/e' for Evaluating Left Ventricular Filling Pressure and Diastolic Dysfunction/Heart Failure With Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

COMPARISON OF TWO THICK SHELL MODELS PERFORMANCE IN NONINVASIVE EVALUATION OF MYOCARDIAL WALL STRESS

Coronary artery stenosis is the most common heart disease, leading to altered myocardial mechanics. This study aimed to compare Ghista–Sandler and Mirsky wall stress models and evaluate the discriminant analysis of noninvasive wall stress based on these models. 59 Coronary artery disease (CAD) patients were divided into two groups; moderate stenosis and severe stenosis in the left anterior descending artery proximal part were enrolled in this study. The wall stress in the end-systolic and end-diastolic phases at LV anterior and interventricular septum wall segments calculated by using the equation proposed by Ghista–Sandler and Mirsky. The specificity and sensitivity of wall stress at groups were calculated by Ghista–Sandler and Mirsky models. The wall thickness and principal radius of segments in healthy subjects and patients with severe and moderate stenosis were shown statistically differences in some segments of anterior and septum walls ([Formula: see text]). Statistical analysis showed that calculated stresses in myocardial wall segments of patients with severe and moderate coronary stenosis and healthy people had a significant difference in systole and diastolic phase. Results of the discriminant analysis showed the specificity value obtained by the Ghista–Sandler model were higher in most wall stress combinations than the Mirsky model. Sensitivity in identifying patients with severe stenosis was higher in the Ghista–Sandler model. It is concluded that specificity and sensitivity based on wall stresses calculated by the Ghista–Sandler model were higher in comparison with the Mirsky model. The Ghista–Sandler model has better performance than the Mirsky model in diagnosing patients with stenosis.

Machine Learning Augmented Echocardiography for Diastolic Function Assessment

Cardiac diastolic dysfunction is prevalent and is a diagnostic criterion for heart failure with preserved ejection fraction—a burgeoning global health issue. As gold-standard invasive haemodynamic assessment of diastolic function is not routinely performed, clinical guidelines advise using echocardiography measures to determine the grade of diastolic function. However, the current process has suboptimal accuracy, regular indeterminate classifications and is susceptible to confounding from comorbidities. Advances in artificial intelligence in recent years have created revolutionary ways to evaluate and integrate large quantities of cardiology data. Imaging is an area of particular strength for the sub-field of machine-learning, with evidence that trained algorithms can accurately discern cardiac structures, reliably estimate chamber volumes, and output systolic function metrics from echocardiographic images. In this review, we present the emerging field of machine-learning based echocardiographic diastolic function assessment. We summarise how machine-learning has made use of diastolic parameters to accurately differentiate pathology, to identify novel phenotypes within diastolic disease, and to grade diastolic function. Perspectives are given about how these innovations could be used to augment clinical practice, whilst areas for future investigation are identified.

Stress Echo 2030: The Novel ABCDE-(FGLPR) Protocol to Define the Future of Imaging

With stress echo (SE) 2020 study, a new standard of practice in stress imaging was developed and disseminated: the ABCDE protocol for functional testing within and beyond CAD. ABCDE protocol was the fruit of SE 2020, and is the seed of SE 2030, which is articulated in 12 projects: 1-SE in coronary artery disease (SECAD); 2-SE in diastolic heart failure (SEDIA); 3-SE in hypertrophic cardiomyopathy (SEHCA); 4-SE post-chest radiotherapy and chemotherapy (SERA); 5-Artificial intelligence SE evaluation (AI-SEE); 6-Environmental stress echocardiography and air pollution (ESTER); 7-SE in repaired Tetralogy of Fallot (SETOF); 8-SE in post-COVID-19 (SECOV); 9: Recovery by stress echo of conventionally unfit donor good hearts (RESURGE); 10-SE for mitral ischemic regurgitation (SEMIR); 11-SE in valvular heart disease (SEVA); 12-SE for coronary vasospasm (SESPASM). The study aims to recruit in the next 5 years (2021-2025) ≥10,000 patients followed for ≥5 years (up to 2030) from ≥20 quality-controlled laboratories from ≥10 countries. In this COVID-19 era of sustainable health care delivery, SE2030 will provide the evidence to finally recommend SE as the optimal and versatile imaging modality for functional testing anywhere, any time, and in any patient.

Pirfenidone in heart failure with preserved ejection fraction: a randomized phase 2 trial

In heart failure with preserved ejection fraction (HFpEF), the occurrence of myocardial fibrosis is associated with adverse outcome. Whether pirfenidone, an oral antifibrotic agent without hemodynamic effect, is efficacious and safe for the treatment of HFpEF is unknown. In this double-blind, phase 2 trial ( NCT02932566 ), we enrolled patients with heart failure, an ejection fraction of 45% or higher and elevated levels of natriuretic peptides. Eligible patients underwent cardiovascular magnetic resonance and those with evidence of myocardial fibrosis, defined as a myocardial extracellular volume of 27% or greater, were randomly assigned to receive pirfenidone or placebo for 52 weeks. Forty-seven patients were randomized to each of the pirfenidone and placebo groups. The primary outcome was change in myocardial extracellular volume, from baseline to 52 weeks. In comparison to placebo, pirfenidone reduced myocardial extracellular volume (between-group difference, -1.21%; 95% confidence interval, -2.12 to -0.31; P = 0.009), meeting the predefined primary outcome. Twelve patients (26%) in the pirfenidone group and 14 patients (30%) in the placebo group experienced one or more serious adverse events. The most common adverse events in the pirfenidone group were nausea, insomnia and rash. In conclusion, among patients with HFpEF and myocardial fibrosis, administration of pirfenidone for 52 weeks reduced myocardial fibrosis. The favorable effects of pirfenidone in patients with HFpEF will need to be confirmed in future trials.

Intraoperative diastolic function assessed by TEE does not agree with preoperative diastolic function grade in CABG patients

OBJECTIVE

To compare the agreement of the 2016 ASE/EACVI guidelines for grading diastolic dysfunction (DD) with the most commonly used intraoperative transesophageal echocardiography (TEE)-based diastolic function grading algorithm in cardiac surgical patients, and to describe the contribution of the echocardiographic variables used in the algorithms to any observed differences.

DESIGN

Retrospective data analysis.

SETTING

University tertiary medical center.

PARTICIPANTS

Hundred and one patients undergoing coronary artery bypass grafting (CABG) at a single institution from June 2017 to February 2019.

INTERVENTIONS

Preoperative transthoracic echocardiography (TTE) diastolic function grade determined by the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines was compared to intraoperative diastolic function grade obtained by TEE.

MEASUREMENTS AND MAIN RESULTS

Incidence of DD on preoperative TTE was only 19.8%, while 62.3% of patients were graded as having DD on the intraoperative TEE exam. There was grade agreement between TTE and TEE in only 47/101 patients (46.5%). The McNemar test showed poor agreement between the two algorithms (OR for disagreement = 15.33, CI = 4.77-49.30; p < 0.0001). Despite the low incidence of DD on preoperative TTE, mean lateral e' values were significantly lower on TTE compared to TEE (7.7 cm/s vs 9.5 cm/s; p = < 0.0001).

CONCLUSIONS

There is strong disagreement between TTE and TEE-based DD grading algorithms. Due to the different echocardiographic variables used in each and the unique clinical settings in which they are applied, they produce fundamentally different results.

Current clinical applications of spectral tissue Doppler echocardiography (E/e' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved ejection fraction. Revisited 15 years later

It is currently well established that more than half of heart failure patients have preserved ejection fraction. The diagnosis of heart failure with preserved ejection fraction is complex in clinical practice despite ESC recommendations issued in 2019. In this context, the demonstration of increased left ventricular filling pressures at rest or during exercise allows a definite diagnosis of heart failure with preserved ejection fraction in patients with signs and/or symptoms compatible with the diagnosis and a preserved ejection fraction. The spectral tissue Doppler-derived E/e' ratio by transthoracic Doppler echocardiography has been validated in the noninvasive assessment of left ventricular diastolic pressures at rest and during exercise. Several studies report the validity of E/e' in the diagnosis of heart failure with preserved ejection fraction in patients with both isolated exertional and acute dyspnea, as well as in risk stratification. In light of the current literature, E/e' deserves to be included on every transthoracic Doppler echocardiography report in patients with suspected heart failure with preserved ejection fraction. This updated review provides an overview of the diagnostic relevance of E/e' in patients in its two modes of clinical presentation, isolated exertional dyspnea and the decompensated congestive form.

