Doppler echocardiographic analysis of left ventricular filling in treated hypertensive patients

Triglyceride glucose index reflects the unfavorable changes of left ventricular diastolic functions and structure in uncomplicated newly diagnosed hypertensive patients

INTRODUCTION

Left ventricular (LV) diastolic dysfunction and structural abnormalities are common cardiac changes in hypertension (HTN), and several factors other than high blood pressure (BP) may play a role in these changes. The aim of this study was to reveal the relationship between triglyceride glucose (TyG) index, a novel parameter for insulin resistance (IR), with LV diastolic function and structure in hypertensive patients.

MATERIAL AND METHOD

A total of 119 newly diagnosed, untrated hypertensive patients free of diabetes and/or cardiovascular complications were included in this study. IR was estimated with the TyG index calculated from ln [fasting TG (mg/dL) × fasting blood glucose (mg/dL)/2]. Two-dimensional and Doppler echocardiographic examinations were performed to assess LV diastolic functions and structure.

RESULTS

Based on median TyG index, 51 patients was assigned as group I (<8.7) and 68 patients as group II (>8.7). In patients with high TyG index, left atrial volume index (LAVi) (p < .001) LV mass index (LVMI) (p = .016), E/e' ratio (p < .001) increased, and e' velocity (p < .001) and E/A ratio (p = .028) decreased. There was a statistically significant correlation between TyG index and these parameters (all p > .05). Stepwise multiple regression analysis demonstrated that the relationship of TyG index with LV diastolic function and structure was independent of potential confounders (all p < .001).

CONCLUSION

This study suggest that a high TyG index is related to LV diastolic functional impairment and structure abnormality in newly diagnosed hypertensive patients in the absence of diabetes or CVD.

The HARVEST. Looking for optimal management of young people with stage 1 hypertension

In the last few decades there has been much debate about the management of low-risk stage 1 hypertension in youth. In this article, we review the main findings of the HARVEST cohort accrued over 30 years, highlighting the contribution of this study to the existing literature. Tachycardia and sympathetic overdrive were closely intertwined in our HARVEST participants, promoting the development of sustained hypertension, metabolic abnormalities, and increased susceptibility to vascular complications. Short-term blood pressure variability in this age group had a prognostic power even greater than that of average 24h blood pressure. In the HARVEST participants, changes in left ventricular anatomy and contractility were the earliest signs of hypertensive cardiac involvement, whereas left ventricular filling was only marginally affected. Our results highlighted the role of glomerular hyperfiltration in determining microalbuminuria and renal damage in the early stage of hypertension. The genetic approach provided an important contribution to risk stratification and patient management. The HARVEST confirmed the importance of maintaining a good lifestyle for preventing the onset of hypertension, diabetes and cardiovascular events. Isolated systolic hypertension in the first decades of life appeared as a heterogeneous condition. To establish whether antihypertensive drug treatment should be started in this condition the clinician should consider the individual cardiovascular risk profile, the level of office mean BP and central BP. Despite recent progress in our knowledge, systolic hypertension still represents a challenging issue for the clinician. Hopefully, the HARVEST will continue to contribute data that help to fill the present gaps in evidence.

Myocardial performance after successful intervention for native aortic coarctation

Coarctation of the aorta is associated with increased risk for hypertension in adulthood, despite successful repair. The intrinsic mechanisms underscoring hypertension and left ventricular performance in these patients, however, remains to be determined. Our objective was to evaluate left ventricular performance by means of echocardiographic and biochemical parameters at midterm follow-up in normotensive children who have had undergone successful surgical or catheter interventional treatment of coarctation with a residual gradient of less than 20 mmHg at rest. We studied prospectively 14 patients with native aortic coarctation who underwent surgery or balloon angioplasty, the cohort made up of equal numbers of boys and girls, and having a mean age of 8.5 plus or minus 4 years. We also studied 30 age-matched healthy subjects, measuring mitral inflow pulsed wave signals, isovolumic relaxation and contraction times, myocardial performance index parameters, and levels of B-type natriuretic peptide and endothelin-1 in both groups. We found no differences in systolic blood pressure at rest between the patients and their controls. The ventricular septal diastolic dimensions, left ventricular posterior wall dimensions, mitral valve E wave, deceleration time, isovolumic relaxation time, isovolumic contraction time and myocardial performance index were all significantly increased in the patients. Levels of plasma B-type natriuretic peptide and endothelin-1 were also significantly higher in the patients when compared to the control group. We conclude that aortic coarctation is a chronic disease characterized by persistency of myocardial and vascular alterations. The elevated levels of plasma b-type natriuretic peptide and endothelin-1 may be indicative of late onset hypertension after successful treatment of native coarctation in early childhood.

Modified TEI Index: A Promising Parameter in Essential Hypertension?

PURPOSE

Modified TEI index is pointed to be more effective in the evaluation of global cardiac functions compared to systolic and diastolic measurements alone. We planned to determine its applicability in hypertension and relation with left ventricular mass index (LVMI).

METHODS

We studied 48 patients with mild/moderate hypertension and normal coronary angiograms. In total 22 patients (12 men, 10 women, mean age: 55 +/- 6) with normal LVMI were studied in group I, 26 patients (12 men, 14 women, mean age: 57 +/- 7) with increased LVMI in group II, and 20 patients (10 men, 10 women, mean age: 53 +/- 7) with normal blood pressure as a control group. Standard 2D, Doppler, and mitral annulus pulse wave tissue Doppler were used for all measurements. Modified TEI index was calculated as diastolic time interval measured from end of Am wave to origin of Em (a') minus systolic Sm duration (b') divided by b(a'-b'/b').

RESULTS

Modified TEI index was significantly higher in both groups than normal group and in group II than in group I. (

CONTROL GROUP

0.33 +/- 0.05, group I: 0.51 +/- 0.17, group II: 0.68 +/- 0.16, P< 0.0001).

CONCLUSION

Modified TEI index, a marker of left ventricular systolic and diastolic functions, is impaired in hypertensives before hypertrophy develops and impairment is more prominent in hypertrophy. Therefore, (1) modified TEI index in hypertensives is a safe, feasible, and sensitive index for evaluation of global ventricular functions. (2) Evaluation of hypertensives with this index periodically may guide interventions directed toward saving systolic and diastolic functions. (3) Modified TEI index is gaining importance as a complementary parameter to standard Doppler or in cases where standard Doppler has its limitations.

MRI and echocardiographic assessment of the diastolic dysfunction of normal aging: altered LV pressure decline or load?

Changes in diastolic indexes during normal aging, including reduced early filling velocity ( E), lengthened E deceleration time (DT), augmented late filling ( A), and prolonged isovolumic relaxation time (IVRT), have been attributed to slower left ventricular (LV) pressure (LVP) decay. Indeed, this constellation of findings is often referred to as the “abnormal relaxation” pattern. However, LV filling is determined by the atrioventricular pressure gradient, which depends on both LVP decline and left atrial (LA) pressure (LAP). To assess the relative influence of LVP decline and LAP, we studied 122 normal subjects aged 21–92 yr by Doppler echocardiography and MRI. LVP decline was assessed by color M-mode ( Vp) and the LV untwisting rate. Early diastolic LAP was evaluated using pulmonary vein flow systolic fraction, pulmonary vein flow diastolic DT, color M-mode ( E/ Vp), and tissue Doppler ( E/ Em). Linear regression showed the expected reduction of E, increase in A, and prolongation of IVRT and DT with advancing age. There was no relation of age to parameters reflecting the rate of LVP decline. However, older age was associated with reduced E/ Vp ( P = 0.008) and increased pulmonary vein systolic fraction ( P < 0.001), pulmonary vein DT ( P = 0.0026), and E/ Em ( P < 0.0001), all suggesting reduced early LAP. Therefore, reduced early filling in older adults may be more closely related to a reduced early diastolic LAP than to slower LVP decline. This effect also explains the prolonged IVRT. We postulate that changes in LA active or passive properties may contribute to development of the abnormal relaxation pattern during the aging process.

