The mediating role of the left ventricular mass index on the relationship between the fluid balance and left ventricular diastolic function in patients with chronic kidney disease

BACKGROUND

The pathophysiological mechanism of cardiovascular disease in patients with chronic kidney disease (CKD) is complicated. Mediation analysis is an important statistical tool for gaining insight into the complex mechanisms of exposure-outcome effects. We investigated the potential mediating role of the left ventricular mass index (LVMI) on the association between fluid balance (overhydration/extracellular water, OH/ECW) and left ventricular diastolic function (E/e´ ratio) in patients with CKD not yet on dialysis.

METHODS

Bioimpedance spectroscopy, echocardiography, and laboratory evaluations were performed on 425 consecutive patients on the same day. The patients were classified into two groups according to the estimated glomerular filtration rate corresponding to CKD stages 3 and 5. Mediation analysis was performed using the PROCESS macro and bootstrapping methods.

RESULTS

OH/ECW and LVMI were positively correlated with the E/e´ ratio in both the CKD stages 3 and five groups. In CKD stage 5, there was a statistically significant association between OH/ECW and LVMI, whereas no correlation was observed in CKD stage 3. In the mediation analysis, LVMI positively mediated the relationship between OH/ECW and E/e´ ratio when controlling for confounders in patients with CKD stage 5 (B = 2.602; Boot 95% confidence interval, 1.313-4.076).

CONCLUSION

In our analysis, the indirect effect of mediators was significant in patients with advanced CKD. Therefore, our study suggests that further research on several other risk factors may be needed to determine the underlying mechanisms of association between the associated factors in all CKD stages.

Left atrial strain as a predictor of left ventricular filling pressures in coronary artery disease with preserved ejection fraction: a comprehensive study with left ventricular end-diastolic and pre-atrial contraction pressures

Assessing left ventricular (LV) filling pressure (LVFP) is challenging in patients with coronary artery disease (CAD) and preserved LV ejection fraction (LVEF). We aimed to correlate left atrial strain (LAS) with two invasive complementary parameters of LVFP and compared its accuracy to other echocardiographic data to predict high LVFP. This cross-sectional, single-center study enrolled 81 outpatients with LVEF > 50% and significant CAD from a database. Near-simultaneous echocardiography and invasive measurements of both LV end-diastolic pressure (LVEDP) and LV pre-atrial contraction (pre-A) pressure were performed in each patient, based on the definition of LVEDP > 16 mmHg and LV pre-A > 12 mmHg as high LVFP. A moderate to strong correlation was observed between LAS reservoir (LASr), contractile strain, and LVEDP (r: 0.67 and 0.62, respectively; p < 0.001); the same was true for LV pre-A (r: 0.65 and 0.63, respectively; p < 0.001). LASr displayed good diagnostic performance to identify elevated LVFP, which was higher when compared to traditional parameters. Median value of LASr was higher for an isolated increase of LVEDP than for simultaneously high LV pre-A. The cutoff found to predict high LVFP was lower for LV pre-A than that one for LVEDP. In the current study, LASr did not provide an additional contribution to the 2016 diastolic function algorithm. LAS is a valuable tool for predicting LVFP in patients with CAD and preserved LVEF. The choice of LVEDP or LV pre-A as the representative marker of LVFP leads to different cutoffs to predict high pressures. The best strategy for adding this tool to a multiparametric algorithm requires further investigation.

Cerebral arterial flow dynamics during systole and diastole phases in young and older healthy adults

BACKGROUND

Since arterial flow is the leading actor in neuro-fluids flow dynamics, it might be interesting to assess whether it is meaningful to study the arterial flow waveform in more detail and whether this provides new important information. Few studies have focused on determining the influence of heart rate variation over time on the arterial flow curve. Therefore, this study aimed to evaluate cerebral arterial flow waveforms at extracranial and intracranial compartments in young and elderly healthy adults, also considering systole and diastole phases.

METHODS

Cine phase-contrast magnetic resonance imaging (CINE-PC MRI) was performed on twenty-eight healthy young volunteers (HYV) and twenty healthy elderly volunteers (HEV) to measure arterial blood flows at the extracranial and intracranial planes. A semi-automated protocol using MATLAB scripts was implemented to identify the main representative points in the arterial flow waveforms. Representative arterial profiles were estimated for each group. Moreover, the effects of age and sex on flow times, amplitude-related parameters, and parameters related to systole and diastole phases were evaluated at the extracranial and intracranial compartments. Student's t-test or Wilcoxon's test (depending on the normality of the distribution) was used to detect significant differences.

RESULTS

In HYVs, significant differences were observed between extracranial and intracranial levels in parameters related to the AP1 amplitude. Besides the detected differences in pulsatility index (extracranial: 0.92 ± 0.20 vs. 1.28 ± 0.33; intracranial: 0.79 ± 0.15 vs. 1.14 ± 0.18, p < .001) and average flow (715 ± 136 vs. 607 ± 125 ml/min, p = .008) between HYV and HEV, differences in the amplitude value of the arterial flow profile feature points were also noted. Contrary to systole duration (HYV: 360 ± 29 ms; HEV: 364 ± 47 ms), diastole duration presented higher inter-individual variability in both populations (HYV: 472 ± 145 ms; HEV: 456 ± 106 ms). Our results also showed that, with age, it is mainly the diastolic phase that changes. Although no significant differences in duration were observed between the two populations, the mean flow value in the diastolic phase was significantly lower in HEV (extracranial: 628 ± 128 vs. 457 ± 111 ml/min; intracranial: 599 ± 121 vs. 473 ± 100 ml/min, p < .001). No significant differences were observed in the arterial flow parameters evaluated between females and males in either HYV or HEV.

CONCLUSION

Our study provides a novel contribution on the influence of the cardiac cycle phases on cerebral arterial flow. The main contribution in this study concerns the identification of age-related alterations in cerebral blood flow, which occur mainly during the diastolic phase. Specifically, we observed that mean flow significantly decreases with age during diastole, whereas mean flow during systole is consistent.

Cardiac imaging for the prediction of sudden cardiac arrest in patients with heart failure

The identification of heart failure (HF) patients at risk for arrhythmic sudden cardiac arrest (SCA) is a major challenge in the cardiovascular field. In addition to optimal medical treatment for HF, implantable cardioverter defibrillator (ICD) is currently recommended to prevent SCA in patients with reduced left ventricular ejection fraction (LVEF). The indication for an ICD implantation, in addition to HF etiology, New York Health Association (NYHA) class and life expectancy, mainly depends on LVEF value at echocardiography. However, the actual role of LVEF in the prediction of SCA has recently been debated, while newer multimodality imaging techniques with increased prognostic accuracy have been developed. Speckle tracking imaging allows the quantification of mechanical dispersion, a marker of electrophysiological heterogeneity predisposing to malignant arrhythmias, while advanced cardiac magnetic resonance techniques such as myocardial T1-mapping and extracellular volume fraction assessment allow the evaluation of interstitial diffuse fibrosis. Nuclear imaging is helpful for the appraisal of sympathetic nervous system dysfunction, while newer computed tomography techniques assessing myocardial delayed enhancement allow the identification of focal myocardial scar. This review will focus on the most modern advances in the field of cardiovascular imaging along with its applications for the prediction of SCA in patients with HF. Modern artificial intelligence applications in cardiovascular imaging will also be discussed.

Usefulness of electrocardiography QT interval for prediction of left ventricular diastolic dysfunction: a cross-sectional study

Heart failure (HF) is a leading cause of morbidity and mortality worldwide, with projections showing a further rise in incidence, impacting a decline in quality of life and the costs incurred in its diagnosis and treatment. The authors aim to establish the correlation between the prediction of left ventricular diastolic dysfunction based on a change in QT wave intervals.

Methods

A cross-sectional at Holy-family Hospital, Rawalpindi Medical University, Pakistan. One thousand five hundred patients were referred for electrocardiography (ECG) for clinical suspicion of HF between May and July 2022. Ejection fraction (EF), lateral mitral annulus velocity (e'), mitral inflow early (E) and late (A) velocities, left ventricular filling pressure (E/e' ratio), and QT interval (QTc) was calculated. Odds ratios with a 95% CI (odds) were obtained by comparing QTc with all variables.

Results

The patients were mostly middle-aged adults with a mean age of 30.27 (±7.64). Male to female ratio was nearly balanced, with 771 (51.4%) males included in the clinical survey. The ECG parameters were; QT interval-494.07 (±63.61), EF-57.11 (±11.96), early to atrial filling velocity ratio-0.71 (±0.20), and lateral mitral annulus velocity-8.29 (±1.64).

Conclusion

The promising results for correlation between QT interval and ECG parameters, particularly EF and lateral mitral annulus velocity, should not be considered as the alternative in diagnosing left ventricular diastolic dysfunction thus far. Prolonged electrocardiographic QTc interval in patients with HF is useful in predicting diastolic dysfunction.

Evaluation of right ventricular systolic and diastolic dysfunctions in patients with type 2 diabetes mellitus with poor glycemic control by layer specific global longitudinal strain and strain rate

BACKGROUND

In order to evaluate right ventricular (RV) systolic and diastolic dysfunctions in patients with type 2 diabetes mellitus (T2DM) with poor glycemic control by layer specific global longitudinal strain (GLS) and strain rate (GLSr).

METHODS

68 T2DM patients and 66 normal controls were enrolled for the present study. RV layer specific GLS (GLSEpi, GLSMid and GLSEndo represent the epimyocardial, middle layer and endomyocardial strains, respectively) and GLSr (GLSr-S, GLSr-E and GLSr-A represent the systole, early-diastole and late-diastole strain rate) were calculated by averaging each of the three regional peak systolic strains and strain rates along the entire RV free-wall (RVFW), entire RV free-wall and septal wall (RVFSW) on RV-focused view.