Invasive validation of the left ventricular global longitudinal strain for estimating left ventricular filling pressure

PURPOSE

An elevated left ventricular (LV) filling pressure is the main finding in heart failure patients with preserved ejection fraction, which is estimated with an algorithm using echocardiographic parameters recommended by the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines. In this study, we sought to determine the efficacy of the LV global longitudinal strain (GLS) in predicting an elevated LV filling pressure.

METHODS AND RESULTS

A total of 73 prospectively selected patients undergoing LV catheterization (mean age 63.19 ± 9.64, 69% male) participated in this study. Using the algorithm, the LV filling pressure was estimated using the echocardiographic parameters obtained within 24 hours before catheterization. The LV GLS was measured using an automated functional imaging system (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to the mean left atrial pressure (LAP) was used as a reference, and a LAP of >12 mm Hg was defined as elevated. Invasive LV filling pressure was elevated in 43 patients (59%) and normal in 30 patients (41%). Nine of 73 (12%) patients were defined as indeterminate based on the 2016 algorithm. Using the ROC method, -18.1% of LV GLS determined the elevated LAP (AUC =0.79; specificity, 73%; sensitivity, 84%) with better sensitivity compared to that by the algorithm (AUC =0.76; specificity, 77%; sensitivity, 72%).

CONCLUSIONS

We demonstrated that LV GLS was an independent predictor of elevated LAP as the E/e' ratio and TR jet velocity and may be used as a major criterion for the diagnosis of HFpEF.

Risk stratification with echocardiographic biomarkers in heart failure with preserved ejection fraction: the media echo score

AIMS

Echocardiographic predictors of outcomes in heart failure with preserved ejection fraction (HFpEF) have not been systematically or independently validated. We aimed at identifying echocardiographic predictors of cardiovascular events in a large cohort of patients with HFpEF and to validate these in an independent large cohort.

METHODS AND RESULTS

We assessed the association between echocardiographic parameters and cardiovascular outcomes in 515 patients with heart failure with preserved left ventricular (LV) ejection fraction (>50%) in the MEtabolic Road to DIAstolic Heart Failure (MEDIA) multicentre study. We validated out findings in 286 patients from the Karolinska-Rennes Prospective Study of HFpEF (KaRen). After multiple adjustments including N-terminal pro-brain natriuretic peptide (NT-proBNP), the significant predictors of death or cardiovascular hospitalization were pulmonary arterial systolic pressure > 40 mmHg, respiratory variation in inferior vena cava diameter > 0.5, E/e' > 9, and lateral mitral annular s' < 7 cm/s. The combination of these four variables differentiated patients with <10% vs. >35% 1 year risk. Adding these four echocardiographic variables on top of clinical variables and NT-proBNP yielded significant net reclassification improvement (33.8%, P < 0.0001) and increase in C-index (5.3%, a change from 72.2% to 77.5%, P = 0.015) of similar magnitude as the addition of NT-proBNP on top of clinical variables alone. In the KaRen cohort, these four variables yielded a similar improvement in net reclassification improvement (22.3%, P = 0.014) and C-index (4.0%, P = 0.029).

CONCLUSIONS

Use of four simple echocardiographic parameters (within the MEDIA echo score), indicative of pulmonary hypertension, elevated central venous pressure, LV diastolic dysfunction, and LV long-axis systolic dysfunction, independently predicted prognosis and improved risk stratification additionally to clinical variables and NT-proBNP in HFpEF. This finding was validated in an independent cohort.

Estimation of Pulmonary Artery Occlusion Pressure Using Doppler Echocardiography in Mechanically Ventilated Patients

OBJECTIVES

Evaluation of left atrial pressure is frequently required for mechanically ventilated critically ill patients. The objective of the present study was to evaluate the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for assessment of the pulmonary artery occlusion pressure (a frequent surrogate of left atrial pressure) in this population.

DESIGN

A pooled analysis of three prospective cohorts of patients simultaneously assessed with a pulmonary artery catheter and echocardiography.

SETTINGS

Medical-surgical intensive care department of two university hospitals in France.

PATIENTS

Mechanically ventilated critically ill patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 98 included patients (males: 67%; mean ± SD age: 59 ± 16; and mean Simplified Acute Physiology Score 2: 54 ± 20), 53 (54%) experienced septic shock. Using the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, the predicted pulmonary artery occlusion pressure was indeterminate in 48 of the 98 patients (49%). Of the 24 patients with an elevated predicted left atrial pressure (grade II/III diastolic dysfunction), only 17 (71%) had a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg. Similarly, 20 of the 26 patients (77%) with a normal predicted left atrial pressure (grade I diastolic dysfunction) had a measured pulmonary artery occlusion pressure less than 18 mm Hg. The sensitivity and specificity of American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for predicting elevated pulmonary artery occlusion pressure were both 74%. The agreement between echocardiography and the pulmonary artery catheter was moderate (Cohen's Kappa, 0.48; 95% CI, 0.39-0.70). In a proposed alternative algorithm, the best echocardiographic predictors of a normal pulmonary artery occlusion pressure were a lateral e'-wave greater than 8 (for a left ventricular ejection fraction ≥ 45%) or an E/A ratio less than or equal to 1.5 (for a left ventricular ejection fraction < 45%).

CONCLUSIONS

The American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines do not accurately assess pulmonary artery occlusion pressure in ventilated critically ill patients. Simple Doppler measurements gave a similar level of diagnostic performance with less uncertainly.

The E/e' Ratio-Role in Risk Stratification of Acute Heart Failure with Preserved Ejection Fraction

Background and Objectives: Heart failure with preserved ejection fraction (HFpEF) remains a worldwide management problem. Although there is a general effort for characterizing this population, few studies have assessed the predictive value of the echocardiographic E/e’ ratio in patients with acute HFpEF. The aim of the study was to identify groups with different prognosis in patients hospitalized with a first acute episode of HFpEF. Materials and Methods: The primary endpoint of the study was heart failure readmissions (HFR) at 6 months, while the secondary outcome was six-month mortality. We consecutively enrolled 91 patients hospitalized for the first time with acute HFpEF. We examined the E/e’ ratio as an independent predictor for HFR using univariate regression. Results: We identified and validated the E/e’ ratio as an independent predictor for HFR. An E/e’ ratio threshold value of 13.80 was calculated [(area under the receiver operating characteristic curve (AUROC) = 0.693, sensitivity = 78.60%, specificity = 55%, p < 0.004)] and validated as an inflection point for an increased number of HFR. Thus, we divided the study cohort into two groups: group 1 with an E/e’ ratio < 13.80 (n = 39) and group 2 with an E/e’ ratio > 13.80 (n = 49). Compared to group 1, group 2 had an increased number of HFR (p = 0.003) and a shorter time to first HFR (p = 0.002). However, this parameter did not influence all-cause mortality within six months (p = 0.84). Conclusions: The dimensionless E/e’ ratio is a useful discriminator between patients with acute HFpEF. An E/e’ value over 13.80 represents a simple, yet effective instrument for assessing the HFR risk. However, all-cause mortality at six months is not influenced by the E/e’ ratio.

