Ratio of left ventricular peak E-wave velocity to flow propagation velocity assessed by color M-mode Doppler echocardiography in first myocardial infarction: prognostic and clinical implications

Cardiac Computed Tomography Evaluation of Association of Left Ventricle Disfunction and Epicardial Adipose Tissue Density in Patients with Low to Intermediate Cardiovascular Risk

Background and objectives: Epicardial adipose tissue density (EAD) has been associated with coronary arteries calcium score, a higher load of coronary artery disease (CAD) and plaque vulnerability. This effect can be related to endocrine and paracrine effect of molecules produced by epicardial adipose tissue (EAT), that may influence myocardial contractility. Using coronary computed tomography angiography (CCT) the evaluation of EAD is possible in basal scans. The aim of the study is to investigate possible associations between EAD and cardiac function. Material and Methods: 93 consecutive patients undergoing CCT without and with contrast medium for known or suspected coronary CAD were evaluated. EAD was measured on basal scans, at the level of the coronary ostia, the lateral free wall of the left ventricle, at the level of the cardiac apex, and at the origin of the posterior interventricular artery. Cardiac function was evaluated in post-contrast CT scans in order to calculate ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), and stroke volume (SV). Results: A statistically significant positive correlation between EAD and ejection fraction (r = 0.29, p-value < 0.01) was found. Additionally, a statistically significant negative correlation between EAD and ESV (r = -0.25, p-value < 0.01) was present. Conclusion: EAD could be considered a new risk factor associated with reduced cardiac function. The evaluation of this parameter with cardiac CT in patients with low to intermediate cardiovascular risk is possible.

The long-term prognostic value of E/e' in patients with ST segment elevation myocardial infarction

Objectives

This study aimed to evaluate the long-term prognostic value of E/e’ ratio in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

We retrospectively assessed 314 patients who underwent primary coronary interventions between January 2010 and December 2015. The included patients were classified into two groups according to the E/e’ ratios: E/e’<15 (n = 245) and E/e’≥15 (n = 69). We investigated the incidence of major adverse cardiac events (MACEs) from the event to the final follow-up period of at least three years.

Results

A total of 55 cases of MACEs occurred during the follow-up. The E/e’≥15 group showed a significantly higher rate of MACEs than the E/e’<15 group (34.8% vs. 12.7%, p < 0.001). Among the MACE, the percentage of cardiac deaths (17.4% vs. 0.4%, p < 0.001) was higher in the E/e’≥15 group than in the E/e’<15 group. In the multivariable model, E/e’≥15 was demonstrated as the strongest prognostic factor for MACEs (hazard ratio [HR], 2.597; 95% confidence interval [CI], 1.294–5.211; p = 0.007) and cardiac death (HR, 27.537; 95% CI, 3.287–230.689; p = 0.002), while left ventricular ejection fraction (LVEF) was not. Neither the discrepancy of systolic nor diastolic function between initial and follow-up echocardiography affected the overall prevalence of MACEs. A disparity was observed between the two groups, with a significant increase in the rate of MACEs in the E/e’≥15 group (log-rank test, p < 0.001).

Conclusion

The baseline E/e’≥15 in patients with STEMI after successful reperfusion is the strongest predictor of poor long-term clinical outcomes among those analyzed.

Lipids and diastolic dysfunction: Recent evidence and findings

AIM

Diastolic dysfunction is the decreased flexibility of the left ventricle due to the impaired ability of the myocardium to relax and plays an important role in the pathogenesis of heart failure. Lipid metabolism is a well-known contributor to cardiac conditions, including ventricular function. In this article, we aimed to review the literature addressing the connections between lipids, their storage, and metabolism with left ventricular diastolic dysfunction.

DATA SYNTHESIS

We searched Google scholar, Pubmed, Embase and Researchgate for our keywords: "Diastolic function", "Fat" and "Lipid profile". Initially, 250 articles were selected by title and 84 of them were chosen as most relevant and directly reviewed.

CONCLUSIONS

Alterations of lipid metabolism in cardiac muscle and cardiac lipid content can occur in many conditions, including consumption of a high-fat diet, obesity, metabolic syndrome, and non-alcoholic fatty liver disease (NAFLD). These conditions induce alterations in myocardial lipid metabolism, increase myocardial fat content and epicardial fat thickness and increase inflammation and oxidative stress which ultimately lead to cardiac lipotoxicity and diastolic dysfunction. The effects of lipids on diastolic function can differ based on gender. Lipid profile and metabolism are as important in the pathogenesis of diastolic dysfunction as they are in other cardiovascular disorders. A more careful look at cardiac lipid metabolism in molecular, histological and gross levels results in more precise understanding of its role in myocardial function and leads to development of potential treatments for diastolic dysfunction.

Impact of guideline-recommended versus non-guideline-recommended β-blocker and Doppler echocardiographic parameters on 1-year mortality in Thai ischemic cardiomyopathy patients: A prospective multicenter registry

Background

Ischemic cardiomyopathy is a high-cost, resource-intensive public health burden that is associated with a 1-year mortality rate of about 16% in western population. Different in patient ethnicity and pattern of practice may impact the clinical outcome. We aim to determine 1-year mortality and to identify factors that significantly predicts 1-year mortality of Thai patients with ischemic cardiomyopathy.

Methods

This prospective multicenter registry enrolled consecutive Thai patients that were diagnosed with ischemic cardiomyopathy at 9 institutions located across Thailand. Patients with left ventricular function < 40% and one of the following criteria were included: 1) presence of epicardial coronary stenoses > 75% in the left main or proximal left anterior descending artery or coronary angiography, and/or two major epicardial coronary stenoses; 2) prior myocardial infarction; 3) prior revascularization by coronary artery bypass graft or percutaneous coronary intervention; or, 4) magnetic resonance imaging pattern compatible with ischemic cardiomyopathy. Baseline clinical characteristics, coronary and echocardiographic data were recorded. The 1-year clinical outcome was pre-specified.

