Reference values for Doppler indexes of left ventricular diastolic filling in the elderly

Evaluation of cardiac electromechanics in patients with newly diagnosed hypertension

OBJECTIVES

This study aimed to investigate the relationship between subclinical left ventricular (LV) systolic dysfunction and ECG parameters in newly diagnosed hypertension patients.

METHODS

In this cross-sectional study, adults diagnosed with hypertension based on 24-h ambulatory blood pressure monitor recordings were included. The patients were classified into two groups based on the presence of subclinical LV systolic dysfunction according to LV global longitudinal strain (LVGLS). Findings were compared between the two groups.

RESULTS

A total of 244 patients (female, 55.7%) were included. Based on LVGLS, 82 (33.6%) patients had subclinical LV systolic dysfunction. The proportion of early repolarization pattern (ERP) on ECG was significantly higher in patients with subclinical LV systolic dysfunction than in patients with normal LV systolic function [24 (28.6%) vs. 8 (5%), P < 0.001]. PR and corrected QT intervals were also significantly longer in patients with subclinical LV systolic dysfunction than in patients with normal LV systolic function [median (interquartile range), 148 (132-158) vs. 141 (127-152), P = 0.036 and 443 (427-459) vs. 431 (411-455), P = 0.007, respectively]. According to multivariate regression analysis ERP, early (E) wave velocity/late (A) wave velocity (E/A), and LV mass index were independently associated with subclinical LV systolic dysfunction.

CONCLUSION

In newly diagnosed hypertension patients, the ERP on admission ECG could be a sign of subclinical systolic dysfunction.

Echo-Doppler estimation of left ventricular filling pressure: results of the multicentre EACVI Euro-Filling study

Aims

The present Euro-Filling report aimed at comparing the diagnostic accuracy of the 2009 and 2016 echocardiographic grading algorithms for predicting invasively measured left ventricular filling pressure (LVFP).

Method and results

A total of 159 patients who underwent simultaneous evaluation of echo estimates of LVFP and invasive measurements of LV end-diastolic pressure (LVEDP) were enrolled at nine EACVI centres. Thirty-nine (25%) patients had a reduced LV ejection fraction (<50%), 77 (64%) were in NYHA ≥ II, and 85 (53%) had coronary artery disease. Sixty-four (40%) patients had elevated LVEDP (≥15 mmHg). Taken individually, all echocardiographic Doppler estimates of LVFP (E/A, E/e', left atrial volume, tricuspid regurgitation jet velocity) were marginally correlated with LVEDP. By using the 2016 recommendations, 65% of patients with normal non-invasive estimate of LVFP had normal LVEDP, while 79% of those with elevated non-invasive LVFP had elevated invasive LVEDP. By using 2009 recommendations, 68% of the patients with normal non-invasive LVFP had normal LVEDP, while 55% of those with elevated non-invasive LVFP had elevated LVEDP. The 2016 recommendations (sensitivity 75%, specificity 74%, positive predictive value 39%, negative predictive value 93%, AUC 0.78) identified slightly better patients with elevated invasive LVEDP (≥ 15 mmHg) as compared with the 2009 recommendations (sensitivity 43%, specificity 75%, positive predictive value 49%, negative predictive value 71%, AUC 0.68).

Conclusion

The present Euro-Filling study demonstrates that the new 2016 recommendations for assessing LVFP non-invasively are fairly reliable and clinically useful, as well as superior to the 2009 recommendations in estimating invasive LVEDP.

Assessment of left ventricle systolic and diastolic functions in schizophrenia patients

The objective of the study was to scrutinize in detail the changes that occur in left ventricle (LV) systolic and diastolic functions using echocardiography in patients with at least 5 years of history and 40 healthy volunteers matching the patients in age and gender, who were enrolled in a cross-sectional study. All cases were examined with Tei Index, an index that could assess LV systolic and diastolic functions in conjuction, and with LV ejection fraction (LVEF) that assesses systolic function. In addition, Mitral E and A wave velocities, Isovolemic relaxation time (IVRT), Tissue Doppler Em (peak early motion) and Am (peak after motion) waves, which evaluate diastolic functions were measured. Tei Index was calculated as 0.61±0.19 in the patient group, and as 0.39±0.10 in the control group and the difference was statistically significant (p<0.001). LVEF was measured as 58%±5 in the patient group, and as 62%±3 in the control group and the difference was statistically significant (p<0.001). Also the IVRT values were significantly different between the tissue Doppler Em and Em/Am ratio among the groups (p<0.001). Echocardiographic myocardial performance, LV systolic and diastolic functions in schizophrenia patients was found to be worse than those of the control group.

[Study of echocardiographic parameters of rheumatoid arthritis black African without clinically evident cardiovascular manifestations: A cross-sectional study of 73 cases in Senegal]

INTRODUCTION

Research of cardiac involvement in patients with rheumatoid arthritis can prevent complications and place in a logical secondary prevention. The objective of this study was to investigate the echocardiographic parameters in a population of Senegalese patients with rheumatoid arthritis without clinically evident cardiovascular manifestations.