LA reservoir strain: a sensitive parameter for estimating LV filling pressure in patients with preserved EF

An elevated left ventricular (LV) filling pressure is the main finding in patients with heart failure with preserved ejection fraction (HFpEF), and LV filling pressure is estimated with an algorithm in the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guideline. In this study, we sought to determine the efficacy of LA global longitudinal strain to estimate elevated LV filling pressure. Seventy-one consecutive patients (mean age of 63.2  ±  9.75, 70% male) who underwent left ventricular catheterization were included. Transthoracic echocardiography was performed within 24 h before catheterization. The LV filling pressure was estimated using echo parameters based on the 2016 ASE/EACVI algorithm. LA GLS was measured using 2D speckle tracking echocardiography in a four-chamber view (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to the mean left atrial pressure (LAP) was used as a reference, and > 12 mm Hg was defined as elevated. Invasive LV filling pressure was defined as elevated in 41 (58%) and normal in 30 patients (42%). The LV filling pressure of 9 (13%) of 71 patients was defined as indeterminate based on the 2016 algorithm. Using the ROC method, 25.5% of LA reservoir strain (LASr) had a higher sensitivity (AUC = 0.79, specificity 77%, sensitivity 80%) in estimating LV filling pressure than the 2016 ASE/EACVI algorithm (AUC = 0.75, specificity 77%, sensitivity 70%). LASr, with higher sensitivity than 2016 ASE/EACVI algorithm, may be used as a single parameter to estimate LV filling pressure and hence may add incremental value toHFpEF diagnosis.

Tissue Doppler Imaging (E/e') and Pulmonary Capillary Wedge Pressure in Patients With Severe Aortic Stenosis

OBJECTIVE

Although American and European consensus statements advocate using the ratio of the transmitral E velocity and tissue Doppler early diastolic mitral annular velocity (E/e') in the assessment of left-sided heart filling pressures, recent reports have questioned the reliability of this ratio to predict left atrial pressures in a variety of disease states. The authors hypothesized that there is a clinically significant correlation between E/e' and pulmonary capillary wedge pressure (PCWP) in patients with severe aortic stenosis.

DESIGN

Retrospective cohort study.

PARTICIPANTS

The study comprised 733 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve replacement for severe aortic stenosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

PCWP and E/e'_ave (average of the lateral and medial annulus tissue Doppler velocities) were measured with a pulmonary artery catheter and transthoracic echocardiography during preprocedural evaluation. Patients were grouped by left ventricular ejection fraction (LVEF) ≥50% and LVEF <50%. Spearman rank correlation, analysis of variance, and t and chi-square tests were used to analyze the data. Seventy-nine patients met the inclusion criteria. There was no significant correlation between E/e'_ave and PCWP (n = 79, Spearman r = 0.096; p = 0.3994). This correlation did not improve when ventricular function was considered (LVEF <50%: n = 11, Spearman r = -0.097; p = 0.776 and LVEF ≥50%: n = 68, Spearman r = 0.116; p = 0.345). There was no statistically significant difference in mean PCWP between each range of E/e'_ave.

CONCLUSION

A clinically relevant relationship between E/e' and PCWP was not observed in patients with severe aortic stenosis.

Echocardiography 2020: Toward deciphering the "Rosetta stone" of left ventricular diastolic function

In the year 1997, nearly a quarter-century ago, Nishimura and Tajik (J Am Coll Cardiol. 1997;30:8) suggested that Doppler echocardiography was the "Rosetta stone" (a metaphor for decrypting secrets of diastole) of left ventricular diastole, based solely on transmitral E/A ratio and its progression from grade I through IV, supported by cardiac catheterization, as the filling pressure started to increase to over 15 mm Hg. Ten years later, in 2007, the same Mayo group (Nagueh et al, J Am Coll Cardiology. 2008;51:679) was searching to decipher the secrets of diastole using multiple measures such as left atrial (LA) volume, E/E' ratio, pulmonary venous flow, and mitral inflow propagation velocity. This substantial leap from E/A ratio led to the more formal recommendation proposed by the American Society of Echocardiography in 2009 (Nagueh et al, J Am Soc Echocardiogr. 2009;22:107) and, as an update, in the year 2016 (Nagueh et al, J Am Soc Echocardiogr. 2016;29:277): the later version gained popularity for the simplified approach to identify diastolic dysfunction in healthy subjects as well as in those with poorly contracting left ventricle. Despite 30 years of continuous search, we are not sure if we have been able to decipher the hidden secrets of diastolic function. With this background, the Echocardiography Journal under the leadership of Dr Navin Nanda as the Editor-in-Chief has taken this initiative to publish a theme issue on left ventricular diastolic function and when this becomes dysfunctional to diminish life.

The role of systolic-diastolic coupling in distinguishing impaired diastolic recoil in healthy aging and heart failure with preserved ejection fraction

BACKGROUND

Age-related changes to left ventricular (LV) early diastolic recoil confound the diagnostic value of e' velocity in heart failure with preserved ejection fraction (HFpEF). Systolic-diastolic coupling quantifies passive left ventricular elastic recoil and may be superior to e' in differentiating abnormal diastolic recoil in HFpEF from healthy aging. This study aims to determine the effect of healthy aging and HFpEF on systolic-diastolic coupling.

METHODS

Healthy adults (n = 141, aged 20-90 years) underwent right heart catheterization (RHC) to quantify LV filling pressure and tissue Doppler echocardiography to define peak velocities and excursion (velocity time integral) of the mitral annulus. Separately, HFpEF patients (n = 12, age 67 ± 5 years) and controls (n = 12, age 68 ± 5 years) underwent RHC and echocardiography. Systolic-diastolic coupling was measured as early diastolic excursion (ED_exc ) divided by systolic excursion (S_exc ).

RESULTS

In healthy adults, ED_exc / S_exc declined by 15% per decade of life (r²  = 0.53, P < .001). ED_exc /S_exc was significantly lower in HFpEF compared with controls (0.43 ± 0.11 vs 0.56 ± 0.11, P = .011), while e' was similar (6.2 ± 1.5 vs 6.8 ± 1.3 cm/s, P = .33). Using ROC analysis, ED_exc /S_exc had an AUC to detect HFpEF of 0.82 (0.61-0.95, P = .007), which was superior to e' alone (AUC 0.60(0.39-0.80), P = .39; P = .026 for difference).

CONCLUSIONS

Systolic-diastolic coupling, quantified by the ED_exc /S_exc ratio, declined linearly with healthy aging. The ED_exc /S_exc ratio was further reduced in HFpEF and able to predict HFpEF more accurately than e' alone. Systolic-diastolic coupling may be a useful diagnostic tool to detect HFpEF.

Association between insulin resistance and left ventricular hypertrophy in asymptomatic, Black, sub-Saharan African, hypertensive patients: a case-control study

Background

Conflicting information exists regarding the association between insulin resistance (IR) and left ventricular hypertrophy (LVH). We described the associations between obesity, fasting insulinemia, homeostasis model assessment of insulin resistance (HOMA-IR), and LVH in Black patients with essential hypertension.

Methods

A case–control study was conducted at the Centre Médical de Kinshasa (CMK), the Democratic Republic of the Congo, between January and December 2019. Cases and controls were hypertensive patients with and without LVH, respectively. The relationships between obesity indices, physical inactivity, glucose metabolism and lipid disorder parameters, and LVH were assessed using linear and logistic regression analyses in simple and univariate exploratory analyses, respectively. When differences were observed between LVH and independent variables, the effects of potential confounders were studied through the use of multiple linear regression and in conditional logistic regression in multivariate analyses. The coefficients of determination (R²), adjusted odds ratios (aORs), and their 95% confidence intervals (95% CIs) were calculated to determine associations between LVH and the independent variables.

Results

Eighty-eight LVH cases (52 men) were compared against 132 controls (81 men). Variation in left ventricular mass (LVM) could be predicted by the following variables: age (19%), duration of hypertension (31.3%), body mass index (BMI, 44.4%), waist circumference (WC, 42.5%), glycemia (20%), insulinemia (44.8%), and HOMA-IR (43.7%). Hypertension duration, BMI, insulinemia, and HOMA-IR explained 68.3% of LVM variability in the multiple linear regression analysis. In the logistic regression model, obesity increased the risk of LVH by threefold [aOR 2.8; 95% CI (1.06–7.4); p = 0.038], and IR increased the risk of LVH by eightfold [aOR 8.4; 95 (3.7–15.7); p < 0.001].

Conclusion

Obesity and IR appear to be the primary predictors of LVH in Black sub-Saharan African hypertensive patients. The comprehensive management of cardiovascular risk factors should be emphasized, with particular attention paid to obesity and IR. A prospective population-based study of Black sub-Saharan individuals that includes the use of serial imaging remains essential to better understand subclinical LV deterioration over time and to confirm the role played by IR in Black sub-Saharan individuals with hypertension.