Results

Four hundred and nineteen patients were enrolled. Thirty-nine patients (9.9%) had died at 1 year, with 27 experiencing cardiovascular death, and 12 experiencing non-cardiovascular death. A comparison between patients who were alive and patients who were dead at 1 year revealed lower baseline left ventricular ejection fraction (LVEF) (26.7 ± 7.6% vs 30.2 ± 7.8%; p = 0.021), higher left ventricular end-diastolic volume (LVEDV) (185.8 ± 73.2 ml vs 155.6 ± 64.2 ml; p = 0.014), shorter mitral valve deceleration time (142.9 ± 57.5 ml vs 182.4 ± 85.7 ml; p = 0.041), and lower use of statins (94.7% vs 99.7%; p = 0.029) among deceased patients. Patients receiving guideline-recommended β-blockers had lower mortality than patients receiving non-guideline-recommended β-blockers (8.1% vs 18.2%; p = 0.05).

Conclusions

The results of this study revealed a 9.9% 1-year mortality rate among Thai ischemic cardiomyopathy patients. Doppler echocardiographic parameters significantly associated with 1-year mortality were LVEF, LVEDV, mitral E velocity, and mitral valve deceleration time. The use of non-guideline-recommended β-blockers rather than guideline recommended β-blockers were associated with increased with 1-year mortality. Guidelines recommended β-blockers should be preferred.

Trial registration

Thai Clinical Trials Registry TCTR20190722002. Registered 22 July 2019. “Retrospectively registered”.

Effect of diastolic dysfunction on intraventricular velocity behavior in early diastole by flow mapping

Intraventricular velocity distribution reflects left ventricular (LV) diastolic function and can be measured non-invasively by flow mapping technologies. We designed our study to compare intraventricular velocities and gradients, obtained by vector flow mapping (VFM) technology during early diastole in consecutive patients diagnosed with mild and advanced diastolic dysfunction at echocardiography and a control group with a purpose to validate the hypothesis of relationship between new parameters and severity of diastolic dysfunction and conventional markers of elevated LV filling pressure. Two-dimensional streamline fields were obtained using VFM technology in 121 subjects (57 with normal diastolic function, 38 with mild diastolic dysfunction and 26 with advanced diastolic dysfunction). We measured several velocities and calculated a gradient along the selected streamline, which we compared between groups and correlated them with conventional echocardiographic parameters. Apical intraventricular velocity gradient (Gr_IV) was the lowest in control group, followed by mild and advanced diastolic dysfunction groups (5.3 ± 1.9 vs. 6.8 ± 2.5 vs. 13.6 ± 5.0/s, p < 0.001) and showed good correlation with E/e' (r = 0.751, p < 000.1). Gr_IV/e' ratio was the strongest single predictor of severity of diastolic dysfunction. Different degrees of diastolic dysfunction affect the Intraventricular velocity behavior during early diastole obtained by VFM. Gr_IV could discriminate between groups with different levels of diastolic dysfunction and was closely associated with classical echocardiographic indices of elevated LV filling pressure. Gr_IV/e' ratio has a potential to become a single parameter needed to assess left ventricular diastolic function.

Correlation between ST segment shift and cardiac diastolic function in patients with acute myocardial infarction

BACKGROUND

Diastolic dysfunction is the early sign of myocardial ischemia that usually occurs earlier than ECG changes.

AIM OF THE STUDY

To determine the existence of a correlation between ST segment shift and diastolic dysfunction among patients with AMI.

METHODS

Fourty six patients with significant ST segment elevation or depression and having symptoms of acute myocardial infarction for <12 h were enrolled in this study. Patients were examined for serial ECG, cardiac enzymes, and echocardiography.

RESULTS

There was no significant correlation between ST segment elevation or depression and majority of the diastolic indices. Few diastolic parameters; such as, E/A ratio of the mitral valve and deceleration time of the tricuspid valve showed a direct correlation with the ECG changes. Whereas, the Tei Index of the LV function showed a borderline correlation to the ST segment elevation at discharge.

CONCLUSION

Overall, there was no correlation between either ST segment elevation or depression and the LV or RV diastolic function in patients with acute coronary syndrome (ACS). Improvement of the ST segment total score was associated with improvement of the diastolic function grades at discharge. Moreover, this association has shown an evidence of dose response relationship, the more improvement in total score at discharge the more improvement in diastolic function grade level.

Two-year Follow-up of Patients With Unstable Angina/Non-ST Segment Elevation Myocardial Infarction Undergoing Early Invasive Strategy: Predictors of Normal or Near-Normal Coronary Angiography and Mortality

BACKGROUND

Predictors of normal or near-normal coronary angiography (NONCAG) in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and their importance regarding the prognosis are not understood. Accordingly, we determined these predictors as well as mortality risk factors at 2-year follow-up of UA/NSTEMI patients managed by the early invasive strategy.

METHODS

We prospectively studied consecutive patients with UA/NSTEMI managed with the early invasive strategy at Tehran Heart Center, in 1-year period. Echocardiography was performed before coronary angiography (CAG) for all the patients. Baseline characteristics, laboratory parameters, echocardiographic findings, invasive treatment modalities, and survival status after 2 years of follow-up were collected. We identified the predictors of NONCAG in the first phase of the study and then the risk factors of mortality in the second phase.

