Age-related changes in left and right ventricular filling velocity profiles and their relationship in normal subjects

Echocardiographic evaluation of cardiac function in cynomolgus monkeys over a wide age range

Various cardiovascular diseases can be detected and diagnosed using echocardiography. The demand for cardiovascular system research using nonhuman primates is increasing, but echocardiographic references for nonhuman primates are limited. This report describes the first comparison of echocardiographic reference values in 247 normal cynomolgus monkeys (135 females, 112 males) over a wide age range. Echocardiography, electrocardiography, blood pressure and chest X-ray images were acquired under immobilization with intramuscular ketamine hydrochloride, then cardiac structure, function, and flow velocity were assessed. Cardiac hormone levels were also tested. We found that cardiac structures positively correlated with weight, that the size of these structures stabilized after reaching maturity and that cardiac output increased according to heart size. In contrast, fractional shortening of the left ventricle, ejection fraction and flow velocity showed no significant correlations with weight or age, and age and E wave correlated negatively. These findings appear sufficiently similar to those in humans to suggest that cynomolgus monkeys can serve as a suitable model of human cardiac disease. Our data should also prove useful for surveying cardiac dysfunction in monkeys.

Usefulness of plasma brain natriuretic peptide measurement and tissue Doppler imaging in identifying isolated left ventricular diastolic dysfunction without heart failure

Left ventricular (LV) diastolic dysfunction carries a substantial risk for the subsequent development of heart failure and reduced survival, even when it is asymptomatic. Plasma brain natriuretic peptide (BNP) level and tissue Doppler imaging indexes provide powerful incremental assessment of LV diastolic function. Accordingly, the aim of this study was to clarify whether these methodologies could identify LV diastolic dysfunction without heart failure in 280 patients with preserved LV ejection fractions (> or =50%) who underwent echocardiography and cardiac catheterization for the evaluation of coronary artery disease. Patients were classified into 2 groups, those with diastolic dysfunction (tau > or =48 ms; n = 91) and those with normal diastolic function (tau <48 ms; n = 189). Plasma BNP > or =22.4 pg/ml, an unexpectedly low value, had sensitivity of 74.7% and specificity of 60.8% for identifying isolated LV diastolic dysfunction; the combined use of BNP > or =22.4 pg/mL and mitral annular velocity during early diastole <7.4 cm/s had relatively low sensitivity of 44.0% but high specificity of 86.8%. In conclusion, using plasma BNP level and with the combination of BNP level and mitral annular velocity during early diastole, invasively proved isolated LV diastolic dysfunction without heart failure could be identified in patients with coronary artery disease.

Relation of tricuspid inflow E-wave peak velocity to severity of tricuspid regurgitation

E-wave velocity in mitral flow has previously been shown to discriminate between severe and nonsevere mitral regurgitation. In this study, we sought to explore this association in the tricuspid position. The peak velocity of the tricuspid inflow E wave was measured in 118 patients (mean age 62 +/- 16.6 years; 48% women). Patients with tricuspid stenosis, transvenous pacemakers, and tricuspid prostheses were excluded. E-wave measurements were taken during shallow breathing. Tricuspid regurgitation (TR) was quantified as none or mild (group 1), moderate (group 2), or severe (group 3), according to American Society of Echocardiography guidelines. Forty-three patients had mild TR, 43 had moderate TR, and 33 had severe TR. Peak E-wave velocity was 48.6 +/- 13.8, 48.6 +/- 11.7, and 78.3 +/- 26.1 cm/s in groups 1, 2, and 3, respectively (p > 0.0001). Mean E-wave velocity was similar in groups 1 and 2 but greater in group 3 (p < 0.0001). A peak E-wave velocity of > or = 65 cm/s had a sensitivity of 73% and specificity of 88% for the detection of severe TR. In conclusion, increased peak tricuspid E-wave velocity is associated with severe TR and thus can be used as a simple measure of TR grade.

Diagnosis of heart failure in primary care

Heart failure is becoming an increasing concern to healthcare worldwide. It is the only cardiovascular disorder that continues to increase in both prevalence and incidence, and as the population continues to age, it is expected that the prevalence of this disease will continue to rise. Guidelines on diagnosis and treatment of heart failure are to be met. Most patients with heart failure will present themselves in general practice. Therefore, the community management of heart failure has become increasingly important and the role of General Practitioners even more crucial. Improving the reliability of diagnosis in primary care is essential since determining the aetiology and stage of heart failure leads to different management choices to improve symptoms, quality of life and disease prognosis. Furthermore, early diagnosis is needed, when there may be no symptoms, since treatment can delay or reverse disease progression. Diagnostic methods may therefore need to encompass screening strategies, as well as symptomatic case identification, in the future. General Practitioners must make correct decisions regarding appropriate further investigation, treatment and referral. A correct diagnosis is the cornerstone leading to effective management. The aim of this paper is to review the role of symptoms and signs and diagnostic tests, such as, chest X-ray, ECG, natriuretic peptides and echocardiography, for diagnosing heart failure in the primary care setting. Improving diagnostic skills remains a continuous challenge for clinicians. Simple and reliable diagnostic procedures are crucial to comply with Guidelines and reduce healthcare utilisation and costs.

Effect of carvedilol on diastolic function in patients with diastolic heart failure and preserved systolic function. Results of the Swedish Doppler-echocardiographic study (SWEDIC)

AIM

The purpose of this study was to investigate the effects of carvedilol on diastolic function (DF) in heart failure patients with preserved left ventricular (LV) systolic function and abnormal DF.

PATIENTS AND METHODS

We randomised 113 patients with diastolic heart failure (DHF) (symptomatic, with normal systolic LV function and abnormal DF) into a double blind multi-centre study. The patients received either carvedilol or matching placebo in addition to conventional treatment. After uptitration, treatment was continued for 6 months. Two-dimensional and Doppler echocardiography were used for quantification of LV function at baseline and at follow-up. Four different DF variables were evaluated by Doppler echocardiography: mitral flow E:A ratio, deceleration time (DT), isovolumic relaxation time (IVRT) and the ratio of systolic/diastolic pulmonary venous flow velocity (pv-S/D). Primary endpoint was change in the integrated quantitative assessment of all four variables during the study.

RESULTS

Ninety-seven patients completed the study. A mitral flow pattern reflecting a relaxation abnormality was recorded in 95 patients. There was no effect on the primary endpoint, although a trend towards a better effect in carvedilol treated patients was noticed in patients with heart rates above 71 beats per minute. At the end of the study, there was a statistically significant improvement in E:A ratio in patients treated with carvedilol (0.72 to 0.83) vs. placebo (0.71 to 0.76), P<0.05.