Assessment of Global and Regional Left Ventricular Diastolic Function in Hypertensive Heart Disease Using Automated Border Detection Techniques

Acoustic quantification (AQ) and color kinesis (CK) are techniques that involve automated detection and tracking of endocardial borders. These methods are useful for the evaluation of global and regional left ventricular (LV) systolic function and more recently have been applied to evaluating LV diastolic performance. Assessment of diastolic dysfunction in hypertensive heart disease is a relevant clinical issue in which these techniques have proven useful. The diastolic portion of left atrium and LV AQ area waveforms are frequently abnormal in patients with left ventricular hypertrophy (LVH). Left ventricular AQ curves consistently demonstrate reduced rapid filling fraction (RFF) and peak rapid filling rate (PRFR), elevated atrial filling fraction (AFF), peak atrial filling rate (PAFR), and reductions in the ratio PRFR/PAFR. Acoustic quantification complements traditional Doppler echocardiographic evaluation of global diastolic function. Many patients with significant LVH and normal Doppler diastolic parameters can be identified as having diastolic dysfunction with AQ. In addition, CK has allowed the evaluation of regional diastolic performance in hypertensive patients. Regional filling curves obtained from CK have demonstrated that endocardial diastolic motion is commonly delayed and heterogeneous in patients with LVH.

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.

Intraventricular dispersion and temporal delay of early left ventricular filling after acute myocardial infarction. Assessment by magnetic resonance velocity mapping

This article aims to describe early left ventricular diastolic inflow using magnetic resonance velocity mapping in patients with recent acute myocardial infarction and in normal volunteers. Magnetic resonance velocity mapping was performed in a long axis plane through the hearts of 46 patients with recent, first time acute myocardial infarction and 43 age-matched normal volunteers. The peak velocities at six levels of the early diastolic inflow stream were recorded. A velocity index was calculated as the peak velocity in each position relative to the peak velocity at the mitral leaflet tips. Also, the temporal delay of velocity propagation was computed. Velocity index 4 cm downstream of mitral leaflet tips was lower in the acute myocardial infarction group (0.42 (0.17)) (mean (SD)) compared to controls (0.59 (0.25)) (p < 0.001). Temporal delay in the same position was longer in the acute myocardial infarction group (62 (67) ms) than in controls (32 (39) ms) (p < 0.02). Blood flow patterns in patients after acute myocardial infarction were characterized by increased dispersion of velocities and increased temporal delay of velocity propagation, probably reflecting impaired active left ventricular relaxation. Intraventricular flow measurements constitute a promising new technique for non-invasive assessment of left ventricular diastolic function.

Early signs of cardiac involvement in hypertension

BACKGROUND

Whether abnormalities of diastolic function are the earliest cardiac change in hypertension is still a matter for dispute. The aim of this study was to assess whether left ventricular diastolic dysfunction is an early sign of cardiac involvement in hypertension.

METHODS

In 578 young patients with stage I hypertension from the Hypertension and Ambulatory Recording Venetia Study (HARVEST) and 101 normotensive control patients echocardiographic Doppler examination and ambulatory blood pressure monitoring were performed.

RESULTS

Left ventricular mass, wall thickness, and relative wall thickness, adjusted for confounders, were greater in the hypertensive than in the normotensive patients (all P <.0001). After adjustment for confounders, the A-wave peak velocity was higher in the hypertensive patients (51.5 +/- 11.5 vs 43.4 +/- 8 cm/s, P <.001) as were A-wave velocity time integral (5.6 +/- 1.7 vs 4.6 +/- 1.3 cm, P =.01), total area (16.9 +/- 4.4 vs 15.6 +/- 3.1 cm, P =.04), and E-wave peak velocity (69.9 +/- 15.2 vs 67.5 +/- 13.3 cm/s, P =.03). All indexes of diastolic function were similar in the hypertensive subjects subdivided according to whether they had "white-coat" or sustained hypertension. Among the hypertensive subjects, age and heart rate were the strongest predictors of diastolic indexes, whereas ambulatory blood pressure explained only a marginal part of the E/A ratio, A-wave peak velocity, and the first one third total area ratio (P =.04, P =.02, and P =.05, respectively). Left ventricular mass and wall thickness were not associated with any Doppler index. When a clustering of diastolic indexes (E/A wave ratio, deceleration time, first one third of diastole, and peak E-wave-velocity) was used to identify subjects with diastolic dysfunction, no significant differences in either clinic or ambulatory blood pressure were observed between the group with diastolic dysfunction and the group with normal function.

CONCLUSIONS

We conclude that the earliest signs of cardiac involvement in hypertension are left ventricular structural abnormalities. Left ventricular diastolic function is only marginally affected, even when multiple parameters of left ventricular filling are taken into account.

Diastolic function in hypertension

Diastolic dysfunction in patients with hypertension may present as asymptomatic findings on noninvasive testing, or as fulminant pulmonary edema, despite normal left ventricular systolic function. Up to 40% of hypertensive patients presenting with clinical signs of congestive heart failure have normal systolic left ventricular function. In this article we review the pathophysiologic factors affecting diastolic function in individuals with diastolic function, current and emerging tools for measuring diastolic function, and current concepts regarding the treatment of patients with diastolic congestive heart failure.

Echocardiographic evaluation of left and right ventricular function in mild hypertension

Thirty-one cases of untreated 'mild hypertension' and equal number of age and sex matched controls with 'normal' blood pressure were evaluated by echocardiography. Patients with mild hypertension had significantly increased left ventricular mass index, concentric remodeling, and diastolic dysfunction. Thickness of right ventricular anterior wall, flow velocities across tricuspid and pulmonary valves were also significantly higher in hypertensives. Pulmonary flow acceleration time was significantly less in hypertensives. On multiple regression analysis, mitral valve 'A' wave velocity alone correlated with systolic blood pressure. Other echocardiographic variables did not have any relation with blood pressure readings. Height, weight, body surface area and body mass index could also explain only around 50% of variability in echocardiographic parameters. Cardiac structure and functions in hypertensives are affected by factors other than blood pressure reading, body surface area or body mass index. Routine echocardiography can be useful in identifying those patients of mild hypertension who have disproportionate increase in left ventricular mass or disproportionate impairment of diastolic functions.

The use of echocardiography in the critical care setting

Echocardiography has become an invaluable tool in the management of critically ill patients. Its safety and portability allow for use at the bedside to provide rapid, detailed information regarding the cardiovascular system. Echocardiography can elucidate cardiac structure and mechanical function. Recently, the power of clinical echocardiography has been augmented by the use of Doppler techniques to evaluate cardiovascular hemodynamics. An in-depth understanding of the proper use of echocardiography is a prerequisite for the intensivist.

Left ventricular midwall function improves with antihypertensive therapy and regression of left ventricular hypertrophy in patients with asymptomatic hypertension

Recent evidence suggests that regression of left ventricular hypertrophy (LVH) with antihypertensive therapy improves prognosis. The mechanism for this benefit is unknown but may be related to effects on myocardial performance. Midwall fractional shortening (mFS) is often depressed in patients with asymptomatic hypertension, is associated with LVH, and is a potent, independent predictor of outcome. We therefore examined whether antihypertensive therapy may improve midwall performance. mFS as well as conventional echocardiographic parameters were measured serially among 29 hypertensive persons during 6 months of drug therapy. Stress-adjusted and absolute midwall function improved by 10% and 11%, respectively (p <0.05), whereas no significant changes were detected in other measures of chamber function. Improvement in function was more pronounced in patients with concentrically remodeled ventricular geometry and in those who achieved greater reductions in left ventricular (LV) mass. Antihypertensive therapy and LV mass regression is associated with demonstrable improvements in cardiac performance when assessed using mFS. Determinations of mFS may have a promising role in identifying patients with early hypertensive heart disease, tracking responses to therapy, and in elucidating the potential beneficial effects associated with LV mass regression.

Effects of antihypertensive agents on the left ventricle: clinical implications

Hypertensive heart disease (HHD) is characterized by left ventricular hypertrophy (LVH), alterations of cardiac function, and coronary flow abnormalities. LVH is an independent cardiovascular risk factor related to cardiovascular complications in patients with hypertension. Therefore, a decrease in left ventricular mass is a therapeutic goal in these patients. The effect of the different antihypertensive agents on LVH regression has been studied in nearly 500 clinical trials. Most studies conclude that there is regression of LVH after significant decrease in blood pressure with most commonly prescribed antihypertensive agents. However, the ability to regress LVH is different between antihypertensive drug classes. ACE inhibitors and calcium channel antagonists are more potent in reducing left ventricular mass than beta-blockers, with diuretics falling in the intermediate group. Recent data suggest that angiotensin AT(1) receptor antagonists reduce left ventricular mass to a similar extent as ACE inibitors or calcium channel antagonists. Although a large number of studies have established that reversal of LVH decreases the occurrence of adverse cardiovascular events in patients with hypertension, the hypothesis that LVH regression is beneficial has not yet been conclusively proven. On the other hand, the time has come to revisit the current management of HHD simply focused on controlling blood pressure and reducing left ventricular mass. In fact, it is necessary to develop new approaches aimed to repair myocardial structure and protect myocardial perfusion and function and, in doing so, to reduce in a more effective manner, adverse risk associated with HHD. The identification of genes involved in both the process of HHD and the response to therapy may be critical for the development of these new approaches. This article will review briefly the available data on the effects of antihypertensive agents on HHD. In addition, the emerging new concepts on the pharmacology of hypertensive myocardial remodeling and the pharmacogenetic basis of the treatment of HHD will be also considered.