PATIENTS AND METHOD

We conducted a descriptive cross-sectional study, which included prospectively from outpatients in the internal medicine department of university hospital center Aristide Le Dantec in Dakar, Senegal, with a diagnosis of rheumatoid arthritis without clinically evident cardiovascular disease. It focused on a sample of 73 patients of both sexes aged at least 18 years. Following clinical examination, we conducted laboratory tests (CRP, fibrinogen, ESR, rheumatoid factors: Latex and Waaler-Rose, anti-CCP, antinuclear factors and anti-ENA antibodies), ECG, echocardiography standard. Data were analyzed using a descriptive study of the different variables with the calculation of proportions for categorical variables, and the positional parameters and dispersion for quantitative variables.

RESULTS

A total of 73 patients with rheumatoid arthritis without obvious cardiac events and meeting the criteria of definition of the ACR 1987 were included in the study. The mean age was 44.17±14.43 years with extremes of 18 and 75 years. The mean duration of RA was 5.93±4.78 years. The concept of family inflammatory arthritis was reported in 35.60% of cases and almost one in six patients had at least a factor of cardiovascular risk (16.96%). The abnormalities found in Doppler echocardiography were dominated by diastolic LV dysfunction (42.46%), increased left ventricular mass in 35.61%. Valvular leaks of variable grades were highlighted regarding all orifices but were rarely significant.

CONCLUSION

The realization of echocardiography in patients with rheumatoid arthritis without clinically evident cardiovascular manifestations helps to highlight cardiovascular abnormalities related to the natural course of the disease.

Normal values of regional and global myocardial wall motion in young and elderly individuals using navigator gated tissue phase mapping

The purpose of this study was to evaluate normal values for regional and global myocardial wall motion parameters in young and elderly individuals, as detected by navigator gated high temporal resolution tissue phase mapping. Radial, longitudinal and circumferential ventricular wall motion, as well as ventricular torsion and longitudinal strain rates, were assessed in two age groups of volunteers, 23 ± 3 (n = 14) and 66 ± 7 years old (n = 9), respectively. All subjects were healthy, non-smokers without known cardiac disease. An increased global left ventricular (LV) torsion rate (peak systolic torsion rate 20.6 ± 2.0 versus 14.5 ± 1.0°/s/cm, peak diastolic torsion rate -25.2 ± 1.8 versus -14.1 ± 1.3°/s/cm) and a decrease in longitudinal LV motion (peak systolic values at mid-ventricle 5.9 ± 0.5 versus 8.5 ± 0.8 cm/s, peak diastolic values -10.7 ± 0.7 versus -15.2 ± 0.9 cm/s) in the older age group were the most prominent findings. Lower peak diastolic radial velocities with a longer time-to-peak values, most pronounced at the apex, are consistent with reduced diastolic function with ageing. Lower peak clockwise and counter-clockwise velocities at all LV levels revealed limitations in resting LV rotational motions in the older group. Significant changes in the undulating pattern of the rotational motions of the left ventricle were also observed. The results demonstrate distinct changes in regional and global myocardial wall motion in elderly individuals. Increased LV torsion rate and reduced LV longitudinal motion were particularly prominent in the older group. These parameters may have a role in the assessment of global LV contractility and help differentiate age-related changes from cardiac disease.

Diagnosis and management of pulmonary hypertension associated with left ventricular diastolic dysfunction

Pulmonary hypertension (PH) is commonly seen in patients who present with left ventricular diastolic dysfunction (LVDD) and is considered a marker of poor prognosis. While PH in this setting is thought to result from pulmonary venous congestion, there is a subset of patients in which pulmonary pressures fail to improve with appropriate management of diastolic heart failure and go on to develop a clinical picture similar to that of patients with pulmonary arterial hypertension (PAH). Despite the utility of Doppler echocardiography and exercise testing in the initial evaluation of patients with suspected PH-LVDD, the diagnosis can only be confirmed using right heart catheterization. Management of PH-LVDD centers on both optimizing fluid management and afterload reduction to reducing left ventricular diastolic pressures and also increase pulmonary venous return. To date, there is no clear evidence that addition of PH-specific drugs can improve clinical outcomes, and their use should only be considered in the setting of clinical trials. In conclusion, PH-LVDD remains a challenging clinical entity that complicates the management of left ventricular dysfunction and significantly contributes to its morbidity and mortality. Determination of the optimal diagnostic and treatment strategies for this form of PH should be the goal of future studies.

Echocardiographic diastolic parameters and risk of atrial fibrillation: the Cardiovascular Health Study

AIMS

Atrial fibrillation (AF) is the most common sustained arrhythmia in the elderly, and shares several risk factors with diastolic dysfunction, including hypertension and advanced age. The purpose of this study is to examine diastolic dysfunction as a risk for incident AF.