CONCLUSIONS

Treatment with carvedilol resulted in a significant improvement in E:A ratio in patients with heart failure due to a LV relaxation abnormality. E:A ratio was found to be the most useful variable to identify diastolic dysfunction in this patient population. This effect was observed particularly in patients with higher heart rates at baseline.

The epidemiological enigma of heart failure with preserved systolic function

BACKGROUND

Current epidemiological evidence suggests that the prevalence of preserved systolic function in patients with heart failure varies widely from 13 to 74%. This inconsistency suggests a lack of consensus as to what this condition really is and how it has been characterised for epidemiological studies.

AIMS

In this review, we summarise and discuss the current understanding of the epidemiology of heart failure with preserved systolic function and the challenges that this raises.

METHODS

Studies were identified from Medline and Embase Literature Database searches using the subject headings heart failure, diastolic heart failure, epidemiology, incidence, prevalence, diagnosis, prognosis and mortality.

RESULTS

Sixty-one studies of congestive heart failure with preserved systolic function were reviewed. There is great diversity in the criteria used to determine whether heart failure is present, the patient population, the setting of the study and methods of evaluating left ventricular function. This makes epidemiological studies of prevalence, morbidity and mortality impossible to compare.

CONCLUSIONS

The diagnosis of this syndrome might be better defined in terms of symptoms, elevated neuro hormones and impaired cardiac workload. This would allow accurate identification of cases so that further research could be conducted to measure outcome and assess therapeutic benefit.

Can natriuretic peptides be used for the diagnosis of diastolic heart failure?

Many patients with heart failure have stiff hearts with an increased wall thickness and small volumes leading to diastolic dysfunction. Different definitions for diastolic heart failure have been proposed but today there is no generally accepted definition and there are few large controlled studies telling us how it should be managed. Natriuretic peptides (BNP or NT-proBNP) might be used to detect patients with diastolic dysfunction especially in those patients having a restrictive filling pattern or pseudo-normalised mitral flow pattern and in those, who are symptomatic. However, patients with relaxation abnormalities and mild symptoms or asymptomatic may have normal levels of the natriuretic peptides indicating no or only slight elevation of the left ventricular filling pressures. Thus low levels cannot be used as a rule out diagnosis of diastolic dysfunction.

Developmental changes in left and right ventricular diastolic filling patterns in mice

Developmental changes in left and right ventricular diastolic filling patterns were determined noninvasively in isoflurane-anesthetized outbred ICR mice. Blood velocities in the mitral and tricuspid orifices were recorded in 16 embryos at days 14.5 (E14.5) and 17.5 of gestation (E17.5) using an ultrasound biomicroscope and also serially in three groups of postnatal mice aged 1-7 days (n = 23), 1-4 wk (n = 18), and 4-12 wk (n = 27) using 20-MHz pulsed Doppler. Postnatal body weight increased rapidly to 8 wk. Heart rate increased rapidly from approximately 180 beats/min at E14.5 to approximately 380 beats/min at 1 wk after birth and then more gradually to plateau at approximately 450 beats/min after 4 wk. Ventricular filling was quantified using the ratio of peak velocity of early ventricular filling due to active relaxation (E wave) to that of the late ventricular filling caused by atrial contraction (A wave) (peak E/A ratio) and the ratio of the peak E velocity to total time-velocity integral of E and A waves (peak E/total TVI ratio). Both ventricles had similar diastolic filling patterns in embryos (peak E/A ratio of 0.28 +/- 0.02 for mitral flow and 0.27 +/- 0.02 for tricuspid flow at E14.5). After birth, mitral peak E/A increased to >1 between the third and fifth day, continued to increase to 2.25 +/- 0.25 at approximately 3 wk, and then remained stable. The tricuspid peak E/A ratio increased much less but stabilized at the same age (increased to 0.79 +/- 0.03 at 3 wk). The peak E/total TVI ratio showed similar left-right differences and changes with development. Age-related changes were largely due to increases in peak E velocity. The results suggest that diastolic function matures approximately 3 wk postnatally, presumably in association with maturation of ventricular recoil and relaxation mechanisms.

Assessment of right ventricular diastolic filling parameters by Doppler echocardiography

BACKGROUND

Right ventricular diastolic function has been evaluated in various diseases by the pulsed Doppler technique. Right ventricular diastolic filling parameters show changes with age, heart rate and respiration. Evidences of diastolic left and right ventricular dysfunctions have been reported by echocardiographic studies in asthmatic patients. In the present study, before and after treatment of asthma the right ventricular diastolic filling parameters were compared in children with moderate asthma by Doppler echocardiography (a non-invasive technique).

METHODS

The study group consisted of 20 children (eight girls, 12 boys) with asthma. During the present study these patients were treated with inhaled steroid and beta-2 agonist daily. Before treatment all patients were evaluated by Doppler echocardiography. At 4-6 weeks after treatment 15 patients that had shown improvement in their symptoms according to the symptom score were also evaluated by Doppler echocardiography.

RESULTS

The mean age was 8.6 +/- 2.69 years and mean period of symptoms were 56.4 +/- 35.8 months. When compared with results of echocardiography before and after treatment, the right ventricular diastolic filling parameters (acceleration time: P < 0.01, deceleration time: P < 0.01 and isovolumetric relaxation time: P < 0.05) were found to be significantly different.

CONCLUSIONS

We observed significant improvement of right ventricular diastolic filling parameters by Doppler echocardiography after treatment in children with asthma.

Assessment of left and right ventricular systolic and diastolic synchronicity in normal subjects by tissue Doppler echocardiography and the effects of age and heart rate

OBJECTIVES

This study examined inter- and intraventricular synchronicity in systole and diastole by tissue Doppler imaging (TDI), and investigated if these parameters and the regional velocities were affected by age and heart rate.

METHODS

TDI was performed in 106 normal subjects (64.3 +/- 9.5 years, 60% male) using three apical views and a six-basal, six mid-segmental model. The regional parameters measured off line in both ventricles included peak isovolumic contraction velocity IVC(M), peak sustained systolic velocity (SM), peak early diastolic velocity (EM), peak late diastolic velocity (AM), and the E/AM ratio, as well as their time to these peak velocities: T(IVC), T(S), T(E), and T(A).