Echocardiographic diagnosis of left ventricular diastolic dysfunction: Impact of coronary artery disease

BACKGROUND

In 2016, the American Society of Echocardiography (ASE) released guidelines for identifying left ventricular (LV) diastolic dysfunction (DD), but its ability to detect early hemodynamic abnormalities is not well established, especially in the setting of subclinical coronary artery disease (CAD). We hypothesize that the accuracy of ASE categorization of early LVDD is affected by knowledge of whether CAD history is present.

METHODS

We studied 34 patients (age 62 ± 7 years) with NYHA class I to II symptoms and with transthoracic echocardiography without findings suggesting myocardial disease (all with preserved LV ejection fraction), who underwent cardiac catheterization with high-fidelity LV pressure measurement. Echocardiographic images were evaluated for LVDD using ASE algorithm without and with knowledge of CAD history and angiography findings. CAD was considered as having DD for the algorithm.

RESULTS

CAD was identified in 22 patients at catheterization (65%). Using ASE guidelines without including history of CAD or angiographic results, 29 patients were DD-, 3 were DD+ (all grade II), and 2 were indeterminate. Inclusion of CAD history recategorized 59% (n = 20) patients to DD+ (all grade I) from DD- (P < .0001). Nineteen of the recategorized patients (95%) had increased isovolumetric relaxation time (IVRT). The addition of echocardiographic IVRT improved discrimination between DD- and DD+, when the presence of CAD is unknown.

CONCLUSIONS

2016-ASE algorithm reasonably accurately identifies early LVDD at rest as reflected by LV catheterization when CAD is disclosed, but without knowledge of the presence of CAD, it underdiagnoses DD+ grade I. The addition of IVRT may improve early LVDD diagnostics.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Discrepancies in Assessing Diastolic Function in Pre-Clinical Heart Failure Using Different Algorithms-A Primary Care Study

Background: Current guidelines on diastolic function (DF) by the American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) have been disputed and two alternative algorithms have been proposed by Johansen et al. and Oh et al. We sought (a) to assess the concordance of ASE/EACVI guidelines on DF using these proposed alternative approaches and (b) to evaluate the prevalence of indeterminate diastolic dysfunction (DD) by each method, exploring means for reducing their number. Methods: We retrospectively analyzed the echocardiographic reports of 1158 outpatients including subjects at risk of heart failure without (n = 644) or with (n = 241) structural heart disease, and 273 healthy individuals. Concordance was calculated using the k coefficient and overall proportion of DD reclassification rate. The effectiveness of pulmonary vein flow (PVF), Valsalva maneuver, and left atrial volume index/late diastolic a’-ratio (LAVi/a’) over indeterminate grading was assessed. Results: The DD reclassification rate was 30.1% (k = 0.35) for ASE/EACVI and OH, 36.5% (k = 0.27) for ASE/EACVI and JOHANSEN and 31.1% (k = 0.37) for OH and JOHANSEN (p < 0.0001 for all comparisons). DF could not be graded only by ASE/EACVI and OH in 9% and 11% patients, respectively. The majority of patients could be reclassified using PVF or Valsalva maneuver or LAVi/a’, with the latter being the single most effective parameter. Conclusion: Inconsistencies between updated guidelines and independent approaches to assess and grade DF impede their interchangeable clinical use. The inconclusive diagnoses can be reconciled by conventional echocardiography in most patients, and LAVi/a’ emerges as a simple and effective approach to this aim.

On the search for the right definition of heart failure with preserved ejection fraction

The definition of heart failure with preserved ejection fraction (HFpEF) has evolved from a clinically based "diagnosis of exclusion" to definitions focused on objective evidence of diastolic dysfunction and/or elevated left ventricular filling pressures. Despite advances in our understanding of HFpEF pathophysiology and the development of more sophisticated imaging modalities, the diagnosis of HFpEF remains challenging, especially in the chronic setting, given that symptoms are provoked by exertion and diagnostic evaluation is largely conducted at rest. Invasive hemodynamic study, and in particular - invasive exercise testing, is considered the reference method for HFpEF diagnosis. However, its use is limited as opposed to the high number of patients with suspected HFpEF. Thus, diagnostic criteria for HFpEF should be principally based on non-invasive measurements. As no single non-invasive variable can adequately corroborate or refute the diagnosis, different combinations of clinical, echocardiographic, and/or biochemical parameters have been introduced. Recent years have brought an abundance of HFpEF definitions. Here, we present and compare four of them: 1) the 2016 European Society of Cardiology criteria for HFpEF; 2) the 2016 echocardiographic algorithm for diagnosing diastolic dysfunction; 3) the 2018 evidence-based H2FPEF score; and 4) the most recent, 2019 Heart Failure Association HFA-PEFF algorithm. These definitions vary in their approach to diagnosis, as well as sensitivity and specificity. Further studies to validate and compare the diagnostic accuracy of HFpEF definitions are warranted. Nevertheless, it seems that the best HFpEF definition would originate from a randomized clinical trial showing a favorable effect of an intervention on prognosis in HFpEF.

Left Atrial Strain in Evaluation of Heart Failure with Preserved Ejection Fraction

BACKGROUND

Patients with heart failure with preserved ejection fraction (HFpEF) may have elevated left ventricular filling pressure with exercise (LVFP-ex), despite normal LVFP at rest. The aim of this study was to assess the diagnostic value of resting left atrial strain (LAS) in detecting elevated LVFP-ex in patients with dyspnea evaluated on exercise stress echocardiography.

METHODS

Two-dimensional speckle-tracking analysis for LAS was performed in 669 consecutive patients (mean age, 64 ± 14 years; 53% men) who underwent treadmill echocardiographic evaluation and had left ventricular ejection fractions ≥ 50%. Assessment of LVFP at rest LVFP-ex was based on the 2016 American Society of Echocardiography guidelines for diastolic function assessment. An E/e' ratio ≥ 15 after exercise is considered to indicate elevated LVFP-ex. A continuous diagnostic score of HFpEF was calculated on the basis of the European Society of Cardiology HFA-PEFF diagnostic algorithm.

RESULTS

LAS_reservoir was lowest in patients with elevated LVFP at rest (n = 81) and lower in those with normal resting filling pressure who developed elevated LVFP-ex (n = 108) compared with those who maintained normal LVFP-ex (29.0 ± 5.2% vs 33.1 ± 5.0% vs 39.3 ± 4.8%, P < .001). Lower LAS_reservoir was associated with worse exercise capacity as assessed by metabolic equivalents, exercise time, and functional aerobic capacity (multivariate-adjusted P values all < .05). In patients with normal or indeterminate LVFP at rest (n = 587), LAS_reservoir and preexercise HFA-PEFF score demonstrated areas under the curve of 0.82 and 0.7, respectively, for elevated LVFP-ex. There were 28% higher odds of developing elevated LVFP-ex per 1% decrease in LAS_reservoir (odds ratio, 0.78; 95% CI, 0.74-0.82). Among patients with intermediate scores (n = 461), 123 developed elevations in LVFP-ex and were classified as having HFpEF per the diagnostic algorithm. The addition of LAS_reservoir improved the diagnostic value of HFA-PEFF score for HFpEF (area under the curve increased from 0.71 to 0.80, P = .01).

CONCLUSIONS

LAS_reservoir has potential to identify patients with intermediate scores for HFpEF who may develop elevated LVFP-ex only and is therefore a promising alternative to aid in diagnosis when exercise testing is not feasible.

Is heart failure misdiagnosed in hospitalized patients with preserved ejection fraction? From the European Society of Cardiology - Heart Failure Association EURObservational Research Programme Heart Failure Long-Term Registry

Aims

In hospitalized patients with a clinical diagnosis of acute heart failure (HF) with preserved ejection fraction (HFpEF), the aims of this study were (i) to assess the proportion meeting the 2016 European Society of Cardiology (ESC) HFpEF criteria and (ii) to compare patients with restrictive/pseudonormal mitral inflow pattern (MIP) vs. patients with MIP other than restrictive/pseudonormal.