METHODS AND RESULTS

We examined the association of echocardiographic parameters of diastolic function with the incidence of AF in 4480 participants enrolled in the Cardiovascular Health Study, an ongoing cohort of community-dwelling older adults from four US communities. Participants underwent baseline echocardiography in 1989-1990 and were followed for incident AF on routine follow-up and hospitalizations. After 50 941 person-years of follow-up (median follow-up time 12.1 years), 1219 participants developed AF. In multivariable-adjusted age-stratified Cox models, diastolic echocardiographic parameters were significantly associated with the risk of incident AF. The most significant parameters were the Doppler peak E-wave velocity and left atrial diameter, which demonstrated a positive nonlinear association [HR 1.5 (CI 1.3-1.9) and HR 1.7 (CI 1.4-2.1) for highest vs. lowest quintile, respectively], and Doppler A-wave velocity time integral, which displayed a U-shaped relationship with the risk of AF [HR 0.7 (CI 0.6-0.9) for middle vs. lowest quintile]. Each diastolic parameter displayed a significant association with adjusted NT-proBNP levels, although the nature of the association did not entirely parallel the risk of AF. Further cluster analysis revealed unique patterns of diastolic function that may identify patients at risk for AF.

CONCLUSION

In a community-based population of older adults, echocardiographic measures of diastolic function are significantly associated with an increased risk of AF.

Cardiac dysfunction and noncardiac dysfunction as precursors of heart failure with reduced and preserved ejection fraction in the community

BACKGROUND

Heart failure (HF) is a clinical syndrome characterized by signs and symptoms involving multiple organ systems. Longitudinal data demonstrating that asymptomatic cardiac dysfunction precedes overt HF are scarce, and the contribution of noncardiac dysfunction to HF progression is unclear. We hypothesized that subclinical cardiac and noncardiac organ dysfunction would accelerate the manifestation of HF.

METHODS AND RESULTS

We studied 1038 participants of the Framingham Heart Study original cohort (mean age, 76±5 years; 39% men) with routine assessment of left ventricular systolic and diastolic function. Major noncardiac organ systems were assessed with the use of serum creatinine (renal), serum albumin (hepatic), ratio of forced expiratory volume in 1 second to forced vital capacity (FEV(1):FVC ratio; pulmonary), hemoglobin concentration (hematologic/oxygen-carrying capacity), and white blood cell count (systemic inflammation). On follow-up (mean, 11 years), there were 248 incident HF events (146 in women). After adjustment for established HF risk factors, antecedent left ventricular systolic dysfunction (hazard ratio, 2.33; 95% confidence interval, 1.43 to 3.78) and diastolic dysfunction (hazard ratio, 1.32; 95% confidence interval, 1.01 to 1.71) were associated with increased HF risk. After adjustment for cardiac dysfunction, higher serum creatinine, lower FEV1:FVC ratios, and lower hemoglobin concentrations were associated with increased HF risk (all P<0.05); serum albumin and white blood cell count were not. Subclinical dysfunction in each noncardiac organ system was associated with a 30% increased risk of HF (P=0.013).

CONCLUSIONS

Antecedent cardiac dysfunction and noncardiac organ dysfunction are associated with increased incidence of HF, supporting the notion that HF is a progressive syndrome and underscoring the importance of noncardiac factors in its occurrence.

Key role of Doppler echocardiography in the emergency management of elderly patients

Owing to modern epidemiology in Western countries, ageing represents a growing health burden. In general, because of age itself and comorbid conditions, all clinical cardiovascular manifestations have a higher mortality rate and a worse outcome in older people compared with in younger individuals. Diagnosis of the disease in the elderly in an emergency setting is particularly challenging for the practitioner. Age-related cardiovascular changes and comorbid conditions may alter signs, symptoms and adaptation to the disease and response to treatment. Bedside Doppler echocardiography is likely to play a major role in guiding diagnosis, therapeutic strategies and prognosis. The purpose of this review is to appraise the application of echocardiographic examination in helping the clinician facing emergency situations that involve the cardiovascular system in the older population.

Regional diastolic contour abnormalities during contrast stress echocardiography: improved detection of coronary artery disease

BACKGROUND

Use of contrast improves detection of systolic regional wall motion abnormalities (RWMAs) during stress echocardiography. We evaluated regional diastolic contour abnormalities (RDCAs) that were associated with coronary artery disease (CAD).

METHODS

From August of 2003 to September of 2004, we evaluated 89 patients who underwent contrast stress echocardiography (CSE) and coronary angiography within a 3-month period ("invasive" group) and 17 patients with lower CAD risk who underwent CSE only ("reference" group).

RESULTS

RDCAs were present in 73 patients in the invasive group and were associated with higher Framingham risk scores (relative risk, 3.6; 95% confidence interval, 1.9-6.6). RDCAs were present in 1 patient in the reference group. When combined with RWMA, RDCA improved sensitivity of CSE from 78% to 97% and specificity from 26% to 59% (diagnostic threshold for CAD was 70% stenosis).

CONCLUSION

RDCAs were a novel observation associated with higher CAD risk and improved the diagnostic accuracy of CSE.

