Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: a serial color M-mode Doppler echocardiographic study

Usefulness of left ventricular diastolic wall motion abnormality as an early predictor of left ventricular dilation after a first acute myocardial infarction

To determine the relation between regional diastolic wall motion abnormality and left ventricular remodeling after acute myocardial infarction (AMI), Doppler echocardiography and color kinesis with assessment of global and regional systolic and diastolic functions were performed in 84 patients who developed AMI within 24 hours of admission. In a multivariate logistic regression analysis, the percentage of left ventricular myocardial segments with diastolic wall motion abnormality (p = 0.008), absence of myocardial viability (p = 0.01), and overall diastolic function (p = 0.001) were predictors of remodeling after AMI.

Diastolic wall motion abnormality after myocardial infarction: relation to neurohormonal activation and prognostic implications

BACKGROUND

Systolic wall motion abnormality (WMA) after acute myocardial infarction (AMI) is a major determinant of outcome; the presence and importance of diastolic WMA after AMI are unknown. We therefore sought to detect diastolic WMA using color kinesis and to assess its relation to neurohormonal activation and its prognostic importance in a consecutive population with a first AMI.

METHODS

Complete color-encoded color kinesis and 2-dimensional and Doppler echocardiography were performed in 149 consecutive patients with documented first AMI within 24 hours of their admission. N-terminal pro-brain natriuretic peptide was measured 3 days after AMI. Study end point was cardiac death or readmission for heart failure.

RESULTS

Diastolic area of WMA exceeded the systolic area in all but 5 patients (97%) and was significantly correlated with brain natriuretic peptide (unadjusted beta = .67, P < .0001; adjusted for systolic function, age, Killip class, and overall diastolic function beta = .27, P = .007). Diastolic WMA was also correlated with the number of diseased vessels on coronary angiography (beta = .59, P < .0001). During follow-up, 25 patients died and 11 were readmitted because of recurrent heart failure. On univariate analysis, the area of diastolic WMA was a predictor of the composite end point (hazard ratio 1.07 [95% CI 1.05-1.09], P < .0001) and remained a predictor on multivariate Cox analysis after adjustment of well-known risk factors, left ventricular systolic and overall diastolic functions (hazard ratio 1.09 [95% CI 1.06-1.15], P < .001).

CONCLUSION

The extent of diastolic WMA can be assessed early after AMI using color kinesis. Diastolic WMA is associated with neurohormonal activation and angiographic severity of coronary artery disease and provides independent prognostic information.

Characteristics of Left Ventricular Diastolic Function in Patients with Systolic Heart Failure: A Doppler Tissue Imaging Study

OBJECTIVE

Our aim was to characterize myocardial velocity profiles in different types of diastolic dysfunction for patients with severely decreased left ventricular (LV) systolic function.

METHODS

A total of 126 patients with congestive heart failure and an LV ejection fraction of 35% or less were included. Patients underwent an echocardiographic Doppler examination, with measurement of the transmitral inflow pattern, and Doppler tissue imaging of the mitral annulus.

RESULTS

Compared with age-matched control subjects, the patients had decreased systolic (9.5 vs 4.9 cm/s, P < .001) and early diastolic (11.6 vs 5.6 cm/s, P < .001) mitral annular velocities. According to the transmitral inflow pattern, 56 patients had signs of a LV restrictive pattern, 36 had a pseudonormalization pattern, and 34 had an abnormal relaxation pattern. The peak systolic and early diastolic mitral annular velocities were quite similarly reduced in different diastolic groups (systolic velocities of 4.6, 5.0, and 5.3 cm/s, and early diastolic velocities of 5.7, 5.8, and 5.1 cm/s at restrictive, pseudonormal, and abnormal relaxation, respectively). The ratio of the transmitral early wave and mitral annular early velocity, an expression of LV filling pressure, was highest in the restrictive group compared with other groups (17.0, 14.6, and 11.7 in the above 3 groups, respectively, P < .001 among groups). The ratio of the transmitral early wave and mitral annular early velocity was also higher in the pseudonormal group than in a control group of patients with ejection fraction of 35% or more with signs of a normal/pseudonormal pattern (14.6 vs 9.0, P < .001).

CONCLUSION

Doppler tissue imaging may enhance the estimates of diastolic dysfunction in patients with decreased LV systolic function, and help to disclose abnormal diastolic function especially in a pseudonormal group.

The Doppler myocardial performance index during low-dose dobutamine echocardiography predicts mortality and left ventricular dilation after a first acute myocardial infarction

BACKGROUND

Myocardial viability can be detected by wall motion analysis during low-dose dobutamine echocardiography (LDDE) after acute myocardial infarction (AMI). However, wall motion analysis describes only left ventricular (LV) systolic reserve. The Doppler myocardial performance index (MPI) is a quantitative measure of combined LV systolic and diastolic function. We hypothesized that an increase (deterioration) in MPI during LDDE, reflecting reduced systolic and diastolic LV reserve, could provide prognostic information beyond conventional systolic wall motion analysis on mortality, morbidity, and LV remodeling after AMI.

METHODS

Low-dose dobutamine echocardiography (10 microg/kg per minute) was performed within 24 hours and echocardiography was repeated 5 days and 1, 3, and 6 months after a first AMI in 162 consecutive patients. Patients were followed for 25 +/- 11 months. End points were all-cause mortality and cardiac events (cardiac death or readmission for heart failure or reinfarction).