Increased left ventricular mass is not associated with impaired left ventricular diastolic filling in normal individuals

BACKGROUND

Hypertensive left ventricular (LV) hypertrophy has been associated with diastolic dysfunction. However, the underlying physiological relationship between LV size and diastolic function remains to be clarified. The aim of this study was to evaluate the relationship between several measures of diastolic filling and LV mass in a population sample.

METHODS

We used M-mode and Doppler echocardiography to compare left ventricular mass index (LVMI) and wall thickness with five measures of ventricular diastolic filling (ratio of the peak early mitral inflow velocity to the peak atrial mitral inflow velocity, deceleration time of early mitral inflow, isovolumetric relaxation time, ratio of the peak pulmonary venous systolic to diastolic flow and difference between the durations of the pulmonary venous and mitral inflow atrial waves) in 159 healthy volunteers.

RESULTS

LVMI was significantly (P< 0.0001) greater in men (81.3 g/m2, interquartile range: 67-94) than women (59.7 g/m2, interquartile range: 49-74), but no gender differences were observed in diastolic filling. Higher age, blood pressure and heart rate showed significant correlation with diminished diastolic filling. However, no measure of diastolic filling correlated with LVMI or wall thickness in either univariate or multiple regression analyses that adjusted for relevant covariates.

CONCLUSIONS

LVMI does not explain physiological differences in diastolic filling. The significant decline in diastolic filling with age reflects changes in the quality rather than the quantity of myocardial tissue.

Left ventricular diastolic dysfunction in patients with hypertension and preserved systolic function

OBJECTIVE

To assess prospectively diastolic function in hypertensive patients with preserved left ventricular function, particularly focusing on the limitation of the transmitral flow velocity curve alone to detect diastolic dysfunction.

PATIENTS AND METHODS

Comprehensive Doppler analysis was performed in 51 hypertensive patients with preserved left ventricular systolic function.

RESULTS

The ratio of the peak early diastolic filling wave velocity to the peak velocity of filling wave at atrial contraction was less than the age-adjusted mean value minus 2 SD in 16 patients, and the other 35 patients had a "normal" transmitral Doppler signal. However, the combined transmitral and pulmonary venous Doppler analysis revealed that 12 of these 35 patients had a "pseudonormal" pattern. The prevalence of diastolic dysfunction was estimated at 31% with use of transmitral Doppler alone but increased to 55% when comprehensive Doppler analysis was used (P < .05).

CONCLUSION

The presence of diastolic dysfunction has been frequently overlooked in hypertensive patients with transmitral Doppler analysis alone, and an assessment of diastolic function with a comprehensive Doppler analysis is needed in patients at risk for diastolic dysfunction.

Effects of posture on left ventricular diastolic filling during exercise

BACKGROUND

Measuring the transmitral flow velocity with Doppler echocardiography is a useful method for evaluating left ventricular diastolic function. However, there are few data regarding the effect of posture during exercise on transmitral flow velocity.

METHODS

The transmitral flow velocity with pulsed-wave Doppler echocardiography was measured during supine and upright bicycle ergometer exercise in 10 normal young men without cardiac disease (26.7 +/- 5.5 yr).

RESULTS

The ratio of the early rapid filling wave to the atrial filling wave (E/A) was gradually decreased with increasing exercise intensity. At rest and during recovery, the E/A ratio was significantly higher (P < 0.01) in the supine position than in the upright position. This difference was caused mainly by the higher E wave in the supine position. However, E wave and E/A ratio did not differ between the upright and supine position during exercise.

CONCLUSION

Although measurement of left ventricular filling is completely noninvasive and clinically useful for evaluating diastolic function, it was found that the E/A ratio was profoundly influenced by posture and exercise intensity. These results suggest that the potential influences of posture and exercise intensity on the filling velocities should be taken into account when interpreting diastolic function by Doppler echocardiography.

Ambulatory blood pressure monitoring and echocardiography--noninvasive techniques for evaluation of the hypertensive patient

Clinic blood pressure measurements have only limited ability to determine which hypertensive patients are at greatest risk of cardiovascular events. Ambulatory blood pressure monitoring allows for noninvasive measurement of blood pressure throughout the 24-hour period. This may help to clarify discrepancies between blood pressure values obtained in and out of the clinic and confirm the presence of white-coat hypertension, broadly defined as an elevated clinic blood pressure but a normal ambulatory blood pressure. Ambulatory blood pressure values have been shown to have a better relationship to cardiovascular morbidity and mortality and end-organ damage than clinic blood pressure values. Further, patients with white-coat hypertension appear to be at greater risk of cardiovascular morbidity and end-organ damage than a normotensive population, although they are at less overall risk than a hypertensive population. Hypertensive heart disease is characterized by diastolic dysfunction, increased left ventricular mass, and coronary flow abnormalities. Left ventricular hypertrophy increases the risk of coronary heart disease, congestive heart failure, stroke, ventricular arrhythmias, and sudden death. A variety of invasive and noninvasive techniques are described herein that measure left ventricular mass, diastolic function, and coronary blood flow abnormalities. Most antihypertensive treatments promote regression of left ventricular hypertrophy and reversal of diastolic dysfunction, which may decrease symptoms of congestive heart failure and improve survival.

Left ventricular diastolic properties of hypertensive patients measured by pulsed tissue Doppler imaging

Examination of left ventricular (LV) diastolic dysfunction in hypertensive patients has been based on parameters obtained from the transmitral flow velocity during pulsed Doppler echocardiography. However, these parameters are affected by loading conditions. We evaluated LV diastolic function along the longitudinal and transverse axes by pulsed tissue Doppler imaging (TDI) in 50 hypertensive (HT) patients and 36 age-matched healthy volunteers (N). Transmitral flow velocity was recorded by pulsed Doppler echocardiography. LV posterior wall motion velocity along the longitudinal and transverse axes also was recorded by pulsed TDI. In both groups, peak early diastolic velocity of the LV posterior wall (Ew) along the transverse axis (N: 15.8+/-5.2 cm/s, HT: 12.2+/-4.4 cm/s) was higher than that along the longitudinal axis (N: 12.7+/-3.1 cm/s, HT: 9.5+/-3.3 cm/s). Peak atrial systolic velocity of the LV posterior wall (Aw) along the longitudinal axis (N: 9.1+/-1.8 cm/s, HT: 9.7 +/-2.6 cm/s) significantly exceeded that along the transverse axis (N: 8.0+/-2.2 cm/s, HT: 8.4+/-2.4 cm/s) in both groups. The Ews were lower and the Aws were higher along both axes in the patient group than in the control group. The time intervals from the aortic component of the second heart sound to the peak of the early diastolic wave (IIA-Ews) along both the transverse (N: 142+/-18 ms, HT: 154+/-19 ms) and longitudinal (N: 151 16 ms, HT: 162+/-20 ms) axes were longer in the patient group. In 29 patients, Ews along both axes correlated negatively (transverse: r = -0.80, P < .0001; longitudinal: r = -0.71, P < .0001) and IIA-Ews correlated positively (transverse: r = 0.81, P < .0001; longitudinal: r = 0.74, P < .001) with the time constant of the LV pressure decay during isovolumic diastole. The Aws along both axes in the 24 patients without pseudonormalization in transmitral flow velocity correlated positively (transverse: r = 0.60, P < .001; longitudinal: r = 0.74, P < .0001) with the LV end-diastolic pressure. In conclusion, LV relaxation and filling along the longitudinal and transverse axes were impaired in many patients with hypertension. Pulsed TDI was useful for evaluating LV diastolic dynamics in this disease.