Methods and results

We included hospitalized participants of the ESC‐Heart Failure Association (HFA) EURObservational Research Programme (EORP) HF Long‐Term Registry who had echocardiogram with ejection fraction (EF) ≥ 50% during index hospitalization. As no data on e', E/e' and left ventricular (LV) mass index were gathered in the registry, the 2016 ESC HFpEF definition was modified as follows: elevated B‐type natriuretic peptide (BNP) (≥100 pg/mL for acute HF) and/or N‐terminal pro‐BNP (≥300 pg/mL) and at least one of the echocardiographic criteria: (i) presence of LV hypertrophy (yes/no), (ii) left atrial volume index (LAVI) of >34 mL/m²), or (iii) restrictive/pseudonormal MIP. Next, all patients were divided into four groups: (i) patients with restrictive/pseudonormal MIP on echocardiography [i.e. with presumably elevated left atrial (LA) pressure], (ii) patients with MIP other than restrictive/pseudonormal (i.e. with presumably normal LA pressure), (iii) atrial fibrillation (AF) group, and (iv) ‘grey area’ (no consistent description of MIP despite no report of AF). Of 6365 hospitalized patients, 1848 (29%) had EF ≥ 50%. Natriuretic peptides were assessed in 28%, LV hypertrophy in 92%, LAVI in 13%, and MIP in 67%. The 2016 ESC HFpEF criteria could be assessed in 27% of the 1848 patients and, if assessed, were met in 52%. Of the 1848 patients, 19% had restrictive/pseudonormal MIP, 43% had MIP other than restrictive/pseudonormal, 18% had AF and 20% were grey area. There were no differences in long‐term all‐cause or cardiovascular mortality, or all‐cause hospitalizations or HF rehospitalizations between the four groups. Despite fewer non‐cardiac comorbidities reported at baseline, patients with MIP other than restrictive/pseudonormal (i.e. with presumably normal LA pressure) had more non‐cardiovascular (14.0 vs. 6.7 per 100 patient‐years, P < 0.001) and cardiovascular non‐HF (13.2 vs. 8.0 per 100 patient‐years, P = 0.016) hospitalizations in long‐term follow‐up than patients with restrictive/pseudonormal MIP.

Conclusions

Acute HFpEF diagnosis could be assessed (based on the 2016 ESC criteria) in only a quarter of patients and confirmed in half of these. When assessed, only one in three patients had restrictive/pseudonormal MIP suggestive of elevated LA pressure. Patients with MIP other than restrictive/pseudonormal (suggestive of normal LA pressure) could have been misdiagnosed with acute HFpEF or had echocardiography performed after normalization of LA pressure. They were more often hospitalized for non‐HF reasons during follow‐up. Symptoms suggestive of acute HFpEF may in some patients represent non‐HF comorbidities.

Multilayer myocardial strain improves the diagnosis of heart failure with preserved ejection fraction

Aims

The diagnostic and treatment of patients with heart failure with preserved ejection fraction (HFpEF) are both hampered by an incomplete understanding of the pathophysiology of the disease. Novel imaging tools to adequately identify these patients from individuals with a normal cardiac function and respectively patients with HF with reduced EF are warranted. Computing multilayer myocardial strain with feature tracking is a fast and accurate method to assess cardiac deformation. Our purpose was to assess the HFpEF diagnostic ability of multilayer strain parameters and compare their sensitivity and specificity with other established parameters.

Methods and results

We included 20 patients with a diagnosis of HFpEF and, respectively, 20 matched controls. We assessed using feature‐tracking cardiac magnetic resonance longitudinal and circumferential myocardial strain at three distinct layers of the myocardium: subendocardial (Endo‐), mid‐myocardial (Myo‐), and subepicardial (Epi‐). Comparatively, we additionally assessed various others clinical, imaging, and biochemical parameters with a putative role in HFpEF diagnostic: left ventricular end‐diastolic volume (LVEDV), left ventricular mass (LVM), interventricular septum (IVS) wall thickness and free wall thickness, left atrial volume and strain, septal and lateral mitral annular early diastolic velocity (e`), E/e´ ratio, and plasma levels of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP). Global longitudinal strain (GLS) is significantly impaired at Endo (−20.8 ± 4.0 vs. −23.2 ± 3.4, P = 0.046), Myo‐ (−18.0 ± 3.0 vs. −21.0 ± 2.5, P = 0.002), and Epi‐ (−12.2 ± 2.0 vs. −16.2 ± 2.5, P < 0.001) levels. Compared with any other imaging parameter, an Epi‐GLS lower than 13% shows the highest ability to detect patients with HFpEF [area under the curve (AUC) = 0.90 (0.81–1), P < 0.001] and in tandem with NT‐proBNP can diagnose with maximal sensibility (93%) and specificity (100%), patients with HFpEF from normal, composed variable [AUC = 0.98 (0.95–1), P < 0.001]. In a logistic regression model, a composite predictive variable taking into account both GLS Epi and NT‐proBNP values in each individual subject reached a sensitivity of 89% and a specificity of 100% with an AUC of 0.98 (0.95–1), P < 0.001, to detect HFpEF.

Conclusions

Epi‐GLS is a promising new imaging parameter to be considered in the clinical assessment of HFpEF patients. Given its excellent specificity, in tandem with a highly sensitive parameter such as NT‐proBNP, Epi‐GLS holds the potential to greatly improve the current diagnostic algorithms.

Extended-Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction

Background

Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent form of heart failure, representing half of the total burden of heart failure. We hypothesised that modulation of the phosphodiesterase type 3/cyclic AMP using a novel oral formulation of milrinone might exert favorable effects HFpEF via pulmonary and systemic vasodilation and enhancement of ventricular relaxation. We assessed the safety and efficacy of oral milrinone on quality of life and functional outcomes in patients with HFpEF.

Methods and Results

The MilHFPEF (Extended Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction) study was a randomized, double‐blind, placebo‐controlled pilot study in 23 patients with symptomatic HFpEF. Efficacy end points included changes from baseline in Kansas City Cardiomyopathy Questionnaire summary score and 6‐minute walk distance. The primary safety end point was the development of clinically significant arrhythmia. The Kansas City Cardiomyopathy Questionnaire score improved significantly in milrinone‐treated patients compared with placebo (+10±13 versus −3±15; P=0.046). Six‐minute walk distance also tended to improve in the treatment group compared with placebo (+22 [−8 to 49] versus −47 [−97 to 12]; P=0.092). Heart rate (−1±5 versus −2±9 bpm; P=0.9) and systolic blood pressure (−3±18 versus +1±12 mm Hg; P=0.57) were unchanged. Early filling velocity/early mitral annular velocity (−0.3±3.0 versus −1.9±4.8; P=0.38) was unchanged. One patient in the placebo arm was hospitalized for heart failure. Holter monitoring did not demonstrate evidence of a proarrhythmic effect of milrinone.

Conclusions

In this novel pilot study, extended release oral milrinone was well tolerated and associated with improved quality of life in patients with HFpEF. Further longer‐term studies are warranted to establish the role of this therapeutic approach in HFpEF.

Registration

URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12616000619448.

Diastolic function in young patients with cryptogenic stroke: A case-control pilot study

BACKGROUND

Ischaemic stroke in young individuals often remains cryptogenic. In this pilot study, we investigated, whether advanced echocardiography methods could find differences in the diastolic function between young cryptogenic stroke patients and stroke-free controls.

METHODS

We recruited 30 cryptogenic ischaemic stroke patients aged 18-49 and 30 age- and sex-matched stroke-free controls among participants of the Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO) study (NCT01934725). We measured diastolic function parameters derived from speckle tracking strain rate, Doppler techniques and 4D volumetry. We also performed statistical analyses comparing only the highest and lowest tertile of cases and controls for each parameter.

RESULTS

None of our patients or controls had diastolic dysfunction according to ASE/EACVI criteria. However, compared to stroke-free controls, the stroke patient group had lower E/A ratio of mitral inflow, lower lateral and mean e', lower A/a' ratio, lower strain rate in early diastole and lower speckle tracking-derived e/a ratio. When comparing the lowest tertiles, patients also had a lower peak filling rate by 4D volumetry, a lower peak early filling fraction (fraction of left ventricular filling during early diastole), and lower velocities in a series of the tissue Doppler-derived diastolic parameters and blood flow/tissue velocity ratios.