RESULTS

In 72 (44%) patients, MPI increased during LDDE. This was independently associated with subsequent LV dilation at 6 months of follow-up (beta = .73, P < .0001). An increase in MPI during LDDE was a powerful prognostic indicator and remained a predictor of mortality (HR 1.92, 95% CI 1.36-2.71, P < .0001) and cardiac events (HR 2.45, 95% CI 1.83-3.27, P < .0001) after adjustment for clinical data, indices of LV function at rest, and wall motion analysis during LDDE.

CONCLUSIONS

Early after AMI, deterioration in MPI during LDDE predicts subsequent LV dilation and provides prognostic information incremental to clinical data, indices of LV function at rest, and conventional stress echocardiographic data.

Prognostic importance of secondary pulmonary hypertension after acute myocardial infarction

We studied 536 patients with acute myocardial infarction and echocardiographic assessment of left ventricular systolic and diastolic function and measurement of right ventricular systolic pressure. On multivariable analysis, the grade of diastolic function, mitral regurgitation severity, age, and wall motion score index were independent predictors of right ventricular systolic pressure, and an increase in right ventricular systolic pressure was independently predictive of mortality (hazard ratio 1.22 per 10 mm Hg, p <0.0001), after adjustment for conventional risk factors and left ventricular function.

Diastolic dysfunction and mortality in diabetic patients on hemodialysis: a 4.25-year controlled prospective study

Among patients on hemodialysis, the mortality rate is higher in individuals with diabetes than in nondiabetic individuals, especially due to cardiovascular causes. The objective of the present study was to evaluate the role of echocardiographic abnormalities to predict mortality in diabetic patients starting hemodialysis. A 4.25-year prospective study was carried out with 40 diabetic and 28 nondiabetic patients starting hemodialysis in five dialysis centers in the metropolitan area of Porto Alegre, Brazil, between August 1996 and June 1999. Cardiovascular status was evaluated based on World Health Organization criteria, resting electrocardiogram (ECG), myocardial scintigraphy (at rest and after dipyridamole administration), and M-mode and Doppler echocardiography. Left ventricular diastolic function was classified into the following filling patterns: normal, impaired relaxation, pseudonormal, or restrictive. The survival rate was analyzed by Kaplan-Meier curves and predictors of death by Cox's proportional-hazards model. At the end of the study, the overall mortality rate was higher in patients with diabetes [19/40 (47.5%)] than in those without diabetes [2/28 (7.1%), P=.0013, log rank test]. Pseudonormal and restrictive filling patterns (HR: 3.2; 95% CI: 1.2-8.8; P=.02) and presence of diabetes (HR: 4.7; 95% CI: 1.03-21.4; P=.04) were associated with mortality. In conclusion, left ventricular diastolic dysfunction (LVDD) was the main predictor of mortality in this cohort of diabetic and nondiabetic patients starting dialysis. Intensive treatment of cardiovascular risk factors before the start of dialysis and during the treatment might reduce the mortality rate in diabetic patients.

Usefulness of four echocardiographic risk assessments in predicting 30-day outcome in acute myocardial infarction

One thousand fifty-one consecutive patients who had acute myocardial infarction were classified into 3 risk groups by 4 echocardiographic risk assessments: left ventricular ejection fraction, left ventricular filling pattern, estimated systolic pulmonary artery pressure, and mitral regurgitation, with 30-day mortality rates of 13.7%, 3.8%, and 1%, respectively (p <0.001). Independent echocardiographic and clinical predictors of 30-day mortality included age (10 years, hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.91 to 1.89), female gender (HR 2.12, 95% CI 0.94 to 4.74), Killip's class > or =II on admission (HR 3.09, 95% CI 1.38 to 7.11), group 2 (moderate) risk (HR 2.89, 95% CI 1.07 to 8.56), and group 1 (high) risk (HR 8.16, 95% CI 2.95 to 25.23).

Relation between plasma amino-terminal propeptide of procollagen type III and left ventricular longitudinal strain in essential hypertension

OBJECTIVE

To investigate whether myocardial fibrosis assessed non-invasively is related to left ventricular (LV) longitudinal systolic function in patients with essential hypertension.

DESIGN

The study consisted of 30 control subjects and 40 patients with hypertension with normal LV ejection fraction. Tissue Doppler echocardiography was performed to assess LV longitudinal systolic strain from the apical views. Mean strain was calculated from the basal and mid segments. Plasma concentrations of the amino-terminal propeptide of type III procollagen (PIIINP) were measured.

RESULTS

In the hypertension group, mean strain was significantly reduced (mean (SD) 13 (6)% v 21 (6)%, p < 0.01) and plasma PIIINP were increased compared with controls (3.0 (0.7) microg/l v 2.1 (0.3) microg/l, p < 0.001). A significant correlation was found between mean strain and PIIINP (r = -0.56, p < 0.001). In patients with abnormal diastolic filling (n = 21) mean strain was reduced compared with patients with normal LV filling (n = 19) (10 (6)% v 15 (6)%, p < 0.01) and the serological marker PIIINP was increased (3.5 (0.6) microg/l v 2.5 (0.5) microg/l, p < 0.001).