Midwall fractional shortening is an independent predictor of left ventricular diastolic dysfunction in asymptomatic patients with systemic hypertension

Conventional measures of left ventricular (LV) systolic performance suggest that diastolic dysfunction precedes the development of systolic dysfunction in hypertension. Midwall fractional shortening is a new measure of systolic function that identifies hypertensive patients who have evidence of target-organ damage, impaired contractile reserve, and increased mortality. We therefore sought to determine whether depressed midwall fiber shortening is associated with abnormal diastolic function. Echocardiograms were obtained in 102 otherwise healthy hypertensive patients without treatment with normal conventional measures of systolic function. Of these, 15 had depressed midwall shortening based on previously described normative relations. Patients with depressed midwall shortening had slightly higher blood pressure. Abnormal diastolic function, defined as late (A) LV inflow velocity greater than early (E) velocity, was observed in 33% of those with normal midwall shortening but in 60% of those with depressed shortening (p <0.05). Patients with A/E >1 had lower absolute midwall fiber shortening (15 +/- 3% vs 18 +/- 3%, p <0.0001) but similar endocardial shortening. Patients with abnormal midwall shortening had higher A/E and longer isovolumic relaxation times (both p <0.05). In multivariate analysis, midwall fractional shortening, age, and heart rate were independent predictors (p <0.01) of A/E in a model including blood pressure, LV mass, and endocardial shortening. We conclude that subnormal midwall shortening predicts LV diastolic abnormalities in this population of hypertensive patients with otherwise normal measures of LV systolic function. Contrary to our previous understanding, depressed LV systolic performance, when identified with this newer method, occurs coincidentally with impaired diastolic function.

Use of intraventricular dispersion of the peak diastolic flow velocity as a marker of left ventricular diastolic dysfunction in patients with atrial fibrillation

The aim of this study was to evaluate the use of intraventricular dispersion of the peak diastolic flow velocity as a marker of left ventricular diastolic dysfunction in patients with atrial fibrillation. Regional diastolic flow velocity patterns at 1, 2, and 3 cm away from the mitral tip toward the apex were simultaneously recorded with the mitral flow velocity pattern by using pulsed Doppler echocardiography in 24 patients with atrial fibrillation before electrical or medical cardioversion. Echocardiographic examination was repeated after 10 to 30 days (ie, at the time of recovery of left atrial mechanical functions) after cardioversion of atrial fibrillation in all patients. Thirteen patients were found to have diastolic dysfunction; the remaining 11 patients with a normal E/A ratio constituted the control group. Afterward, the data recorded before the cardioversion were analyzed for each patient. In subjects with normal diastolic function, the peak diastolic flow velocity (PDFV) at the mitral tips also was maintained at the positions 1 to 3 cm away from the tip in the left ventricular cavity (PDFV at the mitral tips: 0.84 m/s, PDFV at 3 cm: 0.85 m/s; P =.34). In contrast, the regional PDFV progressively decreased toward the apex in patients with diastolic dysfunction (PDFV at the mitral tips: 0.82 m/s, PDFV at 3 cm: 0.63 m/s; P =.0004). Only 77% of the initial velocity was maintained at 3 cm away from the mitral tips in patients with diastolic dysfunction, whereas almost 100% of the initial velocity was preserved in patients with normal diastolic function (P <.001). These findings suggest that the assessment of the intraventricular decrease in mitral PDFV may be used as a reliable marker of diastolic dysfunction in patients with atrial fibrillation.

Doppler echocardiographic study of left ventricular diastole in non-anaesthetized healthy cats

The current study: (1) describes the Doppler technique for the assessment of diastolic function in feline patients; (2) reports normal Doppler diastolic values; and (3) determines the effect of ageing on these parameters. Doppler echocardiography was performed on 20 non-anaesthetized healthy cats. Each diastolic parameter was correlated with age, body weight, body surface area and R-R interval. To assess the isovolumetric relaxation phase of diastole, isovolumetric relaxation time was measured. To assess the filling phase of diastole, we measured peak flow velocities of the E and A waves, diastolic filling time, acceleration and deceleration time of the E wave and the E/A ratio of transmitral flow, peak flow velocity of the S, D and the A retrograde waves, as well as the S/D ratio and the systolic fraction of pulmonary venous flow. We found a significant correlation between age and peak flow velocity of the A wave, normalized peak flow velocity of the A wave, the E/A ratio, the acceleration time of the E wave, the diastolic filling time, the velocity time integral of the E wave, the peak flow velocity of the S wave and the systolic fraction. It was concluded that Doppler echocardiographic analysis of diastole is possible in the cat and that age has most effect on filling parameters.

Cardiac function in patients with treated hypertension during aortic aneurysm repair

OBJECTIVES

To investigate the impact of arterial hypertension on cardiac function during aortic cross-clamping and declamping.

DESIGN

Prospective study.

SETTING

University hospital.

PARTICIPANTS

Twenty treated hypertensive males with slight left ventricular hypertrophy and 10 normotensive controls undergoing elective repair of an abdominal aortic aneurysm.

INTERVENTIONS

Using transesophageal echocardiography, the mitral inflow profile was evaluated during aortic cross-clamping and declamping.

MEASUREMENTS AND MAIN RESULTS

During the clamping period, the ratio of peak atrial to peak early filling velocity (PA/PE) was significantly higher in the hypertensive patients. One minute after aortic cross-clamping, mean arterial pressure (MAP) and pulmonary artery occlusion pressure significantly increased in the hypertensive patients, whereas they did not change in the normotensive group. Cardiac index and heart rate significantly decreased after cross-clamping, and increased after clamp release in both groups. PA/PE significantly dropped in both groups after aortic declamping, and returned to baseline values thereafter. MAP also decreased significantly in both groups after clamp release, but the fall of MAP tended to be more pronounced in the hypertensive patients.

CONCLUSIONS

In the treated hypertensive patients, more pronounced hemodynamic and echocardiographic responses to aortic cross-clamping probably mirror the altered diastolic left ventricular function in these patients. With respect to intraoperative management, however, the treated hypertensive patients did not react grossly differently from the normotensive controls.

Changes in patterns of left ventricular diastolic filling revealed by Doppler echocardiography in infants with ventricular septal defect

To evaluate left ventricular diastolic filling in infants with ventricular septal defect, which has yet to be documented, we measured various Doppler echocardiographic indexes from transmitral flow in the following groups: 10 infants with ventricular septal defect without pulmonary hypertension; 10 infants with ventricular septal defect with pulmonary hypertension; and 9 normal infants to serve as controls. The peak A, total velocity time integral, E area, and A area in patients without pulmonary hypertension were all significantly larger than those in controls. The peak ratio E/A, and 1/3 filling fraction, in patients without pulmonary hypertension were significantly lower than in controls. The peak A, A area, and deceleration time in patients with pulmonary hypertension were significantly larger than in patients without pulmonary hypertension and controls. The peak E/A, area E/A, and 1/3 filling fraction in patients with pulmonary hypertension were significantly lower than in those without pulmonary hypertension and controls. The index of left ventricular mass, as well as the index of end-diastolic left ventricular wall thickness, correlated strongly with peak A, A area, and deceleration time. The ratio between the systolic pulmonary and systemic pressures correlated strongly with peak A, A area, peak E/A, area E/A, and 1/3 filling fraction. These results demonstrated that the patterns of left ventricular filling in infants with ventricular septal defect were different from those in normal infants, and suggested that the abnormal patterns may indicate the insufficiency of adaptation of left ventricle (increase of left ventricular compliance) for volume overload in the presence of a ventricular septal defect.

Prognostic implications of restrictive left ventricular filling in acute myocardial infarction: a serial Doppler echocardiographic study

OBJECTIVES

This study was designed to evaluate the relative prognostic significance of restrictive left ventricular (LV) filling after acute myocardial infarction.

BACKGROUND

Data regarding the contribution of diastolic dysfunction to prognosis after myocardial infarction are limited, and the additional value over the assessment of systolic dysfunction is not known.

METHODS

Serial Doppler echocardiography was performed in 95 patients on days 1, 3 and 7 and 3 months after acute myocardial infarction. Patients were classified into two groups: a restrictive group (n = 12) with a peak velocity of early diastolic filling wave (E)/peak velocity of late filling wave (A) ratio > or = 2 or between 1 and 2 and a deceleration time (DT) < or = 140 ms during at least one echocardiographic study; and a nonrestrictive group (n = 83) with an E/A ratio < or = 1 or between 1 and 2 and a DT > 140 ms at all examinations.

RESULTS

Cardiac death occurred in 10 patients during a mean follow-up interval of 32 +/- 17 months. The survival rate at 1 year was 100% in the nonrestrictive group and only 50% in the restrictive group. After 1 year there was a continuing divergence of mortality, resulting in a 3-year survival rate of 100% and 22%, respectively. Univariate Cox analysis revealed that restrictive LV filling, wall motion score index, ejection fraction and end-systolic and end-diastolic volume indexes, as well as peak creatine kinase, peak MB fraction and heart failure during the hospital course were significant predictors of cardiac death, although restrictive filling was the single best predictor (p < 0.0001). Multivariate analysis showed that restrictive filling adds prognostic information to clinical and echocardiographic variables of systolic dysfunction.

