Doppler diastolic filling indexes in relation to disease states

The predictive value of clinical, radiographic, echocardiographic variables and cardiac biomarkers for assessing risk of the onset of heart failure or cardiac death in dogs with preclinical myxomatous mitral valve disease enrolled in the DELAY study

OBJECTIVES

To identify the predictive value on time to onset of heart failure (HF) or cardiac death of clinical, radiographic, and echocardiographic variables, as well as cardiac biomarkers N-terminal pro brain natriuretic peptide (NT-proBNP) and cardiac troponin I in dogs with preclinical myxomatous mitral valve disease (MMVD).

ANIMALS

One hundred sixty-eight dogs with preclinical MMVD and left atrium to aortic root ratio ≥1.6 (LA:Ao) and normalized left ventricular end-diastolic diameter ≥1.7 were included.

METHODS

Prospective, randomized, multicenter, single-blinded, placebo-controlled study. Clinical, radiographic, echocardiographic variables and plasma cardiac biomarkers concentrations were compared at different time points. Using receiving operating curves analysis, best cutoff for selected variables was identified and the risk to develop the study endpoint at six-month intervals was calculated.

RESULTS

Left atrial to aortic root ratio >2.1 (hazard ratio [HR] 3.2, 95% confidence interval [95% CI] 1.9-5.6), normalized left ventricular end-diastolic diameter > 1.9 (HR: 6.3; 95% CI: 3.3-11.8), early transmitral peak velocity (E peak) > 1 m/sec (HR: 3.9; 95% CI: 2.3-6.7), and NT-proBNP > 1500 ρmol/L (HR: 5.7; 95% CI: 3.3-9.5) were associated with increased risk of HF or cardiac death. The best fit model to predict the risk to reach the endpoint was represented by the plasma NT-proBNP concentrations adjusted for LA:Ao and E peak.

CONCLUSIONS

Logistic and survival models including echocardiographic variables and NT-proBNP can be used to identify dogs with preclinical MMVD at higher risk to develop HF or cardiac death.

Survival characteristics and prognostic variables of dogs with preclinical chronic degenerative mitral valve disease attributable to myxomatous degeneration

BACKGROUND

Preclinical myxomatous mitral valve degeneration (MMVD) includes a heterogeneous group of dogs. Therefore, identifying risk factors for progression of the disease is of clinical importance.

OBJECTIVES

To investigate survival time and risk factors for clinical and echocardiographic variables taken at initial examination for clinical progression in preclinical MMVD dogs.

ANIMALS

A total of 256 dogs with stage B1 or B2 MMVD.

MATERIALS AND METHODS

Medical records of 256 dogs with preclinical MMVD were reviewed retrospectively. Long-term outcome was assessed by telephone interview. Dogs alive at the time of phone interview were asked to return to the hospital for re-evaluation of their cardiac status.

RESULTS

Seventy of 256 (27.3%) dogs died during the observation period. The median survival time, regardless of cause of death, was 588 (range 75-1,668) days. The presence of a murmur was associated with an increased risk of death (AHR 2.14; 95% CI 1.12, 4.11; P = 0.022). Thirty (12%) deaths were considered cardiac related. LA/Ao > 1.4 was the only negative predictor (AHR 2.64; 1.13, 6.13; P = 0.024) for cardiac-related deaths. Eighty-three dogs were re-examined, of which 34 progressed to a more advanced stage of MMVD. The presence of Emax > 1.2 (AHR 2.75; 95% CI 1.01, 7.48; P = 0.047) and cough (AHR 7.89; 95% CI 3.18, 20.07; P < 0.001) were significant in the multivariate analysis.

CONCLUSIONS AND CLINICAL IMPORTANCE

Preclinical MMVD represents a relatively benign condition in dogs. Clinicians might find stratification of this dog population according to risk factors based on clinical and echocardiographic findings helpful in determining treatment.

Color M-mode flow propagation velocity and conventional doppler indices in the assessment of diastolic left ventricular function during isometric exercise

BACKGROUND AND OBJECTIVE

Color M-mode flow propagation velocity (Vp) was shown to be a preload-independent measure of diastolic function. To study the effects of an increase in afterload induced by isometric handgrip exercise on diastolic function assessment in patients with cardiomyopathy, we measured Vp and conventional Doppler indices at baseline and at 30% of predetermined maximum handgrip strength.

METHODS

Twenty-four patients with systolic dysfunction were divided into two groups: Group I comprising 12 patients with E/A < 1 (early filling velocity/atrial contraction velocity) and Group II comprising 12 patients with E/A > 1. All the patients underwent measurement of Vp, E velocity, its deceleration time (DT), A velocity, isovolumic relaxation time (IVRT), and pulmonary atrial flow reversal velocity (PFR) at baseline and at 30% of predetermined maximum handgrip strength. Twelve healthy controls underwent these same measurements.

RESULTS

When comparing baseline to peak echocardiographic data, no significant changes were noted in Vp in any of the groups while a shift of pulsed Doppler indices of Group I toward a pattern closer to that of Group II was noted and a decrease in E velocity and E/A ratio with an increase in IVRT occurred in healthy controls.

