Heart failure with normal left ventricular ejection fraction: role of echocardiography

Factors Associated With Cognitive Impairment in Heart Failure With Preserved Ejection Fraction

BACKGROUND

Cognitive impairment is prevalent in heart failure and is associated with higher mortality rates. The mechanism behind cognitive impairment in heart failure with preserved ejection fraction (HFpEF) has not been established.

OBJECTIVE

The aim of this study was to evaluate associations between abnormal cardiac hemodynamics and cognitive impairment in individuals with HFpEF.

METHODS

A secondary analysis of Atherosclerosis Risk in Communities (Atherosclerosis Risk in Communities) study data was performed. Participants free of stroke or dementia who completed in-person assessments at visit 5 were included. Neurocognitive test scores among participants with HFpEF, heart failure with reduced ejection fraction (HFrEF), and no heart failure were compared. Sociodemographics, comorbid illnesses, medications, and echocardiographic measures of cardiac function that demonstrated significant (P < .10) bivariate associations with neurocognitive test scores were included in multivariate models to identify predictors of neurocognitive test scores among those with HFpEF. Multiple imputation by chained equations was used to account for missing values.

RESULTS

Scores on tests of attention, language, executive function, and global cognitive function were worse among individuals with HFpEF than those with no heart failure. Neurocognitive test scores were not significantly different among participants with HFpEF and HFrEF. Worse diastolic function was weakly associated with worse performance in memory, attention, and language. Higher cardiac index was associated with worse performance on 1 test of attention.

CONCLUSIONS

Cognitive impairment is prevalent in HFpEF and affects several cognitive domains. The current study supports the importance of cognitive screening in patients with heart failure. An association between abnormal cardiac hemodynamics and cognitive impairment was observed, but other factors are likely involved.

Reduced Echocardiographic Inotropy Index after Cardiopulmonary Bypass Is Associated With Complications After Cardiac Surgery: An Institutional Outcomes Study

OBJECTIVE

Despite advances in echocardiography and hemodynamic monitoring, limited progress has been made to effectively quantify left ventricular function during cardiac surgery. Traditional measures, including left ventricular ejection fraction (LVEF) and cardiac index, remain dependent on loading conditions; more complex measures remain impractical in a dynamic surgical setting. However, the Smith-Madigan Inotropy Index (SMII) and potential-to-kinetic energy ratio (PKR) offer promise as measures calculable during cardiac surgery and potentially predictive of outcomes. Using echocardiographic and hemodynamic monitoring data, the authors aimed to calculate SMII and PKR values after cardiopulmonary bypass and understand associations with postoperative outcomes, adjusting for previously identified risk factors.

DESIGN

Observational cohort study.

SETTING

Tertiary care academic hospital.

PATIENTS

The study comprised 189 elective adult cardiac surgical procedures from 2015-2016.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was postoperative mortality or organ system complication (stroke, prolonged ventilation, reintubation, cardiac arrest, acute kidney injury, new-onset atrial fibrillation). After adjustment, SMII <0.83 W/m² independently predicted the primary outcome (adjusted odds ratio 2.19, 95% confidence interval 1.08-4.42); whereas PKR, LVEF, and cardiac index demonstrated no associations. When SMII and PKR were incorporated into a EuroSCORE II risk model, predictive performance improved (net reclassification index improvement 0.457; p = 0.001); whereas a model incorporating LVEF and cardiac index demonstrated no improvement (0.130; p = 0.318).

CONCLUSION

The present study demonstrated that SMII, but not PKR, as a measure of cardiac function was associated with major complications. The study's data may guide investigations of more suitable perioperative goal-directed therapies to reduce complications after cardiac surgery.

Prognostic value of NT-proBNP, and echocardiographic indices of diastolic function, in hospitalized patients with acute heart failure and preserved left ventricular ejection fraction

BACKGROUND

Several parameters have proven useful in assessing prognosis in outpatients with heart failure with preserved ejection fraction (HFpEF). In contrast, prognostic determinants in HFpEF hospitalized for an acute event are poorly investìgated.