RESULTS

The absolute values of RV layer specific GLS (GLSEpi, GLSMid and GLSEndo) in RVFW in T2DM patients were significantly lower than normal controls (P < 0.01), while GLSr-A was significantly larger than normal controls (P < 0.001). The absolute values of RV layer specific GLS (GLSEpi and GLSMid) in RVFSW in T2DM patients were significantly lower than normal controls (P < 0.05), while GLSr-A was significantly larger than normal controls (P < 0.001). HbA1c were poor negatived correlated with GLSEpi in RVFW and RVFSW in T2DM patients (P < 0.05). ROC analysis showed that RV layer specific GLS and GLSr-A had a high diagnostic efficacy in T2DM patients, and GLSr-A in RVFSW have the best diagnostic value in RV diastolic function in T2DM patients (AUC: 0.773).

CONCLUSION

From the research, we found that layer specific GLS and GLSr could detect the RV myocardial dysfunctions and confirmed that the impaired RV systolic and diastole functions in T2DM patients with poor glycemic control. GLSr-A in RVFSW had the best diagnostic value in evaluating RV diastolic function in T2DM patients.

Pre-operative point-of-care assessment of left ventricular diastolic dysfunction, an observational study

BACKGROUND

Left ventricular (LV) diastolic dysfunction is an acknowledged peri-operative risk factor that should be identified before surgery. This study aimed to evaluate a simplified echocardiographic method using e' and E/e' for identification and grading of diastolic dysfunction pre-operatively.

METHODS

Ninety six ambulatory surgical patients were consecutively included to this prospective observational study. Pre-operative transthoracic echocardiography was conducted prior to surgery, and diagnosis of LV diastolic dysfunction was established by comprehensive and simplified assessment, and the results were compared. The accuracy of e'-velocities in order to discriminate patients with diastolic dysfunction was established by calculating accuracy, efficiency, positive (PPV) and negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC).

RESULTS

Comprehensive assessment established diastolic dysfunction in 77% (74/96) of patients. Of these, 22/74 was categorized as mild dysfunction, 43/74 as moderate dysfunction and 9/74 as severe dysfunction. Using the simplified method with e' and E/e', diastolic dysfunction was established in 70.8% (68/96) of patients. Of these, 8/68 was categorized as mild dysfunction, 36/68 as moderate dysfunction and 24/68 as severe dysfunction. To discriminate diastolic dysfunction of any grade, e'-velocities (mean < 9 cm s^- 1) had an AUROC of 0.901 (95%CI 0.840-0.962), with a PPV of 55.2%, a NPV of 90.9% and a test efficiency of 0.78.

CONCLUSIONS

The results of this study indicate that a simplified approach with tissue Doppler e'-velocities may be used to rule out patients with diastolic dysfunction pre-operatively, but together with E/e' ratio the severity of diastolic dysfunction may be overestimated.

TRIAL REGISTRATION

Clinicaltrials.gov, Identifier: NCT03349593 . Date of registration 21/11/2017. https://clinicaltrials.gov .

Mean and Variability of Lipid Measurements and Risk for Development of Subclinical Left Ventricular Diastolic Dysfunction

BACKGROUND

Subclinical left ventricular diastolic dysfunction (LVDD) is an emerging consequence of increased insulin resistance, and dyslipidemia is one of the few correctable risk factors of LVDD. This study evaluated the role of mean and visit-to-visit variability of lipid measurements in risk of LVDD in a healthy population.

METHODS

This was a 3.7-year (interquartile range, 2.1 to 4.9) longitudinal cohort study including 2,817 adults (median age 55 years) with left ventricular ejection fraction >50% who underwent an annual or biannual health screening between January 2008 and July 2016. The mean, standard deviation (SD), coefficient of variation (CV), variability independent of the mean (VIM), and average real variability of total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), apolipoprotein B (apoB), non-HDL-C, and triglycerides were obtained from three to six measurements during the 5 years preceding the first echocardiogram.

RESULTS

Among the 2,817 patients, 560 (19.9%) developed LVDD. The mean of no component of lipid measurements was associated with risk of LVDD. CV (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.10 to 1.67), SD (HR, 1.27; 95% CI, 1.03 to 1.57), and VIM (HR, 1.26; 95% CI, 1.03 to 1.55) of LDL-C and all the variability parameters of apoB were significantly associated with development of LVDD. The association between CV-LDL and risk of LVDD did not have significant interaction with sex, increasing/decreasing trend at baseline, or use of stain and/or lipid-modifying agents.

CONCLUSION

The variability of LDL-C and apoB, rather than their mean, was associated with risk for LVDD.

Metformin in non-diabetic patients with metabolic syndrome and diastolic dysfunction: the MET-DIME randomized trial

PURPOSE

Metabolic syndrome (MetS) affects one out of 3 adults in the western world and is associated with preclinical diastolic dysfunction that impairs functional capacity and quality of life (QoL). This randomized trial was designed to evaluate if the addition of metformin to the standard treatment of non-diabetic patients with MetS improves diastolic dysfunction.

METHODS

Prospective, randomized, open-label, blinded-endpoint trial. Fifty-four non-diabetic adults with MetS and diastolic dysfunction were randomized to lifestyle counseling or lifestyle counseling plus metformin (target dose 1000 mg bid). The primary endpoint was the change in mean e' velocity (assessed at baseline, 6, 12 and 24 months). Secondary endpoints were improvements in insulin resistance, functional capacity and QoL. Linear mixed effects modeling was used for longitudinal data analysis using modified intention-to-treat (mITT) and per-protocol (PP) approaches.

RESULTS

Forty-nine patients were included in the mITT analysis (mean age = 51.8 ± 6.4; 55% males). Metformin treatment was associated with a significant decrease in HOMA-IR. There was a significantly different mean change in e' velocity during the study period between trial arms, both in the mITT (at 24 months, change of +0.67 ± 1.90 cm/s in metformin arm vs. -0.33 ± 1.50 cm/s in control arm) and PP populations (+0.80 ± 1.99 cm/s in metformin arm vs. -0.37 ± 1.52 cm/s in control arm), using a random intercept linear mixed model. There were no significant differences in peak oxygen uptake and SF-36 scores between trial arms.

CONCLUSIONS

Treatment with metformin of non-diabetic MetS patients with diastolic dysfunction, on top of lifestyle counseling, is associated with improved diastolic function.

Oral contraceptives and hypertension in women: results of the enrolment phase of Tabari Cohort Study

BACKGROUND

The association between oral contraceptives (OCP) and hypertension has been reported in the literature with controversial results. According to the growing use of OCPs among women in Iran, this study aims to investigate the association between the duration of the OCP consumption and risk of hypertension among Iranian women.

METHODS

In the current study, the data collected during the enrolment phase of the Tabari cohort were analyzed. Of 6106 women recruited in the cohort, 133 pregnant women were excluded. Epidemiological variables were collected using pre-designed questionnaires as well as the health insurance evidences. In addition, blood pressure and anthropometric factors were measured based on the standard guidelines. Chi square and partial correlation tests as well as logistic regression models were applied for data analysis.

RESULTS

Frequency of oral contraceptive use among 35-70 year-old women in Tabari cohort study (TCS) was 42.2% (2520/5973). Hypertension was observed among 25% (1793/5973) of them. The adjusted odds ratio for OCP use was 1.23 (95% confidence interval: 1.08, 1.40, p = 0.002). The corresponding odds ratios for 61-120 months and more than 120 months OCP use were 1.39 (1.12,1.73) and 1.47 (1.16,1.87) respectively.

CONCLUSIONS

Oral contraceptives especially in long term use can be associated with hypertension.

Assessment of left-ventricular diastolic function in pediatric intensive-care patients: a review of parameters and indications compared with those for adults

BACKGROUND

The incidence of diastolic heart failure has increased over time. The evaluation of left-ventricular diastolic function is complex, ongoing, and remains poorly performed in pediatric intensive-care patients. This study aimed to review the literature and to provide an update on the evaluation of left-ventricular diastolic function in adults and children in intensive care.

DATA SOURCES

We searched data from PubMed/Medline. Thirty-two studies were included. Four pragmatic questions were identified: (1) What is the physiopathology of diastolic dysfunction? (2) Which tools are required to evaluate diastolic function? (3) What are the echocardiographic criteria needed to evaluate diastolic function? (4) When should diastolic function be evaluated in pediatric intensive care?

RESULTS

Early diastole allows characterization of relaxation, whereas compliance assessments and filling pressures are evaluated during late diastole. The evolution of diastolic function differs between adults and children. Unlike in adults, decreased compliance occurs at the same time as delayed relaxation in children. Diastolic function can be evaluated by Doppler echocardiography. The echocardiographic criteria for ventricular relaxation include the E wave, E/A wave ratio, and isovolumic relaxation time. Ventricular compliance can be assessed by the E/e' wave ratio, atrial volume, and Ap wave duration during pulmonary vein flow. In adult intensive-care patients, the E/e' ratio can be used as an index of tolerance for volume expansion in septic patients and to adjust the inotropic support.

CONCLUSION

Clinical studies would allow some of these parameters to be validated for use in children in intensive care.

Impact of Updated 2016 ASE/EACVI VIS-À-VIS 2009 ASE Recommendation on the Prevalence of Diastolic Dysfunction and LV Filling Pressures in Patients with Preserved Ejection Fraction

BACKGROUND

Assessment of diastolic dysfunction (DD) and left ventricular filling pressures (LVFP) by echocardiography is complex in patients with preserved ejection fraction (EF). The American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) jointly published recommendations in 2016 to simplify the diagnosis and classification of DD and the assessment of LVFP. We aimed to study the impact of the updated 2016 ASE/EACVI guidelines vis-à-vis the 2009 ASE recommendations on prevalence of DD and LVFP in patients with preserved EF.

METHODS

Five hundred patients referred to the echocardiography laboratory from March 2020 to May 2020 were analyzed. Patients with left ventricular ejection fraction (LVEF) < 50% were excluded. All patients underwent comprehensive transthoracic echocardiography. DD and LVFP were assessed by the 2016 ASE/EACVI and 2009 ASE recommendations. The concordance between the guidelines was analyzed by kappa coefficient and overall proportion of agreement.

