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

Association between self-reported alcohol consumption and diastolic dysfunction: a cross-sectional study

BACKGROUND AND OBJECTIVES

While alcohol consumption is associated with common risk factors for diastolic dysfunction the independent impact of low levels of alcohol consumption on this condition in a community setting is still unclear.Thus, the aim of this study was to explore this association in a representative population sample employing optimal echocardiographic techniques.

DESIGN

Cross-sectional observational study in community-based population.

SETTINGS, PARTICIPANTS AND METHODS

Participants between 30 and 75 years of age were consecutively invited to a physical examination, interview, conventional echocardiography, including Tissue Velocity Imaging. Diastolic dysfunction was defined according to the European Society of Cardiology criteria, excluding subjects with ejection fraction <45%, self-reported history of heart failure or atrial fibrillation on ECG. Self-reported alcohol intake using a validated questionnaire was categorised as no intake, low and medium-high intake.

RESULTS

In total, 500 men and 538 women (mean age 55.4±13) were successfully examined. Diastolic dysfunction was identified in 16% (79/500) of the men and 13% (58/538) of the women. The multivariable adjusted model revealed a strong and independent association between alcohol intake and diastolic dysfunction. In fact, using no alcohol intake as reference, diastolic dysfunction was independently associated with alcohol consumption in a dose-dependent fashion; low consumption, OR 2.3 (95% CI 1.3 to 4.0) and medium-high consumption OR 3.1 (95% CI 1.6 to 6.2), respectively.

CONCLUSION

There was a significant association between alcohol consumption and diastolic dysfunction starting already at low levels that was supported by a dose-dependent pattern. These results need confirmatory studies and are important in public health policies.

Left ventricular long-axis function in hypertrophic cardiomyopathy - Relationships between e`, early diastolic excursion and duration, and systolic excursion

Background

The peak velocity of early diastolic mitral annular motion (e`) is believed to provide sensitive detection of left ventricular (LV) diastolic dysfunction in hypertrophic cardiomyopathy (HCM), but other aspects of LV long-axis function in HCM have received less attention. Systolic mitral annular excursion (SExc) is also reduced in HCM and must be an intrinsic limitation to the extent of the subsequent motion during diastole. However, the effects of HCM on excursion during early diastole (EDExc) and atrial contraction (AExc), the duration of early diastolic motion (EDDur), and the relationships of EDExc with SExc, and of e`with EDExc and EDDur, are all unknown.

Methods

The study group was 22 subjects with HCM and there were 22 age and sex matched control subjects. SExc, EDExc, e`, AExc and EDDur were measured from pulsed wave tissue Doppler signals acquired from the septal and lateral walls. In the combined group of HCM and control subjects, multivariate analyses were performed to identify independent predictors of EDExc and e`for both LV walls.

Results

SExc, EDExc and e`were all lower, and EDDur was longer in the HCM group compared to the control group for both LV walls (p<0.05 for all). In contrast, AExc was lower for the septal wall in the HCM group (p<0.05), but not different between the groups for the lateral wall. In regression analyses of the combined group, EDExc was positively correlated with SExc, and SExc explained 57–86% of the variances in septal and lateral EDExc, e`was positively correlated with EDExc, and EDExc explained 58–68% of the variances of e`, whereas the combination of EDExc with EDDur explained 87–92% of the variances in e`. A diagnosis of HCM was not an independent predictor of EDExc when in combination with SExc, but was a minor contributor to the prediction of e`in combination with EDExc and EDDur.

Conclusion

In HCM, the decrease in LV longitudinal contraction is the major mechanism accounting for a lower EDExc, the lower e`is accounted for by contributions from the lower EDExc and prolongation of early diastolic motion, and there is no atrial compensation for the reduction of long-axis contraction.

The cardiac isovolumetric contraction time is an independent predictor of incident atrial fibrillation and adverse outcomes following first atrial fibrillation event in the general population

Aims

Colour tissue Doppler imaging (TDI) M-mode through the mitral leaflet is an easy and precise method to obtain cardiac time intervals including the isovolumic contraction time (IVCT), isovolumic relaxation time (IVRT), and ejection time (ET). The myocardial performance index (MPI) was defined as [(IVCT + IVRT)/ET]. Our aim was to investigate if cardiac time intervals can be used to predict atrial fibrillation (AF) in the general population.

Methods and results

A total of 1915 participants from the general population underwent a health examination including TDI echocardiography. The primary endpoint was AF, and the secondary endpoint was complicated AF as assessed by the occurrence of either stroke or heart failure (HF) after the diagnosis of AF. Participants with known AF were excluded (n = 54). During a median follow-up of 11 years, 166 participants (9%) were diagnosed with AF and of these 44 participants (27%) developed HF or stroke. Assessing the association between IVCT and incident AF, the risk increased with 27% per 10 ms increase in IVCT [per 10 ms increase: hazard ratio (HR) 1.27, 95% confidence interval (CI) (1.17–1.38); P &lt; 0.001]. The association remained significant after multivariable adjustment [per 10 ms increase: HR 1.22, 95% CI (1.09–1.35); P &lt; 0.001]. No associations between the IVRT, ET, MPI, and AF remained significant after multivariable adjustment. The IVCT also predicted complicated AF and the association remained significant even after multivariable adjustment [per 10 ms increase: HR 1.39, 95% CI (1.06–1.81); P = 0.015].