AIM

To determine the predictive value of NT-proBNP, and diastolic function (assessed by E/e'), in patients with HFpEF hospitalized for acute heart failure.

METHODS AND RESULTS

We evaluated 205 consecutive HFpEF patients admitted for acute heart failure (median age: 76[53,81], 36% male, median EF: 61 [54,77]). We assessed clinical, echocardiographic, and NT-proBNP values, on admission and at discharge. Primary end-point was the composite of all-cause death and/or HF rehospitalization. After a mean follow up of 28±10 months, 82 patients met the primary end-point; there were 30 deaths (14.6%), and 72 patients (35%) were rehospitalized for HF. By multivariable analysis, predictors of the composite end-point were: discharge E/e´ ≥14 (HR: 4.63 CI 95%: 2.71-18.2, p<0.0001), discharge NT-proBNP ≥1500 pg/ml (HR: 5.23, CI 95%: 2.87-17.8, p < 0.0001), ≥50% NT-proBNP decrease between admission and discharge (HR: 0.62, CI 95%: 0.25-0.79, p = 0.019). Combining E/e´ and NT-proBNP values at discharge further and significantly improved discrimination power compared to each variable analyzed separately (AUC, NT-proBNP at discharge: 0.80; E/e´ at discharge: 0.77; E/e´ + NT-proBNP: 0.88; p < 0.01).

CONCLUSIONS

In HFpEF patients hospitalized with acute heart failure, assessment of E/e´ ratio and NT-proBNP at discharge provides prognostic information on top of other variables, and allows to easily identify a population at higher risk of subsequent death or rehospitalization for heart failure, during a medium-term follow up.

Association between cystatin C and heart failure with preserved ejection fraction in elderly Chinese patients

BACKGROUND

Approximately 50 % of patients with heart failure have a preserved ejection fraction (HFpEF). Cystatin C has been reported to be associated with cardiovascular events. This study was carried out to investigate whether cystatin C is associated with cardiac function and cardiac diastolic properties in elderly Chinese HFpEF patients.

MATERIAL AND METHODS

A cross-sectional study of 381 elderly Chinese HFpEF patients (81 women, average age 82 ± 6 years) was conducted. Serum concentrations of cystatin C and the New York Heart Association (NYHA) classification were assessed and early (E) to late (A) transmitral flow velocity ratios (E/A ratio) were measured to assess cardiac diastolic properties.

RESULTS

Cystatin C levels, N‑terminal pro brain natriuretic peptide (NT-proBNP) levels and age were significantly correlated to the NYHA class (r = 0.605 P < 0.001, r = 0.333 P < 0.001 and r = 0.254 P < 0.001, respectively). Cystatin C levels, age and body mass index (BMI) were negatively correlated to the E/A ratio (r = -0.224 P = 0.005, r = -0.258 P = 0.001 and r = -0.258 P = 0.003, respectively). The patients with cystatin C concentrations below 1.3 mg/l had a higher E/A ratio compared to those with cystatin C concentrations higher than 1.3 mg/l. Cystatin C was also significantly associated with both the NYHA classification and the E/A ratio even after adjustment for the creatinine clearance rate (CCr).

CONCLUSION

Both cystatin C and NT-proBNP were found to be correlated to the NYHA classification. Independent of renal function, higher serum concentrations of cystatin C were associated with a worse NYHA classification and abnormal cardiac diastolic properties in elderly Chinese HFpEF patients.

[The use of echocardiography left ventricular filling pressures in hypertensive patients with heart failure and preserved systolic function in a North Africa unit day]

OBJECTIVE

To assess the left ventricular (LV) filling pressures by Doppler Tissulaire Imaging (DTI) in the management of hypertensive patients with heart failure and preserved systolic function (HF-PEF) in our outpatient clinic. To involve the patient on the basis of their clinical, biological and echocardiography data, in identifying the risk factors that need change.