RESULTS

Mean age was 53 ± 13 years and 63.4% were men. Prevalence of DD and abnormal LVFP were significantly lower with the 2016 recommendations than with the 2009 recommendations (9.4% vs. 16.8%, p < 0.001 and 8.4% vs. 12.8%, p < 0.05). Patients with Grade 1 DD (100%) and Grade 2 DD (46.4%) were reclassified by the 2016 recommendations. Indeterminate diastolic function (9.8%) was strikingly high according to the 2016 recommendations. The concordance between the two recommendations was moderate (kappa = 0.569). The overall proportion of agreement was 85.4%.

CONCLUSIONS

Prevalence of DD and abnormal LV filling pressures were lower with application of the 2016 ASE/EACVI recommendations in patients with preserved EF. There was moderate agreement between the 2009 and 2016 recommendations.

Sex-specific associations of obesity with exercise capacity and diastolic function in Koreans

BACKGROUND AND AIMS

Women with obesity are highly predominant among patients with heart failure with preserved ejection fraction (HFpEF). We aimed to elucidate sex-specific associations of obesity with exercise capacity and diastolic function.

METHODS AND RESULTS

Healthy individuals without known cardiovascular diseases undergoing cardiopulmonary exercise test and echocardiography (n = 736) were included and categorized into 4 groups according to their sex and obesity. Exercise capacity was lower in women than men. Obesity was associated with a lower exercise capacity in women (23.5 ± 7.3 vs. 21.3 ± 5.4 ml/kg/min, p < 0.05) but not in men (28.2 ± 7.8 vs. 28.0 ± 6.6 ml/kg/min, p > 0.10). Overall, women had a higher E/e' than men. Women without obesity had a similar E/e' to men with obesity (8.2 ± 1.8 vs. 8.4 ± 2.1, p > 0.10), and women with obesity had the highest E/e'. Among 5 risk factors (aging, obesity, elevated blood pressure, elevated heart rate, and elevated fasting glucose), obesity was a significant determinant of exercise intolerance in women but not men. Furthermore, obesity was associated with a greater risk of diastolic dysfunction in women than men (women, adjusted odds ratio 4.35 [95% confidence interval 2.44-7.74]; men, adjusted odds ratio 2.91 [95% confidence interval 1.42-5.95]).

CONCLUSION

Obesity had a more deleterious effect on exercise capacity and diastolic function in women than men, even in a healthy cohort. These subclinical changes might contribute to the development of a female predominance among HFpEF patients, particularly among individuals with obesity.

Consumption of animal and plant foods and risk of left ventricular diastolic dysfunction: the Bogalusa Heart Study

AIMS

Left ventricular diastolic dysfunction (LVDD) is an early heart failure with preserved ejection fraction (HFpEF) phenotype that is reversible. Identifying dietary predictors associated with LVDD in diverse populations may help broadly improve HFpEF primary prevention.

METHODS AND RESULTS

This longitudinal analysis included 456 individuals of the Bogalusa Heart Study (27% Black, 63% women, baseline age = 36.1 ± 4.4 years). Diet was measured at baseline through food frequency questionnaires. LVDD was defined at follow-up (median = 12.9 years) through echocardiographic measurement of the E/A ratio, E/e' ratio, isovolumic relaxation time, and deceleration time. Multivariable-adjusted logistic regression estimated the risk of LVDD according to dietary predictor, adjusting for traditional cardiovascular disease risk factors. Compared with the lowest tertile, participants in the middle tertile of total protein (OR = 3.30, 95% CI: 1.46, 7.45) and animal protein (OR = 2.91, 95% CI: 1.34, 6.34) consumption experienced the highest risk of LVDD. There was a 77% and 56% lower risk of LVDD for persons in the middle vs. lowest tertile of vegetable (OR = 0.23, 95% CI: 0.11, 0.49) and legume consumption (OR = 0.44, 95% CI: 0.22, 0.85), respectively. Total protein, animal protein, processed meat, and egg consumption indicated a quadratic trend towards increased risk of LVDD, while legume and vegetable intake conferred a quadratic trend towards decreased risk of LVDD (all quadratic P < 0.05).

CONCLUSIONS

Diets higher in animal foods and lower in plant foods are associated with an increased risk for LVDD. These findings suggest threshold effects of diet on LVDD, past which more traditional cardiometabolic determinants occupy a larger role in HFpEF risk.

Heart failure with preserved ejection fraction: insights into diagnosis and pathophysiology

Heart failure with preserved ejection fraction (HFpEF) accounts for at least half the cases of heart failure, currently diagnosed. There are several cardiac and non-cardiac manifestations of the syndrome. Structure and function abnormalities can include all four cardiac chambers. The left ventricle has abnormal systolic and diastolic functions which can be examined by invasive and non-invasive measurements. In addition, the left atrium enlarges with abnormal left atrial function, pulmonary hypertension occurs, and the right ventricle can develop hypertrophy, enlargement, and systolic dysfunction. There are a paucity of data on calcium handling in HFpEF patients. Growing literature supports the presence of abnormalities in titin and its phosphorylation, and increased interstitial fibrosis contributing to increased chamber stiffness. A systemic inflammatory state causing reduced myocardial cyclic guanosine monophosphate along with defects in the unfolded protein response have been recently reported. Diagnosis relies on signs and symptoms of heart failure, preserved ejection fraction, and detection of diastolic function abnormalities based on echocardiographic findings and abnormally elevated natriuretic peptide levels or invasive measurements of wedge pressure at rest or with exercise. There are currently two diagnostic algorithms: H2FPEF, and HFA-PEFF with limited data comparing their performance head to head in the same patient population. Despite the growing understanding of the syndrome's pathophysiology, there have been little success in developing specific treatment for patients with HFpEF.

Tissue Doppler indices of diastolic function as prognosticator in patients without heart failure in primary care

BACKGROUND

Tissue Doppler imaging (TDI) indices of left ventricular (LV) diastolic function provide incremental prognostic information on mortality and morbidity in the general population and in several clinical scenarios. Their independent, additional role in outpatients with normal LV ejection fraction (LVEF) and without heart failure (HF) is undefined.

METHODS

We reviewed clinical and echocardiographic records of 2628 consecutive outpatients 52.8% male, median age 71 years) with LVEF > 50% without concurrent or prior HF, from the Cardiovascular Center of Trieste. We analyzed septal early mitral annular velocity (e') and its combination with mitral peak early filling velocity (E/e') in relation to the composite end-point of death and cardiovascular hospitalizations.

RESULTS

During follow-up of 26 months (interquartile range: 12-41), 392 (15%) patients experienced the endpoint (88 deaths). Increasing E/e' showed an overall association with the clinical end-point (log rank p < 0.02), but with no prognostic difference between the middle and upper tertile. Decreasing e' also showed an association with the end-point, with a more balanced stepwise risk increase for increasing tertiles (log rank p < 0.01 for all contrasts). At multivariable analysis, E/e' (either in tertiles or dichotomized according to the threshold of 15) was no longer associated with clinical outcome, whereas e' independently predicted the combined endpoint [hazard ratio 0.73 (0.53-0.94), p = 0.04]. The prognostic value of e' was incremental to that of other clinical and echocardiographic variables (p = 0.04).

CONCLUSIONS

In outpatients with normal LVEF and without HF, e' and E/e' are both associated with clinical end-points, though only e' is an independent and incremental predictor of outcome. These findings suggest a potential role for e' as a prognosticator, and spread a cautionary word about the utilization of septal E/e' alone as a surrogate for a comprehensive assessment of diastolic function in this context.

Load-independent effects of empagliflozin contribute to improved cardiac function in experimental heart failure with reduced ejection fraction

BACKGROUND AND AIMS

Sodium-glucose linked cotransporter-2 (SGLT2) inhibitors reduce the likelihood of hospitalization for heart failure and cardiovascular death in both diabetic and non-diabetic individuals with reduced ejection fraction heart failure. Because SGLT2 inhibitors lead to volume contraction with reductions in both preload and afterload, these load-dependent factors are thought to be major contributors to the cardioprotective effects of the drug class. Beyond these effects, we hypothesized that SGLT2 inhibitors may also improve intrinsic cardiac function, independent of loading conditions.

METHODS

Pressure-volume (P-V) relationship analysis was used to elucidate changes in intrinsic cardiac function, independent of alterations in loading conditions in animals with experimental myocardial infarction, a well-established model of HFrEF. Ten-week old, non-diabetic Fischer F344 rats underwent ligation of the left anterior descending (LAD) coronary artery to induce myocardial infarction (MI) of the left ventricle (LV). Following confirmation of infarct size with echocardiography 1-week post MI, animals were randomized to receive vehicle, or the SGLT2 inhibitor, empagliflozin. Cardiac function was assessed by conductance catheterization just prior to termination 6 weeks later.

RESULTS

The circumferential extent of MI in animals that were subsequently randomized to vehicle or empagliflozin groups was similar. Empagliflozin did not affect fractional shortening (FS) as assessed by echocardiography. In contrast, load-insensitive measures of cardiac function were substantially improved with empagliflozin. Load-independent measures of cardiac contractility, preload recruitable stroke work (PRSW) and end-systolic pressure volume relationship (ESPVR) were higher in rats that had received empagliflozin. Consistent with enhanced cardiac performance in the heart failure setting, systolic blood pressure (SBP) was higher in rats that had received empagliflozin despite its diuretic effects. A trend to improved diastolic function, as evidenced by reduction in left ventricular end-diastolic pressure (LVEDP) was also seen with empagliflozin. MI animals treated with vehicle demonstrated myocyte hypertrophy, interstitial fibrosis and evidence for changes in key calcium handling proteins (all p < 0.05) that were not affected by empagliflozin therapy.

CONCLUSION

Empagliflozin therapy improves cardiac function independent of loading conditions. These findings suggest that its salutary effects are, at least in part, due to actions beyond a direct effect of reduced preload and afterload.

Influence of Bentall Procedure on Left Ventricular Function

Objective

To evaluate the influence of Bentall procedure on left ventricular function and condition on long-term follow-up.