Heart failure in the "oldest old": clinical and echocardiographic insights

While the incidence and prevalence of heart failure (HF) increase markedly with age, few studies have included data on a large series of patients aged 85 years and older. Clinical and echocardiographic data from 533 patients admitted to a tertiary care hospital for acute HF were obtained. Data from the oldest old (>or=85 years; n=252; mean age, 91.9+/-3.6 years) were compared with data from those aged 65 to 74 years (n=123; mean age, 70.1+/-2.8 years) and 75 to 84 years (n=158; mean age, 79.4+/-2.9 years). Echocardiographic data were consistent with hypertensive remodeling. The proportion of patients with HF and a preserved left ventricular ejection fraction was greatest in the oldest patients (61%) in comparison to patients aged 65 to 74 years (48%) and 75 to 84 years (48%). Approximately three-fourths of the oldest patients were women, and two-thirds of women had a left ventricular ejection fraction >or=50%.

Diastolic function abnormalities in active rheumatoid arthritis evaluation by conventional Doppler and tissue Doppler: relation with duration of disease

OBJECTIVE

The aim of this study was to evaluate left ventricular diastolic function in patients with active rheumatoid arthritis (RA), analyzing conventional Doppler and tissue Doppler echocardiographic imaging (TDI) which is a new echocardiographic application, with special regard to disease duration.

METHODS

Fifty-two patients with active RA and 47 healthy persons were included in this study. Duration of disease ranged from 3 to 324 months (mean 76+/-85 months). All patients and the control group were evaluated by M-mod, two-dimensional, conventional Doppler echocardiography and TDI.

RESULTS

Among conventional Doppler transvalvular mitral flow parameters, late diastolic flow velocity (A) and deceleration time (DT) values were higher in patients with RA than that in the control group (p<0.001). E (early diastolic flow velocity)/A ratio was found to be lower in patients with RA than that in the control group (p<0.001). Mitral annular early diastolic velocity (E (m)), among TDI parameters, was found to be lower in patients with RA than that in the control group (p<0.001). E (m)/A (m) (mitral annular late diastolic velocity) ratio was found to be lower in RA patients compared with that in the control group (p<0.001). The relation was found between A (r=0.43, p=0.001), DT (r=0.30, p=0.03), E/A ratio (r=0.40, p=0.004), E (m) (r=0.32, p=0.02), E (m)/A (m) ratio (r=0.30, p=0.03), and E/E (m) (r=0.32, p=0.02), with disease duration in patients with RA.

CONCLUSION

At present, it is concluded that active RA patients, in the absence of clinical evidence of heart disease, show diastolic dysfunction characterized by impaired E/A ratio, E (m)/A (m) ratio, and DT. The relation between diastolic dysfunction and disease duration suggests a subclinical myocardial involvement.

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

BACKGROUND AND AIMS

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

METHOD AND RESULTS

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

CONCLUSION

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

Use of tissue Doppler and its comparison with other conventional Doppler techniques in the assessment of diastolic functions in patients with active rheumatoid arthritis

OBJECTIVE

This study aims to assess left ventricular diastolic functions with tissue Doppler imaging (TDI), which is a new technique, and to compare it with conventional Doppler echocardiography techniques in patients with active rheumatoid arthritis (RA).

METHODS

Fifty-two patients with active RA and 47 healthy persons were included in this study. All patients and the control group were evaluated by M-mod, two-dimensional, conventional Doppler echocardiography and TDI.

RESULTS

Left ventricular early diastolic (E)/late diastolic (A) flow velocity (E/A ratio) was found to be lower in patients with RA than in the control group (p<0.001). Mitral annular early diastolic (E(m))/late diastolic (A(m)) velocity(E(m)/A(m) ratio) was found to decrease in RA patients compared with the control group (p<0.001). E/E(m) ratio was higher in patients with RA than in the control group (p<0.001).

CONCLUSION

Left ventricular diastolic functions were impaired in patients with RA. We have concluded that TDI alone, or together with conventional Doppler echocardiography, is useful for the evaluation of diastolic functions in RA patients.

Bedside tests of B-type natriuretic peptide in the diagnosis of left ventricular diastolic dysfunction in hypertensive patients

AIMS

To investigate the value of B-type natriuretic peptide (BNP) in diagnosing left ventricular diastolic dysfunction in patients with hypertension.

METHODS

The left ventricular diastolic function and plasma BNP levels were assessed prospectively in 135 hypertensive patients.

RESULTS

The plasma BNP in patients with (n=61) and without (n=74) diastolic dysfunction was 122+/-105 and 18+/-16 pg/ml, respectively (p<0.001). Increased BNP levels were associated with systolic blood pressure (p<0.05), left ventricular mass index (p<0.001), the E/A ratio of transmitral flow (p<0.01) and the isovolumic relaxation time (p<0.01). A receiver-operator characteristic curve showing the sensitivity and specificity of BNP against the echocardiography diagnosis of diastolic dysfunction revealed an area under the curve (accuracy) of 0.904 (p<0.01). Using a cut-off value of >40 pg/ml, the sensitivity and specificity of plasma BNP in diagnosing left ventricular diastolic dysfunction were 79% and 92%, respectively.

CONCLUSIONS

The plasma BNP levels in patients with hypertension are closely related to left ventricular hypertrophy and filling impairment. Plasma BNP may be used to facilitate the diagnosis of left ventricular diastolic dysfunction.