PATIENTS AND METHODS

From 2004 to 2014, heart failure with preserved systolic function (HF-PEF) has been diagnosed in 200 consecutive hypertensive patients (pts) at our Algerian outpatient unit. Data were collected on blood pressure at the time of the examination, body mass index (BMI), waist, comorbid conditions including dyslipidemia, diabetes and atrial fibrillation (AF). LV ejection fraction>50 % is taken as the including criteria with acquisition as described in the Chamber Quantification update. Left ventricular global systolic function by biplane disk summation Simpson method and diastolic function is assessed by the mitral inflow measurements regarding recommendations for the evaluation of left ventricular diastolic function by echocardiography from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE).

RESULTS

Mean age was 65±11 yrs; 66 % were female; waist circumference in men>102cm and in women>88cm was found in 82 % of the pts and 50 % were diabetics. Body weight (BMI)>30kg/m(2) is depicted in 88 (44 %). Dyslipidemia is depicted in 78 pts (39 %). Ischemic heart disease was diagnosed in 64 pts (32 %); history of thromboembolic event in 78 pts (39 %); valvular disease in 40 pts (20 %). ECG showed AF in 60 pts (30 %), complete left bundle branch block (LBBB) in 20 pts (10 %). The echographic findings were as follow: left ventricular hypertrophy (LVH) in 126 pts (63 %) and left atrial (LA) enlargement in 111 pts (55 %). Mean left ventricular ejection fraction (LVEF) is about 55±10 %. Delayed relaxation (Em/Am<1) and deceleration time>150ms (DT) in 80 pts (40 %), of them, 56 had increased filling pressures (Em/Ea>8 and Ap>Am); pseudo-normal patterns (1<Em/Am<2 and DT<150ms) in 80 pts (40 %); restrictive filling pattern (Em/Am≥2) and short DT<100ms in 40 pts (20 %).

CONCLUSIONS

The hypertensive pts referred for an echo examination are often diabetics and frequently demonstrate preserved left ventricular function with increased filling pressures. This is useful for managing their treatments in the context of a cardiac rehabilitation programme.

Left Atrial Volume and Pulmonary Artery Diameter Are Noninvasive Measures of Age-Related Diastolic Dysfunction in Mice

Impaired cardiac diastolic function occurs with aging in many species and may be difficult to measure noninvasively. In humans, left atrial (LA) volume is a robust measure of chronic diastolic function as the LA is exposed to increased left ventricular filling pressures. We hypothesized that LA volume would be a useful indicator of diastolic function in aging mice. Further, we asked whether pressures were propagated backwards affecting pulmonary arteries (PAs) and right ventricle (RV). We measured LA, PA, and RV infundibulum dimensions with echocardiography and used mouse-specific Doppler systems and pressure catheters for noninvasive and invasive measures. As C57BL/6 mice aged from 3 to 29-31 months, LA volume almost tripled. LA volume increases correlated with traditional diastolic function measures. Within groups of 14- and 31-month-old mice, LA volume correlated with diastolic function measured invasively. In serial studies, mice evaluated at 20 and 24 months showed monotonic increases in LA volume; other parameters changed less predictably. PA diameters, larger in 30-month-old mice than 6-month-old mice, correlated with LA volumes. Noninvasive LA volume and PA diameter assessments are useful and state independent measures of diastolic function in mice, correlating with other measures of diastolic dysfunction in aging. Furthermore, serial measurements over 4 months demonstrated consistent increases in LA volume suitable for longitudinal cardiac aging studies.

Ventricular diastolic abnormalities in the critically ill

PURPOSE OF REVIEW

Left-ventricular diastolic dysfunction is associated with various conditions frequently encountered in ICU patients. Due to prolonged relaxation and increased left-ventricular stiffness, patients with diastolic dysfunction are at high risk of developing abrupt pulmonary venous congestion. The present review describes the clinical spectrum of left-ventricular diastolic abnormalities in ICU patients.