CONCLUSIONS

There is a significant association between the extent of myocardial fibrosis and reduced LV longitudinal contractility.

Comparison of the usefulness of Doppler-derived deceleration time versus plasma brain natriuretic peptide to predict left ventricular remodeling after mechanical revascularization in patients with ST-elevation acute myocardial infarction and left ventricular systolic dysfunction

The correlation between Doppler deceleration time (DT) and brain natriuretic peptide (BNP) and their predictive value for detecting left ventricular (LV) remodeling in patients who are treated with primary percutaneous intervention for infarction and LV dysfunction are unknown. Fifty-six patients (64 +/- 12 years of age; 11 women) who had a first ST-segment elevation myocardial infarction and systolic dysfunction that was successfully treated with direct primary coronary intervention underwent 2-dimensional Doppler echocardiographic and plasma BNP evaluation at days 1 and 3 and 1 and 6 months after the index infarction. Repeat coronary angiograms were obtained at 1 and 6 months. Because of previous consistent evidence, 3 days after the index infarction was the time point of comparison between BNP and DT values. Echocardiographic LV remodeling was defined as an increase in end-diastolic volume index above baseline values of 2 x SD. Ventricular remodeling occurred in 20 patients (36%). Multivariate analyses that included BNP level, Doppler DT, echocardiographic measurements of systolic function, peak creatine kinase, and anterior infarct location showed Doppler DT to be the only predictor of LV remodeling (odds ratio 0.963, 95% confidence interval 0.936 to 0.990, p = 0.008). The optimal cutoff for DT in the prediction of 6-month LV remodeling was <136 ms (sensitivity 75%, specificity 97%, accuracy 81%, area under receiver-operating characteristic curve 0.90). Thus, in patients who have a first ST-segment elevation myocardial infarction and LV systolic dysfunction that is successfully treated with primary percutaneous coronary intervention, Doppler-derived DT 3 days after index infarction is more effective than BNP level in detecting patients who are at higher risk for 6-month LV remodeling.

Relation of aneurysmectomy in patients with advanced left ventricular remodeling to postoperative left ventricular filling pressure, redilatation with ischemic mitral regurgitation

Left ventricular (LV) volume, mitral E deceleration time, and mitral regurgitation (MR) fraction were measured by echocardiography in 14 patients with surgical LV aneurysmectomy. Late MR developed 3 to 6 months after surgery in 5 of the 14 patients (36%). Compared with patients without late MR, those with late MR had a significantly greater preoperative LV end-diastolic volume index (LVEDVI) (134 +/- 21 vs 93 +/- 19 ml/m(2), p <0.01), surgical reduction in LVEDVI (-51 +/- 14 vs -20 +/- 16 ml/m(2), p <0.01), early postoperative LV diastolic dysfunction with shortened mitral E deceleration time (106 +/- 23 vs 141 +/- 24 ms, p <0.01), and a late postoperative reincrease in LVEDVI (+28 +/- 4 vs +3 +/- 8 ml/m(2), p <0.01), suggesting that surgical LV aneurysmectomy in patients with advanced preoperative LV remodeling may result in postoperative LV diastolic dysfunction, promoting later LV redilation with ischemic MR.

Prediction of Prognosis in the UM-X7.1 Hamster Model of Congestive Heart Failure Using the Tei Index

BACKGROUND

Cardiac function is difficult to evaluate in small animal models of heart disease. The Doppler Tei index is a simple and non-invasive measure that can express global cardiac function even in small animal models of congestive heart failure. However, its ability to predict prognosis has not been evaluated.

METHODS AND RESULTS

We tested the hypothesis that cardiac functional indices, such as the Tei index, can predict the prognosis of hamsters with cardiac dysfunction. The Tei index, defined as the sum of the isovolume contraction and relaxation time divided by ejection time, and the percent fractional shortening of the left ventricle was measured in 48 anesthetized male hamsters (19.7+/-0.4 weeks old) with cardiac dysfunction (UM-X7.1), using Doppler and 2-dimensional echocardiography. The hamsters were separated into 2 groups based on the median Tei index (0.50) and % fractional shortening (FS) (21%). Kaplan-Meier analysis determined the survival rates of the groups. Both the Tei index and %FS enabled significant distinction of better and poorer survival (p < 0.01), and the survival curves were less overlapped when the animals were separated according to the Tei index.

CONCLUSION

The Tei index can predict prognosis in a small animal model of heart failure.

Noninvasive prediction of complications with anteroseptal acute myocardial infarction by left ventricular Tei index

BACKGROUND

Tei index has been proposed as a noninvasive and simple index that enables the evaluation of global left ventricular (LV) function and prediction of patient prognosis. However, its use to predict complications with acute myocardial infarction (AMI) is not fully investigated. Therefore, the purpose of this study was to investigate whether or not LV Tei index allows noninvasive prediction of complications with AMI.

METHODS

In all, 80 consecutive patients with anteroseptal AMI were enrolled. LV Tei index was measured at the time of admission as (a - b)/ b , where a is the interval between cessation and onset of mitral filling flow and interval b is the aortic flow ejection time. Subsequent complications including cardiac death, shock, congestive heart failure, ventricular tachycardia/fibrillation, paroxysmal atrial fibrillation/flutter, advanced atrioventricular block requiring pacing, pericardial effusion, and LV aneurysm during the 30 days after the onset of AMI were prospectively evaluated and compared with the initial Tei index at admission.