RESULTS

In the study period, 298 patients including 211 (71%) males, with the age of 59.31 ± 10.72 years were enrolled. The following factors were predictors of NONCAG: the female sex (P < 0.001); negative family history of CAD (P = 0.028); Thrombolysis in Myocardial Infarction (TIMI) risk score (P < 0.001); and early transmitral flow velocity/mean mitral annular velocity (E/E'mean) (P = 0.003). The following items were significant protective factors against mortality: percutaneous coronary intervention (PCI) (P = 0.012), age (P = 0.001), and E/E'mean (P = 0.020).

CONCLUSION

Patients' baseline characteristics as well as echocardiographic data could help in predicting those with NONCAG and PCI can be considered as the treatment of strategy with the most protection against mortality.

Diastolic dysfunction revisited: A new, feasible, and unambiguous echocardiographic classification predicts major cardiovascular events

BACKGROUND

Echocardiographic classification of DDF has been widely discussed. The aim of this study was to investigate the independent prognostic value of established echocardiographic measures in a community-based population and create a new classification of DDF.

METHODS

Within the Copenhagen City Heart Study, a prospective, community-based study, 1851 participants were examined by echocardiography including Tissue Doppler Imaging (TDI) in 2001 to 2003 and followed with regard to MACE (median, 10.9 years).

RESULTS

We found that persons with impaired myocardial relaxation as defined by low peak early diastolic mitral annular velocity e' by TDI had higher incidence of clinical and echocardiographic markers of cardiac dysfunction and increased risk of MACE. Among persons with impaired relaxation, only echocardiographic indices of increased filling pressures such as LAVi≥34 mL/m² (HR 1.97 (1.13-3.45, P=.017), E/e' ≥ 17 (HR 1.89 (1.34-2.65), P<.001), and E/A>2 (HR 5.24 (1.91-14.42), P=.001) provided additional and independent prognostic information on MACE. Based on these findings, we created a new classification of DDF where all grades were significant predictors of MACE independently of age, sex, and cardiac clinical risk markers (Mild DDF: HR 1.99 (1.23-3.21), P=.005; Moderate DDF: HR 3.11 (1.81-5.34), P<.001; Severe DDF: HR 4.20 (1.81-9.73), P<.001). Increasing severity of DDF was linearly associated with increasing plasma proBNP concentrations.

CONCLUSIONS

In the general population, the presence of echocardiographic markers of elevated filling pressures in persons with impaired relaxation increased the risk of MACE significantly. Based on this, we present a new, feasible, and unambiguous classification of DDF capable of accurate risk prediction in the community.

Early changes of left ventricular filling pattern after reperfused ST-elevation myocardial infarction and doxycycline therapy: Insights from the TIPTOP trial

AIM

Metalloproteinases inhibition by doxycycline reduces cardiac protein degradation at extracellular and intracellular level in the experimental model ischemia/reperfusion injury. Since both extracellular cardiac matrix and titin filaments inside the cardiomyocyte are responsible for the myocardial stiffness, we hypothesized that doxycycline could favorably act on left ventricular (LV) filling pressures in patients after reperfused acute ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

Seventy-three of 110 patients of the TIPTOP trial underwent a 2D-Echo-Doppler on admission, and at pre-discharge and at 6-month after a primary PCI for STEMI and LV dysfunction. From admission to pre-discharge, LV filling changed from a high filling pressure (HFP) to a normal filling pressure (NFP) pattern in 91% of the doxycycline-group, and in 67% of the control-group. Conversely, 1% of the doxycycline-group, and 37% of the control-group changed the LV filling from NFP to HFP pattern. Overall, a pre-discharge HFP pattern was present in 4 patients (11%) of the doxycycline-group and in 13 patients (36%) of the control-group (p=0.025). The evaluation of metalloproteinases and their tissue inhibitors plasma concentrations provide possible favorable action of doxycycline. On the multivariate analyses, troponine I peak (p=0.026), doxycycline (p=0.033), and on admission to pre-discharge LVEF changes (p=0.044) were found to be associated with pre-discharge HFP pattern. Independently of their baseline LV filling behavior, the 6-month remodeling was less in patients with pre-discharge NFP pattern than in patients with HFP pattern.

CONCLUSIONS

In patients with STEMI and LV dysfunction doxycycline can favorably modulate the LV filling pattern early after primary PCI.

Effect of CPAP on diastolic function in coronary artery disease patients with nonsleepy obstructive sleep apnea: A randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) has been associated with worse diastolic function in patients with coronary artery disease (CAD). This analysis determined whether continuous positive airway pressure (CPAP) treatment would improve diastolic function in CAD patients with nonsleepy OSA.

METHODS

Between December 2005 and November 2010, 244 revascularized CAD patients with nonsleepy OSA (apnea-hypopnea index (AHI) ≥15/h, Epworth Sleepiness Scale [ESS] score<10) were randomly assigned to CPAP or no-CPAP. Echocardiographic measurements were obtained at baseline, and after 3 and 12months.

RESULTS

A total of 171 patients with preserved left ventricular ejection fraction (≥50%), no atrial fibrillation or severe valve abnormalities, and technically adequate echocardiograms at baseline and follow-up visits were included (CPAP, n=87; no-CPAP, n=84). In the intention-to-treat analysis, CPAP had no significant effect on echocardiographic parameters of mild (enlarged left atrium or decreased diastolic relaxation velocity) or worse (increased E/é filling index [presumed elevated left ventricular filling pressure]) diastolic function. Post-hoc analysis revealed a significant association between CPAP usage for ≥4h/night and an increase in diastolic relaxation velocity at 12months' follow-up (odds ratio 2.3, 95% confidence interval 1.0-4.9; p=0.039) after adjustment for age, sex, body mass index, and left atrium diameter at baseline.