CONCLUSIONS

Restrictive LV filling after acute myocardial infarction is the single best predictor of cardiac death and adds significantly to clinical and echocardiographic markers of systolic dysfunction.

Can trasmitral Doppler E-waves differentiate hypertensive hearts from normal?

Physiological models of transmitral flow predict E-wave contour alteration in response to variation of model parameters (stiffness, relaxation, mass) reflecting the physiology of hypertension. Accordingly, analysis of only the E-wave (rather than the E-to-A ratio) should be able to differentiate between hypertensive subjects and control subjects. Conventional versus model-based image processing methods have never been compared in their ability to differentiate E-waves of hypertensive subjects with respect to age-matched control subjects. Digitally acquired transmitral Doppler flow images were analyzed by an automated model-based image processing method. Model-derived indexes were compared with conventional E-wave indexes in 22 subjects: 11 with hypertension and echocardiographically verified ventricular hypertrophy and 11 age-matched nonhypertensive control subjects. Conventional E-wave indexes included peak E, E, and acceleration and deceleration times. Model-based image processing-derived indexes included acceleration and deceleration times, potential energy index, and damping and kinematic constants. Intergroup comparison yielded lower probability values for model-based compared with conventional indexes. In the subjects studied, Doppler E-wave images analyzed by this automated method (which eliminates the need for hand-digitizing contours or the manual placement of cursors) demonstrate diastolic function alteration secondary to hypertension made discernible by model-based indexes. The method uses the entire E-wave contour, quantitatively differentiates between hypertensive subjects and control subjects, and has potential for automated noninvasive diastolic function evaluation in large patient populations, such as hypertension and other transmitral flow velocity-altering pathophysiological states.

Considerations for racial differences in the athlete's heart and related cardiovascular disease

Athletic training is often associated with modest increases in left ventricular chamber size, wall thickness, and mass, which appear to be related to the level and intensity of training as well as the type of activity performed. It appears that for given levels and types of training, some individuals show more marked morphologic changes. It has been speculated that the cardiac alterations that occur with athletic conditioning may be due, in part, to genetic factors that exist independent of training. Related to this issue is the possibility that racial (or biologic) differences in cardiac response to exercise may also exist. This article reviews the available data that address racial differences in the cardiac response to exercise and to left ventricular pressure overload and the implications of these findings.

Cardiovascular function during rest and exercise in patients with sickle-cell anemia and coexisting alpha thalassemia-2

Cardiac function was measured at rest and during exercise in 9 patients with sickle-cell anemia (SS) and coexisting homozygous alpha thalassemia-2 (alpha thal-2). Results were compared with 18 sickle cell patients with normal alpha globin genes, who were matched to the study group by age, gender, and size, and to published normal values. SS alpha thal-2 patients were less anemic: 9.9 +/- 1.0 vs 8.2 +/- 1.2 gm/dl for SS alone (P<.05). Left ventricular dimensions were normal in SS alpha thal-2 (4.9 +/- 0.7 cm), but increased in SS (5.4 +/- 0.7, cm P=.05) (normal range, 3.7-5.6 cm). Left ventricular wall thickness was, however, dramatically increased in the SS alpha thal-2 patients (free wall, 1.8 +/- 0.6 cm; septum, 1.6 +/- 0.4 cm), though SS controls had normal wall thickness (free wall, 1.0 +/- 0.2 cm; septum, 1.0 +/- 0.2 cm, P<.001) (normal range, 0.6-1.1 cm). At rest, Doppler indices of systolic function were not significantly different between sickle groups and normal values. SS alpha thal-2 patients did have abnormal diastolic filling at rest, as evidenced by a reduced ratio of early/late diastolic filling, 1.4 +/- 0.3 vs. 2.0 +/- 0.5 for SS controls (P<.01), and 1.8 +/- 0.4 for normals. An analysis of covariance suggested that this abnormality persisted after taking into account the previously demonstrated hypertrophy. During exercise, SS alpha thal-2 patients had higher heart rates and blood pressures than SS controls in spite of performing the same or less work. This resulted in a higher double product (an estimate of oxygen consumption) in SS alpha thal-2 patients (37,470 +/- 2,310 mm Hg-BPM) than in SS controls (33,310 +/- 1,490 mm Hg-BPM, P<.01). Work capacity, peak heart rate, and blood pressure were all abnormally decreased in both sickle-cell groups when compared to normal. Cardiac abnormalities noted at rest and during exercise in SS alpha thal-2 patients suggest a role of microvascular occlusion and a protective effect of decreased hemoglobin.

The Effects of Amlodipine on Left Ventricular Mass and Diastolic Function in Concentric and Eccentric Left Ventricular Hypertrophy

BACKGROUND: The effects of the antihypertensive therapy with amlodipine (5-10 mg/day) on left ventricular mass and diastolic function were examined in 30 mild to moderate essential hypertensive patients who have left ventricular hypertrophy (LVH) and diastolic dysfunction. METHODS AND RESULTS: Each patient's left ventricular mass was measured, and left ventricular diastolic function was assessed by echocardiographic Doppler examination at entry, and at 3 and 6 months after the initiation of the treatment. Amlodipine reduced both blood pressure (from 164 +/- 14/104 +/- 6 mmHg to 134 +/- 9/83 +/- 4 mmHg) and left ventricular mass index (from 160 +/- 30 g/m(2) to 137 +/- 26 g/m(2)) significantly at 3 months and both parameters maintained at these levels for 6 months. When the patients were classified according to the type of the LVH, a significant regression in left ventricular mass index was seen only in the patients who had concentric LVH was a relative wall thickness >/=0.44 (n = 16), but not in the eccentric LVH group (n = 14), although both groups were not significantly different from each other regarding the basal hemodynamic parameters, baseline left ventricular mass index and the decrease in blood pressure in response to amlodipine treatment. The mitral inflow E/A ratio did not show any significant change in either group. CONCLUSIONS: Amlodipine produced significant regression in LVH only in the patients with concentric LVH, but not those with eccentric LVH, while it did not change the diastolic dysfunction. Therefore, the type of LVH seems to be an important feature in determining the effects of antihypertensive treatment on left ventricular mass index.

Improvement of left ventricular diastolic dysfunction in hypertensive patients 1 month after ACE inhibition therapy: evaluation by ultrasonic automated boundary detection

The purpose of this study was to detect any improvement in left ventricular diastolic dysfunction in hypertensive patients 1 month after cilazapril therapy. Twenty-three patients, 5 men and 18 women (mean age, 53.52 +/- 9.10 years), with mild or moderate hypertension (160 +/- 13/98 +/- 10 mm Hg), and free of other cardiac or systemic diseases, were studied using ultrasonic automated boundary detection (ABD) and pulsed Doppler echocardiography, before and 1 month after a daily dose of 2.5 mg of cilazapril. The following new ABD diastolic indices were determined: the time rate of area change in early diastole (dA/dt)E, that in late diastole (dA/dt)A, and their ratio (dA/dt)E/(dA/dt)A, while Doppler transmitral flow measurements of left ventricular diastolic filling were also simultaneously recorded. The ABD results showed left ventricular diastolic dysfunction (LVDD) in 9 of 23 patients (39%) compared with the ABD values of 12 normal volunteers. Neither method revealed any significant difference before and after treatment in the patient group as a whole. However, in the group of 9 patients with diastolic dysfunction, the ABD ratio (dA/dt)E/(dA/dt)A was significantly improved after cilazapril therapy (1.20 +/- 0.21 versus 1.41 +/- 0.17; P < 0.05). We concluded that a large percentage (39%) of patients with mild or moderate hypertension had reduced diastolic performance of the left ventricle at a stage of the disease when systolic dysfunction and/or hypertrophy were not evident. Significant improvement of diastolic dysfunction in hypertensive patients could be detected by the proposed ABD new diastolic indices 1 month after cilazapril therapy. In conclusion, automatic boundary detection should be a useful non-invasive modality for the early diagnosis of left ventricular diastolic dysfunction, as well as early recognition of its improvement.

Pulmonary venous flow as assessed by Doppler echocardiography: potential clinical applications

During the past few years Doppler assessment of pulmonary venous flow has gained increasing interest. The growing experience with the use of transesophageal echocardiography, the approach that nearly always yields registrations adequate for quantitative analysis, has markedly contributed in this respect. The Doppler-derived pulmonary venous flow pattern can be regarded as a measure of left atrial inflow and it augments the clinical significance of Doppler transmitral flow in the evaluation of diastolic left ventricular function. This article summarizes physiological background, possible applications, and limitations of Doppler echocardiography of pulmonary venous flow in clinical cardiology.