Conclusion

In the general population, the IVCT provides novel and independent prognostic information on the long-term risk of AF. Additionally, the IVCT can identify persons in risk of complicated AF.

Aging and the relationships between long-axis systolic and early diastolic excursion, isovolumic relaxation time and left ventricular length-Implications for the interpretation of aging effects on e`

BACKGROUND

Both the left ventricular (LV) long-axis peak early diastolic lengthening velocity (e`) and long-axis early diastolic excursion (EDExc) decrease with age, but the mechanisms underlying these decreases are not fully understood. The aim of this study was to investigate the relative contributions to aging-related decreases in e`and EDExc from LV long-axis systolic excursion (SExc), isovolumic relaxation time (IVRT, as a measure of the speed of relaxation) and LV end-diastolic length (LVEDL).

METHODS

The study group was 50 healthy adult subjects of ages 17-75 years with a normal LV ejection fraction. SExc, EDExc, e`and IVRT were measured from pulsed wave tissue Doppler signals acquired from the septal and lateral walls. Multivariate modelling was performed to identify independent predictors of EDExc and e`which were consistent for the septal and lateral walls.

RESULTS

EDExc decreased with age and the major determinant of EDExc was SExc, which also decreased with age. There was also a decrease of e`with age, and the major determinant of e`was EDExc. IVRT decreased with age and on univariate analysis was not only inversely correlated with EDExc and e`, but also with SExc. IVRT was only a minor contributor to models of EDExc which included SExc, and was an inconsistent contributor to models of e`which included EDExc. LVEDL decreased with age independent of sex and body size, and was positively correlated with SExc, EDExc and e`.

CONCLUSION

Major mechanisms underlying the decrease in e`seen during aging are the concomitant decreases in long-axis contraction and early diastolic excursion, which are in turn related in part to long-axis remodelling of the left ventricle. After adjusting for the extent of systolic and early diastolic excursion, slowing of relaxation, as reflected in prolongation of the IVRT, makes no more than a minor contribution to aging-related decreases in EDExc and e`.

Treatment with atorvastatin is associated with a better prognosis in chronic heart failure with systolic dysfunction: results from The Daunia Heart Failure Registry

BACKGROUND

Few works have evaluated the effect of statins on left ventricular dysfunction in patients with chronic heart failure (CHF), by using tissue Doppler imaging (TDI). We therefore aimed to investigate whether atorvastatin treatment may influence prognosis and myocardial performance evaluated by TDI in subjects with CHF.

METHODS

Five hundred thirty-two consecutive CHF outpatients enrolled in a local registry, the Daunia Heart Failure Registry, were prospectively analysed. 195 patients with CHF and left ventricular ejection fraction (LVEF) ≤40 %, either in treatment with atorvastatin (N: 114) or without statins (N: 81), underwent TDI examination. Adverse events were evaluated during follow-up.

RESULTS

The atorvastatin group showed a lower incidence of adverse events (cardiac death: 0 % vs 7 %, p < 0.01), and better TDI performance (E/E' 15 ± 5.7 vs 18 ± 8.3, p < 001) than controls. Ischaemic CHF patients in treatment with atorvastatin also showed a lower incidence of adverse events (death: 10 % vs 26 %, p < 0.05; sustained ventricular arrhythmias: 5 % vs 19 %, p < 0.05, cardiac death: 0 vs 8 %, p < 0.05) and better TDI performance (E/E' ratio: 15.00 ± 5.68 vs 19.72 ± 9.14, p < 0.01; St: 353.70 ± 48.96 vs 303.33 ± 68.52 msec, p < 0.01) than controls. The association between atorvastatin and lower rates of cardiac death remained statistically significant even after correction in a multivariable analysis (RR 0.83, 95 % CI 0.71-0.96, p < 0.05 in CHF with LVEF ≤40 %; RR 0.77, 95 % CI 0.62-0.95, p < 0.05 in ischaemic CHF with LVEF ≤40 %).

CONCLUSIONS

Treatment with atorvastatin in outpatients with systolic CHF is associated with fewer cardiac deaths, and a better left ventricular performance, as assessed by TDI.

Tissue Doppler imaging in coronary artery diseases and heart failure

Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as coronary artery disease (CAD) and heart failure (HF). In these conditions, myocardial mitral annular systolic (S’) and early diastolic (E’) velocities have been shown to predict mortality or cardiovascular events. In heart failure non invasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/E’) is a strong prognosticator, especially when E/E’ is > or =15. Moreover, other parameters derived by TDI, as cardiac time intervals and Myocardial Performance Index, might play a role in the prognostic stratification in CAD and HF. Recently, a three-dimensional (3-D) TDI imaging modality, triplane TDI, has become available, and this allows calculation of 3-Dvolumes and LV ejection fraction. We present a brief update of TDI.

Time intervals and myocardial performance index by tissue Doppler imaging

The application of tissue Doppler imaging (TDI) has shown remarkable growth in clinical practice during the past few years, especially, in risk stratification of patients with coronary heart disease or heart failure (systolic and diastolic). Myocardial performance index (MPI) is a Doppler echocardiographic parameter defined as the sum of the isovolemic contraction and relaxation times divided by the ejection time. It is considered as a reliable parameter to assess global left ventricular function. Cardiac time intervals and MPI have also been found as new applications in diagnosing cardiotoxicity from chemotherapy, COPD, valvular heart disease, pulmonary hypertension and endocrinopathies.