Methods

Seventy-three consecutive patients who underwent an aortic root and ascending aorta replacement with composite valve button Bentall or flanged Bentall technique, from January 2007 to November 2018, were included in this retrospective study.

Results

Postoperative left ventricular ejection fraction significantly increased (52.14±11.38 vs. 56.79±11.36; P=0.041), left ventricular end-systolic diameter significantly reduced (38.25±9.31 mm vs. 34.17±9.15 mm; P=0.027), left ventricular end-diastolic diameter significantly reduced (56.42±9.72 mm vs. 51.58±9.03 mm; P=0.01), and left atrial diameter significantly reduced (45.33±12.77 mm vs. 39.25±12.41 mm; P=0.01), compared to preoperative values. Our long-term survival results are comparable with previous studies in which survival rates in 5 years and 10 years were 83.5% and 69.8%, respectively. In comparing patients according to their New York Heart Association (NYHA) functional class, it was shown that their postoperative functional capacity was improved during the follow-up period (2.1±0.56 vs. 1.2±0.42; P=0.001).

Conclusion

The Bentall procedure significantly improved the left ventricular systolic function and condition and decreased the left ventricular end-systolic and end-diastolic diameters and the left atrial diameter on long-term follow-up, based on the transthoracic echocardiography. Bentall procedure can be performed with acceptable mortality and morbidity rates on long-term follow-up.

Functional Magnetic Resonance Imaging in the Evaluation of the Elastic Properties of Ascending Aortic Aneurysm

Objective

To evaluate the aortic wall elasticity using the maximal rate of systolic distension (MRSD) and maximal rate of diastolic recoil (MRDR) and their correlation with the aortic size index (ASI).

Methods

Forty-eight patients with thoracic aortic aneurysm were enrolled in this study. A standard magnetic resonance imaging (MRI) protocol was used to calculate MRSD and MRDR. Both MRSD and MRDR were expressed as percentile of maximal area/10^-3 sec. ASI (maximal aortic diameter/body surface area) was calculated. A correlation between MRSD, MRDR, ASI, and the patient’s age was performed using regression plot.

Results

A significant correlation between MRSD (t=-4,36; r²=0.29; P≤0.0001), MRDR (t=3.92; r²=0.25; P=0.0003), and ASI (25±4.33 mm/m²; range 15,48-35,14 mm/m²) is observed. As ASI increases, aortic MRSD and MRDR decrease. Such inverse correlation between MRSD, MRDR, and ASI indicates increased stiffness of the ascending aorta. A significant correlation between the patient’s age and the decrease in MRSD and MRDR is observed.

Conclusion

MRSD and MRDR are significantly correlated with ASI and the patient’s age. They seem to describe properly the increasing stiffness of aortas. These two new indexes provide a promising, accessible, and reproducible approach to evaluate the biomechanical property of the aorta.

Effects of sarcopenia, body mass indices, and sarcopenic obesity on diastolic function and exercise capacity in Koreans

AIMS

Obesity induces left ventricular diastolic dysfunction and ultimately causes heart failure. Sarcopenic obesity is common in heart failure with preserved ejection fraction (HFpEF). However, the precise mechanism by which sarcopenic obesity is related to HFpEF is poorly understood. We aimed to evaluate the combined effect of sarcopenia (SP) and obesity on left ventricular diastolic function and exercise capacity.

METHODS

This study included 733 healthy subjects who underwent health check-ups in a tertiary hospital in Korea. All participants were categorized into four groups: non-SP/non-obese, SP/non-obese, non-SP/obese, and SP/obese. Comprehensive echocardiography with cardiopulmonary exercise testing was performed. Diastolic dysfunction was defined as an E/e' ratio ≥ 10.

RESULTS

Across SP and obesity groups, a gradual decrease in e' velocity and an increase in the E/e' ratio was noted after adjustment for age and sex. Furthermore, a gradual decrease in percent-predicted peak VO₂ was observed across the groups. In the multivariate logistic regression analysis, the SP/obese group had the highest risk for diastolic dysfunction (OR 4.27, 95% CI 2.41-7.57), followed by the non-SP/obese group (OR 2.88, 95% CI 1.57-5.29) and the SP/non-obese group (OR 1.90, 95% CI 1.01-3.56) compared with the reference (non-SP/non-obese) group even after controlling for various confounders.

CONCLUSION

Sarcopenic obesity was associated with impaired diastolic function and decreased exercise capacity, suggesting a possible mechanism by which sarcopenic obesity contributes to the development of HFpEF.

Blood Pressure and Incident Atrial Fibrillation in Older Patients Initiating Hemodialysis

BACKGROUND AND OBJECTIVES

We examined the association of predialysis systolic and diastolic BP and intradialytic hypotension with incident atrial fibrillation in older patients initiating hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used the US Renal Data System linked to the records of a large dialysis provider to identify patients aged ≥67 years initiating hemodialysis between January 2006 and October 2011. We examined quarterly average predialysis systolic BP, diastolic BP, and proportion of sessions with intradialytic hypotension (i.e., nadir systolic BP <90 mm Hg). We applied an extended Cox model to compute adjusted hazard ratios (HRs) of each exposure with incident atrial fibrillation.

RESULTS

Among 17,003 patients, 3785 developed atrial fibrillation. When comparing predialysis systolic BP to a fixed reference of 140 mm Hg, lower predialysis systolic BP was associated with a higher hazard of atrial fibrillation, whereas higher systolic BP was associated with a lower hazard of atrial fibrillation. When comparing across a range of systolic BP for two hypothetical patients with similar measured covariates, the association varied by mean systolic BP: at systolic BP 190 mm Hg, each 10 mm Hg lower systolic BP was associated with lower atrial fibrillation hazard (HR, 0.94; 95% confidence interval, 0.90 to 1.00), whereas at systolic BP 140 mm Hg, a 10 mm Hg lower systolic BP was associated with a higher atrial fibrillation hazard (HR, 1.12; 95% confidence interval, 1.10 to 1.14). Lower diastolic BP was associated with higher atrial fibrillation hazards. Intradialytic hypotension was weakly associated with atrial fibrillation.

CONCLUSIONS

In this observational study of older patients initiating hemodialysis, lower predialysis systolic BP and diastolic BP were associated with higher incidence of atrial fibrillation.

Does maintain consistency with a high quality of cardiac compression force between diastole and systole phase?

The aim of the study was to analyze the cardiac compression force using the vertical force with normalized (100%) in cardiopulmonary resuscitation. Nineteen subjects with basic life support license and instructor career participated in this study. Cardiac compression was performed in a situation positioned practical manikin on ground reaction force and with 1,000 Hz of sample rate. Cardiac compression force in vertical direction showed significant difference among 30 times cardiac compression. Vertical cardiac compression force (N) showed significant difference according to the 30 times of cardiac compression in each diastole (45.79 N) and systole (714.38 N) phase. Also, normalized vertical force showed significant difference according to the 30 times cardiac compression in each diastole (6.80%) and systole (93.20%) phase. This suggests that there is a greater difficulty in performing diastole forces close to 0% than performing a sufficient maximal cardiac compression force in cardiopulmonary resuscitation.

Diastology for the clinician

Diastolic filling of the heart is a complex sequence of multiple inter-related events consisting of processes such as ventricular relaxation, erectile coronary effect, visco-elastic forces of the myocardium, ventricular interaction, myocardial stress strain relationships, pericardial restraint, passive filling, and atrial contraction. However, in order to understand diastolic filling from a clinical aspect, a simplified foundation can be used which divides the cardiac cycle into contraction, relaxation, passive filling, and filling at atrial contraction. The mitral flow velocity curves are representative of the relative driving pressure between left atrium and left ventricle and allow one to grade the progression of diastolic dysfunction which occurs in disease states. Doppler tissue imaging is necessary as a surrogate of ventricular relaxation to further determine the stages of diastolic dysfunction in patients with preserved ejection fraction. These Doppler flow velocity curves can be applied to understanding diastolic filling of the heart in patients with both reduced ejection fraction and preserved ejection fraction.

Resting and Exercise Doppler Hemodynamics: How and Why?

Exercise intolerance is the clinical hallmark of the failing heart. Evidence of hemodynamic derangement is not always present at rest, often necessitating dynamic challenges to accentuate abnormalities. Although cardiac catheterization, particularly with exercise, remains the gold standard method for hemodynamic assessment, it is limited by practicality, access, risk, and its invasive nature; consequently, there is a need to better understand noninvasive measures. Echocardiography and cardiac MRI offer promising modalities to quantify ventriculo-vascular interactions. Significant heterogeneity exists around exercise protocols, and there is a need to develop consensus methodology and to validate these noninvasive measures in all forms of heart failure.

How myofilament strain and strain rate lead the dance of the cardiac cycle

Movement of the myocardium can modify organ-level cardiac function and its molecular (crossbridge) mechanisms. This motion, which is defined by myocardial strain and strain rate (muscle shortening, lengthening, and the speed of these movements), occurs throughout the cardiac cycle, including during isovolumic periods. This review highlights how the left ventricular myocardium moves throughout the cardiac cycle, how muscle mechanics experiments provide insight into the regulation of forces used to move blood in and out of the left ventricle, and its impact on (and regulation by) crossbridge and sarcomere kinetics. We specifically highlight how muscle mechanics experiments explain how myocardial relaxation is accelerated by lengthening (strain rate) during late systole and isovolumic relaxation, a lengthening which has been measured in human hearts. Advancing and refining both in vivo measurement and ex vivo protocols with physiologic strain and strain rates could reveal important insights into molecular (crossbridge) kinetics. These advances could provide an improvement in both diagnosis and precise treatment of cardiac dysfunction.

The significant coronary tortuosity and atherosclerotic coronary artery disease; What is the relation?

Introduction: Although coronary tortuosity is relatively common in coronary angiograms, there is much debate over the significance of this anatomical variation. So in this study the relation between significant coronary tortuosity (SCT) and coronary artery disease (CAD) was examined.