Intraventricular dispersion of early diastolic filling: a new marker of left ventricular diastolic dysfunction

Mitral flow velocity patterns are frequently "normalized" by the alteration in the loading condition even in the presence of left ventricular (LV) diastolic dysfunction. In addition, a simple index, the ratio of mitral peak early diastolic flow velocity to mitral peak flow velocity at atrial contraction, is not obtainable in patients with atrial fibrillation (Af). Thus these limitations hamper the value of analyzing the mitral flow velocity pattern in the assessment of abnormal LV diastolic characteristics. This study was designed to elucidate the hypothesis that peak early diastolic flow velocity decreases progressively from the base to the apex in patients with LV diastolic dysfunction. Regional diastolic flow velocity patterns at 1, 2, or 3 cm from the mitral tip toward the apex were simultaneously recorded with the mitral flow velocity pattern by using multigate pulsed Doppler echocardiography in 42 subjects with normal LV function (31 normal volunteers and 11 patients with Af only), 17 patients with hypertensive heart disease, and 22 patients with dilated cardiomyopathy. In the normal subjects early diastolic flow velocity at the mitral tip was maintained at the positions 1 to 3 cm away from the tip into the LV cavity. In contrast, regional peak early diastolic flow velocity progressively decreased toward the apex in patients with hypertensive heart disease and dilated cardiomyopathy. These findings were observed even in patients with a normalized mitral flow velocity pattern or those with Af. Thus the assessment of the intraventricular decrease in peak early diastolic flow velocity may be useful in detecting LV diastolic dysfunction, particularly in patients with Af or a "normalized" mitral flow velocity pattern.

Noninvasive assessment of left ventricular relaxation using continuous-wave Doppler aortic regurgitant velocity curve. Its comparative value to the mitral regurgitation method

BACKGROUND

The most established parameters of left ventricular (LV) relaxation are peak negative value of the first derivative of LV pressure (-dP/dtmax) and the time constant of isovolumic LV pressure fall. The instantaneous pressure gradient between the aorta and the LV during diastole can be calculated from the continuous-wave Doppler aortic regurgitant velocity spectrum. Because the fluctuation of aortic pressure during LV isovolumic relaxation is negligibly minor and because LV minimal pressure is negligibly low, LV pressure during the isovolumic relaxation period may be derived from the continuous-wave Doppler aortic regurgitant velocity spectrum. This study was designed to clarify whether analysis of continuous-wave Doppler aortic regurgitation recording provides accurate measures of LV relaxation over a wide range of LV function and to determine comparative values of aortic and mitral regurgitation methods in the assessment of LV relaxation.

METHODS AND RESULTS

In eight mongrel dogs with acute ischemic LV dysfunction, the continuous-wave Doppler aortic regurgitant velocity spectrum was recorded simultaneously with high-fidelity LV and aortic pressures, while the continuous-wave Doppler mitral regurgitant velocity spectrum was recorded simultaneously with high-fidelity left atrial and LV pressures. The aortic regurgitant velocity spectrum was provided for the determination of Doppler-derived mean rate of LV pressure fall in 20 ms after the onset of aortic regurgitation (delta P/delta t-AR) and the time interval from the onset of aortic regurgitation to the point at (1-1/e)1/2 of the maximal aortic regurgitant velocity as an estimate of the time constant. The mitral regurgitant velocity spectrum was provided for Doppler-derived mean rate of LV pressure fall in 20 ms after the point of -dP/dtmax (delta P/delta t-MR) and the time interval from the point of -dP/dtmax to the point with mitral regurgitant velocity of (1/e)1/2 of the mitral regurgitant velocity at the point of -dP/dtmax as an estimate of the time constant. delta P/delta t-AR and delta P/delta t-MR correlated well with catheter-derived -dP/dtmax (r = .92, r = .98, P < .01, respectively). The time constant derived from aortic and mitral regurgitant velocity spectra (tau-AR and tau-MR) also correlated well with catheter-derived time constant (r = .84, r = .76, P < .01, respectively). However, a mean difference of the catheter-derived time constant minus tau-MR was larger than tau-AR (29 +/- 30 versus 4 +/- 17 ms, P < .01, presented as mean +/- 2 SD).

CONCLUSIONS

LV relaxation can be assessed from the continuous-wave Doppler aortic regurgitant velocity spectrum. The aortic regurgitation method provides an even more accurate estimate of the time constant compared with the mitral regurgitation method, particularly in the presence of LV dysfunction.

Transthoracic Doppler assessment of pattern of left ventricular dysfunction in hypertensive heart disease: combined analysis of mitral and pulmonary venous flow velocity patterns

Although mitral flow velocity pattern changes with the progression of left ventricular (LV) diastolic dysfunction, it lacks predictive value in individual patients because of pseudonormalization in the presence of congestive heart failure and many physiologic and pathologic contributors to the mitral flow velocity pattern. To determine whether analysis of pulmonary venous flow velocity patterns complements the information obtainable from the mitral flow velocity patterns in the evaluation of patterns of LV dysfunction of hypertensive heart disease in individual patients, the ratio of the peak early diastolic filling velocity/peak filling velocity at atrial contraction (E/A ratio) in the mitral flow velocity pattern and the ratio of the peak systolic forward flow velocity (S)/peak diastolic forward flow velocity (D) (S/D ratio) in the pulmonary venous flow velocity pattern by the transthoracic approach were determined in 107 hypertensive patients with and without congestive heart failure. Age-related normal values of the E/A and S/D ratios were determined in 61 normal subjects and used to judge the normality or abnormality of the patterns. Results of the study indicate that (1) although an increased mitral E/A ratio is strongly indicative of heart failure with normal LV systolic function, the mitral E/A ratio is frequently within the normal range in hypertensive patients with heart failure; (2) association of decreased pulmonary venous S/D ratios with a normal mitral flow velocity pattern indicates the presence of heart failure as a result of LV systolic dysfunction that is usually observed at the most advanced pattern of LV dysfunction; (3) mild LV diastolic dysfunction is likely to exist in patients with normal E/A ratios if the pulmonary venous S/D ratio is higher than normal value; (4) predictive accuracy in the detection of LV systolic and diastolic dysfunction would be improved if both mitral and pulmonary venous flow velocity patterns rather than the mitral flow velocity pattern alone were analyzed. In conclusion, analysis of pulmonary venous flow velocity recordings improves accuracy and reliability of the Doppler assessment of LV systolic and diastolic dysfunction, particularly in individual hypertensive patients with normal mitral flow velocity patterns.

Abnormal coronary flow velocity pattern in patients with left ventricular hypertrophy, angina pectoris, and normal coronary arteries: a transesophageal Doppler echocardiographic study

Previous invasive studies have suggested that coronary flow reserve is impaired in patients with left ventricular hypertrophy (LVH) and symptoms of ischemia. We tested whether transesophageal Doppler, a semiinvasive technique, can detect altered characteristics of baseline coronary blood flow velocity in such patients. Thirty patients with LVH (hypertrophic cardiomyopathy in 4, aortic stenosis in 17, hypertension in 9) were studied. Fourteen patients had asymptomatic LVH. Sixteen patients had clinical symptoms of ischemia with angiographically normal epicardial coronary arteries. Ten subjects with no cardiovascular disease were studied as a control group. Peak diastolic and systolic coronary flow velocities were recorded in the proximal part of the left anterior descending artery (LAD) with the use of pulsed Doppler guided by color flow imaging. Patients with symptomatic LVH had higher diastolic peak coronary flow velocity (81 +/- 10 cm/sec, p = 0.0001) compared with normal subjects (41 +/- 8 cm/sec) and patients with asymptomatic LVH (44 +/- 8 cm/sec). In patients with asymptomatic LVH the diastolic coronary flow velocity/indexed ventricular mass ratio was lower (0.28 +/- 0.09 cm/gm/m2, p = 0.0001) compared with symptomatic patients (0.52 +/- 0.12 cm/gm/m2) and compared with controls (0.47 +/- 0.16 cm/gm/m2). Patients with symptomatic LVH but no aortic stenosis also had higher peak systolic coronary flow velocity (38 +/- 9 cm/sec) compared with the other groups (p = 0.0001). In the group of patients with aortic stenosis a significant inverse linear relation was found between peak systolic coronary flow velocity and peak pressure gradient (r = -0.60, p 0.01). In conclusion, patients with symptomatic LVH have abnormally high baseline coronary flow velocities resulting in magnified intimal shear stress. Because flow velocity equals flow/vessel cross-sectional area, it is suggested that high coronary flow velocities in patients with symptomatic LVH result from both augmented coronary flow and failure of the vessel to enlarge commensurately with the increase in LV mass (relative functional stenosis). In patients with aortic stenosis, peak systolic coronary flow velocity appears to be influenced by transvalvular pressure drop.