Diastolic function predicts survival after renal revascularization

PURPOSE

The purpose of this study was to define the relationship between left ventricular diastolic function and survival after renal revascularization.

METHODS

Seventy-six adult patients (49 women, 27 men; mean age: 63 ± 13 years) with preoperative echocardiography who underwent renal revascularization for atherosclerotic disease were identified. Diastolic function was estimated from the early diastolic transmitral flow velocity (E), the atrial transmitral flow velocity (A), and the mitral annular tissue doppler velocity (e'). Patients were divided into two groups of diastolic dysfunction as either none/mild (E/A ≤ 0.75, E/e' <10) or moderate/severe (E/A >0.75, E/e' ≥ 10). Perioperative and follow-up mortality were determined from a prospective vascular database and the National Death Index. Descriptive statistics were calculated and postoperative survival was estimated by product-limit methods. Associations between preoperative factors, perioperative factors, and follow-up survival were examined using proportional hazards regression models. A forward stepwise variable selection procedure was used to select a "best" model to predict follow-up survival.

RESULTS

Seventy-six patients were followed for an average of 41.9 months after renal revascularization. Within this group, 47 of 76 patients (61.8%) were identified as having moderate or severe diastolic dysfunction. Diastolic dysfunction had no apparent association with abnormal systolic function. The mean ejection fraction for those with moderate/severe diastolic dysfunction was 57.7% ± 11.5%. When comparing the moderate/severe and none/mild groupings of diastolic dysfunction, there was a significant difference in left ventricular mass index (151.9 ± 48.9 vs 125.3 ± 31.7; P = .0087). There were five deaths in the perioperative period and 20 deaths on follow-up. Among perioperative survivors, hypertension was cured or improved in 82% of the none/mild group and 53% of the moderate/severe group (P = .012). In multivariable analysis, none/mild diastolic dysfunction was significantly and independently associated with an improvement in blood pressure after revascularization (odds ratio [OR], 6.2; 95% confidence interval [CI], 1.4-28.6; P = .018). Ejection fraction was not associated with survival. After forward variable selection, moderate/severe diastolic dysfunction (hazard ratio [HR], 5.8; 95% CI 1.4-25; P = .018) was the only variable to demonstrate a significant and independent association with follow-up survival.

CONCLUSION

Diastolic dysfunction, but not systolic dysfunction, was frequent in patients with renovascular disease. Blood pressure response and follow-up survival after renal revascularization demonstrated significant and independent associations with diastolic function. Consideration of diastolic function should be included in the management of patients with atherosclerotic renovascular disease.

Usefulness of tissue Doppler imaging-myocardial performance index in the evaluation of diastolic dysfunction and heart failure with preserved ejection fraction

BACKGROUND

In heart failure with preserved ejection fraction (HFPEF), physiological abnormalities are not solely restricted to diastolic function. Because the tissue Doppler imaging (TDI)-derived myocardial performance index (MPI) offers the advantage of recording systolic and diastolic tissue velocity simultaneously in the same cardiac cycle, this study aimed to determine whether TDI-MPI is an informative index for assessing HFPEF, compared with conventional echo parameters.

HYPOTHESIS

In patients with HFPEF, TDI-MPI would be an independent predictor for adverse cardiac events.

METHODS

Among 408 patients who had diastolic dysfunction without heart failure (HF) or HFPEF, cardiac function was evaluated by mitral flow (MF) or TDI-MPI. During the median follow-up of 32 months, clinical outcomes, which were defined as the composite of cardiovascular death and admission for HF, were assessed.

RESULTS

Mean MF and TDI-MPI were significantly greater in the HFPEF group. TDI-MPI rather than MF had a significant correlation with N-terminal pro-brain natriuretic peptide level. The area under the receiver operating characteristic curve of TDI-MPI for the detection of HFPEF was 0.86. With regard to clinical outcomes, 31 events were identified during follow-up periods. On a multivariate analysis, TDI-MPI >0.66 was the best prognostic predictor of events and provided incremental predictive value.

CONCLUSIONS

Compared to MF-MPI, TDI-MPI may be a more useful parameter for the evaluation of patients with HFPEF.

Statin therapy blunts inflammatory activation and improves prognosis and left ventricular performance assessed by Tissue Doppler Imaging in subjects with chronic ischemic heart failure: results from the Daunia Heart Failure Registry

BACKGROUND

A limited number of studies have used Tissue Doppler Imaging (TDI) to evaluate the effect of statin therapy on left ventricular dysfunction in patients with chronic heart failure. In this work, we aimed to determine whether statin administration influenced prognosis, inflammatory activation and myocardial performance evaluated by Tissue Doppler Imaging in subjects enrolled in the Daunia Heart Failure Registry, a local registry of patients with chronic heart failure.

METHODS

This study retrospectively analyzed 353 consecutive outpatients with chronic heart failure (mean follow-up 384 days), based on whether statin therapy was used. In all patients, several Tissue Doppler Imaging parameters were measured; circulating levels of interleukin (IL)-6, IL-10 and C-reactive protein were also assayed.