RESULTS

The systole and diastole within the left ventricle (LV) was highly synchronized without difference in T (IVC), TS, TE, and TA. However, the right ventricle (RV) was about 20 msec later than the LV for T(IVC) and TS. For regional velocities, IVC(M), S(M), E(M), and A(M) were significantly higher in basal than mid-segments (all P < 0.001). In the base of the LV, SM, and EM were the highest at the lateral segment and the lowest at the anterolateral segment. Age and heart rate did not affect systolic velocities or the timing of events. In diastole, age correlated negatively with EM(r =-0.36 to -0.48, P <or= 0.001)and E/AM ratio(r =-0.37 to -0.51, P <or= 0.01), while increasing heart rate affected AM (r = 0.17 to 0.43) positively and TE(r =-0.49 to -0.66, P < 0.001)and TA(r =-0.85 to -0.93, P < 0.001)negatively.

CONCLUSION

(1). Systolic and diastolic functions of the normal hearts are highly synchronized, though LV contraction slightly preceded that of RV. (2). Age and heart rate predominantly affect the diastolic, but not systolic, parameters that need to be taken into account.

Longitudinal motion of the atrioventricular annuli in children: reference values, growth related changes, and effects of right ventricular volume and pressure overload

The goals of this study were to characterize normal patterns of longitudinal motion of atrioventricular annuli in the young, establish reference values and assess growth-related changes (n = 40). Sensitivity to changes in right ventricular volume and pressure load was assessed in patients with atrial septal defect (ASD) (n = 25) and with primary pulmonary hypertension (PPH) (n = 20). M-mode of the annuli were obtained from apical views. In healthy subjects, longitudinal %displacement decreased with growth, lateral tricuspid annulus had highest %displacement, velocity of annular descent did not change with growth, tricuspid lateral annulus had the highest velocity of descent, only ascent velocity of the lateral tricuspid annulus decreased with growth, velocities of ascent for the lateral annuli were similar and higher than the septum, and heart rate had no effect on parameters tested. In patients with ASD, the findings were an exaggerated normal pattern. In patients with PPH, %displacement and ascent velocities were blunted. Our results demonstrate the utility of this technique to assess annular dynamics in pediatric patients.

Clinical characteristics influence left and right ventricular diastolic function in healthy individuals

The aim of this study was to determine whether clinical characteristics have an influence on left (LV) and right ventricular (RV) diastolic function indices measured by echocardiography in healthy individuals. Five hundred and three volunteers (253 women and 250 men) aged 18-66 years (mean 36.9 +/- 11.9) who were normotensive and free of clinically apparent heart disease were included in the study. Mitral and tricuspid peak E wave and A wave velocities, E/A ratio, deceleration time (DT) of the E wave, and left ventricular isovolumetric relaxation time (IVRT) were evaluated as left and right ventricular diastolic function indices. In order to determine the effects of age, gender, body surface area (BSA), waist/hip ratio (WHR), and heart rate (HR) on left and right ventricular diastolic function indices Student's t test and correlation and linear regression analysis were used. IVRT and deceleration time of the mitral E wave (DTm) were significantly longer in men. Mitral and tricuspid A wave velocities, tricuspid E/A ratio, and deceleration time of the tricuspid E wave (DTt) were similar in both genders. Mitral and tricuspid E wave velocities and mitral E/A ratio were greater in women. Mitral E wave velocity and IVRT mostly correlated with WHR. Age was found to be the most important factor affecting mitral A wave velocity, DTm, E/A ratio, and right ventricular diastolic function indices. This study shows that age, heart rate, body surface area, and waist/hip ratio have important correlations with Doppler echocardiographic diastolic indices in normal individuals and should be considered in the evaluation of LV and RV diastolic function.

Use of an age-adjusted Doppler E/A ratio in patients with moderate to severe hypertension

OBJECTIVE

To assess the ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity (Doppler E/A ratio) before and after adjustment for age in patients with moderate to severe hypertension, in whom left ventricular diastolic dysfunction is an early finding. Mitral flow patterns can be used to assess diastolic filling characteristics, and the Doppler E/A ratio is the parameter most commonly used, although it is known to be strongly age dependent. There are no established normal values for this ratio.

DESIGN

Retrospective data analysis.

SETTING

A 2000-bed tertiary-care teaching hospital.

PATIENTS

We studied 190 patients (99 women and 91 men; ages 55 +/- 13 years) with moderate to severe hypertension.

INTERVENTIONS

The ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity was measured. As this ratio depends on age, a Z score was calculated to control for this influence. The Z score is the standardized normal deviation of the mean, with a normal value of 0 +/- 2.

MAIN OUTCOME MEASURES

Sensitivities and specificities for detecting an age-dependent reduction in Doppler E/A score (Z score less than -2) with a non-age-dependent Doppler E/A ratio (less than 1) were calculated.

RESULTS

In 106 of the patients (56%) the Doppler E/A ratio was less than 1.0. Only nine patients (4.7%) had a Z score less than -2. The sensitivity of the Doppler E/A ratio threshold of 1.0 for detecting a Z score less than -2 was 0.89 and the specificity was 0.46. A Z score less than -2 was found only in patients younger than 45 years.

CONCLUSIONS

The Doppler E/A ratio was reduced in a large proportion of our patients. However, after correction for age it was decreased in only 4.7% of these patients. The use of a single Doppler E/A ratio threshold value has a weak diagnostic power to detect age-independent changes in mitral flow patterns.

Doppler tissue imaging in congestive heart failure patients due to diastolic or systolic dysfunction: a comparison with Doppler echocardiography and the atrio-ventricular plane displacement technique

BACKGROUND

Doppler tissue imaging (DTI) is an echocardiographic technique by which regional contractility, relaxation properties and time intervals are obtained easily. DTI has been reported to be relatively pre-load independent and could, in comparison with the commonly used mitral pulse wave Doppler (MPWD) method, be of clinical interest for identification of patients with diastolic dysfunction. The atrio-ventricular plane displacement (AVPD) method is an established technique to assess left ventricular systolic function.

AIMS

To determine the pulsed Doppler DTI-pattern in patients with heart failure and to examine whether it has a similar capacity as MPWD and AVPD to diagnose diastolic dysfunction.

METHODS

We studied 15 controls without congestive heart failure (CHF), 15 patients with diastolic (EF>45%+CHF) and 15 patients with systolic (EF<35%+CHF) left ventricular dysfunction and CHF.

RESULTS

The DTI maximal velocities during systole (s), early filling wave (e) and atrial filling wave (a), decrease with reduced left ventricular ejection fraction, r=0.75, r=0.56 and r=0.66 (P<0.001) and regional isovolumetric contraction and intraventricular relaxation time measured by DTI are prolonged, r=0.59 and r=0.73, respectively (P<0.001). The 15 patients with diastolic heart failure were identified by MPWD or DTI but only 11 by AVPD with 8, 10 and 9 false-positive, respectively (P<0.01, P<0.05 and NS).