RESULTS

Complications developed in 31 of 80 (39%) patients with AMI. The Tei index was significantly increased for patients with complications compared with those without them (0.69 +/- 0.16 vs 0.50 +/- 0.11, P < .0001). When Tei index > or = 0.59 was used for the criteria, the sensitivity, specificity, and overall accuracy to predict subsequent complications were 77%, 86%, and 85%, respectively.

CONCLUSION

In patients with anteroseptal AMI, LV Tei index at arrival to the hospital in the acute phase allows noninvasive prediction of subsequent complications.

Echocardiographic predictors of prognosis after first acute myocardial infarction

We prospectively studied 490 patients who had a first myocardial infarction and performed a complete 2-dimensional echocardiographic study <or=48 hours of admission. In addition to left ventricular ejection fraction, multiple echocardiographic parameters of left ventricular systolic and diastolic performances were found to be independent predictors of 2-year mortality rate and congestive heart failure.

Usefulness of left atrial volume as a predictor of mortality in patients with ischemic cardiomyopathy

Left atrial (LA) volume is a load-independent marker of left ventricular diastolic function. To determine the value of LA volume to predict mortality in patients with ischemic cardiomyopathy, clinical and echocardiographic variables, including Doppler parameters, were evaluated in 109 patients with ischemic cardiomyopathy. LA volume was the only independent predictor of mortality (hazard ratio 1.03, 95% confidence interval 1.001 to 1.057, p = 0.03).

Preload-dependent variation of the propagation velocity in patients with congestive heart failure

BACKGROUND

Although color Doppler M-mode propagation velocity (Vp) is preload-independent, the variation in Vp with the temporal variation of preload in the clinical setting has not been evaluated. Because left ventricular filling pressure changes dramatically with treatment of congestive heart failure (CHF), we hypothesized that preload-dependent variations in Vp occur with treatment of CHF.

METHODS

We performed Doppler echocardiographic and hemodynamic evaluation in 24 patients with CHF (15 men, 62 +/- 10 years) at initial presentation (baseline study) and after CHF had improved with therapy (second study).

RESULTS

The interval between the baseline and the second study was 48.6 +/- 21.5 hours. Vp decreased between the baseline study (41 +/- 5 cm/s) and the second study (28 +/- 5 cm/s, P <.0001). Only the change in pulmonary capillary wedge pressure (-8.3 +/- 3.3 mm Hg) between the baseline and second study was an independent predictor of the change in Vp (-12.5 +/- 5.9 cm/s) by stepwise linear regression (r = 0.68, P =.0002).

CONCLUSIONS

Vp decreases significantly with decreases in pulmonary capillary wedge pressure with the treatment of CHF. The preload-dependent variation should be taken into account in the assessment of Vp in patients with CHF.

Long-term prognostic significance of left atrial volume in acute myocardial infarction

OBJECTIVES

The aim of this study was to evaluate the significance of increased left atrial (LA) volume determined within the first 48 h of admission as a long-term predictor of outcome in patients with acute myocardial infarction (MI).

BACKGROUND

The LA volume reflects left ventricular (LV) diastolic properties. Whereas other LV Doppler diastolic characteristics are influenced by acute changes in LV function, LA volume is stable and reflects diastolic properties before MI.

METHODS

Clinical and echocardiographic parameters were prospectively collected in 395 consecutive patients with acute MI. Patients with LA volume index (LAVI) >32 ml/m(2) (normal + 2 standard deviations) were compared with those with LAVI <==32 ml/m(2). Independent clinical and echocardiographic prognostic risk factors for five years' mortality were determined by the Cox proportional hazard model.

RESULTS

Left atrial volume index >32 ml/m(2) was found in 63 patients (19%) who had a higher incidence of congestive heart failure on admission (24% vs. 12%, p < 0.01), a higher incidence of mitral regurgitation, increased LV dimensions, and reduced LV ejection fraction when compared with patients with LAVI <==32 ml/m(2). Their five-year mortality rate was 34.5% versus 14.2% (p < 0.001). Significant independent risk predictors of five years' mortality were age (10 years) (odds ratio [OR] 1.45; 95% confidence interval [CI]1.14 to 1.86), Killip class >/=2 on admission (OR 2.30; 95% CI 1.29 to 4.09), LAVI >32 ml/m(2) (OR 2.22; 95% CI 1.25 to 3.96), diabetes (OR 1.94; 95% CI 1.15 to 3.28), and LV restrictive filling pattern (OR 1.89; 95% CI 1.09 to 3.31).

CONCLUSIONS

In patients with acute MI, increased LA volume, determined within the first 48 h of admission, is an independent predictor of five-year mortality with incremental prognostic information to clinical and echocardiographic data.

Is left ventricular diastolic function an independent marker of prognosis after acute myocardial infarction?

BACKGROUND

In addition to clinical risk markers, indices of left ventricular (LV) systolic function are valuable prognostic markers after acute myocardial infarction (MI). Previous studies have also suggested that LV diastolic function may contribute with prognostic information. The present study assessed whether this assumption applies to a large population of patients with acute MI who underwent thrombolytic therapy.