CONCLUSIONS

CPAP did not improve diastolic dysfunction in CAD patients with nonsleepy OSA. However, good CPAP adherence was significantly associated with an increase in diastolic relaxation velocity after one year.

Serial Echocardiographic Assessment of Left Ventricular Filling Pressure and Remodeling among ST-Segment Elevation Myocardial Infarction Patients Treated by Primary Percutaneous Intervention

BACKGROUND

Acute myocardial infarction and remodeling of the left ventricle is associated with significant changes in systolic and diastolic echocardiographic derived indices. The investigators have tried to determine whether persistence of increased ratio of transmitral flow velocity (E) to early mitral annulus velocity (e'), signifying increased cardiac filling pressure, is associated with left ventricular (LV) remodeling and increased chamber size among patients presenting with ST-segment elevation myocardial infarction, who underwent successful reperfusion with primary percutaneous coronary intervention.

METHODS

Fifty-two patients (76% men; mean age, 61 ± 10 years) with first ST-segment elevation myocardial infarctions who underwent primary percutaneous coronary intervention were retrospectively studied. Echocardiography was performed at baseline (days 1-3) and after 178 ± 62 days. Patients were stratified according to E/septal e' ratio >15 and ≤15 in both examinations. All patients received optimal medical therapy according to guidelines and local practice.

RESULTS

Patients with maintained or worsened E/septal e' ratios to >15 demonstrated on the second examination worse LV ejection fractions (mean, 45 ± 12% vs 52 ± 8%; P = .03) and higher indexed LV end-diastolic volumes (mean, 81.3 ± 22.9 vs 69.2 ± 13.4 mL/m(2); P = .01) and end-systolic volumes (mean, 33.0 ± 12.2 vs 23.7 ± 13.4 mL/m(2); P = .02) compared with the first examination, representing LV remodeling. Patients with E/septal e' ratios > 15 on the second examination demonstrated a positive correlation between the change in E/septal e' ratio and the change in indexed LV end-diastolic volume (linear R(2) = 0.344, P = .03).

CONCLUSIONS

Among patients with ST-segment elevation myocardial infarctions undergoing primary percutaneous coronary intervention, early and persistent elevation of the E/septal e' ratio may be associated with LV remodeling.

Prognostic role of left atrial strain and its combination index with transmitral E-wave velocity in patients with atrial fibrillation

Left atrial (LA) strain can reflect LA remodeling and is reduced in atrial fibrillation (AF) patients with prior stroke. This study sought to examine the ability of LA strain in predicting subsequent stroke event in AF and also evaluated whether E/LA strain could predict cardiovascular (CV) events in these patients. In 190 persistent AF patients, we performed comprehensive echocardiography with assessment of LA strain. There were 69 CV events including 19 CV death, 32 hospitalizations for heart failure, 3 myocardial infarctions, and 15 strokes during an average follow-up of 29 months. Multivariate analysis showed old age, chronic heart failure, increased left ventricular (LV) mass index, and increased E/LA strain were associated with CV events and decreased LA strain was associated with subsequent stroke event. The addition of E/LA strain and LA strain to a model containing CHA2DS2-VASc score and LV function significantly improved the values in predicting CV events and subsequent stroke event, respectively. In conclusion, E/LA strain and LA strain were respectively useful in predicting CV events and subsequent stroke event in AF. E/LA strain and LA strain could provide incremental values for CV outcome and subsequent stroke outcome prediction over conventional clinical and echocardiographic parameters in AF, respectively.

Impaired Diastolic Recovery after Acute Myocardial Infarction as a Predictor of Adverse Events

BACKGROUND

To investigate the impact of left ventricular (LV) diastolic functional recovery on major adverse cardiac events (MACE) 6 months after acute myocardial infarction (AMI) in patients with preserved LV systolic function.

METHODS

A total 463 patients with preserved LV systolic function at 6 months after an AMI were divided into two groups based on the extent of diastolic recovery assessed by echocardiography: group I (n = 241) showed improving diastolic function and group II (n = 222) did not. MACE included death, recurrent myocardial infarction, and rehospitalization due to heart failure, and these events were compared with the patients' characteristics at baseline.

RESULTS

Compared with group I, the patients in group II were older and had a higher prevalence of hypertension and diabetes. Blood levels of hemoglobin and triglyceride were lower in group II, whereas the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and of high-sensitivity C-reactive protein were higher in this group than in group I. MACE were significantly more frequent in group II than in group I. Age, elevated NT-proBNP, and impaired diastolic recovery were significant independent predictors of MACE.

CONCLUSION

Despite improvement in LV systolic function, LV diastolic function had not improved in 222 patients (47.9%) by the 6-month follow-up after the index AMI, and impaired diastolic functional recovery was found to be an independent predictor of MACE. Evaluation of diastolic function would be a useful way to stratify risk in patients discharged after an index AMI.