RESULTS

Statin administration in 128 subjects with ischemic heart disease was associated with a lower incidence of adverse events (rehospitalization for HF 15% vs. 46%, p<0.001; ventricular arrhythmias 5% vs. 21%, p<0.01; cardiac death 1% vs. 8%, p<0.05), lower circulating levels of IL-6 (p<0.05) and IL-10 (p<0.01), lower rates of chronic heart failure (p<0.001) and better Tissue Doppler Imaging performance (E/E' ratio 12.82 ± 5.42 vs. 19.85 ± 9.14, p<0.001; ET: 260.62 ± 44.16 vs. 227.11 ± 37.58 ms, p<0.05; TP: 176.79 ± 49.93 vs. 136.7 ± 37.78 ms, p<0.05 and St: 352.35 ± 43.17 vs. 310.67 ± 66.46 ± 37.78 ms, p<0.05).

CONCLUSIONS

Chronic ischemic heart failure outpatients undergoing statin treatment had fewer readmissions for adverse events, blunted inflammatory activation and improved left ventricular performance assessed by Tissue Doppler Imaging.

Differential effects of antihypertensive treatment on left ventricular diastolic function: an ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) substudy

OBJECTIVES

We hypothesized that an amlodipine-based regimen would have more favorable effects on left ventricular (LV) diastolic function.

BACKGROUND

Different antihypertensive therapies may vary in their effect on LV diastolic function.

METHODS

The HACVD (Hypertension Associated Cardiovascular Disease) substudy of ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) collected detailed cardiovascular phenotypic data on a subset of 1,006 participants recruited from 2 centers (St. Mary's Hospital, London, and Beaumont Hospital, Dublin). Conventional and tissue Doppler echocardiography and measurement of plasma B-type natriuretic peptide (BNP) were performed approximately 1 year after randomization to atenolol-based or amlodipine-based antihypertensive treatment to assess LV diastolic function.

RESULTS

On-treatment blood pressure (BP) (mean +/- SD) was similar in both groups: atenolol-based regimen, systolic BP of 137 +/- 17 mm Hg, diastolic BP of 82 +/- 9 mm Hg; amlodipine-based regimen, systolic BP of 136 +/- 15 mm Hg, diastolic BP of 80 +/- 9 mm Hg. Ejection fraction did not differ between groups, but early diastolic mitral annular velocity (E'), a measure of diastolic relaxation, was lower in patients on the atenolol-based regimen: atenolol-based regimen, 7.9 +/- 1.8; amlodipine-based regimen, 8.8 +/- 2.0. A measure of left ventricular filling pressure, E/E', and BNP were significantly higher in patients on the atenolol-based regimen. Differences in E', E/E', and BNP remained significant after adjustment for age and sex. Further adjustment for systolic BP, LV mass index, and heart rate had no impact on differences in mean E' or BNP. The difference in E/E' was attenuated.

CONCLUSIONS

Patients receiving treatment with an amlodipine-based regimen had better diastolic function than patients treated with the atenolol-based regimen. Treatment-related differences in diastolic function were independent of BP reduction and other factors that are known to affect diastolic function.

Tissue Doppler is a More Reliable Method in Early Detection of Cardiac Dysfunction in Patients with AA Amyloidosis

OBJECTIVE

Cardiac deposition of AA amyloidosis may result in increasing left ventricular mass and systolic and diastolic dysfunction (DD). The aim of this study was to investigate the left ventricular systolic and diastolic functions by both tissue Doppler imaging (TDI) and pulsed wave Doppler echocardiography (PWD) in patients with AA amyloidosis without congestive heart failure symptoms or arrthymia.

METHODS AND RESULTS

Twenty-four patients with AA amyloidosis without congestive heart failure symptoms or arrthymia (15 men and nine women; mean age 44.3 +/- 16.7 years) and 25 healthy subjects (19 men and six women; mean age 43.1 +/- 9.2 years) as controls were included in the study. M-mode, two-dimensional, PWD, and TDI were performed. Peak transmitral filling velocity (E wave), peak transmitral atrial filling velocity (A wave), deceleration time, and isovolumic relaxation time were measured by PWD recordings. Peak myocardial systolic velocity (Sm), peak myocardial early (Em), and late diastolic velocities (Am) were also recorded by TDI. E/A ratio less than one was accepted as DD for both methods. Ejection fraction (EF) was calculated by Teicholtz method. The subjects were divided into three groups as follows: healthy controls (group 1), patients without DD (group 2), and patients with DD (group 3) according to the PWD findings. PWD echocardiography showed that DD was present in 50% of the patients, whereas TDI showed DD in 66% of such cases. In subgroup analysis, Sm wave as a systolic function index was lower in group 3 than in groups 1 and 2, whereas mean EF values were similar in all groups.

CONCLUSION

Although AA amyloidosis uncommonly causes cardiac symptoms and findings, according to our results, patients with AA amyloidosis may have systolic and diastolic dysfunction eventhough they are asymptomatic. Also, tissue Doppler imaging is a more reliable method in the early detection of cardiac dysfunction in such patients.