CONCLUSIONS

Regional DTI show a consistent pattern in patients with left ventricular dysfunction and heart failure. Regional DTI has similar accuracy as MPWD in identifying diastolic heart failure patients and is superior to the AVPD technique. DTI may be a useful diagnostic tool in diastolic heart failure patients.

Dynamic morphology of the secundum atrial septal defect evaluated by three dimensional transoesophageal echocardiography

OBJECTIVE

To define by three dimensional echocardiography the pattern and potential determinants of contraction of a secundum atrial septal defect through the cardiac cycle, and to evaluate the possibility of using cross sectional transthoracic and transoesophageal imaging to assess the dynamic nature of the defect.

DESIGN

Three dimensional echocardiography was performed using a multiplane transoesophageal probe on 50 patients with a secundum atrial septal defect (median age 9.8 years). Nine patients were excluded because of poor images or morphological features that precluded defect measurement. In 41 cases, defect area, long and short axis length, and distance of the attenuated anterior rim were measured in their largest and smallest dimensions.

RESULTS

Defect area changed significantly through the cardiac cycle (mean change 61%, p < 0.0001; range 17% to 86%). The defect contracted symmetrically and was not related to patient age, defect size, heart rate, Qp/Qs ratio, the presence of an aneurysmal atrial septum, or attenuated anterior rim. In all cases with an attenuated anterior rim (n = 13), the length of the rim significantly decreased (p = 0. 001) during atrial systole. Dynamic changes measured by either transthoracic or transoesophageal cross sectional images did not correlate with those obtained by three dimensional imaging.

CONCLUSIONS

Three dimensional echocardiography shows dynamic features of defects in the atrial septum. This information may lead to an improved understanding of the pathophysiology of atrial shunting.

Normal regional right ventricular function and its change with age: a Doppler myocardial imaging study

BACKGROUND

Doppler Myocardial Imaging (DMI) is a new technique currently being studied for the assessment of regional systolic and diastolic left ventricular (LV) function. No normal values or data on age-related changes in regional myocardial right ventricular (RV) velocities are available.

METHODS AND RESULTS

Color DMI was used in 32 healthy volunteers (aged 16-76 years) to derive regional velocities from basal, medial, and apical segments of the RV free wall in the apical 4-chamber view, and from distal segments as well as from the tricuspid annulus in the parasternal long-axis view. Both mitral annular and regional LV velocities (4-chamber, long-axis parasternal view) were also recorded and compared with corresponding RV regional velocities. The M-mode displacement of the cardiac base was measured. Corresponding RV and LV DMI data sets were compared. For longitudinal function, RV free wall systolic velocities were consistently higher than velocities recorded in corresponding LV segments (analysis of variance, P <.05). Older subjects (40-76 years; 13 men, 2 women) had lower RV long-axis regional velocities than younger subjects (16-39 years; 15 men, 2 women), but had higher short-axis RV systolic velocities. For diastolic velocities, a negative correlation between age and the ratio of regional early diastolic to late diastolic velocity was shown for all RV free wall segments (eg, basal segment: r = -0.63, P <.0001).

CONCLUSIONS

The right ventricle has higher long-axis regional velocities, a greater excursion of its lateral atrioventricular valve ring, and reduced circumferential shortening velocities compared with the left ventricle. Right ventricular longitudinal shortening is dominant over short-axis function in healthy young subjects. Normal age-related changes of diastolic velocities for each segment of the normal RV free wall have been defined.

Right ventricular diastolic filling assessed by conventional doppler and tissue Doppler imaging in normal children

To examine age-related changes in right ventricular filling dynamics, we performed conventional pulsed Doppler (n=99) and tissue Doppler (n=30) echocardiographic studies in normal subjects aged 7 days to 273 months. The tricuspid flow velocity during early diastole (peak E) wave correlated significantly but weakly with the logarithm of age. The peak E wave in the early neonatal period was almost 80% of the older children's values and increased to 100% by 36 months of age. In the right ventricular tissue Doppler imaging, the peak myocardial velocity during early diastole also increased significantly with the logarithm of age. However, the tissue Doppler peak A did not change with age. There was a significant correlation between the tissue Doppler peak E wave and the tricuspid peak E wave and between the tissue Doppler peak E/A wave and the tricuspid peak E/A wave. The age-related changes in the tricuspid inflow velocity patterns were similar to the age-related alterations in the right ventricular myocardial velocity patterns. Age-related changes in the tricuspid inflow velocity and myocardial velocity patterns may be related to age-related maturation in the right ventricular diastolic performance.

Assessment of Right Ventricular and Right Atrial Systolic and Diastolic Performance Using Automated Border Detection

Noninvasive assessment of right ventricular (RV) function is important clinically, but current techniques have limitations. Acoustic quantification (AQ) is an automated endocardial border detection technique that allows continuous determination of RV and right atrial (RA) area waveforms and may be useful for the assessment of RA and RV systolic and diastolic performance. Fifty patients (10 normal, 40 with RV pathology) were studied. Signal-averaged RA and RV AQ area waveforms were obtained and analyzed to compute parameters of diastolic and systolic function. All groups demonstrated significant diastolic dysfunction on the RA AQ waveform as manifested by a reduced percentage of passive atrial emptying and increased dependence on active atrial emptying. Abnormalities of diastolic performance were noted in all subgroups on RV AQ analysis as evidenced by a reduction in the percentage of ventricular filling occurring during early diastole and an increased contribution from active atrial contraction. This study demonstrates the feasibility of using automated analysis of signal-averaged RA and RV area waveforms for the evaluation of RV systolic and diastolic performance. This technique identified significant systolic and diastolic dysfunction in four groups of commonly seen right heart pathologies including biventricular heart failure, pulmonary hypertension, pressure and volume overloaded RVs, and biventricular hypertrophy.