Methods: The cross-sectional study included 737 patients (57% male) who were admitted to the hospital for a coronary angiography, based on their symptoms or non-invasive imaging. Coronary arteries defined as SCT are in the presence of either ≥3 consecutive curvatures of 90◦ to 180◦ or ≥2 consecutive curvatures of ≥180◦ measured at the end-diastole, in a major epicardial coronary artery ≥2 mm in diameter.

Results: 29.17% of the patients had SCT of which females (64.7% vs. 34.1%, P < 0.001) and higher aged persons (62.9±8.4 vs. 57.8±10.7 years ± SD; P < 0.001) were significantly associated with SCT compared to non-SCT. Left anterior descending artery (LAD), left circumflex artery (LCX) and right coronary artery (RCA) with SCT in comparison to non-SCT, had lesser probability of CAD with stenosis severity of ≥50% (34.5% vs. 46.1%; P = 0.019 and 17.7% vs. 31.1%; P = 0.001 and 27.9% vs. 43.5%; P = 0.013 respectively) and also had significant lower Gensini scores (4.1±5.3 vs. 8.4±11.9; P = 0.011; 2.1±3.4 vs. 5.2±9.5; P = 0.01 and 1.2±1.9 vs. 5.03±8.9; P < 0.001 respectively) but higher TIMI frame count (15.7±5.3 vs. 11.9±4.6; P < 0.001 and 17.1±4.4 vs. 12.7±4.4; P < 0.001 and 15.2±3.9 vs. 11.6±4.8; P < 0.001 respectively).

Conclusion: SCT is negatively correlated with CAD and there is a significant association between SCT and reduced coronary flow rate.

MR extracellular volume mapping and non-contrast T1ρ mapping allow early detection of myocardial fibrosis in diabetic monkeys

Objective

To detect diffuse myocardial fibrosis in different severity levels of left ventricular diastolic dysfunction (DD) in spontaneous type 2 diabetes mellitus (T2DM) rhesus monkeys.

Methods

Eighteen spontaneous T2DM and nine healthy monkeys were studied. Echocardiography was performed for diastolic function classification. Cardiac magnetic resonance (CMR) imaging was performed to obtain extracellular volume fraction (ECV) maps and T1ρ maps at two different spin-locking frequencies. ECV values, T1ρ values, and myocardial fibrosis index (mFI) values which are based on the dispersion of T1ρ, were calculated. Global peak diastolic longitudinal strain rates (GSrL) were also obtained.

Results

Echocardiography results showed mild DD in nine T2DM monkeys and moderate DD in the other nine. The global ECV values were significantly different among healthy animals as compared with animals with mild DD or moderate DD, and the ECV values of animals with moderate DD were significantly higher as compared with those of mild DD. The mFI values increased progressively from healthy animals to those with mild DD and then to those with moderate DD. Diastolic function indicators (e.g., early diastolic mitral annulus velocity, GSrL) correlated well with ECV and mFI.

Conclusions

Monkeys with T2DM exhibit increased ECV, T1ρ, and mFI values, which may be indicative of the expansion of extracellular volume and the deposition of excessive collagen. T1ρ mapping may have the potential to be used for diffuse myocardial fibrosis assessment.

Key Points

• Monkeys with T2DM exhibit increased ECV, T1ρ, and mFI values, which may be indicative of the expansion of extracellular volume and the deposition of excessive collagen.

• The relationship between diastolic dysfunction and diffuse myocardial fibrosis may be demonstrated by imaging markers.

• Non-contrast T1ρ mapping may have the potential to be used for diffuse myocardial assessment.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5950-9) contains supplementary material, which is available to authorized users.

Beta-Blockers in Patients with Heart Failure with Preserved Ejection Fraction: Results from The Korea Acute Heart Failure (KorAHF) Registry

Background and Objectives

Beta-blockers are indicated in patients with heart failure (HF) with reduced ejection fraction. However, their efficacy in patients with HF with preserved ejection fraction (HFpEF) is uncertain. We investigated the hypothesis that beta-blockers are associated with reduced adverse events in patients with HFpEF.

Methods

The Korea Acute Heart Failure (KorAHF) is a prospective observational multicentre cohort study. The 5,625 patients hospitalized for acute HF syndrome in 10 tertiary university hospitals across the country have been consecutively enrolled between March 2011 and February 2014. Of these patients, 2,152 patients with HFpEF (ejection fraction ≥40%) were investigated. The primary outcome was all-cause mortality according to beta-blocker use.

Results

During a median follow-up duration of 807 days, 702 patients died. In Cox proportional hazards model beta-blocker use was associated with a 14% reduced all-cause death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.75–0.98), but not with reduce rehospitalization (HR, 1.03; 95% CI, 0.85–1.27). In the propensity-score matched population, beta-blockers were also associated with reduced all-cause death (HR, 0.80; 95% CI, 0.69–0.94) but not with reduced rehospitalization (HR, 1.08; 95% CI, 0.87–1.33).

Conclusions

In Korean patients with HFpEF, use of beta-blockers is associated with reduced all-cause death but not with reduced rehospitalization.

Diastolic dysfunction evaluated by cardiac magnetic resonance: the value of the combined assessment of atrial and ventricular function

OBJECTIVES

We sought to evaluate the role of cardiac magnetic resonance imaging (CMR) in the evaluation of diastolic function by a combined assessment of left ventricular (LV) and left atrial (LA) function in a cohort of subjects with various degrees of diastolic dysfunction (DD) detected by echocardiography.

METHODS

Forty patients with different stages of DD and 18 healthy controls underwent CMR. Short-axis cine steady-state free precession images covering the entire LA and LV were acquired. Parameters of diastolic function were measured by the analysis of the LV and LA volume/time (V/t) curves and the respective derivative dV/dt curves.

RESULTS

At receiver operating characteristic (ROC) curve analysis, the peak of emptying rate A indexed by the LV filling volume with a cut-off of 3.8 was able to detect patients with grade I DD from other groups (area under the curve [AUC] 0.975, 95% confidence interval [CI] 0.86-1). ROC analysis showed that LA ejection fraction with a cut-off of ≤36% was able to distinguish controls and grade I DD patients from those with grade II and grade III DD (AUC 0.996, 95% CI 0.92-1, p < 0.001). The isovolumetric pulmonary vein transit ratio with a cut-off of 2.4 allowed class III DD to be distinguished from other groups (AUC 1.0, 95%CI 0.93-1, p < 0.001).

CONCLUSIONS

Analysis of LV and LA V/t curves by CMR may be useful for the evaluation of DD.

KEY POINTS

• Combined atrial and ventricular volume/time curves allow evaluation of diastolic function. • Atrial emptying fraction allows distinction between impaired relaxation and restrictive/pseudo-normal filling. • Isovolumetric pulmonary vein transit ratio allows distinction between restrictive and pseudo-normal filling.

Blood hammer phenomenon in human aorta: Theory and modeling

This paper contains the results of computing of a blood pressure and a flow speed in a human aorta in a diastolic phase of a heart cycle. The model is based on the one-dimensional flow approach. The blood hammer effect means abrupt increasing of pressure in a blood vessels due to the sharp changes in flow speed. The closing of aortic valve at the proto-diastole phase causes such blood hammer. We consider an aorta as a simple cylindrical conduit with elastic walls. The aortic valve and the bifurcation were located in the opposite ends of the conduit. The analysis of possible types of blood hammer effect in the "conduit-blood" system was performed. The lifelike initial and boundary conditions for the problem were proposed. We found a strong peak of pressure during the first third of diastole at the normal closure of the aortic valve. We observed the minor fluctuations of pressure in the later part of diastole too. Blood flow speed also has minor oscillations during the diastole. Such results are typical under the complete blood hammer effect condition. An abnormal long valve closure causes an incomplete blood hammer effect. In that case the calculated oscillations of the flow speed had higher intensity without strong pressure peak. The Fourier spectra of pressure fluctuations are located in the range of 16-87 Hz, that is nearby to known frequencies of the second heart sound produced by aortic valve.

Dual inhibition of sodium-glucose linked cotransporters 1 and 2 exacerbates cardiac dysfunction following experimental myocardial infarction

Background

Inhibiting both type 1 and 2 sodium–glucose linked cotransporter (SGLT1/2) offers the potential to not only increase glucosuria beyond that seen with selective SGLT2 inhibition alone but to reduce glucose absorption from the gut and to thereby also stimulate glucagon-like peptide 1 secretion. However, beyond the kidney and gut, SGLT1 is expressed in a range of other organs particularly the heart where it potentially assists GLUT-mediated glucose transport. Since cardiac myocytes become more reliant on glucose as a fuel source in the setting of stress, the present study sought to compare the effects of dual SGLT1/2 inhibition with selective SGLT2 inhibition in the normal and diseased heart.

Methods

Fischer F344 rats underwent ligation of the left anterior descending coronary artery or sham ligation before being randomized to receive the dual SGLT1/2 inhibitor, T-1095, the selective SGLT2 inhibitor, dapagliflozin or vehicle. In addition to measuring laboratory parameters, animals also underwent echocardiography and cardiac catheterization to assess systolic and diastolic function in detail.

Results

When compared with rats that had received either vehicle or dapagliflozin, T-1095 exacerbated cardiac dysfunction in the post myocardial infarction setting. In addition to higher lung weights, T-1095 treated rats had evidence of worsened systolic function with lower ejection fractions and reduction in the rate of left ventricle pressure rise in early systole (dP/dt_max). Diastolic function was also worse in animals that had received T-1095 with prolongation of the time constant for isovolumic-pressure decline (Tau) and an increase in the end-diastolic pressure volume relationship, indices of the active, energy-dependent and passive phases of cardiac relaxation.

Conclusions

The exacerbation of post myocardial infarction cardiac dysfunction with T-1095 in the experimental setting suggests the need for caution with the use of dual SGLT1/2 inhibitors in humans.