METHODS AND RESULTS

520 out of 608 patients participating in the ATTenuation by Adenosine of Cardiac Complications (ATTACC) study, with an ST-elevation acute MI underwent two-dimensional and Doppler echocardiographic examination at 4 (range 2-10) days after admission. During the follow-up period of 31 (S.D. +/- 11) months, cardiovascular death occurred in 57 (11%) patients, nonfatal acute MI occurred in 77 (15%), and 124 (24%) patients suffered a combined cardiovascular end-point (either nonfatal acute MI or cardiovascular death). Univariate regression analysis showed that all indices of LV systolic function predicted cardiovascular death and combined cardiovascular end-points. Regarding LV diastolic function only a restrictive filling pattern predicted cardiovascular death. In a multistep multivariate regression analysis in which the variables were introduced in a hierarchic order age, history of systemic hypertension, wall motion score index (WMSi), and history of previous MI and diabetes mellitus were independent predictors of cardiovascular death. A history of systemic hypertension or congestive heart failure were independent predictors of nonfatal acute MI, while a history of systemic hypertension, wall motion score index and diabetes mellitus independently predicted combined cardiovascular end-points.

CONCLUSIONS

The results of this study confirmed that clinical risk indicators and LV systolic function were the most important independent predictors of cardiovascular death and combined cardiovascular end-points. LV diastolic function assessed by Doppler-echocardiography did not provide additional prognostic information.

Congestive heart failure with preserved left ventricular systolic function after acute myocardial infarction: clinical and prognostic implications

AIMS

To characterise the prevalence, in-hospital complications, management, and long-term outcome of patients with congestive heart failure but preserved left ventricular systolic function after acute myocardial infarction.

METHODS

3166 consecutive patients screened for entry in the Bucindolol Evaluation in Acute Myocardial Infarction Trial with definite acute myocardial infarction and echocardiographic assessment of left ventricular systolic function were included between 1998 and 1999 in this prospective observational study. Main outcome measures were occurrences of in-hospital complications and all cause mortality.

RESULTS

Congestive heart failure was seen during hospitalisation in 1464 patients (46%), 717 patients had preserved left ventricular systolic function (wall motion index > or =1.3 corresponding to ejection fraction > or =0.40), and 732 patients had systolic dysfunction (wall motion index <1.3). One year mortality in patients with no heart failure, heart failure with preserved systolic function, and heart failure with systolic dysfunction were 6, 22 and 35%, P<0.0001. Unadjusted risk of death from all causes associated with heart failure and preserved systolic function was 3.3 (95% CI 2.8-4.0), and after adjustment for baseline characteristics and left ventricular systolic function in multivariate Cox proportional hazards analysis the risk was 2.1 (95% CI 1.7-2.6), P<0.0001.

CONCLUSIONS

Congestive heart failure is frequently present in patients with preserved left ventricular systolic function, and is associated with increased risk of in-hospital complications and death following acute myocardial infarction.

Prognostic implications of echocardiography in advanced heart failure

PURPOSE OF REVIEW

The growing epidemic of systolic congestive heart failure mandates strategies to identify accurately people with high morbidity and mortality. Echocardiography remains the most widely available noninvasive tool for the assessment of cardiac structure, function, and hemodynamics. Clinical data paired with echocardiographic analysis in patients with systolic heart failure obtained from a variety of investigations have allowed for the evaluation of this modality as a prognostic tool.

RECENT FINDINGS

Detailed appraisal of the literature has revealed five distinct, easy-to-evaluate echocardiographic parameters that may assist clinicians to segregate high-risk patients. The presence of or the inability to modify a left ventricular ejection fraction less than 25%, impaired right ventricular function (assessed by any of four methods), left ventricular end-diastolic dimension greater than 6.5 to 7 cm, a restrictive mitral inflow, or pulmonary hypertension (peak tricuspid regurgitant velocity >2.5 m/s) should alert clinicians of patients with high morbidity (recurrent congestive heart failure admission, arrhythmia, impaired functional capacity) and mortality. Particularly important among these variables is the presence of a restrictive mitral inflow pattern.

SUMMARY

Detailed analysis of two-dimensional and Doppler data routinely obtained from echocardiograms has established prognostic implications among patients with systolic heart failure. Although prospective clinical trials are lacking, the use of echocardiography to segregate risk should be incorporated into current strategies to treat congestive heart failure and influence clinical listing for cardiac transplantation.

Doppler-derived mitral deceleration time as a strong prognostic marker of left ventricular remodeling and survival after acute myocardial infarction

OBJECTIVES

The goal of this study was to assess the impact of left ventricular (LV) diastolic filling on remodeling and survival after acute myocardial infarction (AMI).

BACKGROUND

Little is known regarding the link between LV filling, its changes over time, and six-month remodeling and late survival in uncomplicated AMI.

METHODS

Doppler mitral profile, end-diastolic volume index (EDVi) and end-systolic volume index (ESVi), ejection fraction (EF), and wall motion abnormalities (%WMA) were evaluated in 571 patients from the GISSI-3 Echo substudy at baseline, pre-discharge, and six months after AMI. Patients with baseline early mitral deceleration time (DT) 130 ms were assigned to the restrictive group (n = 147), and those with DT >130 ms to the nonrestrictive group (n = 424).