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

AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

European reference values for Doppler indices of left ventricular diastolic filling

The European Study Group on diastolic heart failure requires objective evidence of abnormal left ventricular diastolic function to establish the diagnosis of diastolic heart failure, which is common in older people. Reference values for Doppler indices of transmitral flow, used to assess left ventricular diastolic function, have not been reported for people 70 years and over in Europe. The aim of this study was to establish reference values for these Doppler indices of transmitral flow in older people. A random sample of 355 subjects aged 70 and over, living in the community underwent clinical assessment and echocardiography. Asymptomatic subjects with no cardiovascular disease and cardiovascular risk factors were identified. Measurements of five commonly used Doppler indices of transmitral flow from these subjects were obtained and reference range expressed as mean+/-2 standard deviations and as percentiles. We have therefore generated reference Doppler values of transmitral flow for people aged over 70 in a British population.

Association of newer diastolic function parameters with age in healthy subjects: a population-based study

OBJECTIVES

We sought to determine if newer Doppler diastolic function parameters are associated with age and to define age-stratified reference ranges for these parameters in a population-based setting.

BACKGROUND

Although newer Doppler parameters aid in the evaluation of diastolic function and filling pressures, age-specific reference ranges are poorly described.

METHODS

Randomly selected residents of Olmsted County, Minn, age >/= 45 years were studied (n = 2042) prospectively. Those without a history of cardiovascular disease or abnormal 2-dimensional echocardiograms were selected. Measured parameters included the transmitral early (E) and late (A) filling velocities at rest and with Valsalva, A duration, pulmonary venous atrial reversal duration, lateral and septal early diastolic mitral annular velocities, E/lateral early diastolic mitral annular velocity, E/septal early diastolic mitral annular velocity, and the index of left ventricular myocardial performance.

RESULTS

A total of 1012 subjects met the inclusion criteria. Both A duration (r = 0.18, P <.001) and pulmonary venous atrial reversal duration (r = 0.28, P <.001) were longer in older subjects, whereas their difference showed a marginal correlation with age (r = 0.07, P =.036). The E/A ratio at peak Valsalva correlated with age (r = -0.54, P <.001) whereas the change in E/A with Valsalva (corrected for E-A fusion) showed a marginal correlation with age (r = 0.08, P =.032). Both E/lateral early diastolic mitral annular velocity (r = 0.39, P <.001) and E/septal early diastolic mitral annular velocity (r = 0.27, P <.001) increased with age. Left ventricular myocardial performance showed a marginal correlation with age (r = 0.08, P =.014). Age specific reference ranges (median, 5th and 95th percentiles) for all parameters are provided.

CONCLUSIONS

All newer Doppler diastolic function parameters showed a variable but significant correlation with age. Age-specific reference values will aid in the interpretation of diastolic function parameters.

Cardiovascular aging and heart failure

The aging process is a major factor that contributes to changes seen in the cardiovascular system in older people. Stiffening of the arterial tree alters afterload and left ventricular geometry and although resting left ventricular systolic function is maintained, left ventricular diastolic function changes substantially. Cardiovascular function in older people during exercise is also significantly altered but can be modified by exercise training in older adults or genetic modification in animals. Age-related changes in cardiovascular structure and function also lower the threshold at which cardiac diseases become apparent. This review describes the changes in cardiovascular structure and function at rest and during exercise in older people and highlights their consequences.

Left ventricular filling patterns and pulmonary artery pressures in patients aged 90 to 100 years with normal echocardiography results

Left ventricular filling and pulmonary artery pressure (PAP) have not been well described in patients > or = 90 years old. We reviewed our database to obtain echocardiograms with normal findings in this age group. The peak early and late mitral filling velocities, the early and late velocity-time integral (VTI), the mitral deceleration time, and the atrial filling fraction (late VTI/total VTI) were measured. PAP was obtained from the peak tricuspid regurgitation velocity. Of 252 echocardiograms performed on patients > or = 90 years old, 47 (19%) were normal. The mean +/- SD values were: ratio of peak early and late mitral filling velocities, 0.69 +/- 0.16; deceleration time, 240 milliseconds +/- 31; ratio of early and late VTI, 1.0 +/- 0.3; atrial filling fraction, 47% +/- 7; and PAP, 31 mm Hg +/- 6. Left ventricular filling in patients aged 90 to 100 years demonstrates increasingly impaired left ventricular relaxation from patients in their eighth and ninth decades. PAP continues to increase with age and PAP < or = 40 mm Hg in the elderly could be considered normal.

Effects of age, body weight, and heart rate on transmitral and pulmonary venous flow in clinically normal dogs

OBJECTIVE

To determine the influence of age, body weight (BW), heart rate (HR), sex, and left ventricular shortening fraction (LVSF) on transmitral and pulmonary venous flow in clinically normal dogs.

ANIMALS

92 client-owned dogs 3 months to 19 years old.