The PPARGC1A Gly482Ser polymorphism is associated with left ventricular diastolic dysfunction in men

Background

The Gly482Ser polymorphism in peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PPARGC1A) has been demonstrated to be associated with diabetes, obesity and hypertension, all of which are important risk factors for left ventricular diastolic dysfunction.

Methods

The PPARGC1A Gly482Ser polymorphism was genotyped in a community-based cohort of 499 men and 533 women, who also underwent an echocardiographic examination to determine their left ventricular diastolic function. The association between the polymorphism and the presence of diastolic dysfunction was evaluated using logistic regression models.

Results

The Ser allele of the PPARGC1A Gly482Ser polymorphism was significantly associated with a lower risk of diastolic dysfunction in men, but not in women. In a model adjusting for potential confounders (age, body mass index, leisure time physical activity, hypertension and diabetes) the results were still significant and substantial (odds ratio 0.13, 95% confidence interval 0.03–0.54, p for trend = 0.004). The results were consistent in a series of models, and they imply a multiplicative, protective effect of the Ser allele, with lower risk of diastolic dysfunction for each copy of the allele.

Conclusion

The Ser allele of the PPARGC1A Gly482Ser polymorphism was associated with decreased risk of diastolic left ventricular dysfunction in men, but not in women, in our large community-based sample. It was associated with a substantially decreased risk, even after adjustment for potential confounders. The clinical importance of the findings has to be established in further studies.

Ethnicity and left ventricular diastolic function in hypertension an ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) substudy

OBJECTIVES

We investigated whether diastolic function differs between hypertensive patients of African-Caribbean or white European origin and established whether differences could be explained by confounding variables.

BACKGROUND

African Caribbeans are known to have a higher prevalence of heart failure than white Europeans but it is unclear whether this is a result of known risk factors. Tissue Doppler technology now allows accurate quantification of diastolic function, which is recognized as an important factor in the development of heart failure.

METHODS

Participants from a single center participating in the ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial), composed of patients with hypertension but no evidence of heart failure, were studied. Left ventricular structure and function were measured in 509 patients using conventional and tissue Doppler echocardiography. Diastolic function was assessed using the tissue Doppler early diastolic velocity E' (averaged from 3 left ventricular segments) and the ratio of this and the transmitral early filling velocity E (E/E').

RESULTS

In African-Caribbean patients, mean E' was significantly lower (7.7 cm/s vs. 8.6 cm/s, p = 0.003) and mean E/E' was significantly higher (8.85 vs. 7.93, p = 0.003). After adjustment for confounding variables-age, gender, systolic blood pressure, pulse pressure, cholesterol, smoking, ejection fraction, left ventricular mass index, and diabetes mellitus-the effect of African-Caribbean ethnicity on diastolic function remained highly significant (E': 7.52 vs. 8.51; p < 0.001; E/E': 8.89 vs. 7.93; p = 0.003; African Caribbeans vs. white Europeans for both comparisons).

CONCLUSIONS

Diastolic function is significantly worse in hypertensive patients of African-Caribbean origin than in white Europeans. This difference in diastolic performance is not due to known confounding variables.

Maternal cardiac function in normotensive and pre-eclamptic intrauterine growth restriction

OBJECTIVES

To compare maternal cardiac function between pregnancies complicated by normotensive and pre-eclamptic intrauterine growth restriction (IUGR).

METHODS

Two-dimensional Doppler echocardiography and Doppler tissue imaging (DTI) were used to examine 19 pregnant women with IUGR and 17 with pre-eclampsia complicated by IUGR at 20-38 weeks of gestation. Indices were converted into differences in SDs from the expected normal mean for gestation (Z-scores) and compared.

RESULTS

With respect to normal pregnancy, in the normotensive IUGR compared with the pre-eclamptic IUGR group, there were similar reductions in maternal cardiac output (Z-score, - 1.71 vs. - 1.37, P = 0.26) and heart rate (Z-score, - 3.67 vs. - 9.43, P = 0.1) and a similar increase in total vascular resistance (Z-score, 2.91 vs. 3.93, P = 0.05). There was also a greater decrease in stroke volume (Z-score, - 1.72 vs. - 0.69, P = 0.01), a smaller increase in mean arterial pressure (Z-score, 0.73 vs. 2.94, P < 0.01) and a smaller decrease in DTI systolic velocity at the lateral mitral margin (Z-score, - 0.4 vs. - 1.42, P = 0.02). In terms of diastolic function, there was a smaller transmitral late diastolic velocity (Z-score, 0.04 vs. 0.93, P = 0.03) and a greater DTI early diastolic velocity at the lateral mitral margin (Z-score, - 0.17 vs. - 1.6, P < 0.01).

CONCLUSIONS

In normotensive IUGR and pre-eclamptic IUGR there is a similar alteration in maternal left ventricular systolic function, but there is greater impairment in maternal diastolic function in pre-eclamptic IUGR.