Renin-Angiotensin Activation and Oxidative Stress in Early Heart Failure with Preserved Ejection Fraction

Animal models have suggested a role of renin-angiotensin system (RAS) activation and subsequent cardiac oxidation in heart failure with preserved ejection fraction (HFpEF). Nevertheless, RAS blockade has failed to show efficacy in treatment of HFpEF. We evaluated the role of RAS activation and subsequent systemic oxidation in HFpEF. Oxidative stress markers were compared in 50 subjects with and without early HFpEF. Derivatives of reactive oxidative metabolites (DROMs), F2-isoprostanes (IsoPs), and ratios of oxidized to reduced glutathione (E h GSH) and cysteine (E h CyS) were measured. Angiotensin converting enzyme (ACE) levels and activity were measured. On univariate analysis, HFpEF was associated with male sex (p = 0.04), higher body mass index (BMI) (p = 0.003), less oxidized E h CyS (p = 0.001), lower DROMs (p = 0.02), and lower IsoP (p = 0.03). Higher BMI (OR: 1.3; 95% CI: 1.1-1.6) and less oxidized E h CyS (OR: 1.2; 95% CI: 1.1-1.4) maintained associations with HFpEF on multivariate analysis. Though ACE levels were higher in early HFpEF (OR: 1.09; 95% CI: 1.01-1.05), ACE activity was similar to that in controls. HFpEF is not associated with significant systemic RAS activation or oxidative stress. This may explain the failure of RAS inhibitors to alter outcomes in HFpEF.

Left ventricular diastolic function in hypertension: methodological considerations and clinical implications

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination of hypertensive patient; indeed when LV diastolic function is impaired, it is possible to have heart failure even with preserved LV ejection fraction. Left ventricular diastolic dysfunction (LVDD) occurs frequently and is associated to heart disease. Doppler echocardiography is the best tool for early LVDD diagnosis. Hypertension affects LV relaxation and when left ventricular hypertrophy (LVH) occurs, it decreases compliance too, so it is important to calculate Doppler echocardiography parameters, for diastolic function evaluation, in all hypertensive patients. The purpose of our review was to discuss about the strong relationship between LVDD and hypertension, and their relationship with LV systolic function. Furthermore, we aimed to assess the relationship between the arterial stiffness and LV structure and function in hypertensive patients.

Obstructive sleep apnea is independently associated with worse diastolic function in coronary artery disease

BACKGROUND

Diastolic dysfunction is common in patients with coronary artery disease (CAD). We hypothesize that patients with CAD and preserved left ventricular ejection fraction (LVEF) and obstructive sleep apnea (OSA) will have worse diastolic function than similar patients without OSA.

MATERIAL AND METHODS

We analyzed sleep-study recordings and echocardiographic measurements obtained at baseline in a randomized controlled trial (RICCADSA) of revascularized patients with CAD who had LVEF of at least 50%. OSA was defined as an apnea-hypopnea-index (AHI) ≥15 events/h, and, no OSA, as an AHI <5. Worse diastolic function was defined as assumed elevated left ventricular filling pressure based on peak flow velocity in early diastole/Tissue Doppler of early diastolic ventricular filling (E/é) of >13 (or >9 in patients with an enlarged left atrial diameter [≥39 mm for women and ≥40 mm for men]).

RESULTS

Data from 431 patients were evaluated (mean age: 63.7 ± 8.8 y; men: 82.5%; OSA: n = 331). Worse diastolic function was more common among the patients with OSA than those without (54.4% vs 41.0%, p = 0.019). In multivariate analysis, OSA was associated with worse diastolic function (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.13; 3.18) adjusted for female sex (OR 2.28, 95% CI 1.28; 4.07), hypertension (OR 1.84, 95% CI 1.20; 2.82), and diabetes mellitus (OR 2.45, 95% CI 1.42; 4.23). Age ≥60 years, obesity, and current smoking were nonsignificant.

CONCLUSIONS

In this cohort with CAD and preserved LVEF, OSA was associated with worse diastolic function independent of the traditionally recognized risk indicators.

Exercise tolerance in asymptomatic patients with moderate-severe valvular heart disease and preserved ejection fraction

INTRODUCTION

For asymptomatic patients with moderate-severe valvular heart disease, in whom symptoms may be obscured, objective exercise tolerance measures are warranted for decisions concerning physical activities and surgical treatment.

MATERIAL AND METHODS

We compared 61 patients (39 with aortic stenosis, 22 with aortic or mitral regurgitation) to 23 controls without valvular heart disease but with indications for stress testing. All participants underwent cardiopulmonary function testing and dobutamine stress echocardiography. Blood was drawn before as well as after bicycle stress to assess high-sensitivity cardiac troponin T (hscTnT). Patients who underwent surgery were re-evaluated 1.5 ±0.9 years after the operation.

RESULTS

Conventional bicycle test following guideline criteria revealed a pathologic result in 26% of the patients, whereas spiroergometry showed an objectively reduced exercise tolerance in 59%, reaching a prognostically relevant feature in 39%. Stress echocardiography detected a reduced systolic reserve in 33% and elevated filling pressures in 62%. These abnormalities were significantly less present in the control group (4, 17, 9, 9, 4% respectively, p < 0.05 each). Baseline hscTnT detected patients with the prognostically important feature of reduced exercise tolerance (area under the curve 0.689 (95% CI: 0.546-0.831), p = 0.015). Objective preoperative exercise tolerance predicted sustained cardiocirculatory and myocardial dysfunction postoperatively.

CONCLUSIONS

Cardiopulmonary function testing and dobutamine stress echocardiography identify exercise intolerance in patients with asymptomatic valvular heart disease beyond stress-test criteria recommended in recent guidelines. High-sensitivity cardiac troponin I may be of additional value. Results of these tests presage post-operative function.

Use and Limitations of E/e' to Assess Left Ventricular Filling Pressure by Echocardiography

Measurement of left ventricular (LV) filling pressure is useful in decision making and prediction of outcomes in various cardiovascular diseases. Invasive cardiac catheterization has been the gold standard in LV filling pressure measurement, but carries the risk of complications and has a similar predictive value for clinical outcomes compared with non-invasive LV filling pressure estimation by echocardiography. A variety of echocardiographic measurement methods have been suggested to estimate LV filling pressure. The most frequently used method for this purpose is the ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e'), which has become central in the guidelines for diastolic evaluation. This review will discuss the use the E/e' ratio in prediction of LV filling pressure and its potential pitfalls.