Aortic Reservoir Function has a Strong Impact on the Cardiac Blood Supply-Workload Balance in Children

It has been reported that more than half of the ejected blood from the left ventricle is stored in the aorta during systole and expelled during diastole. One important organ that receives blood flow mainly during diastole is the heart. It is also reported that the cardiac blood supply-workload balance in small children is disadvantageous to the heart. Therefore, we measured the aortic reservoir function and examined the relationship between the aortic reservoir function and the cardiac blood supply-workload balance. The percent diastolic runoff, which is the percentage of the diastolic blood flow of the total cardiac output, was measured as the index of the aortic reservoir function. The subendocardial viability ratio-the ratio of the diastolic pressure time index (the blood supply to the heart) to the tension time index (implying the myocardial oxygen demand)-was investigated as an index of the cardiac blood supply-workload balance in children. The percent diastolic runoff was 51.7 ± 4.5%, smaller than that in adult. It had a significant positive relationship to age (r² = 0.32, p = 0.0052). The subendocardial viability ratio was 100.8 ± 19.6% and had a strong relationship to the percent diastolic runoff (r² = 0.92, p < 0.0001). The percent diastolic runoff had a positive relationship with age during childhood. The value had a strong impact on the cardiac blood supply-workload balance.

The Role of Doppler Imaging in the Assessment of Right Ventricular Function: a Case-control Study of Acute Inferior Wall Infarction

Background

Right ventricular infarction (RVI) develops in 30-50% of patients with inferior wall infarction (IWI). The rates of mortality, morbidity, and complications in these patients are greater than in the patients without RVI. We compared the tissue Doppler imaging (TDI) indices between a group of patients with IWI and RVI, with a similar group of patients who had IWI alone to investigate the application of TDI indices in the evaluation and detection of right ventricular function.

Material and Methods

We studied 49 patients with first acute IWI in two groups. Group 1 (N=24) were patients with IWI and RVI while group 2 consisted of patients with IWI alone (N=25), based on standard electrocardiogram criteria. The peak systolic (Sm), peak early (Em) and late (Am) diastolic velocities, and Em/Am ratio were obtained from the apical four chamber view, at the lateral side of the tricuspid annulus. We measured trans-tricuspid early (ET) and peak (AT) filling velocity, ET/AT ratio, right ventricular end diastolic diameter (RVEDD), and tricuspid annular plane systolic excursion (TAPSE) by M-mode TDI projected at the long axis of parasternal view.

Results

The RVEDD and E/Em ratio were increased, while the TAPSE was significantly decreased in the patients with RVI as compared to those without RVI (4.7± 0.6 vs. 3.1±0.2 cm; p < 0.005, 5.6±2.21 Vs 4.5±1.2; p<0.006 and 1.7±0.4 vs. 2.3±0.5 cm; p <0.0001, respectively). However, the other statistically measured parameters were not significantly different between these groups.

Conclusion

The measurement of RVEDD, E/Em ratio, and TAPSE, as right ventricular myocardial systolic and diastolic parameters by pulse wave TDI could be used to objectively assess the status of RV condition in patients with first acute IWI.

Reference Ranges and Physiologic Variations of Left E/e' Ratio in Healthy Adults: Clinical and Echocardiographic Correlates

Background:

Transthoracic Doppler echocardiographic examination is commonly performed to define the diastolic ventricular function since it is widely available, noninvasive, and inexpensive with respect to other diagnostic imaging modalities. However, data regarding age- and gender-matched reference values are scanty and sometimes conflicting. This study aims to explore the physiologic variations of left ventricular (LV) E/e' ratio as assessed in a large cohort of healthy adults and to investigate clinical and echocardiographic correlates.

Methods:

From June 2007 to February 2014, 1168 healthy Caucasian adults (mean age 45.1 ± 15.6 years) performed standard echocardiographic examination (transthoracic echocardiogram).

Results:

E/e' constantly increases across all the age classes (P < 0.0001, analyses of variance both for males and females) with a strong statistically significant linear positive correlation with age. Stepwise multiple linear regression analysis identified age (P < 0.0001), LV mass (P < 0.001), LV end-diastolic volume (P < 0.01), and left atrial volume (P < 0.001) as the only independent determinants of E/e' ratio (model R² = 0.54, P < 0.0001).

Conclusions:

In healthy subjects, transmitral E velocity to e' ratio changes in relation to the age: it increased with a statistically significant correlation in individuals older than 60 years. Hence, differences related to demographic and anthropometric measurements may potentially develop a misclassification of otherwise normal individuals when established on dichotomically suggested normal reference values. Our study can demonstrate that it is indispensable to apply specific cutoff related to the age and gender to properly assess LV diastolic function.

Variable Hemodynamic Responses during Diastolic Stress Echocardiography in Patients Who Have Relaxation Abnormality with Possible Elevated Filling Pressure

BACKGROUND AND OBJECTIVES

The clinical characteristics of patients with diastolic dysfunction characterized by a relaxation abnormality with possible elevated filling pressure is remain to be determined. We sought to test whether diastolic stress echocardiography (DSE) is useful for characterization of these patients.

METHODS

A total of 120 patients (58 men, mean age of 64±7 years) with E/A ratio <1.0 (mean±SD, 0.7±0.1) and 10≤ E/e' <15 at rest echocardiography was enrolled prospectively for supine bicycle exercise up to 50 W.

RESULTS

During exercise, 47 patients (39%) showed high left ventricular filling pressure (E/e' >15, hLVFP) and 40 (30%) developed exercise-induced pulmonary hypertension (systolic pulomary arterial pressure >50 mmHg, EiPH) without hLVFP. The remaining 33 patients did not show hLVFP or EiPH. The incidence of EiPH with hLVFP was 21% (25/120). By multivariate analysis, age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.00-1.13; p=0.039) and systolic pulmonary artery pressure at rest (OR, 1.14; 95% CI, 1.02-1.27; p=0.02) were associated with EiPH, whereas late diastolic transmitral velocity (OR, 1.04; 95% CI, 1.00-1.08; p=0.03) and diastolic blood pressure (OR, 0.94; 95% CI, 0.90-0.99; p=0.02) were associated with hLVFP during exercise.

CONCLUSIONS

Patients with relaxation abnormality and possibly hLVFP showed markedly heterogeneous hemodynamic changes during low-level exercise and DSE was useful to characterize these patients.

Impaired ventricular filling limits cardiac reserve during submaximal exercise in people with type 2 diabetes

Background

Attenuated increases in ventricular stroke volume during exercise are common in type 2 diabetes and contribute to reduced aerobic capacity. The purpose of this study was to determine whether impaired ventricular filling or reduced systolic ejection were responsible for the attenuated stroke volume reserve in people with uncomplicated type 2 diabetes.

Methods

Peak aerobic capacity and total blood volume were measured in 17 people with diabetes and 16 non-diabetic controls with no evidence of cardiovascular disease. Left ventricular volumes and other systolic and diastolic functional parameters were measured with echocardiography at rest and during semi-recumbent cycle ergometry at 40 and 60% of maximal aerobic power and compared between groups.

Results

People with diabetes had reduced peak aerobic capacity and heart rate reserve, and worked at lower workloads than non-diabetic controls. Cardiac output, stroke volume and ejection fraction were not different at rest, but increased less in people with diabetes during exercise. Left ventricular end systolic volume was not different between groups in any condition but end diastolic volume, although not different at rest, was smaller in people with diabetes during exercise. Total blood volume was not different between the groups, and was only moderately associated with left ventricular volumes.

Conclusions

People with type 2 diabetes exhibit an attenuated increase in stroke volume during exercise attributed to an inability to maintain/increase left ventricular filling volumes at higher heart rates. This study is the first to determine the role of filling in the blunted cardiac reserve in adults with type 2 diabetes.

Electronic supplementary material

The online version of this article (10.1186/s12933-017-0644-1) contains supplementary material, which is available to authorized users.

Placenta-Derived Adherent Stromal Cells Improve Diabetes Mellitus-Associated Left Ventricular Diastolic Performance

Left ventricular (LV) diastolic dysfunction is among others attributed to cardiomyocyte stiffness. Mesenchymal stromal cells (MSC) have cardiac-protective properties. We explored whether intravenous (i.v.) application of PLacenta-eXpanded (PLX) MSC-like cells (PLX) improves LV diastolic relaxation in streptozotocin (STZ)-induced diabetic mice and investigated underlying mechanisms. Diabetes mellitus was induced by STZ application (50 mg/kg body weight) during five subsequent days. One week after the first STZ injection, PLX or saline were i.v. applied. Two weeks later, mice were hemodynamically characterized and sacrificed. At this early stage of diabetic cardiomyopathy with low-grade inflammation and no cardiac fibrosis, PLX reduced LV vascular cell adhesion molecule-1, transforming growth factor-β1, and interferon-γ mRNA expression, induced the percentage of circulating regulatory T cells, and decreased the splenic pro-fibrotic potential in STZ mice. STZ + PLX mice exhibited higher LV vascular endothelial growth factor mRNA expression and arteriole density versus STZ mice. In vitro, hyperglycemic PLX conditioned medium restored the hyperglycemia-impaired tube formation and adhesion capacity of human umbelical vein endothelial cells (HUVEC) via increasing nitric oxide (NO) bioavailability. PLX further induced the diabetes-downregulated activity of the NO downstream protein kinase G, as well as of protein kinase A, in STZ mice, which was associated with a raise in phosphorylation of the titin isoforms N2BA and N2B. Concomitantly, the passive force was lower in single isolated cardiomyocytes from STZ + PLX versus from STZ mice, which led to an improvement of LV diastolic relaxation. We conclude that i.v. PLX injection improves diabetes mellitus-associated diastolic performance via decreasing cardiomyocyte stiffness. Stem Cells Translational Medicine 2017;6:2135-2145.