RESULTS

Restrictive group patients had greater baseline ESVi and %WMA and lower EF than nonrestrictive group, and six-month greater LV dilation (EDVi, ESVi: p < 0.001 for EDVi and ESVi), smaller decrease in %WMA decrease (p < 0.01), and larger EF impairment (p < 0.008). Among the restrictive group, patients (n = 56) with pre-discharge persistent restrictive filling (n = 56) showed six-month greater LV enlargement (p < 0.001) and EF impairment (p < 0.009) than those (n = 91) with reversible restrictive filling. Baseline %WMA and EDVi, together with pre-discharge persistent restrictive filling, predicted severe (>20%) LV dilation. Four-year survival was 93% in nonrestrictive patients versus 88% in the restrictive group (p < 0.06), and 93% in pre-discharge reversible restrictive versus 79% in persistent restrictive (p < 0.0003). The single best predictor of mortality, by Cox analysis, was pre-discharge persistent restrictive filling (chi-square 14.88).

CONCLUSIONS

Left ventricular dilation may occur even after uncomplicated AMI and may be paralleled by an improvement in LV filling. However, a baseline restrictive filling that persists at pre-discharge identifies more compromised patients at higher risk for six-month remodeling and four-year mortality.

The prognostic significance of exercise-induced atrial arrhythmias

OBJECTIVES

The purpose of the study was to determine if atrial ectopy (AE) or atrial arrhythmias during exercise are predictive of an increased risk of cardiac events and death.

BACKGROUND

Although stress-induced atrial arrhythmias are common during exercise testing, there is a paucity of data regarding the correlation with underlying heart disease and cardiovascular outcomes. Atrial arrhythmias may reflect underlying left atrial enlargement and diastolic dysfunction, which are prognostic of mortality. We hypothesized that these stress-induced arrhythmias are associated with long-term adverse cardiac events.

METHODS

Exercise echocardiography was performed in 5,375 patients (age 61 +/- 12 years) with known or suspected coronary artery disease. An abnormal result was defined as exercise-induced atrial fibrillation (AF)/atrial flutter, supraventricular tachycardia (SVT), or AE.

RESULTS

A total of 311 (5.8%) patients died (132 [2.5%] from cardiac causes) over a period of 3.1 +/- 1.7 years. In addition, 193 (3.6%) patients experienced a myocardial infarction (MI) and 531 (9.9%) patients required revascularization. During exercise testing, 1,272 (24%) patients developed AE, 185 (3.4%) developed SVT, and 43 (0.8%) developed AF. The five-year cardiac death rate was not statistically different between groups (none [3.8%], AE [4.3%], SVT [3.7%], AF [0%], p = 0.43). The five-year rate of MI was significantly different between groups (none [5.7%], AE [8.3%], SVT [0%], AF [9.0%], p = 0.005). The five-year rate of revascularization between groups was not significantly different (none [14.2%], AE [17.0%], SVT [11.8%], AF [14.8%], p = 0.50). A composite of all five-year adverse end points was similar between groups (none [22.7%], AE [27.8%], SVT [17.7%], AF [25.7%], p = 0.10). In stepwise multivariate analysis, AE was not predictive of myocardial infarction when taking into account traditional clinical variables and exercise test results.

CONCLUSIONS

In this large cohort of patients, the occurrence of AE was predictive of an increased risk of MI. However, the association did not persist after adjustment for clinical and exercise variables known to predict adverse long-term cardiovascular outcomes. The rate of long-term cardiac death or revascularization was not influenced by the development of stress-induced atrial arrhythmias.

Noninvasive estimation of left ventricular filling pressure by e/e′ is a powerful predictor of survival after acute myocardial infarction

OBJECTIVES

The aim of this study was to assess the prognostic value of a noninvasive measure of left ventricular diastolic pressure (LVDP) early after acute myocardial infarction (MI).

BACKGROUND

The early diastolic velocity of the mitral valve annulus (e') reflects the rate of myocardial relaxation. When combined with measurement of the early transmitral flow velocity (E), the resultant ratio (E/e') correlates well with mean LVDP. In particular, an E/e' ratio >15 is an excellent predictor of an elevated mean LVDP. We hypothesized that an E/e' ratio >15 would predict poorer survival after acute MI.

METHODS

Echocardiograms were obtained in 250 unselected patients 1.6 days after admission for MI. Patients were followed for a median of 13 months. The end point was all-cause mortality.

RESULTS

Seventy-three patients (29%) had an E/e' >15. This was associated with excess mortality (log-rank statistic 21.3, p < 0.0001) and was the most powerful independent predictor of survival (risk ratio 4.8, 95% confidence interval 2.1 to 10.8, p = 0.0002). The addition of E/e' >15 improved the prognostic utility of a model containing clinical variables and conventional echocardiographic indexes of left ventricular systolic and diastolic function (p = 0.001).

CONCLUSIONS

E/e' is a powerful predictor of survival after acute MI. An E/e' ratio >15 is superior, in this respect, to other clinical or echocardiographic features. Furthermore, it provides prognostic information incremental to these parameters.

Echocardiographic Predictors of Remote Outcome in Patients With Angiographically Successful Reflow After Acute Myocardial Infarction

BACKGROUND

The angiographically no-reflow phenomenon after percutaneous coronary intervention (PCI) predicts poor left ventricular (LV) functional recovery and a high risk of cardiac events in patients with their first acute myocardial infarction (AMI). However, risk factors of long-term adverse outcome for patients with angiographically successful reflow (TIMI (Thrombolysis in Myocardial Infarction) flow grade 3) for the AMI remain unknown.