Is the E/V p index useful for evaluating prognosis in chronic heart failure with atrial fibrillation? A pilot study

BACKGROUND

The ratio of transmitral peak E wave velocity to color flow propagation velocity (E/V p index) has proved to be a significant predictor of prognosis in cardiac diseases with sinus rhythm. However, its usefulness in patients with atrial fibrillation (AF) and heart failure has not yet been established. The aim of this study was to determine the feasibility of using the E/V p index for the prediction of mortality and heart failure hospitalization in this group.

METHODS

We studied 66 ambulatory patients with stable congestive heart failure (CHF) functional class I-III and AF. Patients were divided into group A and B according to an E/V p index <1.5 and ≥1.5, respectively.

RESULTS

During follow-up (average 430 days) events were more common in group B (75 vs. 17%, log rank test; hazard ratio (HR)  = 6.8). By means of multivariate logistic regression analysis, E/V p proved to be an independent predictor of events (p = 0.0012).

CONCLUSIONS

In our patients with stable CHF and AF the E/V p index is a significant predictor of clinical outcome.

Diastolic dysfunction: improved understanding using emerging imaging techniques

Diastolic heart failure is increasing in prevalence. Although the pathophysiology is incompletely understood and current therapeutic strategies are limited, identification of diastolic dysfunction is important. We review the role of contemporary techniques with echocardiography and cardiac magnetic resonance imaging (CMRI) in the assessment of diastolic dysfunction. Cardiac catheterization is the criterion standard for demonstrating impaired relaxation and filling by making direct measurements; however, echocardiography has replaced it as the most clinically used tool. By evaluating mitral inflow pulsed-wave Doppler with and without the Valsalva maneuver, isovolumetric relaxation time, pulmonary venous flow Doppler, color M-mode velocity propagation, tissue Doppler imaging, and speckle tracking, echocardiography is considered an accurate method for diagnosis and grading diastolic dysfunction. Evaluation of diastolic function can also be performed by CMRI. Mitral valve inflow velocities, early deceleration time, and pulmonary vein flow velocities are diastolic parameters that can be measured by phase-contrast CMRI. Cardiac magnetic resonance imaging steady-state gradient echo can evaluate functional dimensions for time-volume curves; and myocardial tagging can assess ventricular diastolic "untwisting," which may be important for improved pathophysiologic understanding. Studies have compared echocardiography and CMRI for diagnosing diastolic dysfunction in small patient groups with similar results. Cardiac magnetic resonance imaging can now provide clinically relevant data regarding the underlying cause of diastolic dysfunction and offers promise to gain mechanistic insights for therapeutic strategy development and clinical trial planning.

Clinical significance of positive isovolumetric relaxation velocity of pulsed-wave tissue Doppler imaging

OBJECTIVE

Among the pulsed-wave tissue Doppler imaging (pw-TDI) parameters, there are two different pw-TDI velocities (IVRa and IVRb) after systolic velocity, but before Ea velocity. In our study, we investigated the clinical importance of these two velocities in left ventricular diastolic dysfunction (LVDDF) evaluation.

METHODS

One hundred and eighty cases without exclusion criteria were included in the study. Cases with a transmitral E to A flow (E/A) ratio below 1 were assigned to group 2. In cases with an E/A ratio between 1 and 2, the pw-TDI parameters were taken into consideration. Cases with an Ea/Aa ratio above 1 were assigned to group 1 and cases with an Ea/Aa ratio 1 or below than 1 were assigned to group 3. Group 1 (n: 68) represented normal diastolic left ventricular (LV) inflow while group 2 (n = 87) represented impaired relaxation and group 3 (n = 25) represented pseudonormal LV inflow.

RESULTS

In our study, we found that IVRa velocity was lower in group 1 compared to group 2 and group 3 (P < 0.001 and P = 0.038, respectively). Similarly, this velocity was significantly different in group 3 and group 2 such as it was higher in group 2 compared to group 3 (P = 0.022). There was no difference in IVRb velocity and IVRa/IVRb ratio among the groups. A negative correlation was found between IVRa velocity and Ea velocity (r = 44%, P < 0.001). Positive correlation was found between IVRa velocity and isovolumetric relaxation time (r = 18%, P = 0.014) and also between IVRa velocity and Aa velocity (r = 19%; P = 0.010).

CONCLUSION

Based on the results of our study, we concluded that IVRa velocity is an important pw-TDI parameter in the evaluation of LVDDF, especially in differentiating pseudonormal LVDDF type from normal LV inflow.

Left Atrium Reclassified: Application of the American Society of Echocardiography/European Society of Cardiology Cutoffs to Unselected Outpatients Referred to the Echocardiography Laboratory

OBJECTIVES

We sought to determine whether categorization of abnormal left atrial (LA) size based on volumes indexed to body surface area (LAVi) results in reclassification of LA dilatation if the classic antero-posterior diameter (LAd) was measured. The American Society of Echocardiography/European Society of Cardiology recommended LAVi over linear measurements and recently published cutoffs to qualify LA dilatation. However, many laboratories continue to use the LAd because it appears easier to measure.

METHODS

Unselected adult outpatients referred to the echocardiography laboratory for any indication in the period March 2005 to January 2006 prospectively underwent standard Doppler echocardiography, including real-time measurement of LAd and LAVi.