Normalization of cardiac structure and function after regression of cardiac hypertrophy

Previous studies have shown regression of left ventricular hypertrophy after pharmacologic treatment of hypertensive patients; however, the impact of regression of left ventricular hypertrophy on systolic function and on left and right ventricular diastolic function remains controversial and is difficult to assess because previous studies have not included concurrently studied age-matched control groups. Left ventricular mass, systolic function, and left and right ventricular diastolic function were assessed in 27 hypertensive patients, aged 43 +/- 6 years, by echocardiographic and Doppler studies before and 1, 3, 5, and 7 months after treatment. Left ventricular mass and ventricular function were concurrently evaluated in 27 age-matched normotensive subjects. Treatment with antihypertensive agents resulted in a significant (p < 0.001) reduction in diastolic blood pressure of 15 mmHg, measured at 1 month and sustained throughout the study. In response to hemodynamic unloading, left ventricular mass index decreased from 129 +/- 30 gm/m2 at baseline to 105 +/- 26 (p < 0.05) and 88 +/- 14 gm/m2 (p < 0.05) at 1 and 3 months of treatment, respectively, and remained unchanged over the subsequent 4 months. After 3 months of treatment, left ventricular mass index was similar in treated hypertensive and control subjects. Systolic function, assessed in terms of the relationship between shortening fraction and end-systolic wall stress, was unchanged throughout the treatment period and was no different from that in control subjects. However, patients with an initially depressed shortening fraction experienced a greater increase in shortening fraction during treatment compared to those with an initially normal shortening fraction (11% +/- 4% vs 5% +/- 5%, p < 0.01) and showed an improvement in the relationship between shortening fraction and end-systolic wall stress during treatment. Ventricular filling dynamics improved during the first 3 months of treatment, after which they were unchanged. Ventricular filling dynamics were similar in treated hypertensive patients and control subjects. In conclusion, sustained hemodynamic unloading of the left ventricle results in normalization of left ventricular mass, systolic function, and left and right ventricular diastolic filling dynamics, compared to those in age-matched control subjects.

Doppler-derived mitral deceleration time of early filling as a strong predictor of pulmonary capillary wedge pressure in postinfarction patients with left ventricular systolic dysfunction

OBJECTIVES

The aim of this study was to investigate the correlations between Doppler-derived transmitral flow velocity variables and pulmonary capillary wedge pressure in patients with severe left ventricular systolic dysfunction.

BACKGROUND

Abnormal relaxation and increased chamber stiffness have opposing effects on the left ventricular filling pattern. When both abnormalities are present at the same time, as often occurs in patients with systolic dysfunction, the ability of Doppler recording to assess diastolic function and predict left ventricular filling pressure may be significantly compromised.

METHOD

Pulmonary capillary wedge pressure and Doppler transmitral flow velocity profile were simultaneously recorded in 140 postinfarction patients with ejection fraction < or = 35%.

RESULTS

Correlation between the ratio of mitral peak flow velocity in early diastole to peak flow velocity in late diastole (E/A ratio) and pulmonary capillary wedge pressure was weak (r = 0.65). Although the specificity of E/A > or = 2 in predicting > or = 20 mm Hg in pulmonary capillary wedge pressure was high (99%), its sensitivity was low (43%). Conversely, a very close negative correlation was found between mitral deceleration time of early filling and pulmonary capillary wedge pressure (r = -0.90). Sensitivity and specificity of < or = 120 ms in deceleration time in predicting > or = 20 mm Hg in pulmonary capillary wedge pressure were 100% and 99%, respectively.

CONCLUSIONS

Doppler-derived mitral deceleration time of early filling provides a simple and accurate means of estimating pulmonary capillary wedge pressure that is particularly useful in patients with a normal or normalized mitral flow velocity pattern.

Effects of age on left ventricular dimensions and filling dynamics in 117 normal persons

OBJECTIVE

To determine standard left ventricular Doppler measurements in a large reference group of various ages to reflect the senescence process.

DESIGN

We prospectively studied the influence of aging on left ventricular diastolic filling by performing Doppler echocardiography in 117 normal healthy volunteers.

MATERIAL AND METHODS

Transthoracic pulsed-wave Doppler echocardiographic studies of pulmonary venous flow and left ventricular inflow were done in the 53 male and 64 female study subjects. For analysis, the study subjects were arbitrarily classified into two groups: those younger than 50 years of age (group 1; N = 61) and those 50 years old or older (group 2; N = 56).

RESULTS

A striking difference was found in pulmonary venous flow and left ventricular inflow between group 1 and group 2 subjects. Group 2 had increased pulmonary venous peak systolic flow velocity (71 +/- 9 versus 48 +/- 9 cm/s), decreased peak diastolic flow velocity (38 +/- 9 versus 50 +/- 10 cm/s), increased peak atrial reversal flow velocity (23 +/- 4 versus 19 +/- 4 cm/s), and increased percentage of forward flow in systole (65 +/- 7 versus 55 +/- 8%) in comparison with group 1. In group 2, peak early filling velocity (62 +/- 14 versus 72 +/- 14 cm/s) and ratio of early filling to atrial filling (1.1 +/- 0.3 versus 1.9 +/- 0.6) were lower and peak atrial filling velocity (59 +/- 14 versus 40 +/- 10 cm/s) was higher than in group 1. Deceleration time (210 +/- 36 versus 179 +/- 20 ms) and isovolumic relaxation time (90 +/- 17 versus 76 +/- 11 ms) were prolonged in group 2 in comparison with group 1.

CONCLUSION

This study confirms the major influence of the aging process on left ventricular diastolic function in a large series of normal subjects. This physiologic factor should be considered in Doppler assessment of left ventricular diastolic filling in future studies.

Echocardiographic assessment of left ventricular structure and diastolic filling in elderly subjects with borderline isolated systolic hypertension (the Framingham Heart Study)

Abnormalities in left ventricular (LV) structure and function have been shown in patients with diastolic hypertension and recently in subjects with isolated systolic hypertension. The purpose of this study was to determine whether abnormalities of cardiac structure or function are present in elderly subjects with borderline isolated systolic hypertension (defined as systolic blood pressure [BP] between 140 and 159 mm Hg, and diastolic BP < 90 mm Hg). Ninety-one subjects (mean age 77 years) from the original Framingham Heart Study with untreated borderline isolated systolic hypertension, who were free of cardiovascular disease, were compared with 139 normotensive (BP < 140/90 mm Hg) subjects (mean age 76 years). Measurements included M-mode values for LV structure, and 6 Doppler indexes of LV diastolic filling. Subjects with borderline isolated systolic hypertension and the control group differed in mean systolic (147 vs 125 mm Hg) and diastolic (76 vs 70 mm Hg) BP. Borderline systolic hypertension was the most frequent form of untreated hypertension in this elderly group. The sum of LV wall thicknesses (septum+posterior wall) was significantly higher in borderline hypertensive subjects than in normotensive ones (20.5 vs 19.7 mm; p = 0.002). No difference was detected in LV internal dimension or systolic function. After adjustment for age and other clinical variables, comparisons between the groups revealed significant differences in indexes of Doppler diastolic filling. Peak velocity of early filling, and the ratio of early to late peak velocities were lower in the hypertensive group (40 vs 44 cm/s [p = 0.03] and 0.69 vs 0.76 [p = 0.01], respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

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

To confirm age-related changes in left and right ventricular filling velocity profiles and to compare left and right ventricular filling parameters in normal subjects, we performed pulsed Doppler echocardiographic studies in 108 normal subjects (72 men and 36 women) aged 15 to 78 years. An age-related decrease in peak early velocity (E velocity), an increase in peak atrial velocity (A velocity), and augmented ratio of A velocity to E velocity (A/E) were observed in left ventricle (r = -0.71, 0.63, and 0.83, respectively). Similar age-related changes were found in right ventricle (r = -0.71, 0.54, and 0.78). Aging had a greater effect on the filling of the left ventricle than the right one (i.e., a steeper slope). The difference between left and right ventricular filling increased with advancing age. Left ventricular filling indexes exceeded those of the right ventricle. Significant correlations were observed between the right and left ventricular filling parameters (r = 0.58 to 0.90). A strong relation was noted in A/E (r = 0.90). There was no significant relation between age and left ventricular mass. The left ventricular mass appeared to have little effect on left and right ventricular filling in normal individuals. Thus in clinical studies the age-related decrease in early diastolic filling and the increased atrial filling in both left and right ventricles should be considered. The atrial contribution to ventricular filling may be more pronounced in the left ventricle than the right ventricle in older subjects.