METHODS AND RESULTS

Of 168 echocardiograms were performed before PCI and at discharge, 113 were suitable for analysis. Clinical, angiographic, and echocardiographic variables were submitted to statistical analysis to detect the risk factors of cardiac events. During the follow-up period of 46+/-20 months, 31 patients had cardiac events, though there were no cardiac deaths. The 2 most important risk factors for congestive heart failure (CHF) or total cardiac events were LV dilation (chi-square: 7.5 and 9.4; both p<0.01) and pseudonormal transmitral flow pattern (PN, chi-square: 4.9, p<0.05 and 6.7, p<0.01, respectively). However, only multivessel disease (chi-square: 9.4, p=0.05) became the predictor for revascularization after PCI. The incidence of CHF or total cardiac events in patients with PN and LV dilation at discharge determined by the Kaplan-Meier method were significantly higher than those with normal or abnormal relaxation transmitral flow pattern (log-rank: 41 and 27, both p<0.001) and no LV dilation (log-rank: 20 and 20, both p<0.001).

CONCLUSION

Poor LV diastolic function and LV dilation at discharge are predictors of the cardiac events in patients in whom epicardial coronary flow was well-restored after PCI for the first AMI.

Noninvasive differentiation of pseudonormal/restrictive from normal mitral flow by Tei index: a simultaneous echocardiography-catheterization study in patients with acute anteroseptal myocardial infarction

BACKGROUND

Differentiation of pseudonormal/restrictive from normal mitral flow is still clinically problematic. Pseudonormal/restrictive flow is usually associated with left ventricular dysfunction, which can be detected by Doppler Tei index, combining systolic and diastolic function. Therefore, the purpose of this study was to test the feasibility of the Tei index to differentiate pseudonormal/restrictive from normal mitral flow.

METHODS

In 26 patients with anteroseptal acute myocardial infarction and early diastolic mitral flow velocity (E) to late diastolic mitral flow velocity (A) ratio (E/A) > or = 1, left ventricular volumes; E and A; deceleration time of E; and the Tei index, defined as the sum of the isovolumic contraction and relaxation time divided by ejection time, were evaluated by Doppler echocardiography, and pulmonary capillary wedge pressure was measured by catheterization. Pseudonormal/restrictive mitral flow was defined as E/A > or = 1 associated with pulmonary capillary wedge pressure > 12 mm Hg.

RESULTS

There were 19 and 7 patients with pseudonormal/restrictive and normal mitral flow, respectively. Among the indices of left ventricular function, the Tei index achieved the best correlation with pulmonary capillary wedge pressure (r(2) = 0.66, P <.0001). By setting the Tei index > or = 0.55 as the criteria for pseudonormal/restrictive mitral flow, this diagnosis had the sensitivity, specificity, and accuracy of 84%, 100%, and 88%, respectively.

CONCLUSION

The Tei index allows noninvasive differentiation of pseudonormal/restrictive from normal mitral flow.

Prognostic Value of Global Myocardial Performance Indices in Acute Myocardial Infarction *

STUDY OBJECTIVES

Assessment of global myocardial performance by a single index (ie, the myocardial performance index [MPI]) has been suggested as an appealing alternative to the individual assessment of systolic and diastolic left ventricular (LV) function We sought to test the prognostic value of MPI in comparison to clinical characteristics and echocardiographic parameters of LV filling and ejection in acute myocardial infarction (AMI).

PATIENTS

Four hundred seventeen consecutive patients with AMI were examined within 24 h of hospital admission.

INTERVENTIONS

Doppler echocardiographic measures of systolic, diastolic, and global myocardial performance were assessed within 24 h of hospital admission. In addition to MPI (ie, the sum of the isovolumic time intervals divided by ejection time), we determined the isovolumic/heterovolumic time ratio, which expresses the time "wasted" by the myocardium to generate and decrease LV pressure without moving blood.

RESULTS

The end points of the study at 30 days were death (4.7%), congestive heart failure (23%), and recurrent infarction (4.8%), and occurred in 109 patients, who were compared as group B to 314 patients without an event (group A). Multivariate analysis identified only age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02 to 1.07), LV ejection fraction (LVEF) < or = 40% (OR, 3.82; 95% CI, 2.15 to 6.87), and E-wave deceleration time (EDT) of < or = 130 ms (OR, 2.29; 95% CI, 1.0 to 5.21) as independent predictors of adverse events.

CONCLUSION

LVEF and EDT are powerful and independent echocardiographic predictors of poor outcome following AMI, and are superior to indexes of global LV performance. Both parameters should be taken into consideration when deciding about the management of these patients.

Impact of early changes in left ventricular filling pattern on long-term outcome after acute myocardial infarction

BACKGROUND

In patients with heart failure due to chronic ischemic heart disease improvement of diastolic function indicates improved survival and a reduced morbidity, but whether this is also the case after acute myocardial infarction is not known.