Tissue Doppler imaging adds incremental value in predicting exercise capacity in patients with congestive heart failure

Left ventricular (LV) systolic and diastolic parameters derived from Doppler echocardiography have been used widely to predict functional capacity but diastolic filling is affected by various factors. Tissue Doppler imaging (TDI) that records systolic and diastolic velocities within the myocardium and at the corners of the mitral annulus, has been shown to provide additional information about regional and global LV function. The goal of this study was to examine whether TDI-derived parameters add incremental value to other standard Doppler echocardiographic measurements in predicting exercise capacity. The study enrolled 59 consecutive patients with stable congestive heart failure (CHF). The etiology of heart failure was coronary artery disease in 42 patients and dilated cardiomyopathy in 17. Twenty-three age-matched healthy subjects were recruited as controls. Conventional echocardiographs and TDI were obtained. Early (Ea) and late (Aa) diastolic and systolic (Sa) mitral annulus velocities, the Ea/Aa and E/Ea ratios, were measured by pulsed wave TDI placed at the septal side of the mitral annulus and results were compared with results of cardiopulmonary exercise testing. Systolic and early diastolic velocities of mitral annulus were decreased and the E/Ea ratio was increased in the restrictive group as compared to controls (P = 0.02, P = 0.03, P < 0.001, respectively) but there was no significant difference in late diastolic velocity and the Ea/Aa ratio between the restrictive group and controls. The average peak VO2 of the patients were 14.9 +/- 4.9 ml/min per kg. Achieved peak VO2 of the patients with E/Ea ratio <or=7.5 was 17.4 +/- 5 vs 12.2 +/- 3 ml/min per kg for those with E/Ea >7.5 (P < 0.001). Interestingly, the patients with the nonrestrictive pattern and E/Ea ratio >7.5 had reduced exercise capacity, as did the group with restrictive LV filling patterns (12.8 +/- 3.3 vs 12.9 +/- 4.0 ml/min per kg, P = 0.9). Similarly, there was no significant difference in the mean exercise capacity between the patients with a nonrestrictive pattern vs restrictive pattern with E/Ea ratio <or=7.5 (16.1 +/- 5.0 vs 15.4 +/- 5.1 ml/min per kg, P = 0.78). Univariate analysis demonstrated that the peak Sa (r = 0.30, P = 0.03), peak Ea (r = 0.38, P = 0.004) and peak Aa (r = 0.35, P = 0.009) correlated significantly with maximum exercise capacity. No relationship was observed between the Ea/Aa ratio and peak VO2 (r = -0.09, P = 0.48). By multivariate analysis, including age and heart rate, the E/Ea ratio was found to be an independent prognostic factor at peak VO2 (P < 0.001. In contrast, the comparison of the maximum transmitral early diastolic velocity and the mitral annulus TDI velocity, that is E/Ea ratio, had strong correlation with peak VO2 (r = -0.46, P < 0.001). Receiver operating characteristic (ROC) analysis was performed for prediction of limited exercise capacity from the E/Ea ratio. An E/Ea ratio <or=7.5 was able to predict peak VO2 <or=14 ml/min per kg with a sensitivity of 84% and a specificity of 74%. If restrictive pattern or an E/Ea ratio >7.5 was used, 21 out of 24 patients in the reduced exercise capacity group were identified with 16 false positives in the preserved exercise capacity group (P = 0.001). Mitral annular systolic and diastolic velocities of TDI were associated with cardiopulmonary exercise capacity in patients with LV systolic dysfunction. Index of the E/Ea ratio was found to be the most powerful predictor of peak oxygen uptake.

Procollagen type I carboxy-terminal peptide shows left ventricular hypertrophy and diastolic dysfunction in hypertensive patients

BACKGROUND

An excess of myocardial collagens in hypertension is a result of increased collagen synthesis and unchanged or decreased collagen degradation. Increased collagen content, which is shown by the procollagen type I carboxy-terminal peptide (PIP), promotes cardiac remodeling and function abnormalities.

OBJECTIVES

The objectives of this study were to assess PIP levels as a marker of myocardial collagen synthesis and to investigate the relationship between PIP levels and left ventricular mass index (LVMI) as well as diastolic function in patients with mild-to-moderate essential hypertension.

METHODS

The study subjects were divided into three groups: healthy subjects (Group I, n=30); hypertensive patients without left ventricular hypertrophy (Group II, n=30); and patients with left ventricular hypertrophy (Group III, n=30). Left ventricular diastolic function was assessed by standard echocardiography and tissue Doppler imaging. Serum PIP was measured by radioimmunoassay.

RESULTS

The serum concentration of PIP was higher in Group III than in Groups I and II (P<.001). A positive correlation was found between serum PIP and LVMI in hypertensive patients (r=.57, P<.001). Patients with diastolic dysfunction (DD) had significantly higher PIP levels as compared with patients without DD (177.3+/-52.25 vs. 138.8+/-38.0 microg/L, P<.001). The cutoff values of PIP to predict left ventricular hypertrophy and DD were 155.0 microg/L (sensitivity, 84%; specificity, 73%) and 150.2 microg/L (sensitivity, 71%; specificity, 70%), respectively.

CONCLUSION

An elevated serum concentration of PIP shows left ventricular hypertrophy and DD in the course of hypertension and may be used to follow up on the efficacy of the antihypertensive treatment used.

