Validity of Revised Doppler Echocardiographic Algorithms and Composite Clinical and Angiographic Data in Diagnosis of Diastolic Dysfunction

Prevalence, prospective risk markers, and prognosis associated with the presence of left ventricular diastolic dysfunction in young adults: the coronary artery risk development in young adults study

The authors sought to determine the prevalence, prospective risk markers, and prognosis associated with diastolic dysfunction in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. The CARDIA Study cohort includes approximately equal proportions of white and black men and women. The authors collected data on risk markers at year 0 (1985-1986), and echocardiography was done at year 5 when the participants were 23-35 years of age. Participants were followed for 20 years (through 2010) for a composite endpoint of all-cause mortality, myocardial infarction, heart failure, and stroke. Diastolic function was defined according to a validated hierarchical classification algorithm. In the 2,952 participants included in the primary analysis, severe diastolic dysfunction was present in 1.1% and abnormal relaxation was present in 9.3%. Systolic blood pressure at year 0 was associated with both severe diastolic dysfunction and abnormal relaxation 5 years later, whereas exercise capacity and pulmonary function abnormalities were associated only with abnormal relaxation 5 years later. After multivariate adjustment, the hazard ratios for the composite endpoint in participants with severe diastolic dysfunction and abnormal relaxation were 4.3 (95% confidence interval: 2.0, 9.3) and 1.6 (95% confidence interval: 1.1, 2.5), respectively. Diastolic dysfunction in young adults is associated with increased morbidity and mortality, and the identification of prospective risk markers associated with diastolic dysfunction could allow for targeted primary prevention efforts.

How 40 kilograms of fluid retention can be overlooked: two case reports

INTRODUCTION

With a rising incidence of severe obesity in developed nations, heart failure, a well-recognised co-morbidity, is becoming more common.

CASE PRESENTATION

We describe two recent patients encountered, a 64 year old and a 42 year old, who are both severely obese and presented with fluid retention of approximately 40 kilograms. Assessment revealed that the explanation of the gross clinical features were relatively subtle cardiac abnormalities. These cases illustrate how fluid retention in severe obesity can differ from that seen in 'traditional' heart failure in terms of clinical assessment and management.

CONCLUSION

Severe obesity can result in insidious fluid retention, which can be easily overlooked until large volumes of fluid have accumulated. Cardiac abnormalities are usually found in these patients, but may be relatively subtle, leading to current debate in the definition and classification of heart failure. These scenarios are increasingly being encountered in clinical practice. Recognition, assessment and treatment of the 'clinical syndrome of heart failure' in severe obesity is often difficult.

Cardiac function stratification based on echocardiographic or clinical markers of left ventricular filling pressures predicts death and hospitalization better than stratification by ventricular systolic function alone

BACKGROUND

A normal left ventricular ejection fraction (LVEF) often underestimates the poor prognosis associated with diastolic dysfunction.

METHODS

We compared overall and hospital-free survival according to echocardiographic diastolic function classification (echo class), clinical probability of diastolic dysfunction (clinical class) and LV grades based on biplane LVEF, in 114 subjects followed-up over a median of 47 months. Diastolic function was classified into normal, impaired relaxation, and severe dysfunction (SDD), using a previously validated 3-staged classification.

RESULTS

There were 16 deaths and 42 combined end points of death and hospitalization. Although each classification method globally prognosticated survival (P = 0.001, P =0.046, and P = 0.034 by the echo class, clinical class and LVEF grades, respectively), only echo class correctly distinguished three risk levels. Death was not hierarchically predicted by LVEF whereas severe diastolic dysfunction was associated with a hazard ratio by univariate or a multivariate model (that evaluated the effects of age, gender, and LVEF) of 4.31 (P =0.004) or 3.88 (P = 0.03), respectively. Also, a significant separation was found for the combined end points associated with SDD relative to nonsevere echo classes (P = 0.045). Neither clinical risk staging, nor LV grading showed significant separation of the Kaplan-Meier plots between "high risk" versus others combined, and Normal LV grade versus others combined, respectively. Severe diastolic dysfunction trended strongly as an independent predictor of combined end point with multivariate hazard of 2.29 (95% CI 0.99-5.26 P=0.05).

CONCLUSION

Stratification of the severity of diastolic dysfunction using comprehensive echocardiographic parameters of systolic and diastolic function is effective at predicting death and hospital-free survival.