PROCEDURE

Transthoracic Doppler echocardiography recordings of transmitral flow and pulmonary venous flow were obtained in conscious unsedated dogs. Influence of age, BW, HR, sex, and LVSF on diastolic variables was assessed, using statistical methods such as ANOVA on ranks and univariate and multivariate forward stepwise linear regression analyses.

RESULTS

Age significantly influenced isovolumic relaxation time (IVRT, r = 0.56), ratio between peak velocity of the early diastolic mitral flow wave-to-peak velocity of late diastolic mitral flow wave (E:A; r = -0.44), deceleration time of early diastolic mitral flow (DTE; r = 0.26), and peak velocity of atrial reversal pulmonary venous flow wave (AR-wave; r = 0.37). Significant changes of mitral inflow and pulmonary venous flow variables were evident only in dogs > 6 and > 10 years old, respectively. Body weight significantly influenced DTE (r = 0.63), late diastolic flow duration (r = 0.60), and AR duration (r = 0.47), whereas HR significantly affected DTE (r = -0.34), IVRT (r = -0.33), and peak velocity of AR (r = 0.24). Sex or LVSF (range 22 to 48%) did not influence any echocardiographic variables.

CONCLUSIONS AND CLINICAL RELEVANCE

Age, BW, and HR are important factors that affect filling of the left atrium and left ventricle in clinically normal dogs.

[Value of Doppler-echocardiography in the prognosis and follow up of hypertrophic myocardiopathy]

INTRODUCTION AND OBJECTIVES

The aim of this study was to assess the value of Doppler-echocardiogram for the prognosis and follow up of a hospital-based series of adult patients with hypertrophic cardiomyopathy (HC).

METHODS

One-hundred nineteen consecutive patients with HC (52 +/- 12 years, 60 women) were studied over a follow up period of 9.7 +/- 6.7 years. Echocardiographic evolution was analyzed in 104 patients (67 with dynamic obstruction) who had, at least, two echocardiograms performed within an interval of 3.7 +/- 3 years (1 to 7 years).

RESULTS

Seven patients died during follow up and 31 patients developed severe complications (7 deaths, 15 syncopes, 4 class IV angina, 3 class IV dyspnea and 2 acute myocardial infarctions). The presence of mitral insufficiency (p = 0.001) and dynamic gradient > 50 mmHg (p = 0.02) were predictive of mortality and a left atrial index > 25 mm/m2 was predictive (p = 0.028) of severe complications. Fifteen percent of the patients without dynamic obstruction in the first Doppler-echo showed a gradient > 25 mmHg in the last echo. A greater number of patients with mitral insufficiency (80% vs 66%; p = 0.01) and an increase in its severity (p = 0.038) was observed during follow up.

CONCLUSIONS

Mitral insufficiency, a dynamic gradient > 50 mmHg and a left atrial index > 25 mm/m2 are variables of a bad prognosis in adult patients with HC. An evolution to obstructive HC was observed in 15% of non obstructive HC, and a tendency to increased severity of mitral insufficiency was observed during follow up.

Normal values of regional left ventricular endocardial motion: multicenter color kinesis study

Our goal was to establish normal values for quantitative color kinesis indexes of left ventricular (LV) wall motion over a wide range of ages, which are required for objective diagnosis of regional systolic and diastolic dysfunction. Color-encoded images were obtained in 194 normal subjects (95 males, 99 females, age 2 mo to 79 yr) in four standard views. Quantitative indexes of magnitude and timing of systolic and diastolic function were studied for age- and gender-related differences. Normal limits of all ejection and filling indexes were in a narrow range (< or =25% of the mean), with no major gender-related differences. Despite invariable ejection fractions, both peak filling and ejection rates decreased with age (30 and 20%, correspondingly) with a concomitant increase in mean filling and ejection times, resulting in five- and twofold increases in the late to early filling and ejection ratios, correspondingly. Diastolic asynchrony increased with age (from 4.7 +/- 2.0 to 6.4 +/- 3.2 from the 2nd to 7th decade). The normal values of color kinesis indexes should allow objective detection of regional LV systolic and diastolic dysfunction.

Diastolic dysfunction in the elderly. Genesis and diagnostic and therapeutic implications

Diastolic left ventricular function is altered substantially with advancing age in healthy persons, and diastolic dysfunction impacts most cardiovascular disorders in the elderly. Older, healthy persons have a delayed relaxation Doppler filling pattern and their early deceleration time is similar to, or modestly lengthened, compared with younger, healthy persons. Two abnormal Doppler filling patterns, the pseudo-normal and the restricted, are discerned more easily, and are more specific in the elderly than the young, because they are the opposite (reverse) of the normal elderly pattern. Most heart failure in the elderly occurs in the presence of preserved systolic function (presumed diastolic heart failure). Elderly patients with diastolic heart failure tend to be women with hypertrophied, hyperdynamic left ventricles, and chronic hypertension. Prognosis may be somewhat better than in systolic heart failure, but the difference diminishes when adjusted for gender and in the very elderly. The pathophysiology of this disorder is not well characterized, diagnostic criteria have not been standardized, and there are no large, multicenter, randomized trials to guide therapy. Further research in this area should be a high priority.