CONCLUSION

Our study displayed subtle differences in diastolic function between patients and stroke-free controls, which may play a role in early-onset cryptogenic stroke. The differences were clearer when the lowest tertiles were compared, suggesting that there is a subgroup of young cryptogenic stroke patients with subclinical heart disease.

Diastolic function assessment by echocardiography: A practical manual for clinical use and future applications

Diastole is an important component of the cardiac cycle, during which time optimum filling of the ventricle determines physiological stroke volume ejected in the succeeding systole. Many factors contribute to optimum ventricular filling including venous return, left atrial filling from the pulmonary circulation, and emptying into the left ventricle. Left ventricular filling is also impacted by the cavity emptying function and also its synchronous function which may suppress early diastolic filling in severe cases of dyssynchrony. Sub-optimum LA emptying increases cavity pressure, causes enlarged left atrium, unstable myocardial function, and hence atrial arrhythmia, even atrial fibrillation. Patients with clear signs of raised left atrial pressure are usually symptomatic with exertional breathlessness. Doppler echocardiography is an ideal noninvasive investigation for diagnosing raised left atrial pressure as well as following treatment for heart failure. Spectral Doppler based increased E/A, shortened E-wave deceleration time, increased E/e', and prolonged atrial flow reversal in the pulmonary veins are all signs of raised left atrial pressure. Left atrial reduced myocardial strain is another correlate of raised cavity pressure (>15 mm Hg). In patients with inconclusive signs of raised left atrial pressure at rest, exercise/stress echocardiography or simply passive leg lifting should identify those with stiff left ventricular which suffers raised filling pressures with increased venous return.

Prognostic value of NT-proBNP, and echocardiographic indices of diastolic function, in hospitalized patients with acute heart failure and preserved left ventricular ejection fraction

BACKGROUND

Several parameters have proven useful in assessing prognosis in outpatients with heart failure with preserved ejection fraction (HFpEF). In contrast, prognostic determinants in HFpEF hospitalized for an acute event are poorly investìgated.

AIM

To determine the predictive value of NT-proBNP, and diastolic function (assessed by E/e'), in patients with HFpEF hospitalized for acute heart failure.

METHODS AND RESULTS

We evaluated 205 consecutive HFpEF patients admitted for acute heart failure (median age: 76[53,81], 36% male, median EF: 61 [54,77]). We assessed clinical, echocardiographic, and NT-proBNP values, on admission and at discharge. Primary end-point was the composite of all-cause death and/or HF rehospitalization. After a mean follow up of 28±10 months, 82 patients met the primary end-point; there were 30 deaths (14.6%), and 72 patients (35%) were rehospitalized for HF. By multivariable analysis, predictors of the composite end-point were: discharge E/e´ ≥14 (HR: 4.63 CI 95%: 2.71-18.2, p<0.0001), discharge NT-proBNP ≥1500 pg/ml (HR: 5.23, CI 95%: 2.87-17.8, p < 0.0001), ≥50% NT-proBNP decrease between admission and discharge (HR: 0.62, CI 95%: 0.25-0.79, p = 0.019). Combining E/e´ and NT-proBNP values at discharge further and significantly improved discrimination power compared to each variable analyzed separately (AUC, NT-proBNP at discharge: 0.80; E/e´ at discharge: 0.77; E/e´ + NT-proBNP: 0.88; p < 0.01).

CONCLUSIONS

In HFpEF patients hospitalized with acute heart failure, assessment of E/e´ ratio and NT-proBNP at discharge provides prognostic information on top of other variables, and allows to easily identify a population at higher risk of subsequent death or rehospitalization for heart failure, during a medium-term follow up.

Mythical metrics and methods: Needed paradigm shift in disease recognition and therapy

Current medicine is practiced in an organ-based, function-appraised manner with less attention paid to the tissue characteristics of the appraised organs. The fundamentals of this paradigm have been the product of an oversimplified and often layman-based perceptions of the studied organ over the years. These perceptions drove the current definitions of normality and abnormality, parameters used in the diagnosis of the disease, goals of treatment and studied outcomes. Despite the explosive advancement in technology that could have potentially changed our 'upstream' thinking, practitioners remain captives of these old beliefs and have streamlined current technology in a 'downstream' fashion; in the form of goal-directed protocols, and engineering systems that would study their implementations. As a result, diseases continue to evolve, become more resistant to therapy, late to diagnose, and with a persistent worsening of outcomes. With a primarily focus on the heart and from an anesthesiologist prospective, we challenge the fundamentals of the current paradigm from an 'upstream' prospective. We challenge the current 'territorial' definitions of the organs studied, the current terminology of some diseases, the parameters used in their diagnosis, the diagnostic modalities used and their goals of treatment. We illustrate some examples when the current collective 'myth' meets the 'reality' in an acute care setting, further clarifying the limitations of the current paradigm. We also, provide a theoretical hypothesis of what we believe to be a potential substitute of the current paradigm. Our theory redefines disease from an organ-based functional phenomenon to a structural-based tissue phenomenon, calling for an integrative and holistic approach of tissue assessment rather than a discrete approach that may potentially obscure the interaction of non-appraised organs. We also believe in redirecting technology in an upstream direction to better redefine and early detect diseases rather than submitting to generationally inherited beliefs. Whereas we have started some of our research on our proposed paradigm, our theoretical framework remains to be thought-provoking, and hypothesis-generating at the present time.

E/e' in relation to outcomes in ST-elevation myocardial infarction

BACKGROUND

Myocardial infarction (MI) is a high-risk condition especially when filling pressure is raised, and earlier reports have suggested that E/e' is associated with poor outcome. However, whether E/e' predicts risk better than LVEF, which is the current standard of practice, is not known. We investigated this question in the largest and most rigorous study of MI patients so far.

METHODS AND RESULTS

We studied 660 patients with ST-elevation MI (STEMI) treated with primary percutaneous coronary intervention and related E/e' to short-term mortality (in-hospital death), as well as long-term events at 2 years comprising (a) a composite of MI, stroke, heart failure, and death, and (b) death alone. Short-term models were adjusted for age, sex, and LVEF. Long-term models were adjusted for age, sex, diabetes, revascularization procedure, history of MI, hypertension, renal function, drugs on discharge, and LVEF. Elevated E/e'> 15 indicated higher risk of short-term events (n = 19:7.0% (95% confidence interval 3.4-10.8%) vs. 1.0% (0.3 - 2.3%); adjusted odds ratio 3.7 (1.3-10.5)). While elevated E/e' was also associated with long-term outcomes (n = 103 composite events: 15.9% (11.9% - 21.4%) vs 6.8% (5.2% - 8.7%), P < .001; n = 38 death events: 6.0% (3.9% - 9.5%) vs 2.0% (1.3% - 3.2%), P = .001), E/e' was rendered nonsignificant for long-term outcomes by multivariable adjustment (p = ns for both). LVEF, on the contrary, was a highly significant predictor in the adjusted long-term model.

CONCLUSION

E/e' is associated with poor outcome in STEMI, but LVEF is a stronger predictor of long-term risk.

TrimetaziDine as a Performance-enhancING drug in heart failure with preserved ejection fraction (DoPING-HFpEF): rationale and design of a placebo-controlled cross-over intervention study

BACKGROUND

Currently, no specific treatment exists for heart failure with preserved ejection fraction (HFpEF). Left ventricular (LV) relaxation during diastole is a highly energy-demanding process, while energy homeostasis is known to be compromised in HFpEF. We hypothesise that trimetazidine - a fatty acid β‑oxidation inhibitor - improves LV diastolic function in HFpEF, by altering myocardial substrate use and improving the myocardial energy status.

OBJECTIVES

To assess whether trimetazidine improves LV diastolic function by improving myocardial energy metabolism in HFpEF.