Pharmacological Treatment of Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction is a socioeconomic burden in Japan as well as other developed countries. Diuretics are widely used to attenuate symptoms and signs of congestion in both heart failure with preserved and reduced ejection fraction, although their effects on long-term prognosis of both phenotypes of heart failure have not been demonstrated because of an ethical difficulty in designing a randomized and prospective clinical trial. Guidelines do not provide any guidance on therapy choice, and physicians blindly choose furosemide among loop diuretics in current clinical settings. However, several clinical studies have suggested that the effects of loop diuretics are not consistent, and that furosemide is not necessarily preferable as compared with other loop diuretics. We should pay attention to the choice of loop diuretics. Regarding the improvement of long-term prognosis, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, mineralocorticoid receptor blocker and β-blocker are proven effective for heart failure with reduced ejection fraction. However, none of these drugs have improved prognosis of heart failure with preserved ejection fraction in clinical trials. Observational studies and subanalysis of clinical trials suggest the benefits of these drugs in this phenotype of heart failure. All of clinical trials and observational studies present facts to us, and let us recognize that "one size fits all approach" may be a cause for a lack of evidence about the therapeutic strategy of heart failure with preserved ejection fraction until now. We have to make efforts to clarify characteristics of patients with heart failure and preserved ejection fraction to whom the administration of each drug provides benefits or do not.

Impaired myocardial relaxation with exercise determines peak aerobic exercise capacity in heart failure with preserved ejection fraction

Background

Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterized by impaired exercise capacity due to shortness of breath and/or fatigue. Assessment of diastolic dysfunction at rest and with exercise may provide insight into the pathophysiology of exercise intolerance in HFpEF.

Aims

To measure echocardio‐Doppler‐derived parameters of diastolic function as they relate to various indices of aerobic exercise capacity in HFpEF.

Methods

We selected 16 subjects with clinically stable HFpEF, no evidence of volume overload, but impaired functional capacity by cardiopulmonary exercise testing [peak oxygen consumption (VO₂)]. We measured the transmitral E and A flow velocities, E/A ratio, and E deceleration time (DT) and tissue Doppler E′ velocity. We also indexed the E′ to the DT, as additional measure of impaired relaxation (E′_DT), and calculated the diastolic functional reserve index (DFRI), as the product of E′ at rest and change in E′ with exercise.

Results

E′ velocity, at rest and peak exercise, as well as the DFRI positively correlated with peak VO₂, whereas DT, E′_DT, and E/E′ with exercise inversely correlated with peak VO₂. Of note, the E′_DT at rest also significantly predicted E′ velocity at peak exercise (R = +0.81, P < 0.001). Exercise E′ was the only independent predictor of peak VO₂ at multivariable analysis (R = +0.67, P = 0.005).

Conclusions

The E′ velocity at peak exercise is a strong and independent predictor of aerobic exercise capacity as measured by peak VO₂ in patients with HFpEF, providing the link between abnormal myocardial relaxation with exercise and impaired aerobic exercise capacity in HFpEF.

The Relationships between Body Mass Index and Left Ventricular Diastolic Function in a Structurally Normal Heart with Normal Ejection Fraction

Background

We conducted research to determine the effect of the weight on left ventricular (LV) diastolic function in Asians, who are at greater risk of cardiovascular events compared to individuals from Western countries with similar body mass indices (BMIs).

Methods

We studied 543 participants with structurally normal hearts and normal ejection fractions. Participants were classified as normal-weight (BMI < 23.0 kg/m²), overweight (BMI 23.0–27.4 kg/m²), or obese (BMI ≥ 27.5 kg/m²). Peak E velocity, peak A velocity, and E′ velocity were measured and E/E′ was calculated.

Results

Overweight participants had lower E than normal-weight participants (p = 0.001). E′ velocities in overweight and obese participants were less than those in normal weight participants (both p < 0.001). The E/E′ ratio in obese participants was higher compared to the value in normal-weight participants (p < 0.001) and overweight participants (p = 0.025). BMI was associated with E (R = −0.108), A (R = 0.123), E′ (R = −0.229), and E/E′ ratio (R = 0.138) (all p < 0.05). In multivariate analyses, BMI was independently associated with higher A, lower E′, and higher E/E′. The risk of diastolic dysfunction was significantly higher among overweight [adjusted odds ratio: 2.088; 95% confidence interval (CI): 1.348–3.235; p = 0.001] and obese participants (adjusted odds ratio: 5.910; 95% CI: 2.871–12.162; p < 0.001) compared to normal-weight participants.

Conclusion

Obesity and overweight independently predicted diastolic dysfunction. An optimal body weight lower than the universal cut-off is reasonable for preventing LV heart failure in Asians.

The impact of age and gender on right ventricular diastolic function among healthy adults

BACKGROUND

Doppler echocardiography is ideally suited for assessment of diastolic function, being widely available, non-invasive, and less expensive than other techniques. However, data regarding age- and gender-matched reference values of right ventricular diastolic function are limited. This study aims to explore the physiologic variations of right ventricle (RV) diastolic function in a large cohort of healthy adults, and to investigate clinical and echocardiographic correlates.

METHODS

From June 2007 to February 2014, 1168 healthy Caucasian subjects [mean age 45.1±15.6 years, range 16-92; 555 (47.5%) men] underwent comprehensive transthoracic echocardiography (TTE) following current guidelines. The following RV main diastolic measurements were measured: peak early inflow velocity (E), annular both early (e') and atrial (a') velocities, E/e' ratio.

RESULTS

RV E/e' constantly increases with age in females, but do not change substantially in males. RV E/A constantly decreases with age in both genders. Stepwise multiple linear regression analysis underlined a close significant association of RV diastolic function with both right and left heart morphologic measurements (right atrial area, RV diameters, left atrial volume) and functional indexes (TAPSE, RV tissue Doppler peak systolic velocity, left ventricular E/Ee'), as well as with indexes of increased pulmonary resistance.

CONCLUSION

Our data highlight the potential usefulness of different normal reference values according to the age and gender to correctly evaluate RV diastolic function. Differences in terms of demographic and anthropometric parameters could be useful to avoid potential misclassification of RV diastolic function when based on dichotomously suggested normal cut-off values.

Left Ventricular Diastolic Function Assessment of a Heterogeneous Cohort of Pulmonary Arterial Hypertension Patients

BACKGROUND

Pulmonary arterial hypertension (PAH) is known to trigger right ventricular (RV) remodeling that might compromise left ventricular (LV) filling due to inter-ventricular interdependence. In this study, we aimed to examine standard echocardiographic measurements of LV diastolic function in PAH patients.

METHODS

In this retrospective study, we identified clinical as well as complete echocardiographic data from 128 chronic PAH patients to fully assess LV diastolic dysfunction (LVDD) using standard recommended Doppler guidelines. Accordingly, patients were divided into three groups: LVDD 0, LVDD 1 and LVDD 2.

RESULTS

The mean age of the studied population was 57 ± 14 years with a mean pulmonary artery systolic pressure (PASP) of 55 ± 21 mm Hg. A total of 36% of the study patients had normal LV diastolic function. However, 64% had LVDD with LVDD stage 1 being the most common (48%). In terms of echocardiographic data, significant differences were found among the three LVDD groups in regards to PASP, LV end systolic and diastolic volumes, tricuspid annular plane systolic excursion, right ventricular fractional area change as well as many other tissue Doppler imaging parameters. Finally, just age and PASP were predictors of abnormal LV diastolic function (P < 0.05).

CONCLUSIONS

Impaired relaxation is a common abnormality in PAH patients. Additional studies are warranted to determine whether LVDD alters prognosis or is related to changes in the symptomatic profile of this group of patients.

Myocardial relaxation is accelerated by fast stretch, not reduced afterload

Fast relaxation of cross-bridge generated force in the myocardium facilitates efficient diastolic function. Recently published research studying mechanisms that modulate the relaxation rate has focused on molecular factors. Mechanical factors have received less attention since the 1980s when seminal work established the theory that reducing afterload accelerates the relaxation rate. Clinical trials using afterload reducing drugs, partially based on this theory, have thus far failed to improve outcomes for patients with diastolic dysfunction. Therefore, we reevaluated the protocols that suggest reducing afterload accelerates the relaxation rate and identified that myocardial relengthening was a potential confounding factor. We hypothesized that the speed of myocardial relengthening at end systole (end systolic strain rate), and not afterload, modulates relaxation rate and tested this hypothesis using electrically-stimulated trabeculae from mice, rats, and humans. We used load-clamp techniques to vary afterload and end systolic strain rate independently. Our data show that the rate of relaxation increases monotonically with end systolic strain rate but is not altered by afterload. Computer simulations mimic this behavior and suggest that fast relengthening quickens relaxation by accelerating the detachment of cross-bridges. The relationship between relaxation rate and strain rate is novel and upends the prevailing theory that afterload modifies relaxation. In conclusion, myocardial relaxation is mechanically modified by the rate of stretch at end systole. The rate of myocardial relengthening at end systole may be a new diagnostic indicator or target for treatment of diastolic dysfunction.

Association between ventricular filling patterns and the extent of late enhancement on magnetic resonance imaging in patients with hypertrophic cardiomyopathy

OBJECTIVE

To explore the relationship between ventricular filling curves and the extent of late enhancement on cardiac magnetic resonance imaging (MRI) in patients with hypertrophic cardiomyopathy.

MATERIAL AND METHODS

We retrospectively included consecutive patients with suspected and/or confirmed hypertrophic cardiomyopathy and a control group of patients matched for age and sex who underwent cardiac MRI with evaluation of late enhancement. Among other determinations, we evaluated the following parameters on cine sequences: peak filling rate, time to the first peak filling rate, and filling rate normalized to the filling volume.

RESULTS

Late enhancement was observed in 29 (73%) of the 40 patients with hypertrophic cardiomyopathy. The normalized peak filling rate was significantly lower in patients with late enhancement (4.9 ± 1.6 in those with hypertrophic cardiomyopathy positive for late enhancement vs. 5.8 ± 2.2 in those with hypertrophic cardiomyopathy negative for late enhancement vs. 6.3 ± 1.5 in controls, p = 0.008) and the time to peak filling was longer in patients with late enhancement (540.6 ± 89.7 ms vs. 505.5 ± 99.3 ms in those with hypertrophic cardiomyopathy negative for late enhancement vs. 486.9 ± 86.3 ms in controls, p = 0.02). When the population was stratified into three groups in function of the normalized peak filling rate, significant differences were observed among groups for age (p = 0.002), mean wall thickness (p = 0.036), and myocardial mass (p = 0.046) and atrial dimensions, whereas no significant differences with respect to late enhancement were seen.