Physiological significance of early deceleration time prolongation in asymptomatic elderly subjects

BACKGROUND

Alterations in Doppler-derived diastolic filling patterns are common among elderly persons, but their physiological and prognostic significance remains uncertain, particularly in asymptomatic older persons without overt cardiac disease. This study was designed to determine whether early mitral inflow deceleration time (DT) prolongation is of physiological significance in asymptomatic elderly subjects.

METHODS AND RESULTS

In 15 asymptomatic patients aged 60 to 93 years with no history of heart failure (HF) or edema, we performed two-dimensional and Doppler echocardiography and 60-minute head-out, isothermic water immersion to produce circulatory volume expansion. Plasma levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) were measured immediately before and after water immersion. Seven of 15 patients had a normal mitral early DT (160 to 240 milliseconds; group 1) and 8 of 15 patients had DT prolongation (> 240 milliseconds; group 2). Group 2 subjects had significantly smaller chamber sizes and increased relative wall thickness without increased left ventricular mass. Head-out water immersion produced greater increases in plasma ANP levels in group 2 subjects with longer DTs despite similar degrees of circulatory volume expansion in each group. In contrast, plasma BNP levels did not increase significantly with water immersion in either group.

CONCLUSION

Early DT prolongation in asymptomatic elderly subjects is associated with increased relative wall thickness and enhanced ANP increments after central volume expansion. Such exaggerated responses suggest that, in the elderly, a prolonged DT has physiological significance and may represent a precursor to symptomatic diastolic HF, a condition known to be associated with advancing age.

[Left ventricular diastolic function: physiology, physiopathology, evaluation, therapy, consequences of anesthesia]

With the exception of cardiac surgery, the acute disturbance of the left ventricular diastole occurs mainly in the elderly. Today it represents 30 to 40% of congestive cardiac failures, however with a lower mortality than for acute systolic disturbances. Generally indicated are relaxation anomalies, proto-mesodiastolic mechanism and problems with compliance, an indicator of the pressure/volume diastolic relationship. Invasive techniques remain the standard method. Doppler echocardiography is becoming increasingly important for the assessment of diastolic function. In most cardiopathies, relaxation anomalies occur early, whereas compliance disturbances are mainly associated with advanced cardiac diseases. During anaesthesia, adverse events (auricular fibrillation, hypovolaemia) may worsen a fragile situation. Anaesthetic agents, in particular volatile agents, act on the ventricular diastole. Long-term therapy of diastolic anomalies includes agents amending left ventricular hypertrophy. Emergency therapy has not yet been systematised.

Left Ventricular Diastolic Function in a Population Sample of Elderly Men

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

Diastolic heart failure: standard Doppler approach and beyond

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

Quantitative evaluation of global and regional left ventricular diastolic function with color kinesis

BACKGROUND

Diastolic wall motion asynchrony is a major determinant of impaired left ventricular (LV) filling in patients with concentric hypertrophy and coronary artery disease. We evaluated the ability of Color Kinesis, a new echocardiographic technique that color-encodes endocardial motion, to quantitatively assess global and regional LV filling properties.

METHODS AND RESULTS

Color Kinesis images and mitral and pulmonary vein flow Doppler data were acquired in 29 patients with LV hypertrophy and 29 age-matched control subjects. In addition, Color Kinesis data were correlated to coronary angiographic findings in 15 patients with suspected coronary artery disease. Segmental analysis of Color Kinesis images was used to obtain time histograms of regional diastolic fractional area change, wherein early and late peaks (peaks 1 and 2) reflected rapid LV filling and atrial contraction, respectively. Regional mean LV filling time and filling curves were used to objectively identify diastolic endocardial motion asynchrony in patients with LV hypertrophy and coronary artery disease. None of the mitral and pulmonary vein Doppler indices differentiated patients with normalized mitral Doppler profile (n=13) from control subjects, whereas reduced peak1/peak2 ratio and prolonged mean filling time indicated augmented contribution of atrial contraction toward LV filling (P<.05). In 22 of 25 patients with LV hypertrophy and preserved systolic function and in all patients with coronary artery disease, delayed diastolic endocardial motion was observed in at least one segment.

CONCLUSIONS

Analysis of Color Kinesis images provides objective assessment of global and regional LV filling properties and allows identification of both diastolic dysfunction in patients with normalized Doppler indices and wall motion asynchrony.

Evaluation of diastolic filling of left ventricle in health and disease: Doppler echocardiography is the clinician's Rosetta Stone

Abnormalities of diastolic function have a major role in producing the signs and symptoms of heart failure. However, diastolic function of the heart is a complex sequence of multiple interrelated events, and it has been difficult to understand, diagnose and treat the various abnormalities of diastolic filling that occur in patients with heart disease. Recently, Doppler echocardiography has been used to examine the different diastolic filling patterns of the left ventricle in health and disease, but confusion about diagnosis and treatment options has arisen because of the misinterpretation of these flow velocity curves. This review presents a simplified approach to understanding the process of diastolic filling of the left ventricle and interpreting the Doppler flow velocity curves as they relate to this process. It has been hypothesized that transmitral flow velocity curves show a progression over time with diseases involving the myocardium. This concept can be applied clinically to estimate left ventricular filling pressures and to predict prognosis in selected groups of patients. Specific therapy for diastolic dysfunction based on Doppler flow velocity curves is discussed.