CONCLUSIONS

Color M-mode flow propagation velocity seems to be an afterload-independent measure of diastolic function in patients with moderate to severe cardiomyopathy while pulsed Doppler indices are more sensitive to loading conditions induced by isometric exercise.

Insulin resistance, dietary fat intake and blood pressure predict left ventricular diastolic function 20 years later

BACKGROUND AND AIMS

Our knowledge on the development of left ventricular diastolic dysfunction is scarce. Thus, we aimed to investigate the relationship between left ventricular diastolic function and a wide variety of cardiovascular risk factors, including dietary factors using both cross-sectional and longitudinal data with 20 years follow-up.

METHOD AND RESULTS

A population-based cohort of 505 50-year-old men was examined with determinations of blood pressure, insulin, glucose and fatty acid composition of serum cholesterol esters. A reinvestigation 20 years later also included hyperinsulinaemic euglycaemic clamp, 7-day diet record and Doppler echocardiography with determination of left ventricular diastolic function (early (E) and late (A) peak mitral velocities and left atrial diameter). Blood pressure both at age 50 and 70 was negatively correlated to the E/A ratio (r=-0.15, p<0.001 and r=-0.23, p<0.001) at age 70. Insulin resistance at age 50 and 70 were negatively correlated to the A-wave and left atrial diameter at follow-up. A fatty acid profile indicating a diet high in saturated fats at age 50 was correlated to an increased left atrial diameter 20 years later and the dietary intake of fat was negatively correlated to the E/A ratio (r=-0.09, p<0.05) at age 70. All findings were independent of myocardial infarction and cardiovascular medication.

CONCLUSION

Apart from blood pressure, insulin resistance and dietary fat intake predicted left ventricular diastolic function after 20 years. These findings suggest that both hemodynamic and metabolic factors may play a role for left ventricular diastolic function and disclose new possibilities for prevention of left ventricular diastolic dysfunction.

Left ventricular diastolic dysfunction in patients with chronic renal failure: impact of diabetes mellitus

AIMS

Left ventricular (LV) hypertrophy and LV diastolic dysfunction are cardiac changes commonly observed in patients with chronic renal failure (CRF) as well as hypertension. Although the impairment of LV diastolic function in patients with diabetes mellitus has been shown, little is known about the specific effect of diabetes on LV diastolic function in patients with CRF. The present study was designed to investigate the impact of diabetic nephropathy on LV diastolic dysfunction, independent of LV hypertrophy, in CRF patients.

METHODS

In 67 patients with non-dialysis CRF as a result of chronic glomerulonephritis (n = 33) or diabetic nephropathy (n = 34), and 134 hypertensive patients with normal renal function, two-dimensional and Doppler echocardiographic examinations were performed, and LV dimension, mass, systolic function, and diastolic function were evaluated.

RESULTS

LV mass was increased and LV diastolic dysfunction was advanced in subjects with CRF compared with hypertensive controls. In the comparison of echocardiographic parameters between the two groups of CRF patients, i.e. chronic glomerulonephritis and diabetic nephropathy groups, all indices of LV diastolic function were more deteriorated in the diabetic nephropathy group than in the chronic glomerulonephritis group, although LV structure including hypertrophy and systolic function did not differ between the groups. In a multiple regression analysis, the presence of diabetes (i.e. diabetic nephropathy group) was a significant predictor of LV diastolic dysfunction in CRF subjects, independent of other influencing factors such as age, blood pressure, renal function, anaemia and LV hypertrophy.

CONCLUSION

The present findings suggest that LV diastolic dysfunction, independent of LV hypertrophy, is specifically and markedly progressed in patients with CRF as a result of diabetic nephropathy.

Fasting plasma glucose is an independent determinant of left ventricular diastolic dysfunction in nondiabetic patients with treated essential hypertension

Left ventricular (LV) hypertrophy and LV diastolic dysfunction are common cardiac changes in hypertensive patients, and these changes are modified by various factors other than blood pressure. The present study was conducted to investigate the influence of mild abnormalities in glucose metabolism on LV structure and function in essential hypertension. In 193 nondiabetic patients with treated essential hypertension, two-dimensional and Doppler echocardiographic examinations were performed, and relative wall thickness (RWT), LV mass index (LVMI), fractional shortening, and the ratio of the peak velocity of atrial filling to early diastolic filling (A/E) were calculated. Fasting plasma glucose (FPG) and HbA1c levels were positively correlated with the A/E ratio and the deceleration time of the E wave. However, these plasma levels had no correlation with RWT, LVMI, or fractional shortening. Peak A wave velocity and the A/E ratio were significantly higher in patients who had FPG of > or = 100 mg/dl (and <126 mg/dl) than those who had FPG of <100 mg/dl, although age, blood pressure, RWT, LVMI, and fractional shortening did not differ between the two groups. In a multiple regression analysis of all subjects, only FPG and age were independent determinants of the A/E ratio. These observations suggest that FPG is a sensitive predictor for LV diastolic dysfunction in nondiabetic patients with treated hypertension. Since a slight increase in plasma glucose levels is associated with abnormalities in diastolic function independent of LV hypertrophy, an early stage of impaired glucose metabolism in hypertensive patients may specifically deteriorate cardiac diastolic function.