RESULTS

We enrolled 578 patients (mean age 66 +/- 14 years, 56% women). There was a good positive linear correlation between LAd and LAVi (r = 0.686, P < .0001). When the published cutoffs for LA enlargement were used, 49.0% of patients were classified as having abnormal LA by LAd and 76.3% by LAVi (P < .001). Of the 295 who had normal LA by LAd, 58.6% patients had abnormal LAVi. Conversely, of the 283 with abnormal LAd, almost all patients (94.7%) had abnormal LAVi. The proportion of overall agreement was 67.5% (kappa = 0.357, P < .001).

CONCLUSION

Assessment of LA size by LAVi allows identification of patients with enlarged atria that would have been missed if classified by antero-posterior diameters, especially when cutoffs are applied.

Color M-mode propagation velocity, but not its ratio to early diastolic inflow velocity, changes throughout gestation in normal human fetuses

OBJECTIVES

Color M-mode propagation velocity (Vp) is a measure of diastolic function in adults and, when combined with early diastolic inflow velocity (E), the ratio E/Vp reflects ventricular filling pressure. Early detection of diastolic compromise may benefit fetal patients at risk for developing heart failure. The objectives of this study were to measure values for Vp and inflow peak E in a group of normal fetuses, to analyze age-dependent alterations in these measurements, and to evaluate the interobserver and intraobserver variability of the measurements.

METHODS

Thirty-two normal fetuses at between 20 and 35 weeks' gestation underwent echocardiography. Color M-mode Vp was measured from the four-chamber view for the right (RV) and left (LV) ventricles, and mitral and tricuspid inflow velocities were determined by pulsed-wave Doppler ultrasound. The values obtained were compared with previously reported findings in adults.

RESULTS

Adequate tracings were obtainable in 23 patients for the RV and 29 for the LV. Mean Vp values for the RV (15.3 +/- 3.2 cm/s) and LV (20.8 +/- 5.6 cm/s) were lower than normal adult values, and Vp values were significantly lower for the RV than the LV (P < 0.001). Applying Bazett's heart rate correction, values for RV (23.4 +/- 4.8 cm/s) and LV (31.9 +/- 8.7 cm/s) remained lower than normal adult values. There was a linear correlation of Vp with gestational age for the RV (R = 0.69, P < 0.001), and the ratio of E/Vp corrected for heart rate for the RV (1.51 +/- 0.26) remained constant throughout gestation. Interobserver bias was high but intraobserver bias low, at 19 and 1.1%, respectively.

CONCLUSIONS

Vp is lower in fetal than in adult life. Vp for the RV changes in a manner indicative of improving diastolic function throughout normal gestation, providing insight into the alterations in diastolic function with gestation that contribute to increases in cardiac output. The use of Vp to assess diastolic function disturbance in fetuses is feasible, but high interobserver variability is problematic.

Role of Echocardiography in the Diagnostic Assessment and Etiology of Heart Failure in the Elderly—Opacify, Quantify, and Rectify

Echocardiography offers comprehensive, noninvasive, and relatively inexpensive tools for diagnosing cardiac pathology in the elderly. With an organized approach using two-dimensional echocardiography and Doppler echocardiography, clinicians can determine the systolic and diastolic left ventricular performance; estimate the cardiac output, pulmonary artery, and ventricular filling pressures; and identify surgically correctable valve disease. Meanwhile, real-time three-dimensional echocardiography provides unprecedented volume data to quantify the left ventricular status. Tissue Doppler-derived myocardial velocity and strain imaging data provide extremely fine details about the regional variations in myocardial synchrony and predict responders to cardiac resynchronization therapy. Thus, echocardiographic tools provide the basis for determining when to attempt to rectify the left ventricular dysfunction with strategically placed, biventricular pacemaker leads.

Doppler-Derived Indexes and B-Type Natriuretic Peptide in Prediction of Paroxysmal Atrial Fibrillation in Essential Hypertension: A Prospective Study

BACKGROUND

Onset of atrial fibrillation in hypertensive patients is usually associated with a high occurrence of cardiovascular complications. Despite its leading importance as a highly prevalent and modifiable risk factor, only a few data are available regarding the predictors of paroxysmal atrial fibrillation (PAF) in hypertensive patients.

OBJECTIVES

This study was undertaken to determine if PAF could be predicted in hypertensive patients while in sinus rhythm using Doppler-derived indexes and the plasma B-type natriuretic peptide (BNP) concentration.

METHODS

We prospectively evaluated 165 consecutive patients with hypertension and no known history of PAF or cardiovascular events who attended the cardiology outpatient clinic. Their mean age was 62 +/- 12, 94 male, 71 female. The conventional echocardiographic parameters were measured including: left atrial (LA) volume, mitral regurgitation (MR), left ventricular (LV) function, LV mass. The ratio of transmitral peak E-wave velocity to flow propagation velocity (E/V(p)), ratio of E-wave to mitral annular early diastolic velocity (E/E(a)) obtained by Doppler tissue at the lateral and septal corners of the mitral annulus were calculated. The plasma BNP was measured at the study entry.

RESULTS

After a mean follow-up of 15 +/- 3 months, PAF (symptomatic attacks or documented on the ECG) occurred in 36 (21.8%) of 165 patients. The patients with PAF had significant higher BNP levels than those with sinus rhythm (160 +/- 109.8 vs. 87.9 +/- 57.7 pg/ml, P < 0.001) Also, E/E(a) and E/V(p) ratios were significantly higher in hypertensives with PAF (15.1 +/- 2.8 vs. 8.39 +/- 1.33, P < 0.001), and (1.65 +/- 1.29 vs. 1.19 +/- 1.06, P < 0.001) respectively. In univariate analysis, E/V(p), E/E(a), and BNP and LV hypertrophy were significant predictors of PAF. Barely E/V(p) and E/E(a) remained independently significant after adjustment of clinical and other echocardiographic variables by multivariate logistic regression analysis (odd ratio: 3.36, P < 0.001 and 4.93, P < 0.001 respectively). A cutoff value of > or =1.7 for E/V(p) predicted PAF with 91% sensitivity and 88% specificity; E/E(a) >12 has sensitivity 98%, specificity 89%, while BNP>170 pg/ml has 83% and 72% specificity, respectively, for prediction of PAF in hypertensive patients.