METHODS

The DoPING-HFpEF trial is a randomised, double-blind, placebo-controlled cross-over intervention trial comparing the efficacy of trimetazidine and placebo in 25 patients with stable HFpEF. The main inclusion criteria are: New York Heart Association functional class II to IV, LV ejection fraction ≥50%, and evidence of LV diastolic dysfunction. Patients are treated with one 20-mg trimetazidine tablet or placebo thrice daily (twice daily in the case of moderate renal dysfunction) for two periods of 3 months separated by a 2-week washout period. The primary endpoint is the change in pulmonary capillary wedge pressure during different intensities of exercise measured by right heart catheterisation. Our key secondary endpoint is the myocardial phosphocreatine (PCr)/ATP ratio measured by phosphorus-31 magnetic resonance spectroscopy and its relation to the primary endpoint. Exploratory endpoints are 6‑min walk distance, N-terminal pro-brain natriuretic peptide levels, and quality of life.

CONCLUSION

The DoPING-HFpEF is a phase-II trial that evaluates the effect of trimetazidine, a metabolic modulator, on diastolic function and myocardial energy status in HFpEF. [EU Clinical Trial Register: 2018-002170-52; NTR registration: NL7830].

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F₁ : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F₂ : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Tissue Doppler indices of diastolic function as prognosticator in patients without heart failure in primary care

BACKGROUND

Tissue Doppler imaging (TDI) indices of left ventricular (LV) diastolic function provide incremental prognostic information on mortality and morbidity in the general population and in several clinical scenarios. Their independent, additional role in outpatients with normal LV ejection fraction (LVEF) and without heart failure (HF) is undefined.

METHODS

We reviewed clinical and echocardiographic records of 2628 consecutive outpatients 52.8% male, median age 71 years) with LVEF > 50% without concurrent or prior HF, from the Cardiovascular Center of Trieste. We analyzed septal early mitral annular velocity (e') and its combination with mitral peak early filling velocity (E/e') in relation to the composite end-point of death and cardiovascular hospitalizations.

RESULTS

During follow-up of 26 months (interquartile range: 12-41), 392 (15%) patients experienced the endpoint (88 deaths). Increasing E/e' showed an overall association with the clinical end-point (log rank p < 0.02), but with no prognostic difference between the middle and upper tertile. Decreasing e' also showed an association with the end-point, with a more balanced stepwise risk increase for increasing tertiles (log rank p < 0.01 for all contrasts). At multivariable analysis, E/e' (either in tertiles or dichotomized according to the threshold of 15) was no longer associated with clinical outcome, whereas e' independently predicted the combined endpoint [hazard ratio 0.73 (0.53-0.94), p = 0.04]. The prognostic value of e' was incremental to that of other clinical and echocardiographic variables (p = 0.04).

CONCLUSIONS

In outpatients with normal LVEF and without HF, e' and E/e' are both associated with clinical end-points, though only e' is an independent and incremental predictor of outcome. These findings suggest a potential role for e' as a prognosticator, and spread a cautionary word about the utilization of septal E/e' alone as a surrogate for a comprehensive assessment of diastolic function in this context.

Estimation of increased pulmonary wedge pressure by an algorithm based on noninvasively measured pulmonary diastolic pressure in cardiac patients independent of left ventricular ejection fraction

AIM

Pulmonary artery diastolic pressure (PADP) correlates closely with pulmonary wedge pressure (PAWP); therefore, we sought to evaluate whether an algorithm based on PADP assessment by the Doppler pulmonary regurgitation (PR) end-diastolic gradient (PRG) may aid in estimating increased PAWP in cardiac patients with reduced or preserved left ventricular (LV) ejection fraction (EF).

METHODS AND RESULTS

Right heart catheterization, with estimation of PAWP, right atrial pressure (RAP), PADP, and Doppler echocardiography, was carried out in 183 patients with coronary artery disease (n = 63), dilated cardiomyopathy (n = 52), or aortic stenosis (n = 68). One-hundred and seventeen patients had LV EF <50%. We measured the pressure gradients across the tricuspid and pulmonary valves from tricuspid regurgitation (TRV) and PR velocities. Doppler-estimated PADP (e-PADP) was obtained by adding the estimated RAP to PRG. An algorithm based on e-PADP to predict PAWP, that included TRV, left atrial volume index, and mitral E/A, was developed and validated in derivation (n = 90) and validation (n = 93) subgroups. Both invasive PADP (r = .92, P < .001) and e-PADP (r = .72, P < .001) correlated closely with PAWP, and e-PADP predicted PAWP (AUC: 0.85, CI: 0.79-0.91) with a 94% positive predictive value (PPV) and a 55% negative predictive value (NPV), after exclusion of five patients with precapillary pulmonary hypertension. The e-PADP-based algorithm predicted PAWP with higher accuracy (PPV = 94%; NPV = 67%; accuracy = 85%; kappa: 0.65, P < .001) than the ASE-EACVI 2016 recommendations (PPV = 97%; NPV = 47%; accuracy = 68% undetermined = 18.9%; kappa: 0.15, P < .001).

CONCLUSIONS

An algorithm based on noninvasively e-PADP can accurately predict increased PAWP in patients with cardiac disease and reduced or preserved LV EF.

Association of estimated plasma volume status with hemodynamic and echocardiographic parameters

BACKGROUND

Estimated plasma volume status (ePVS) has diagnostic and prognostic value in patients with heart failure (HF). However, it remains unclear which congestion markers (i.e., biological, imaging, and hemodynamic markers) are preferentially associated with ePVS. In addition, there is evidence of sex differences in both the hematopoietic process and myocardial structure/function.

METHOD AND RESULTS

Patients with significant dyspnea (NYHA ≥ 2) underwent echocardiography and lung ultrasound within 4 h prior to cardiac catheterization. Patients were divided according to tertiles based on sex-specific ePVS thresholds calculated from hemoglobin and hematocrit measurements using Duarte's formula. Among the 78 included patients (median age 74.5 years; males 69.2%; HF 48.7%), median ePVS was 4.1 (percentile_25-75 = 3.7-4.9) mL/g in males (N = 54) and 4.8 (4.4-5.3) mL/g in females (N = 24). Patients with the highest ePVS had more frequently HF, higher NT-proBNP, larger left atrial volume, and higher E/e' (all p values < 0.05), but no difference in inferior vena cava diameter or pulmonary congestion assessed by lung ultrasound (all p values > 0.10). In multivariable analysis, higher E/e' and lower diastolic blood pressure were significantly associated with increased ePVS. The association between ePVS and congestion variables was not sex-dependent except for left-ventricular end-diastolic pressure, which was only correlated with ePVS in females (Spearman Rho = 0.53, p < 0.01 in females and Spearman Rho = - 0.04, p = 0.76 in males; p_interaction = 0.08).

CONCLUSION

ePVS is associated with E/e' regardless of sex, while only associated with invasively measured left-ventricular end-diastolic pressure in females. These results suggest that ePVS is preferably associated with left-sided hemodynamic markers of congestion.

Myocardial Strain in the Assessment of Patients With Heart Failure: A Review

Importance

The cornerstones of imaging in heart failure (HF) are the measurement of systolic and diastolic function and left ventricular (LV) filling pressure.

Observations

Ejection fraction and the assessment of LV filling pressure and diastolic dysfunction using the ratio of early transmitral flow and LV relaxation (E/e') are conventional imaging markers of LV function. Despite their extensive use in HF guidelines, both have significant detractions, especially in an era when HF with preserved ejection fraction is becoming the dominant presentation. In contrast, strain imaging has provided a new window into myocardial mechanics. Myocardial strain is now well validated, robust, and can easily be performed on most modern echocardiography machines. This Review summarizes the evidence in 9 situations across the stages of HF where LV global longitudinal strain and other strain parameters may provide information on risk prediction, diagnosis, assessment of treatment response, and follow-up.

Conclusions and Relevance

The evolution of myocardial deformation imaging from research tool to clinical practice will provide clinicians with a useful additional imaging parameter to facilitate the assessment and risk evaluation of patients with HF.

Stress Echocardiography-Derived E/e' Predicts Abnormal Exercise Hemodynamics in Heart Failure With Preserved Ejection Fraction

Background

The correlation between echocardiographic parameters and hemodynamics data in patients with heart failure with preserved ejection fraction (HFpEF) is unclear. It is important to find a non-invasive echocardiographic parameter for predicting exercise pulmonary capillary wedge pressure (PCWP).

Aim

This study sought to determine the correlation between echocardiographic parameters and hemodynamics data at rest and during exercise in HFpEF patients.