Doppler echocardiographic evidence of left ventricular diastolic dysfunction in ankylosing spondylitis

Although cardiac involvement in the form of conduction abnormalities or aortic regurgitation occurs in 5 to 10% of patients with ankylosing spondylitis, few studies have assessed left ventricular (LV) function. This study assesses the prevalence of both systolic and diastolic LV dysfunction and other cardiac abnormalities in patients with ankylosing spondylitis who have no clinical cardiac manifestations. Fifty-nine patients (49 men and 10 women, mean age 42 +/- 10 years) underwent full clinical examination, electrocardiography, 24-hour Holter monitoring and 2-dimensional, M-mode and Doppler echocardiography. Mean disease duration was 17 +/- 9 years (range 1 to 42). Seventeen patients had evidence of noncardiac extraarticular manifestations. Precordial examination was normal in all. An age- and sex-matched control group of 44 healthy subjects was also studied. On echocardiography, abnormal LV diastolic function was detected in 12 patients (20%). Prolonged isovolumic relaxation time, prolonged deceleration time, reduced rate of descent of flow velocity in early diastole (EF slope) and reversal of the early and late peak transmitral diastolic flow velocities (E/A ratio) were noted in 9 patients. In 3 patients there was an increased E/A ratio, reduced deceleration time and increased EF slope. Mild aortic regurgitation and mitral regurgitation was seen in 1 and 3 patients, respectively. No abnormalities of left atrial size, LV systolic or diastolic dimensions or wall thicknesses were noted. There was no correlation between the presence of LV diastolic dysfunction and age, disease severity, disease duration, or the presence of extraarticular manifestations.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of the single and repeated administration of benazepril on systemic and forearm circulation and cardiac function in hypertensive patients

The hemodynamic and cardiac effects of the new angiotensin-converting enzyme inhibitor, benazepril, were studied in 28 hypertensives in a double blind, placebo-controlled, between-patient study. Hemodynamic studies were performed noninvasively by means of M-mode echo (central hemodynamics and left ventricular systolic function), 2-D echo-Doppler (left ventricular diastolic function), and pulsed Doppler flowmetry (forearm circulation). Examinations were done at the end of a placebo run-in period and 3 hours after benazepril administration, both on the first day and after 6 weeks of treatment (10 or 20 mg once daily, according to patient response). In comparison with placebo, benazepril reduced systolic (p = 0.04) and diastolic (p = 0.003) blood pressure, because of a significant reduction in systemic vascular resistance (p = 0.03), while cardiac output was unchanged. Forearm vascular resistance was reduced and brachial artery compliance increased, although not to a statistically significant level (both p = 0.07). Both systolic and diastolic left ventricular function were positively influenced by the afterload reduction: End-systolic stress was reduced by 12% (p = 0.07), as was the late diastolic peak flow velocity (p = 0.02). All hemodynamic changes were evident after acute benazepril administration, and no differences was observed between acute and repeated treatment. We conclude that, similar to other ACE-inhibitors, benazepril reduces blood pressure through a reduction in vascular resistance, while cardiac output and heart rate are unaffected. These hemodynamic effects occur as early as after the first administration and exert a favorable influence on left ventricular dynamics.

Importance of left ventricular minimal pressure as a determinant of transmitral flow velocity pattern in the presence of left ventricular systolic dysfunction

OBJECTIVES

This study was designed to assess whether the transmitral flow velocity pattern provides an estimation of left atrial pressure irrespective of the presence of left ventricular systolic dysfunction and, if not, to clarify the mechanism.

BACKGROUND

The pulsed Doppler transmitral flow velocity pattern, particularly peak early diastolic filling velocity, has been shown to change in parallel with left atrial pressure. However, extremely elevated left atrial pressure in association with heart failure does not necessarily cause an increase in peak early diastolic filling velocity in patients.

METHODS

Left atrial pressure was elevated with intravenous saline infusion in 11 dogs (normal left ventricular function group) and hemodynamic, transesophageal Doppler echocardiographic and M-mode echocardiographic variables were recorded at three different loading levels. In another 12 dogs, left atrial pressure was elevated by production of left ventricular systolic dysfunction with the stepwise injection of microspheres into the left coronary artery (left ventricular dysfunction group) and the same set of recordings was obtained at three different levels of dysfunction.

RESULTS

Peak early diastolic filling velocity increased with left atrial pressure in the normal left ventricular function group and correlated with mean left atrial pressure (r = 0.61, p < 0.01) and early diastolic left atrial to left ventricular crossover pressure (r = 0.71, p < 0.01). In contrast, peak early diastolic filling velocity did not increase with left atrial pressure in the left ventricular dysfunction group and did not correlate with mean left atrial pressure (r = -0.05) or the crossover pressure (r = 0.06). Peak early diastolic filling velocity correlated well with the difference between the crossover pressure and left ventricular minimal pressure in the left ventricular dysfunction group (r = 0.64, p < 0.01). In contrast to peak early diastolic filling velocity, deceleration time of the early diastolic filling wave correlated with mean left atrial pressure and the crossover pressure irrespective of the primary cause of preload alteration (r = -0.54, r = -0.59, p < 0.01 respectively, n = 69 for all data).

CONCLUSIONS

Preload dependency of the Doppler transmitral flow velocity pattern is hampered if an increase in left atrial pressure is due to left ventricular systolic dysfunction. In this setting, the increase in left ventricular minimal pressure due to left ventricular systolic dysfunction cancels the effect of the increase in left atrial pressure on the flow velocity pattern.

Left ventricular filling abnormalities in non-insulin-dependent diabetes mellitus and improvement by a short-term glycemic control

To determine whether left ventricular (LV) filling abnormalities in diabetes are associated with diabetic microangiopathy, and to evaluate the effect of a short-term glycemic control on the filling abnormalities, diastolic filling dynamics were assessed by pulsed Doppler echocardiography in 246 patients with non-insulin-dependent diabetics. Isovolumic relaxation time and the ratio of peak flow velocity of atrial filling wave to peak flow velocity of early filling wave (A/E) were significantly greater in diabetic patients than in age- and sex-matched control subjects. Diabetic patients with retinopathy had significantly greater isovolumic relaxation time and A/E values than those without retinopathy. A/E was significantly decreased 1 month after insulin treatment in those without, but not with retinopathy. It is concluded that LV diastolic filling is impaired in mildly hyperglycemic patients with non-insulin-dependent diabetes mellitus without severe complications, the abnormality being more intense in patients with retinopathy. A short-term glycemic control results in a marked decrease in abnormalities in patients without, but not with retinopathy.

Analysis of pulmonary venous flow velocity patterns in hypertensive hearts: its complementary value in the interpretation of mitral flow velocity patterns

Although the Doppler mitral flow velocity pattern changes in accordance with the degree of left ventricular diastolic dysfunction, it is "normalized" in the presence of heart failure. In this study the pulmonary venous flow velocity pattern was characterized in 43 hypertensive patients with and without heart failure to clarify whether analysis of the pulmonary venous flow velocity pattern provides complementary information in the interpretation of the mitral flow velocity pattern. The mitral flow velocity pattern in 32 hypertensive patients without heart failure was characterized by decreases in the peak early diastolic filling velocity (E) and the ratio of E to peak filling velocity at atrial contraction. The mitral flow velocity pattern was "normalized" in 11 patients with heart failure, with no differences in any mitral flow velocity pattern indexes as compared with 24 normal subjects. The pulmonary venous flow velocity pattern in hypertensive patients without heart failure was characterized by a decreased peak diastolic forward flow velocity (D) and an increased ratio of peak systolic forward flow velocity (S) to D (S/D ratio). In patients with heart failure, D was higher and the S/D ratio was lower compared with hypertensive patients without heart failure (p less than 0.01, p less than 0.01) and normal subjects (p less than 0.01, p less than 0.01). Thus the pulmonary venous flow velocity pattern appeared to be more reliable than the mitral flow velocity pattern in differentiating subgroups of patients with hypertension. Analysis of the pulmonary venous flow velocity pattern in conjunction with the mitral flow velocity pattern provides important and complementary information in the interpretation of the mitral flow velocity pattern in hypertensive patients with and without heart failure.