Effects of age and physiologic variables on right ventricular filling dynamics in normal subjects

The reference values for right ventricular (RV) filling of normal persons and the effects of physiologic variables in a large series have not been described. The objective of this study was to characterize superior vena cava, hepatic vein, and RV inflow Doppler measurements in a large normal reference group to reflect the aging process, gender, heart rate, and effects of respiration. We prospectively performed pulsed-wave Doppler echocardiography of the superior vena cava, hepatic vein, and RV inflow during inspiration, expiration, and apnea in 115 healthy volunteers (62 women and 53 men) ranging in age from 21 to 84 years (mean +/- SEM 48 +/- 17). For analysis, the study subjects were classified by age into 2 groups: those < 50 years of age (group 1; n = 60) and those > or = 50 years of age (group 2; n = 55). Multiregression models were used to assess the influence of age, gender, and heart rate on Doppler variables. There were important differences in superior vena cava and RV inflow between the 2 groups. Group 2 had a greater superior vena cava peak atrial flow velocity (16 +/- 3 vs 13 +/- 3 cm/s), flow integrals (1.5 +/- 0.4 vs 1.1 +/- 0.3 cm), and reverse flow as a percentage of forward flow (17 +/- 6% vs 14 +/- 6%) than group 1. In group 2, peak RV inflow early filling velocity (41 +/- 8 vs 51 +/- 7 cm/s) and ratio of early filling-to-atrial filling (1.3 +/- 0.4 vs 2 +/- 0.5) were lower than that of group 1. Likewise, peak atrial filling velocity was higher (33 +/- 8 vs 27 +/- 8 cm/s) and deceleration time was longer (198 +/- 23 vs 188 +/- 22 ms) in group 2. The superior vena cava and hepatic vein peak forward flow velocities were significantly higher during inspiration than during expiration and apnea. Similarly, RV inflow velocities were significantly higher during inspiration than in expiration and apnea. Multiregression analysis showed that age, gender, and heart rate had important effects on Doppler variables. Thus, this study demonstrates the effects of aging and normal physiologic variable flow velocities in the superior vena cava, hepatic veins, and RV inflow in a large series of normal subjects.

Differentiation of abnormal relaxation pattern with aging from abnormal relaxation pattern with coronary artery disease in transmitral flow with the use of tissue Doppler imaging of the mitral annulus

An abnormal relaxation pattern in transmitral flow velocity waveforms has been observed in older healthy subjects as well as in patients with heart disease. Accordingly, we investigated whether the hemodynamic differences between patients with coronary artery disease (CAD) with an abnormal relaxation pattern in transmitral flow (ratio of E-wave to A-wave velocities < 1.0) and healthy older subjects with an abnormal relaxation pattern can be distinguished with the use of mitral annular velocity (MAV) during early diastole. We measured MAV in the longitudinal direction of the heart during early diastole by M-mode color tissue Doppler imaging in 24 patients with atypical chest pain (defined as healthy subjects in this study) and 70 patients with CAD who underwent cardiac catheterization. In all patients a time constant of left ventricular pressure decay (tau) and the left ventricular (LV) end-systolic volume index were also measured. Twenty-one healthy subjects and 59 patients with CAD had an abnormal relaxation pattern in their transmitral flow. The age, heart rate, mean blood pressure, and ratio of E-wave to A-wave velocities were not different between the two groups. However, the tau was longer and the LV end-systolic volume index was greater in patients who had an abnormal relaxation pattern with CAD than in healthy subjects with an abnormal relaxation pattern. The MAV during early diastole was lower in the former than in the latter (5.8 +/- 1. 9 vs 9.8 +/- 1.9 cm/s, P <.001). Mitral annular velocity during early diastole by M-mode color tissue Doppler imaging can detect the differences in LV relaxation and LV systolic performance between the abnormal relaxation pattern with CAD and the physiologically abnormal relaxation pattern with aging, providing further information regarding the meaning of an LV abnormal relaxation pattern.

Evaluation of Left Ventricular Diastolic Performance Using Automated Border Detection

Acoustic quantification (AQ) is a noninvasive technique which provides online left ventricular (LV) area/volume waveforms. The filling portion of the AQ waveform can be used to assess LV diastolic properties. Analysis of signal-averaged AQ curves enhances the waveforms and allows reliable, quantitative, and automated analysis. From signal-averaged AQ LV waveforms, the phases of diastole can be easily detected and several parameters of diastolic performance calculated. Analysis of signal-averaged LV waveforms is complementary to that of LV AQ analysis. AQ has been used to identify diastolic dysfunction in patients with LV hypertrophy and systemic hypertension. Normal values of these parameters are age dependent and reference values will soon be available.

Age dependency of left atrial and left ventricular acoustic quantification waveforms for the evaluation of diastolic performance in left ventricular hypertrophy

We evaluated diastolic performance in 50 normal subjects and 50 patients with concentric left ventricular (LV) hypertrophy. Age-dependent normal values were determined for LV and left atrial (LA) acoustic quantification parameters. Pulsed wave Doppler echocardiography was also performed on all subjects. Patients with LV hypertrophy had higher peak velocities of atrial contraction and atrial contributions to filling. The acoustic quantification waveforms revealed lower rapid filling percentage of total filling and lower peak rapid filling rates. The LA acoustic quantification analysis confirmed the dependence on active atrial emptying in the patients with LV hypertrophy. There were significant correlations with age for most of the LV and LA acoustic quantification parameters. Acoustic quantification provided confirmatory results in subjects with an abnormal relaxation or restrictive Doppler pattern. In subjects with a normal Doppler pattern, the acoustic quantification was of added diagnostic value, identifying abnormalities in 77% to 80% of the patients.

Left Ventricular Diastolic Function in a Population Sample of Elderly Men

BACKGROUND AND METHODS: Echocardiography with Doppler has been widely used to assess left ventricular (LV) diastolic function. Interpretation of the diastolic indices that are derived, however, is confounded by the effects of physiological aging on the LV diastolic function. In this study, the usefulness of different Doppler-derived indices of LV diastolic function was assessed in elderly subjects by using data from a health screening survey of 584 men aged 70 years. RESULTS: The index of early versus late transmitral blood flow, the E/A ratio, was found to be reduced in the apparently healthy subgroup (n = 195) of the population (0.96 +/- 0.25) compared with previous data from middle-aged subjects. However, E/A ratios similar to those in the apparently healthy subjects were found in subjects with coronary heart disease (CHD), hypertension, and diabetes mellitus. Only subjects with systolic dysfunction (ejection fraction < 40%) showed a significantly decreased E/A ratio (0.79 +/- 0.21, P < 0.05) compared with the apparently healthy subjects. Isovolumic relaxation time (IVRT) was, however, significantly prolonged in subjects with CHD or hypertension compared with the apparently healthy subjects (139 +/- 32, 127 +/- 25, and 118 +/- 21 milliseconds, respectively; P < 0.01), whereas the E wave deceleration times (DT) were alike in both apparently healthy and unhealthy subjects. The diastolic and systolic components of the pulmonary venous blood flow were alike in apparently healthy and unhealthy subjects. Left atrial size was increased in all patients with disease, possibly indicating increased preload. CONCLUSION: In this population sample of elderly men, the commonly used E/A ratio did not distinguish between apparently healthy subjects and those with cardiovascular diseases such as CHD or hypertension, which are known to be associated with LV diastolic dysfunction in the middle-aged population. IVRT appeared to be the most sensitive of the Doppler-derived indices of LV diastolic function used in the present study, but for this variable, the differences between apparently healthy subjects and unhealthy subjects were small. Thus, the age-associated changes in LV compliance appear to override the impact of these disorders on indices of LV diastolic function in elderly populations.