Diabetes mellitus and echocardiographic left ventricular function in free-living elderly men and women: The Cardiovascular Health Study

This report describes the relation among diabetes, blood pressure, and prevalent cardiovascular disease, and echocardiographically measured left ventricular mass and filling (transmitral valve flow) velocities in the Cardiovascular Health Study, a cohort of 5201 men and women > or = 65 years of age. Ventricular septal and left posterior wall thicknesses were greater in diabetic than in nondiabetic subjects, showing a significant linear trend (p = 0.025 for ventricular septal thickness in both sexes combined, p = 0.002 for posterior wall thickness) with increased duration of diabetes. Increased wall thickness of the ventricular septum or the left posterior wall was not associated with prevalent coronary heart disease (CHD) in the cohort. Increased left ventricular mass was associated with diabetic persons not reporting CHD and with all subjects with CHD regardless of glucose tolerance status. After adjusting for body weight, blood pressure, heart rate, and prevalent coronary or cerebrovascular disease, diabetes (as measured by glucose level, insulin use, oral hypoglycemic use, and a positive history of diabetes before baseline examination) remained an independent predictor of increased left ventricular mass among men and women (174.2 gm in diabetic men vs 169.8 gm in normal men, 138.2 gm in diabetic women vs 134.0 gm in normal women, p = 0.043 for both sexes combined). Both early and late diastolic transmitral peak flow velocities were higher with increased duration of diabetes, but the calculated ratio of the early peak flow velocity to the late velocity (E/A ratio) did not differ significantly between subjects with historical diabetes and those with normal fasting glucose (both genders combined, p = 0.190). Glucose level, insulin use, oral hypoglycemic use, and a positive history of diabetes before baseline examination were significant independent predictors of the late transmitral peak flow velocity and its integrated flow-velocity curve but not for the integral of the early peak flow velocity or the E/A ratio. Diabetes is associated with abnormal left ventricular structure and function in elderly persons. This association persists after adjustment for body weight, blood pressure, heart rate, and reported coronary or cerebrovascular disease.

Restrictive left ventricular filling patterns in very old patients with congestive heart failure: clinical correlates and prognostic significance

OBJECTIVES

In certain younger patients with congestive heart failure (CHF), Doppler/echocardiography has identified a "restrictive" pattern of early diastolic ventricular filling characterized by very rapid early filling and a steep deceleration slope. We asked whether a similar restrictive pattern can be identified in very old patients with CHF, and if so, what are its clinical correlates and prognostic implications.

DESIGN

Retrospective cohort with prospective follow-up.

SETTING

Academic long-term care facility.

PARTICIPANTS

Thirty-nine residents with clinical CHF (age 89 +/- 5 (SD) years)

MEASUREMENTS

Transmitral Doppler flow, clinical characteristics, recurrent CHF episodes, hospitalizations, and mortality were measured.

RESULTS

Fifteen (38%) of the subjects had restrictive filling patterns, characterized by a ratio of early to late flow (E/A) > 1.00 and 24 (62%) had nonrestrictive patterns. The restrictive pattern was associated with a longer duration of CHF, more angina, and higher rate of symptomatic recurrences of CHF.

CONCLUSION

A restrictive diastolic filling pattern may represent a late stage in the evolution of congestive heart failure when left ventricular filling pressure is markedly increased. The treatment of CHF in older patients may need to account for different patterns of diastolic filling.

Doppler diastolic filling indexes in relation to disease states

This study compares mean Doppler-derived diastolic filling indexes in a variety of disease states in a large, population-based sample. Pulse-wave Doppler was used to examine 880 eligible participants of the Framingham Heart Study. Peak velocity of early flow and late flow, ratio of early to late peak velocities, atrial filling fraction, and early filling wave acceleration and deceleration times were obtained. Multiple linear regression analyses were performed comparing mean values for individuals with hypertension, diabetes, coronary disease, cardiovascular disease, and pulmonary disease. Hypertension was associated with a greater peak velocity late flow (0.027 m/sec; 95% confidence interval, 0.006, 0.047; p = 0.011), and diabetes was associated with a larger mean deceleration time (0.12 sec, confidence interval, 0.002, 0.021; p = 0.016). In multivariate analyses, hypertension continued to show a strong association with altered Doppler diastolic filling patterns, p value 0.009, whereas in diabetes, the multivariate p value was 0.28.

Echocardiography assessment of left ventricular function in the critically ill

Echocardiography is fast becoming the technique of choice for noninvasive evaluation of left ventricular function in the critically ill patient. Current technology allows for assessment of overall left ventricular performance and for diastolic and systolic function. Doppler technology has greatly enhanced the diagnostic capability of two-dimensional echocardiography. The critical care physician should be aware not only of currently available techniques, but also those which will be used in the routine care of the critically ill subject in the foreseeable future.