CONCLUSIONS

In patients with hypertrophic cardiomyopathy, we found a significant association between ventricular filling patterns and age, wall thicknesses, and atrial dimensions, but not with the extent of late enhancement.

Speckle-Tracking Echocardiographic Measures of Right Ventricular Diastolic Function Correlate with Reference Standard Measures Before and After Preload Alteration in Children

The accuracy of echocardiographic measures of right ventricular (RV) diastolic function has been sparsely studied. Our objective was to evaluate the correlation between echocardiographic and reference standard measures of RV diastolic function derived from micromanometer pressure analysis before and after preload alteration in children. Echocardiograms and micromanometer pressure analyses were prospectively performed before and after fluid bolus in children undergoing right heart catheterization. The isovolumic relaxation time constant (τ) and end-diastolic pressure (EDP) were measured. Conventional and speckle-tracking echocardiographic (STE) parameters of RV systolic and diastolic function were assessed. Normal saline bolus was given to increase RV EDP by 20 %. Twenty-eight studies were performed in 22 patients with congenital heart disease or postheart transplantation. Mean age was 8.7 ± 6.1 years. RV longitudinal early diastolic strain rate (EDSR) correlated with τ before (r = 0.57, p = 0.001) and after fluid bolus (r = 0.48, p = 0.008). No conventional echocardiographic measures correlated with τ both before and after fluid bolus. Multiple regression analysis revealed RV EDSR and LV circumferential EDSR as independent predictors of RV τ. There were no independent predictors of EDP. RV EDSR appears to correlate with the reference standard measure of early active ventricular relaxation in children at baseline and after changes in preload. Conventional echocardiographic measures of diastolic function were not predictive of diastolic function after preload alteration. Future studies should assess the prognostic significance of STE measures of diastolic function in this population.

NT-proBNP and Echocardiographic Parameters for Prediction of Cardiovascular Outcomes in Patients with CKD Stages G2-G4

BACKGROUND AND OBJECTIVES

Natriuretic peptides and echocardiographic parameters both predict cardiovascular events in patients with CKD. However, it is unknown whether simultaneous assessment of amino-terminal probrain natriuretic peptide (NT-proBNP) and echocardiographic parameters provides complementary or redundant predictive information; in the latter case, one of these two might be dispensable. We aimed to analyze the implications of using NT-proBNP alone, echocardiographic parameters alone, or a combination of both for prediction of adverse cardiovascular outcome.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Within the longitudinal Cardiovascular and Renal Outcome in CKD 2-4 Patients-The Fourth Homburg Evaluation Study, we prospectively studied 496 patients with CKD stages G2-G4, in whom we measured NT-proBNP. Left ventricular mass index, left atrial volume index, diastolic left ventricular function, and systolic left ventricular function were assessed echocardiographically. During 4.5±2.0 years of follow-up, the occurrence of (1) decompensated heart failure or all-cause mortality and (2) atherosclerotic events or all-cause mortality was recorded. We assessed the association of NT-proBNP and echocardiographic parameters with outcome (using Cox models) and evaluated the increased discriminative value associated with the addition of echocardiographic parameters and NT-proBNP (using integrated discrimination improvement and net reclassification improvement).

RESULTS

During follow-up, 104 patients suffered decompensated heart failure or all-cause mortality, and 127 patents had atherosclerotic events or all-cause mortality. In univariable analyses, NT-proBNP and echocardiographic parameters predicted cardiovascular events. NT-proBNP remained an independent predictor for both end points in multivariate analysis, whereas left ventricular mass index, left atrial volume index, and diastolic left ventricular function did not. The addition of NT-proBNP on top of clinical and various echocardiographic variables was associated with improvements in reclassification for decompensated heart failure or all-cause mortality (integrated discrimination improvement =6.5%-8.3%; net reclassification improvement =23.1%-27.0%; all P≤0.03). Adding echocardiographic variables on top of clinical variables and NT-proBNP was not associated with significant net reclassification improvement (all P>0.05).

CONCLUSIONS

Our data confirm NT-proBNP is an independent predictor of adverse outcomes in patients with CKD. The additional use of echocardiography for improvement of risk stratification is not supported by our results.

Correlation between Diastolic Function and Endothelial Function in Patients with Type 2 Diabetes and Hypertension

BACKGROUND

Endothelial dysfunction may be involved in the pathophysiology of cardiac abnormalities in patients with diabetes mellitus (DM). A correlation between endothelial dysfunction and diastolic dysfunction in patients with type 1 DM has been demonstrated, but this relationship has not been well investigated in type 2 DM.

OBJECTIVE

Compare groups of patients with type 2 DM and hypertension with and without diastolic dysfunction using endothelial function indexes, and to assess whether correlations exist between the diastolic function and the endothelial function indexes.

METHOD

This was a cross-sectional study of 34 men and women with type 2 DM and hypertension who were aged between 40 and 70 years and were categorized based on assessments of their Doppler echocardiographic parameters as having normal (14 patients) and abnormal (20 patients) diastolic function. Flow-mediated dilatation (FMD) assessments of the brachial artery evaluated the patients' endothelial function.

RESULTS

The mean maximum FMD was 7.15 ± 2.80% for the patients with diastolic dysfunction and it was 11.85 ± 4.77% for the patients with normal diastolic function (p = 0.004). Correlations existed between the maximum FMD and the E/e' ratio (p = 0.040, r = -0.354) and the early wave velocity (e') at the lateral mitral annulus (p = 0.002, r = 0.509).

CONCLUSION

The endothelial function assessed by FMD was worse in hypertensive diabetic patients with diastolic dysfunction. There were correlations between the diastolic function indexes and the endothelial function indexes in our sample.

Echocardiographic evaluation of left ventricular diastolic function in cats: Hemodynamic determinants and pattern recognition

Left ventricular (LV) diastolic dysfunction is highly prevalent in cats and is a functional hallmark of feline cardiomyopathy. The majority of cats with hypertrophic, restrictive, and dilated cardiomyopathy have echocardiographic evidence of abnormal LV filling, even during the occult (preclinical) phase. Moderate and severe diastolic dysfunction is an indicator of advanced myocardial disease, is associated with clinical signs including exercise intolerance and congestive heart failure, affects outcome, and influences therapeutic decisions. Therefore, identification and quantification of LV diastolic dysfunction are clinically important. Surrogate measures of diastolic function determined by transthoracic two-dimensional, M-mode, and Doppler echocardiographic (DE) methods have been used widely for such purpose. Major functional characteristics of LV diastole, including global function, relaxation and untwist, chamber compliance, filling volume, and the resultant filling pressures can be semi-quantified by echocardiographic methods, and variables retrieved from transmitral flow, pulmonary vein flow, and tissue Doppler recordings are most frequently used. Although there is still a critical lack of well-designed studies in the field, knowledge has steadily accumulated over the past 20 years, reference ranges of diastolic echocardiographic variables have been determined, epidemiological studies have been conducted, and new treatments of diastolic dysfunction in cats have been evaluated. This report will give the reader a summary of the current status in the field of feline diastology with focus on the noninvasive diagnostic methods and interpretation of echocardiographic surrogate measures of LV diastolic function. Lastly, a grading system using a composite of left atrial size and various DE variables potentially useful in the functional classification of LV diastole in cats is introduced.

Exercise-Induced Atrial Remodeling: The Forgotten Chamber

Cardiac changes in athletes involve the left ventricle and atrium. Mild left atrial enlargement is common among competitive athletes, possibly a physiologic adaptation to exercise conditioning. The prevalence of this remodeling and the association with supraventricular arrhythmias has not been systematically addressed. Echocardiography screens for patients with disease involving the left atrium. New techniques like speckle tracking can recognize early atrial dysfunction and assess left atrial myocardial function in patients with either physiologic or pathologic left ventricular hypertrophy. This article reviews echocardiographic techniques in delineating the athlete's morphology and functional properties of the left atrium.

Pressure-volume Relationship in the Stress-echocardiography Laboratory: Does (Left Ventricular End-diastolic) Size Matter?

INTRODUCTION AND OBJECTIVES

The variation between rest and peak stress end-systolic pressure-volume relation is an afterload-independent index of left ventricular contractility. Whether and to what extent it depends on end-diastolic volume remains unclear. The aim of this study was to assess the dependence of the delta rest-stress end-systolic pressure-volume relation on end-diastolic volume in patients with negative stress echo and all ranges of resting left ventricular function.

METHODS

We analyzed interpretable data obtained in 891 patients (593 men, age 63 ± 12 years) with ejection fraction 47% ± 12%: 338 were normal or near-normal or hypertensive; 229 patients had coronary artery disease; and 324 patients had ischemic or nonischemic dilated cardiomyopathy. They were studied with exercise (n = 172), dipyridamole (n = 482) or dobutamine (n = 237) stress echocardiography. The end-systolic pressure-volume relation was evaluated at rest and peak stress from raw measurement of systolic arterial pressure by cuff sphygmomanometer and end-systolic volume by biplane Simpson rule 2-dimensional echocardiography.

RESULTS

Absolute values of delta rest-stress end-systolic pressure-volume relation were higher for exercise and dobutamine than for dipyridamole. In the overall population, an inverse relationship between end-systolic pressure-volume relation and end-diastolic volume was present at rest (r² = 0.69, P < .001) and peak stress (r² = 0.56, P < .001), but was absent if the delta rest-stress end-systolic pressure-volume relation was considered (r² = 0.13).

CONCLUSIONS

Left ventricular end-diastolic volume does not affect the rest-stress changes in end-systolic pressure-volume relation in either normal or abnormal left ventricles during physical or pharmacological stress.