Diastolic heart failure: standard Doppler approach and beyond

Evidence of normal systolic left ventricular function has been reported in up to 30-40% of patients with clinical signs of congestive heart failure, suggesting that diastolic dysfunction is an important predictor of prognosis and mortality. Doppler echocardiography as a noninvasive diagnostic procedure is able to provide immediate and relevant information on functional and structural changes underlying the clinical syndrome of heart failure. Four distinct early filling/late diastole (E/A) ratio patterns (normal, delayed relaxation, pseudonormal, restrictive) can be discerned if viewed within the context of other available clinical information. These patterns evolve from one to another in a single individual, with changes in disease evolution, treatment, and loading condition. They represent a continuum from normal to severe diastolic dysfunction, showing progressively increasing left ventricular (LV) chamber stiffness and subsequently decreasing deceleration time. The combination of Doppler restrictive filling pattern and decreased deceleration time provides important information that helps to differentiate gradations of diastolic dysfunction and has been found to be a potent predictor of prognosis and mortality in various cardiac conditions. When clinical and transthoracic data alone are not sufficient in guiding therapy of congestive heart failure, transesophageal echocardiography can be used to assess most Doppler flows, especially pulmonary venous and left atrial (LA) appendage flows. The use of the multiplane transducer in multiple intermediate scan planes further improves the possibility of optimizing the Doppler incident angle and obtaining the best Doppler recordings of the left upper or right upper pulmonary venous flow. Whereas LV diastolic dysfunction is common in patients with congestive heart failure and appears to be an important predictor of prognosis, little information is available about right ventricular (RV) diastolic dysfunction. The role of RV function in congestive heart failure has probably been underestimated and it is possible that RV diastolic dysfunction assessment is equally important in the follow-up of heart failure patients. Recently, 2 novel echocardiographic technologies for the assessment of ventricular wall dynamics have been developed--color kinesis and tissue Doppler imaging. Both techniques have recently been shown to provide global as well as regional information on LV contraction and filling. Complementary use of both techniques may allow a more complete noninvasive assessment of global and regional systo-diastolic LV function.

Variation of flow propagation velocity with age

Flow propagation velocity is a new color Doppler M-mode measurement of left ventricular filling characteristics. This study was designed to establish normal values for this measurement in healthy individuals and to compare these findings with pulsed Doppler transmitral velocities. Complete M-mode, two-dimensional, and Doppler echocardiographic studies were performed on 64 volunteers between 21 and 79 years of age. Significant negative correlations (p < 0.001) with age were noted for flow propagation velocity (r = -0.59), peak early diastolic filling velocity (r = -0.65), and peak early diastolic filling/peak atrial filling ratio (r = -0.80). Positive correlations (p < 0.001) with age were observed for peak atrial filling velocity (r = 0.50) and atrial filling velocity integral (r = 0.71). Flow propagation velocity decreased by 44% between the youngest and oldest age groups. We conclude that flow propagation velocity is influenced by age and that it compares favorably with transmitral Doppler indices of left ventricular filling in this regard. These age-related alterations are present in healthy individuals, in the absence of any apparent cardiovascular disease.

Heart function in patients with chronic glomerulonephritis and mildly to moderately impaired renal function. An echocardiographic study

Left ventricular hypertrophy and diastolic heart dysfunction have been reported in essential hypertension and in patients with chronic renal failure, treated with haemodialysis, but a close association with blood pressure (BP) level has not been uniformly documented. Thus, other factors could be involved in the pathogenesis of cardiac dysfunction. The aims of the present echocardiographic study were to investigate cardiac morphology and function in patients with chronic glomerulonephritis with mildly to moderately impaired renal function, and to study the relation between echocardiographic findings and glomerular filtration rate (GFR), BP and age. Twenty patients with chronic glomerulonephritis and 14 healthy controls, of the same age- and sex-distribution, were examined by 2D-, M-mode and pulsed-wave Doppler echocardiography. In patients, GFR was determined as plasma clearance of Cr-EDTA. The patients had significantly thicker left ventricular (LV) posterior walls in end diastole (8.7 vs 8.1 mm, p < 0.05), and a higher LV mass index (106.5 vs 93.8 g/m2, p < 0.05). Systolic functional indices, i.e. LV fractional shortening and LV ejection fraction, were statistically significantly lower in patients than in controls (p < 0.05). LV diastolic function in patients was characterized by a statistically significantly lower early peak flow velocity (E-Vmax) (0.66 compared with 0.8 m/s) and early to late peak flow velocity ratio (E/A ratio) (1.07 vs 1.41), as well as E/A ratio of time velocity indices (VTI-E/A) (1.45 vs 1.99) (p < 0.05). The right ventricular filling indices showed a tendency towards a lower E-Vmax in patients (0.55 compared with 0.62 m/s, p = 0.1). In patients, statistically significant negative correlations were found between age and mitral E/A ratio (r = -0.76, p < 0.0001), as well as LV VTI-E/A(r = -0.81, p < 0.0001). The same trend was seen for the tricuspid E/A ratio. No statistically significant correlations were found in patients between mitral or tricuspid E/A ratio and GFR, BP, LV mass or heart rate.

IN CONCLUSION

in a group of patients with chronic glomerulonephritis and mildly to moderately impaired renal function, it was found by means of echocardiography that there was a higher LV mass index and decreased systolic function, when compared with healthy controls. In addition, the patients had diastolic dysfunction of primarily the left ventricle. The echocardiographic findings were not correlated to BP level or renal function. This suggests that factors other than GFR or BP per se might be involved in the pathogenesis of cardiac dysfunction, at an early stage.