Diagnosis of heart failure in primary care

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

Evaluation of pulsed Doppler tissue velocity imaging for assessing systolic function of murine global heart failure

The feasibility of Doppler tissue imaging (DTI) for assessing global systolic function has not been determined in small animals, particularly at near-conscious heart rates. Therefore, we compared DTI measurements with conventional M-mode-derived fractional shortening in murine global left ventricular systolic dysfunction induced by intraperitoneal doxorubicin (Dox) injection. In all, 13 female C57BL mice received 20 mg/kg of Dox and 12 mice received saline injection (controls). DTI signals were obtained from the inferior wall through parasternal short-axis views. The heart rate was kept at near-conscious level throughout DTI measurements (approximately 500/min). Left ventricular systolic dysfunction was detectable by measurements of fractional shortening from 4 to 14 days after Dox administration. Among DTI measurements, peak systolic velocity and time to peak systolic velocity decreased from 4 to 14 days after Dox injection. Our results indicate that these new DTI measurements appear feasible to assess global left ventricular systolic dysfunction in mice.

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.

[Evaluation of ventricular asynchronism by Doppler tissue imaging in patients with idiopathic dilated cardiomyopathy]

OBJECTIVES

To study ventricular asynchronism with tissue Doppler imaging in patients with primitive dilated cardiomyopathy and narrow QRS.

PATIENTS AND METHODS

We compared a group of patients with DCM and QRS < 120 ms (gr 1, n=25, 52+/-14 yrs, LVEF: 25+/-9%) with a group of normal patients (gr 2, n=16, 36+/-20 yrs). We measured the delays between the beginning of QRS and the beginnings of aortic (QA), mitral (QM), tricuspid (QT) and pulmonary (QP) flows, and of systolic (QSm) and protodiastolic (QEm) wall motion waves recorded with TDI in the basal portion of interventricular septum (IVS) and LV and RV free walls. We then calculated the differences QA-QP, QM-QT, the interparietal differences for QSm and QEm, and the maximal interparietal systolic (QSm max) and diastolic (QEm max) delays.

RESULTS

QA, QP, QM and QT were significantly lengthened in group 1 patients but there were no difference between both groups for QA-QP and QM-QT. There was a trend toward a lengthening of QSm and QEm in group 1 patients. Interparietal differences of QSm and QEm were similar in both groups; however, QSm max and QEm max were significantly longer in group 1 patients than in group 2.

CONCLUSION

Doppler study of patients with DCM and narrow QRS shows a lengthening of all electromechanical delays and suggests some degree of ventricular asynchronism by showing a significant increase in maximal interparietal systolic and diastolic delays.

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

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

Left ventricular diastolic function assessment by tissue Doppler echocardiography in relation to hormonal replacement therapy in postmenopausal women with diastolic dysfunction

The objective of this study was to evaluate the effect of hormone replacement therapy (HRT) regimens on left ventricular diastolic function by using mitral pulsed wave Doppler (MPWD) and tissue Doppler velocities (TDE). Seventy-eight postmenopausal women with normotensive and impaired diastolic left ventricular filling were included in the study. All the patients began a six-cycle HRT course. This formulation consisted of E2 valerate plus Medroxy progesterone acetate (MPA). Left ventricular diastolic function at rest was evaluated by M-mode, two-dimensional, MPWD and TDE in 78 postmenopausal women with normal blood pressure before the treatment for 6 months of HRT. The M-mode, two-dimensional, and MPWD parameters assessed were heart rate, systolic blood pressure, diastolic blood pressure, left ventricular mass index, ejection fraction of the left ventricle (EF), septal (IVS) and posterior wall (PW) thickness, left ventricular end-systolic (LVESD) and end-diastolic (LVEDD) diameter, left atrial diameter, peak early diastolic velocity (E), peak atrial velocity (A), E/A ratio, E acceleration time, E deceleration time, diastolic filling period, and isovolumic relaxation time (IVRT). The TDE parameters assessed were peak early diastolic velocity (E'), peak late diastolic velocity (A'), peak systolic velocity, E'/A' ratio, E' acceleration time, E' deceleration time, IVRT', and E/E' ratio. Quantitative data were analyzed using Student t test. Among the MPWD parameters, peak A velocity, E deceleration time, and IVRT significantly decreased, while peak E velocity and E/A ratio increased after a 6-month treatment. From the point of TDE parameters, E' velocity and E'/A' ratio increased, while A' velocity, E' deceleration time, E/E' ratio and IVRT' decreased. Some MPWD and TDE parameters were partially reversed after HRT. TDE velocities and especially E/E' ratio may provide better and true information of the diastolic function. TDE parameters were independent from the preload and did not produce pseudonormal pattern. HRT may cause increase in the blood volume and produce pseudonormal pattern in transmitral flow. In that case, TDE may be a beneficial method for evaluation of diastolic function.

Influence of left ventricular geometry on regional systolic and diastolic function in patients with essential hypertension

OBJECTIVE

In essential hypertension, especially in concentric hypertrophy, global diastolic function is impaired. But, whether the left ventricular (LV) geometric pattern influences regional systolic and diastolic function or not, is unknown. This study was aimed to evaluate the influence of left ventricular geometric pattern on regional systolic and diastolic function in hypertensive patients.

DESIGN

Ninety untreated mild to moderate hypertensive patients were studied. M-mode parameters, standard Doppler and PW tissue Doppler indices were measured. Patients were divided into four groups according to left ventricular mass index and relative wall thickness: normal geometry (n = 16), concentric remodeling (n = 16), eccentric hypertrophy (n = 32) and concentric hypertrophy (n = 26).