CONCLUSION

Paroxysmal atrial fibrillation could be predicted in hypertensive patients while in sinus rhythm using Doppler-derived indexes. Increased E/V(p), E/E(a) ratios and elevated BNP appear to be useful parameters to identify patients at heightened risk. They may reflect early left ventricular dysfunction and atrial hypertension in this population.

Assessment of variables affecting flow propagation velocity of the left ventricle in healthy children

BACKGROUND

The purpose of the present study was to establish the normal values of flow propagation velocity (FPV) in healthy children and examine the variables that affect FPV in clinical situations.

METHODS

Two hundred and thirty- five healthy children and adolescents were assessed (aged 0-22.6 years, mean age 7.4 +/- 5.4 years; male, n = 142; female, n = 93). FPV was obtained from an apical four-chamber view and determined as the slope of aliasing velocity of early diastolic transmitral flow on the color M-mode using Aloka SSD-5500 with 5.0 MHz transducer. Aliasing velocity was set at 50-70% of the peak transmitral flow velocity. Peak transmitral flow velocities in early diastole (E) and during atrial contraction (A), and the ratio of early to late peak velocity (E/A) were obtained. Tei index was also measured for analysis of general left ventricular performance. Left ventricular mass index (LVMI) was obtained from conventional echo measurement. E, E/A, Tei index and LVMI were compared with FPV in healthy subjects.

RESULTS

FPV obtained from all subjects ranged from 23.7 to 96.0 cm/s (61.3 +/- 13.6 cm/s). Normal value of FPV was less dependent on age, body size, heart rate and left ventricular dimension. In contrast, although there was no significant correlation between FPV and ejection fraction, statistically significant correlation was found between FPV, LVMI (P = 0.0008) and Tei index (P = 0.025).

CONCLUSIONS

FPV is independent of age, body size and heart rate and is useful to assess left ventricular relaxation in children.

Diagnostic utility of brain-natriuretic peptide for left ventricular diastolic dysfunction in asymptomatic type 2 diabetic patients

AIM

Left ventricular (LV) diastolic dysfunction has been reported to be prevalent in diabetic subjects, but this recognition could often be missed. We evaluated prevalence of LV diastolic dysfunction and diagnostic utility of brain-natriuretic peptide (BNP) in asymptomatic patients with type 2 diabetes mellitus.

RESEARCH DESIGN AND METHODS

Plasma BNP levels and LV geometry and diastolic filling indices, including the ratio of peak early transmitral Doppler flow (E) over flow propagation velocity (Vp) measured by colour M-mode Doppler echocardiography, were analysed in 98 consecutive asymptomatic patients with type 2 diabetes mellitus and 51 age-matched controls.

RESULTS

The LV mass index and relative wall thickness were higher in diabetic groups than controls without any differences in LV systolic function. The frequency of diastolic dysfunction defined as E/Vp > or = 1.5 were 31% in diabetic groups and 15% in controls (chi(2) = 4.364, p = 0.037). By receiver-operating characteristic (ROC) curve analysis, a BNP cutoff value of 19.2 pg/ml in controls had a 53.1% positive predictive value (53.1%) and a high negative predictive value (94.4%) for E/Vp >/= 1.5, whereas a BNP cutoff value of 18.1 pg/ml in diabetic groups had a 61.8% positive and 97.3% negative predictive values.

CONCLUSIONS

The frequency of E/Vp > or = 1.5 was higher in asymptomatic diabetic patients, suggesting that LV diastolic dysfunction was prevalent. The plasma concentration of BNP could be used to depict LV diastolic dysfunction in such population.

Impact of mitral E/A ratio on the accuracy of different echocardiographic indices to estimate left ventricular end-diastolic pressure

The objective was to determine the influence of left ventricular (LV) inflow pattern on the accuracy of different echocardiographic indices for estimation of LV end-diastolic pressure (LVEDP). Echocardiography with color tissue Doppler imaging (TDI) and LVEDP measurements using fluid-filled catheters were performed in 176 consecutive patients on the same day. Mitral peak diastolic velocities (E, A) and the difference in duration between pulmonary venous retrograde velocity and mitral A-velocity (PV(R)-A) were recorded by pulsed Doppler. Propagation velocity of the early mitral inflow (V(P)) was assessed using color M-mode. Early diastolic longitudinal (E'(lat)) and radial (E'(radial)) velocities of mitral annulus were measured by TDI. Area under ROC curve (AUC) for prediction of elevated LVEDP (> or =15 mm Hg) was computed for each parameter. For E/A > or =1 (98 patients, 46 with elevated LVEDP), the AUC values were: PV(R)-A: 0.914; E/E'(lat): 0.780; E/E'(radial): 0.729; E/V(P): 0.712 (p < 0.001). When E/A <1 (78 patients, 26 with elevated LVEDP), only PV(R)-A reached statistical significance (AUC = 0.893, p < 0.001). The conclusions were: PV(R)-A enabled the most accurate noninvasive estimation of LVEDP irrespective of LV filling profile and combined indices E/V(P), E/E'(lat) and E/E'(radial) represent more feasible alternatives for patients with mitral E/A-1.