Right and left ventricular diastolic function in patients with and without heart failure: effect of age, sex, heart rate, and respiration on Doppler-derived measurements

Doppler echocardiography is widely used to assess right and left ventricular diastolic function. Although the factors affecting Doppler-derived measurements have been described in unaffected patients, there is little information available for patients with heart failure. Therefore we performed two-dimensional Doppler echocardiography studies of right and left ventricular function in 140 subjects, 88 with congestive heart failure and 52 age-matched normal subjects. The separate effects of age, sex, heart rate, and respiration were assessed by correlation analysis and multiple linear regression. In normal subjects both left and right ventricular parameters significantly correlated with age and heart rate. No significant effect of respiration was apparent in left ventricular function, but in the right ventricle inspiration caused a significant increase in transtricuspid peak E-wave velocity, E/A ratio, and shortening of the E-wave deceleration time. There was a significant correlation between left and right ventricular diastolic parameters. In heart failure, age correlated weakly with mitral valve peak A wave (r = 0.23, p = 0.03) and with tricuspid valve peak E-wave velocity (r = 0.37, p < 0.001), although in those with a restrictive filling pattern age was associated with a significant increased shortening of the mitral E-wave deceleration time (r = -0.8; p = 0.0015). Heart rate and deceleration time of mitral and tricuspid E wave significantly correlated, but heart rate did not correlate with either mitral or tricuspid peak E-wave or A-wave velocities or E/A ratio. In heart failure the effect of respiration was similar to normal subjects. Sex was not associated with Doppler variables in either normals or heart failure subjects. Thus this study demonstrates that age, heart rate, and respiration have important and separate associations with Doppler echo diastolic parameters of the right and left ventricle in normal subjects and similar, although weaker relations in patients with heart failure.

Diastolic heart failure. What primary care physicians need to know

Congestive heart failure (CHF) with normal left ventricular systolic function and abnormal diastolic performance is a common clinical entity. Typically, signs and symptoms are indistinguishable from those of heart failure related to systolic dysfunction. Coronary artery disease, systemic hypertension, and aging are all associated with diastolic CHF. Diagnosis depends on a clinical suspicion of heart failure, followed by assessment of left ventricular systolic performance, which is normal in this condition. Ventricular diastolic performance can be assessed by noninvasive procedures, the most reliable and easily performed of which is echocardiography. General guidelines include searching for precipitants such as ischemia, tachycardia, and loss of atrial-ventricular synchrony. Treatment includes judicious use of nitrates and diuretics to relieve pulmonary congestion. There is no specific therapy to improve left ventricular diastolic function directly. However, calcium channel blockers and beta blockers are beneficial, and there is growing evidence that angiotensin-converting enzyme inhibitors may prove valuable.

Echo-Doppler evaluation of left ventricular impairment in chronic cor pulmonale

The effects of acute right ventricular (RV) pressure and volume overloads on left ventricular (LV) filling are well known, while the significance of chronic RV pressure overload on LV function has been less studied. To evaluate the LV impairment, 30 patients with chronic cor pulmonale and pulmonary arterial hypertension secondary to chronic obstructive lung diseases (COLDs) were studied. All patients underwent respiratory tests and arterial blood gas assessment. An echo-Doppler examination was made to measure LV ejection fraction (EF), RV and LV end-diastolic and end-systolic diameters and areas, RV/LV area indexes, LV diastolic and systolic eccentricity indexes, mitral and tricuspid flow patterns, and mitral flow velocity in late and early diastole (A/E) indexes. A right heart catheterization was carried out to determine the resting mean pulmonary arterial pressure (mPAP). The data showed a marked enlargement of RV, compressing the left through a leftward shift of interventricular septum. A linear regression analysis detected a significant correlation between mPAP and the following parameters: RV/LV diastolic and systolic area indexes (r=0.75, p<0.0001; r=0.84, p<0.000, respectively), mitral A/E index (r=0.61, p<0.0005), and LV diastolic and systolic eccentricity indexes (r=0.93, p<0.0001; and r=0.83, p<0.0001). No correlations were found between echo-Doppler data and functional respiratory parameters. From these results, we conclude that chronic RV pressure overload induces LV filling impairment despite a normal systolic phase, due to septal leftward shift. In fact, chronic RV pressure overload distorts early diastolic LV geometry delaying LV filling phase, and the functional diastolic impairment of the LV is closely correlated to pulmonary hypertension levels.

Right ventricular diastolic dysfunction in heart failure

BACKGROUND

Left ventricular (LV) diastolic dysfunction is common in heart failure and is an important predictor of prognosis and mortality. Less attention has been paid to right ventricular (RV) diastolic function. In this study, we compared RV diastolic function in a large cohort of patients with heart failure (HF) with two groups: patients with pulmonary hypertension and normal LV function (the PHT group) and normal subjects.

METHODS AND RESULTS

Transtricuspid and pulmonary artery flow were assessed by two-dimensional Doppler echocardiography at maximum inspiration and expiration in 185 subjects: 114 symptomatic HF patients (ejection fraction < 0.5), 31 PHT patients (pulmonary artery systolic pressure > 40 mm Hg), and 40 normal subjects. A subset was matched for age and heart rate. The results showed a high prevalence of RV diastolic abnormalities: HF patients had lower tricuspid E-A ratios, lower peak E-wave velocity, and prolonged RV isovolumic relaxation time (all P< .0001). Tricuspid E-wave deceleration time was significantly shorter only in those who had an LV restrictive filling pattern. The PHT group had similar findings. Compared with a normal range, more than half of the patients had lower tricuspid E-A ratios (HF, 55%; PHT, 69%), and 61% of HF and 58% of PHT patients had a prolonged RV isovolumic relaxation time. In the PHT group, RV diastolic parameters (E-wave deceleration time, E-A ratio, and isovolumic relaxation time) correlated significantly with pulmonary artery systolic pressure (P< .05). In the HF group, however, only tricuspid E-wave deceleration time correlated significantly with pulmonary artery systolic pressure, and HF patients with normal pulmonary artery systolic pressures had significantly lower tricuspid E-A ratios and prolonged RV isovolumic relaxation times compared with normal subjects. A close correlation existed between individual RV and LV diastolic parameters, suggesting that LV diastolic dysfunction may directly affect RV function, but there was no relation between LV size or systolic function and RV diastolic dysfunction.

CONCLUSIONS

RV diastolic function is frequently abnormal in HF patients, and this is not related to elevated pulmonary artery systolic pressure alone, although high pulmonary artery pressure by itself also is associated with impaired RV diastolic function. Assessment of the role of right ventricular diastolic function in determining the symptoms and prognosis of heart failure is warranted.