RESULTS

Age, gender, body mass index, systolic and diastolic blood pressure were similar among groups. E/A ratio was significantly lower in the concentric hypertrophy group compared with the normal geometry group. Em velocity and Em/Am ratio in basal septum and Em velocity in basal inferior were statistically lower in the concentric hypertrophy group compared with the normal geometry group. In the concentric hypertrophy group, the number of segments with diastolic dysfunction was significantly higher compared with the normal geometry group. LV ejection fraction and regional S velocity could be compared among groups.

CONCLUSION

LV regional diastolic function is being impaired in concentric hypertrophy. LV regional systolic function does not show a difference according to the LV geometric pattern.

Diagnosing diastolic heart failure

BACKGROUND

increasing evidence supports the existence of left ventricular diastolic dysfunction as an important cause of congestive heart failure, present in up to 40% of heart failure patients.

AIM

to review the pathophysiology of LV diastolic dysfunction and diastolic heart failure and the currently available methods to diagnose these disorders.

RESULTS

for diagnosing LV diastolic dysfunction, invasive hemodynamic measurements are the gold standard. Additional exercise testing with assessment of LV volumes and pressures may be of help in detecting exercise-induced elevation of filling pressures because of diastolic dysfunction. However, echocardiography is obtained more easily, and will remain the most often used method for diagnosing diastolic heart failure in the coming years. MRI may provide noninvasive determination of LV three-dimensional motion during diastole, but data on correlation of MRI data with clinical findings are scant, and possibilities for widespread application are limited at this moment.

CONCLUSIONS

in the forthcoming years, optimal diagnostic and therapeutic strategies for patients with primary diastolic heart failure have to be developed. Therefore, future heart failure trials should incorporate patients with diastolic heart failure, describing precise details of LV systolic and diastolic function in their study populations.

Doppler-echocardiographic indices of diastolic function in heart failure admissions with preserved left ventricular systolic function

Many patients admitted to hospital with heart failure have preserved left ventricular (LV) systolic function. The incidence of isolated diastolic dysfunction as a cause of such admission remains unclear. We aimed to examine diastolic function in unselected admissions from the community with heart failure using the European Study Group on Diastolic Heart Failure (ESGDHF) Doppler-echocardiographic indices of diastolic dysfunction. Primary heart failure was confirmed in 210 of 309 sequential admissions with suspected heart failure. Doppler echocardiography was used to assess left ventricular ejection fraction, wall thickness and parameters of diastolic function including E:A ratio, E-wave deceleration time and isovolumic relaxation time. Of 210 patients studied (118 female), ejection fraction was <45% in 111, leaving a population of 99 with preserved systolic function. We excluded those with significant valvular disease, leaving 56 patients (mean age=77 years) with an ejection fraction >45% and no other relevant abnormality. Twenty were in atrial fibrillation. E-wave deceleration time was >280 ms in 42%. E:A was reversed in 30 of 36 patients in sinus rhythm, but only seven met the ESGDHF criterion of E:A<0.5. Isovolumic relaxation time was >105 ms in 38%. Wall thickness was increased in 75% of cases. The ESGDHF Doppler-echocardiographic criteria for diastolic heart failure were fulfilled in 43%. In clinically confirmed heart failure, 27% of patients had preserved systolic function and no significant valvular disease. Only 43% of this group had confirmed diastolic heart failure by these ESGDHF criteria. The pathophysiological basis of the syndrome in the remaining 57% remains unclear.

Discriminative ability of conventional echocardiography and tissue Doppler imaging techniques for the detection of subclinical cardiotoxic effects of treatment with anthracyclines

This study investigated improvement of diagnosing myocardial damage caused by anthracyclines using tissue Doppler imaging (TDI). The optimal set of conventional echocardiographic and/or TDI parameters, needed for the discrimination of survivors from healthy controls, was retrospectively assessed. A total of 60 patients and 99 controls, age range 8.5 to 17.6 years, were studied. The survivors received 50 to 400 mg/m(2) cumulative dose of anthracyclines, with a mean follow-up of 7.3 (+/-2.3) years. The parameters used in the discriminant score (S-score) were selected from a large set of 51 echocardiographic parameters, using logistic regression analysis (stepwise selection). The correct classification probability (C-index) and the generalized distance (d) between the distributions of S-scores were used to measure the overall discriminative performance of each echocardiographic technique separately and in combination. The overall discriminative performance of the conventional echo-Doppler parameters (C = 77.3%, d = 1.04) was lower than that of the TDI (C = 84.2%, d = 1.37); the highest C-index was obtained using both techniques (C = 89.2%, d = 1.66). The set of parameters includes: LV fractional shortening and MV early diastolic flow velocity, two long-axis and five apical 4-CV TDI wall velocities (systolic and diastolic). In the patient group, the S-score was positively associated with cumulative dose of anthracyclines (p = 0.05) and duration of treatment (p = 0.01). The diagnostic index S-score, based on a limited number of variables from both techniques simultaneously, could retrospectively discriminate asymptomatic children with anthracycline-induced cardiomyopathy from healthy controls. The potentials of the S-score for serial and prospective studies are further investigated.