Relations of diastolic left ventricular filling to systolic chamber and myocardial contractility in hypertensive patients with left ventricular hypertrophy (The PRESERVE Study)

Abnormalities of left ventricular (LV) diastolic filling and stress-corrected midwall shortening (MWS) have been described in hypertensive patients with normal ejection fraction (EF). However, whether stress-corrected MWS parallels LV diastolic filling better than EF does remains uncertain. Blood pressure, body mass index, echocardiographic LV mass and LV geometry, EF and stress-corrected MWS, LV diastolic filling (peak E- and A-wave velocities, E-wave deceleration time, and atrial filling fraction) were evaluated in 212 hypertensive patients with LV hypertrophy enrolled in the Prospective Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement study. LV structure, geometry, as well as LV diastolic filling, were compared between patients with reduced EF (<55%, n = 39, 18%) and those with normal EF (>55%) as well as between patients with reduced stress-corrected MWS (<89.2%, n = 31, 15%) and those with normal stress-corrected MWS (>89.2%). Patients with reduced EF had higher LV mass, eccentric LV geometry, and higher heart rate than those with normal EF, although they did not differ in age, blood pressure, or body mass index. LV filling pattern was also similar in those 2 groups. Patients with reduced stress-corrected MWS had higher atrial filling fraction, body mass index, heart rate, LV mass, and concentric geometry than those with normal stress-corrected MWS. Atrial filling fraction was negatively associated with stress-corrected MWS, but not with EF in multivariate models, independently of age, gender, heart rate, and body mass index. Thus, in hypertensive patients with LV hypertrophy, abnormal LV diastolic filling is more closely related to impaired myocardial contractility than to LV chamber EF.

Factors of Importance to Doppler Indexes of Left Ventricular Filling in 50-Year-Old Hypertensive Persons

Altered left ventricular (LV) diastolic filling has been shown in subjects with hypertension. Age is a major determinant of Doppler indexes of LV diastolic filling; therefore, a group of subjects of uniform age should preferably be chosen, if other determinants of diastolic LV filling are to be studied. A limited body of data is available regarding Doppler indexes of LV filling in hypertensive persons of a similar age. We therefore evaluated 26 hypertensive subjects (13 women and 13 men) 50 years old by Doppler echocardiography. The peak velocity of early diastolic filling (E wave), the peak velocity of atrial filling (A wave), the early-to-atrial peak velocity (E/A) ratio, and the deceleration time of early velocity were measured. The peak E wave velocity was 0.76 +/- 0.11 versus 0.62 +/- 0.13 m/s (P < 0.005), and the E/A ratio was 1.11 +/- 0.24 versus 0.93 +/- 0.23 (P < 0.05) in hypertensive women and men, respectively. The peak A wave velocity was increased and the E/A ratio was decreased in both hypertensive women and men compared with healthy 50-year-old subjects. In multivariate analyses, LV diameter, body mass index, and gender correlated with the E/A ratio in hypertensive persons. It is concluded that there is a significant difference in Doppler LV filling indexes between 50-year-old hypertensive women and men. LV diameter, gender, and body mass index are independent determinants of LV diastolic inflow in similarly aged hypertensive persons.

Ventricular filling patterns of the right and left ventricles in normally grown fetuses: a longitudinal follow-up study from early intrauterine life to age 1 year

OBJECTIVE

Our goal was to determine the effects of advancing age on the Doppler diastolic filling indexes from early gestation to 1 year of life.

STUDY DESIGN

Seventy-nine fetuses were studied. Initial Doppler studies were started at about the 16th week of gestation and repeated every 4-6 weeks until term, on postnatal day 1 and 2, and at ages 6 weeks, 6 months, and 12 months. A minimum of 5 returning Doppler waveforms were traced and analyzed for (1) peak early flow velocity, (2) late peak atrial flow velocity, (3) total area area under the curve, and (4) the acceleration and deceleration phases. The stiffness of the ventricles was estimated. Slopes of the curves for each of the parameters were analyzed for differences across time periods and between right and left ventricles.

RESULTS

(1) Heart rate significantly decreased with advancing age. (2) Left ventricular and right ventricular peak early flow velocity and late peak atrial flow velocity significantly increased during fetal life but not during the 1st year. (3) Atrial predominance was found during fetal life but not during the first year. (4) The deceleration phase of filling significantly increased during the fetal period. (5) Ventricular stiffness progressively decreased during the fetal period. (6) Increased ventricular filling shifted from a right-sided dominance in utero to a left-sided dominance after birth.

CONCLUSIONS

(1) Fetuses have stiffer fetal ventricles than neonates. (2) The diastolic filling patterns in normally grown fetuses mimic those of the diseased adult heart. We speculate that this maturation process may be affected in fetuses born prematurely or small for gestational age.

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.

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.