Left atrial mechanical function in the healthy elderly: new insights from a combined assessment of changes in atrial volume and transmitral flow velocity

To assess left atrial mechanical function in the elderly, 35 old (age > 70 years) and 18 sex-matched young (age < 50 years) healthy subjects were studied. Transmitral flow velocities were recorded with pulsed Doppler echocardiography. Left atrial volumes were measured echocardiographically at mitral valve opening (maximal) and closure (minimal) and at onset of atrial systole (P wave of the electrocardiogram) according to the biplane area-length method. Left atrial passive emptying was assessed with the passive emptying volume (maximal-volume at onset of atrial systole) and fraction (passive emptying volume/maximal). Left atrial active emptying was assessed with the active emptying volume (volume at onset of atrial systole-minimal) and fraction (active emptying volume/volume at onset of atrial systole) and with left atrial ejection force = 0.5.blood density.volume at onset of atrial systole.active emptying fraction.(A velocity)2/A integral. Left atrial volumes were greater in old compared with young subjects (maximal: 31 +/- 10 cm3/m2 vs 24 +/- 8 cm3/m2, p = 0.02; at onset of atrial systole: 23 +/- 8 cm3/m2 vs 15 +/- 5 cm3/m2, p = 0.0002; minimal: 13 +/- 5 cm3/m2 vs 9 +/- 4 cm3/m2, p = 0.001). Passive emptying volume and fraction were lower (7.8 +/- 1.7 cm3/m2 vs 9.2 +/- 3.2 cm3/m2 [p = 0.04] and 26.4% +/- 9.8% vs 37.9% +/- 11.2% [p = 0.003], respectively), whereas atrial ejection force and active emptying volume were greater in old compared with young subjects (6.8 +/- 3.3 kdynes/m2 vs 4.2 +/- 2.8 kdynes/m2 [p = 0.007] and 9.2 +/- 4.1 cm3/m2 vs 5.7 +/- 2.9 cm3/m2 [p = 0.002], respectively). The active emptying fraction was similar in the two groups (39.7% +/- 11% vs 38.4% +/- 13%; difference not significant). Thus advanced age is associated with depressed left atrial passive emptying function and increased left atrial volume. Left atrial dilation contributes to an increase in atrial ejection force and the amount of blood ejected during left atrial systole and may represent an important compensatory mechanism in this age population.

Mechanisms, diagnosis, and treatment of diastolic heart failure

Diastolic heart failure, in the absence of LV systolic dysfunction, is a common clinical condition that can be demonstrated in as many as one third of patients with congestive heart failure. Diastolic dysfunction caused by abnormalities in LV filling can be a result of many pathologic conditions, including hypertrophy, infiltrative cardiomyopathies, or myocardial ischemia. The major physiologic determinants of LV filling can be divided into cellular mechanisms, hemodynamic characteristics, and hormonal influences. Cellular mechanisms for impaired LV inactivation are determined by the handling of calcium within the myocyte during excitation-contraction-relaxation coupling. The hemodynamic characteristics of LV diastolic filling are determined by loading conditions, the time constant of isovolumic relaxation, heart rate, ventricular nonuniformity, pericardial restraint, myocardial elasticity, chamber compliance, and coronary blood flow. The sympathetic nervous system and the renin-angiotensin system are important modulators of diastolic filling, directly or indirectly. The diagnosis of heart failure is confirmed by a combination of clinical tests including invasive and noninvasive techniques, each of which has advantages and disadvantages. Treatment of medical conditions in which diastolic heart failure is a prominent component include pharmacotherapy with calcium channel antagonists, beta-adrenergic blocking agents, diuretic agents, and angiotensin-converting-enzyme inhibitors. Certain conditions associated with diastolic filling abnormalities such as pericardial disease or severe ischemic heart disease may be best managed by surgical or percutaneous intervention. Future research will include further delineation of the cellular mechanisms of active myocardial relaxation and clinical investigation into treatment directed at improving outcome.

Relation between diastolic left ventricular function and myocardial blood volume during adenosine-induced coronary hyperemia

Adenosine infusion is accompanied by increases in coronary blood flow and myocardial blood volume. Myocardial blood volume may produce changes in diastolic left ventricular (LV) performance by increasing myocardial turgor. Diastolic dysfunction may also be the result of myocardial ischemia. The relation between changes in LV mass and diastolic function has not been previously investigated. This study examined the relation between changes in LV mass during adenosine-induced coronary hyperemia and LV diastolic function. Serial two-dimensional and Doppler echocardiographic measurements were made before, during, and after adenosine infusion (140 micrograms/min for 6 min) in 21 patients with (group 1) and 10 patients without (group 2) coronary artery disease (CAD). The LV mass and transmitral diastolic filling indexes were determined from digitized images from apical four-chamber view. Adenosine infusion produced a greater increase in LV mass in group 2 than in group 1 (29% +/- 11% vs 9% +/- 6%, p < 0.0002). The ratio of transmitral early (E) to atrial (A) filling velocity (E/A) increased 10% +/- 16% in group 2 and decreased 8% +/- 20% in group 1 (p < 0.02), and the velocity time integral of early filling increased 11% +/- 52% in group 2 and decreased 20% +/- 31% in group 1 (p < 0.04). There was a correlation between the change in E/A ratio and the LV mass (r = 0.53, p < 0.003). Thus adenosine infusion caused a greater increase in LV mass in normal subjects than in patients with CAD. There were also changes in Doppler-derived indexes of diastolic LV function.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of aging on left ventricular filling in untreated hypertensive patients

The aim of this study was to evaluate the influence of age and other clinical and echocardiographic parameters on left ventricular filling in a group of 174 untreated patients with mild to moderate hypertension (aged 20-82 years; mean 51.2 years) and in 189 age-matched normotensive subjects. All subjects underwent an echocardiographic study with pulsed Doppler evaluation of left ventricular filling. Left ventricular dimensions and indexes of systolic function were similar and within normal limits in both groups. Left ventricular filling was altered in hypertensive subjects < 65 years with a decrease of peak early velocity (peak E), an increase of peak atrial velocity (peak A) and a reduced E/A ratio. However in subjects > or = 65 years, we did not observe any differences in transmitral flow velocity pattern between hypertensive and normotensive subjects. The stepwise regression analysis showed that age alone explains up to 8% of peak E variance, 14% of peak A and 26% of E/A ratio in hypertensives, while in normotensives it explains up to 18% of peak E variance, 50% of peak A and 61% of E/A ratio. The other variables entered into the regression slightly improved the predictive power. In conclusion, age is the major independent factor affecting left ventricular filling in both groups, even if its predictive power was smaller in the hypertensive group. The similarity of diastolic filling pattern in elderly hypertensive and normotensive subjects suggests that the 'aging factor' plays an important role in influencing left ventricular filling pattern so as to mask the effect of hypertension in the elderly patients.