Methods and Results

This study was a cross-sectional cohort exploratory analysis of baseline data from the ILO-HOPE trial. A total of 34 HFpEF patients were enrolled. The average age was 70 ± 12 years, and most (74%) were women. The patients underwent invasive cardiac catheterization and expired gas analysis at rest and during exercise. Echocardiography including tissue Doppler imaging was performed, and global longitudinal strain and other novel diastolic function indexes were analyzed at rest and during exercise. At rest, no significant correlation was noted between resting PCWP and echocardiographic parameters. However, a significant correlation was observed between post-exercise PCWP and stress E/e′ (septal, lateral, and mean) ratio (p = 0.003, 0.031, 0.012). Moreover, post-exercise ΔPCWP showed a good correlation with stress E/e′ (septal, lateral, and mean; all p ≤ 0.001) and global longitudinal strain (GLS) during exercise (p = 0.03). After multivariate regression analysis with adjustment for possible confounding factors including age and sex, there was still a significant correlation between post-exercise ΔPCWP and E/e′ (r = 0.62, p < 0.001 for E/e′_mean).

Conclusion

Only stress echocardiography derived tissue Doppler E/e′ ratio is closely correlated with abnormal exercise hemodynamics (PCWP and post-exercise ΔPCWP) in HFpEF. This echocardiographic marker is substantially more sensitive than other novel echocardiographic parameters during exercise, and may have significant diagnostic utility for ambulatory HFpEF patients with dyspnea.

Clinical Trial Registration

https://www.clinicaltrials.gov, identifier NCT03620526.

[Cardiovascular imaging in heart failure]

Transthoracic echocardiography remains the first-line cardiac imaging for diagnosis, management and screening of heart failure, whatever its phenotype (heart failure with reduced, mid-range and preserved ejection fraction). It allows anatomic characterization, systolic and diastolic functions of left and right ventricles assessment, intracardiac hemodynamic evaluation and for the assessment of valve disease. Myocardial deformation imaging (strain) is indicated in patients with heart failure for the assessment of systolic ventricles function and the diagnosis of specific heart diseases. Strain is indicated for the screening of preclinical myocardial dysfunction in patients at risk or exposed to cardiotoxic treatment. Altered global longitudinal strain is associated with a poor prognosis in heart failure. Cardiac magnetic resonance is recommended for the assessment of myocardial structure and function in subjects with poor acoustic window and patients with complex congenital heart diseases, in order to distinguish between ischemic and non-ischemic myocardial damage in patients with dilated cardiopathy and to characterize myocardial tissue in case of suspected specific heart disease.

Evaluation of Cardiac Function in Women With a History of Preeclampsia: A Systematic Review and Meta-Analysis

Background

Women with a history of preeclampsia are at increased risk of cardiovascular morbidity and mortality. However, the underlying mechanisms of disease association, and the ideal method of monitoring this high‐risk group, remains unclear. This review aims to determine whether women with a history of preeclampsia show clinical or subclinical cardiac changes when evaluated with an echocardiogram.

Methods and Results

A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify studies that examined cardiac function in women with a history of preeclampsia, in comparison with those with normotensive pregnancies. In the 27 included studies, we found no significant differences between preeclampsia and nonpreeclampsia women with regard to left ventricular ejection fraction, isovolumetric relaxation time, or deceleration time. Women with a history of preeclampsia demonstrated a higher left ventricular mass index and relative wall thickness with a mean difference of 4.25 g/m² (95% CI, 2.08, 6.42) and 0.03 (95% CI, 0.01, 0.05), respectively. In comparison with the nonpreeclampsia population, they also demonstrated a lower E/A and a higher E/e′ ratio with a mean difference of −0.08 (95% CI, −0.15, −0.01) and 0.84 (95% CI, 0.41, 1.27), respectively.

Conclusions

In comparison with women who had a normotensive pregnancy, women with a history of preeclampsia demonstrated a trend toward altered cardiac structure and function. Further studies with larger sample sizes and consistent echocardiogram reporting with the use of sensitive preclinical markers are required to assess the role of echocardiography in monitoring this high‐risk population group.

The additive value of echocardiographic pulmonary to left atrial global strain ratio in the diagnosis of pulmonary hypertension

BACKGROUND

The distinction between pre-capillary and post-capillary pulmonary hypertension (PH) is central to accurate diagnosis and appropriate therapy. We aimed to investigate the ability of the novel echocardiographic pulmonary to left atrial global strain ratio (ePLAGS) to distinguish pre-capillary from post-capillary PH and compare its discriminatory strength with the echocardiographic pulmonary to left atrial ratio (ePLAR).

METHODS

Consecutive subjects with unexplained dyspnea or heart failure underwent echocardiography immediately followed by right heart catheterization. Subjects who did not satisfy the ESC/ERS criteria for PH, in atrial fibrillation or under pacemaker therapy, or with significant concomitant valvular disease were excluded. ePLAGS was calculated as peak tricuspid regurgitation velocity divided by left atrial global reservoir strain.

RESULTS

One hundred and thirty PH subjects, as defined by right heart catheterization, were included in the analysis (pre-capillary: n = 64, post-capillary: n = 66). ePLAGS was lower in pre-capillary compared with post-capillary PH (0.19 ± 0.14 vs. 0.45 ± 0.58 m/s/%; p = 0.02) and significantly different between combined post- and pre-capillary PH (Cpc-PH) and isolated post-capillary PH (Ipc-PH) (0.62 ± 0.85 vs. 0.32 ± 0.19 m/s/%; p = 0.04). ePLAR was higher in pre-capillary as compared with post-capillary PH (0.37 ± 0.16 vs. 0.20 ± 0.08; p < 0.001) but did not differ between Ipc-PH and Cpc-PH. ePLAGS demonstrated stronger discriminating power than ePLAR to distinguish pre-capillary from post-capillary PH (AUC = 0.80 vs. 0.70). In the setting of post capillary PH, ePLAGS showed reasonable ability to distinguish Ipc-PH from Cpc-PH (AUC = 0.65). ePLAR, however, did not differentiate these two groups (AUC = 0.49; p > 0.05).

CONCLUSIONS

ePLAGS accurately differentiates pre-capillary from post-capillary PH and demonstrates higher diagnostic ability than ePLAR.

Echocardiographic Detection of Occult Diastolic Dysfunction in Pulmonary Hypertension After Fluid Challenge

Background Identification of occult diastolic dysfunction often requires invasive right heart catheterization with provocative maneuvers such as fluid challenge. Non-invasive predictors of occult diastolic dysfunction have not been identified. We hypothesized that echocardiographic measures of diastolic function are associated with occult diastolic dysfunction identified at catheterization. Methods and Results We retrospectively examined hemodynamic and echocardiographic data from consecutive patients referred for right heart catheterization with fluid challenge from 2009 to 2017. A replication cohort of 52 patients who prospectively underwent simultaneous echocardiography and right heart catheterization before and after fluid challenge at Monaldi Hospital, Naples, Italy. In the retrospective cohort of 126 patients (83% female, 56+14 years), 27/126 (21%) had occult diastolic dysfunction. After adjusting for tricuspid regurgitant velocity and left atrial volume index, E velocity (odds ratio 1.8, 95% CI 1.1-2.9, P=0.01) and E/e' (odds ratio 1.9, 95% CI 1.1-3, P=0.005) were associated with occult diastolic dysfunction with an optimal threshold of E/e' >8.6 for occult diastolic dysfunction (sensitivity 70%, specificity 64%). In the prospective cohort, 5/52 (10%) patients had diastolic dysfunction after fluid challenge. Resting E/e' (odds ratio 8.75, 95% CI 2.3-33, P=0.001) and E velocity (odds ratio 7.7, 95% CI 2-29, P=0.003) remained associated with occult diastolic dysfunction with optimal threshold of E/e' >8 (sensitivity 73%, specificity 90%). Conclusions Among patients referred for right heart catheterization with fluid challenge, E velocity and E/e' are associated with occult diastolic dysfunction after fluid challenge. These findings suggest that routine echocardiographic measurements may help identify patients like to have occult diastolic dysfunction non-invasively.