RECENT FINDINGS

Left-ventricular diastolic dysfunction is associated with a preserved ejection fraction in half of the patients presenting with acute pulmonary edema. These patients may have dramatic presentation, such as flash pulmonary edema during a hypertensive crisis. Left-ventricular diastolic dysfunction is frequently involved in patients who fail extubation and may trigger weaning pulmonary edema. Sepsis and myocardial ischemia may also be associated with left-ventricular diastolic dysfunction. The diagnosis of left-ventricular diastolic dysfunction practically relies on two-dimensional and Doppler echocardiography. Further large-scale clinical studies are needed to better characterize the prevalence, the clinical relevance and time-course of left-ventricular diastolic dysfunction in ICU patients.

SUMMARY

Left-ventricular diastolic dysfunction accounts for a growing proportion of cardiogenic pulmonary edema and weaning failure in ICU patients. It may be reversible when induced by sepsis or myocardial ischemia. Its prognostic value in the ICU settings remains to be further investigated.

[Diastolic heart failure: heart failure with preserved ejection fraction]

The prognosis for patients with diastolic heart failure--heart failure with preserved ejection fraction--has not improved in the last few decades despite improvement of prognosis for all patients with heart failure. Diastolic dysfunction is a typical finding in elderly patients with heart failure. The diagnostic process is a challenge for clinicians who are often faced with comorbidities like COPD, osteoarthritis, sarcopenia, and diabetes. Classical treatment options fail to improve patients with diastolic heart failure; thus, a comprehensive and specific treatment plan is necessary.

Detection of subclinical atherosclerosis and diastolic dysfunction in patients with schizophrenia

BACKGROUND

Patients with schizophrenia have a higher risk for cardiovascular diseases, which is associated with early mortality compared with the nonschizophrenic population. Early diagnosis of cardiovascular diseases in asymptomatic periods in patients with schizophrenia would enhance their quality of life and reduce mortality. Echocardiography, carotid ultrasonography, and ankle brachial index (ABI) measurement are known to be beneficial methods of detecting subclinical cardiovascular diseases and of risk stratification. The present study investigated carotid intima media thickness (CIMT) and ABI and echocardiographic parameters measured via conventional and tissue Doppler echocardiography in patients with schizophrenia in comparison with a control group.

METHODS

The present case-control study included 116 patients with schizophrenia and 88 healthy patients. Participants with any current comorbid psychiatric disorder, current or lifetime neurological and medical problems, current coronary artery disease, diabetes, hypertension, hypothyroidism, or hyperthyroidism or who were using antihypertensives, antidiabetic agents, or antiobesity drugs were excluded. High-resolution B-mode ultrasound images were used to measure CIMT. Conventional and tissue Doppler measurements were performed according to the recommendations of the American Society of Echocardiography.

RESULTS

Low ABI, mitral ratio of the early (E) to late (A) ventricular filling velocities, septal E', septal S', lateral E', lateral S', septal E'/septal A', lateral E'/lateral A', and high septal A', mitral E/septal E', mitral E/lateral E', and CIMT values were observed in the schizophrenia group compared with the control group.

CONCLUSION

Doppler parameters supported the hypothesis that patients with schizophrenia are at high risk for cardiovascular diseases.

Right and left ventricular diastolic pressure-volume relations: a comprehensive review

Ventricular compliance alterations can affect cardiac performance and adaptations. Moreover, diastolic mechanics are important in assessing both diastolic and systolic function, since any filling impairment can compromise systolic function. A sigmoidal passive filling pressure-volume relationship, developed using chronically instrumented, awake-animal disease models, is clinically adaptable to evaluating diastolic dynamics using subject-specific micromanometric and volumetric data from the entire filling period of any heartbeat(s). This innovative relationship is the global, integrated expression of chamber geometry, wall thickness, and passive myocardial wall properties. Chamber and myocardial compliance curves of both ventricles can be computed by the sigmoidal methodology over the entire filling period and plotted over appropriate filling pressure ranges. Important characteristics of the compliance curves can be examined and compared between the right and the left ventricle and for different physiological and pathological conditions. The sigmoidal paradigm is more accurate and, therefore, a better alternative to the conventional exponential pressure-volume approximation.