METHODS

To assess the prognostic importance of changes in left ventricular filling pattern, assessed with mitral deceleration time and colour M-mode flow propagation velocity, on cardiac death and readmission due to heart failure serial Doppler echocardiography was carried out in 103 patients with a first myocardial infarction. Based on echocardiography on hospital admission and after 1 month, patients were divided into three groups: group A (n=29) comprised patients with normal filling at either examination, group B (n=29) comprised patients with improvement of initially abnormal filling, and group C (n=45) patients with deterioration or no change of an abnormal filling pattern.

RESULTS

One-year survival free of cardiac death or hospitalisation for heart failure was 97% in group A, 86% in group B and 64% in group C (P<0.0001). In Cox analysis persistence of abnormal filling or deterioration of left ventricular filling was still a predictor of the combined endpoint (risk ratio 4.4, 95% CI 1.8-12.0, P=0.003) after adjustment of LV filling on admission, left ventricular systolic function and clinical variables. Serial analyses of left ventricular systolic function demonstrated a significant improvement after 1 year in ejection fraction in groups A and B, whereas ejection fraction remained unchanged in group C.

CONCLUSION

Patients with a persistently abnormal or a deterioration of left ventricular filling pattern as opposed to improved or normal filling are at increased risk of cardiac death and readmission due to heart failure after acute myocardial infarction.

Left atrial volume: a powerful predictor of survival after acute myocardial infarction

BACKGROUND

After acute myocardial infarction (AMI), diastolic function assessed by Doppler echocardiography provides important prognostic information that is incremental to systolic function. However, Doppler variables are affected by multiple factors and may change rapidly. In contrast, left atrial (LA) volume is less influenced by acute changes and reflects subacute or chronic diastolic function. This may be of importance when one assesses risk in patients with AMI.

METHODS AND RESULTS

Three hundred fourteen patients with AMI who had a transthoracic echocardiogram with assessment of left ventricular (LV) systolic and diastolic function and measurement of LA volume during admission were identified. The LA volume was corrected for body surface area, and the population was divided according to LA volume index of 32 mL/m2 (2 SDs above normal). LA volume index was >32 mL/m2 in 142 (45%). The primary study end point was all-cause mortality. During follow-up of 15 (range 0 to 33) months, 46 patients (15%) died. LA volume index was a powerful predictor of mortality and remained an independent predictor (hazard ratio 1.05 per 1-mL/m2 change, 95% CI 1.03 to 1.06, P<0.001) after adjustment for clinical factors, LV systolic function, and Doppler-derived parameters of diastolic function.

CONCLUSIONS

Increased LA volume index is a powerful predictor of mortality after AMI and provides prognostic information incremental to clinical data and conventional measures of LV systolic and diastolic function.

Prognostic value of pseudonormal and restrictive filling patterns on left ventricular remodeling and cardiac events after coronary artery bypass grafting

This study was aimed to assess the prognostic value of transmitral flow (TMF) patterns on patients after coronary artery bypass grafting (CABG). TMF, left ventricular (LV) end-diastolic diameter (LVDd) and LV ejection fraction (LVEF) were studied in 102 patients before and after CABG by echocardiography. Patients were subdivided into 4 groups according to TMF patterns during hospital stay shortly after CABG; group 1 (n = 37) had normal filling patterns; group 2 (n = 29) had abnormal relaxation patterns; group 3 (n = 24) had pseudonormal patterns; and group 4 (n = 12) had restrictive patterns. One year after CABG, LVDd was greater and LVEF was lower in groups 3 and 4 than in groups 1 and 2, although there were no significant differences in LVDd and LVEF among the 4 groups before and shortly after CABG. During the follow-up period of 29 +/- 20 months, 19 patients had cardiac events. The incidence of cardiac events in groups 3 and 4 determined by the Kaplan-Meier method was significantly higher than that in groups 1 and 2 (Mantel-Cox test, p <0.01). Patients' gender, clinical findings, and echocardiographic variables were compared for their ability to predict cardiac events by means of the Cox proportional hazards model, and only the LVDd and TMF patterns during the hospital stay after CABG were recognized as independent predictors of cardiac events (chi-square 4.9 and 11.3, respectively; p <0.05). Pseudonormal or restrictive TMF patterns during hospital stay shortly after CABG are useful indicators for predicting outcome.

Noninvasive differentiation of normal from pseudonormal/restrictive mitral flow using TEI index combining systolic and diastolic function

Differentiation of normal from pseudonorma/restrictive mitral flow is not necessarily easy. Pseudonormal/restrictive flow is usually associated with left ventricular (LV) dysfunction, which can be detected using the TEI index, combining systolic and diastolic function. The purpose of this study was to test the feasibility of using the TEI index to differentiate pseudonormal/restrictive from normal mitral flow. In 33 patients with mitral flow E/A > or = 1 and LV mid-diastolic pressure measured by catheterization, the LV volumes, mitral E and A velocity, deceleration time of the E velocity, and the TEI index, defined as the sum of the isovolumic contraction and relaxation time divided by ejection time, were evaluated using Doppler echocardiography. Pseudonormal/restrictive mitral flow was defined as mitral flow E/A > or = 1 associated with LV mid-diastolic pressure > 12 mmHg. There were 22 and 11 patients with normal and pseudonorma/restrictive mitral flow, respectively. Among the indices of LV function, the TEI index achieved the best correlation with LV mid-diastolic pressures (r2 = 0.63, p < 0.0001). By setting the TEI index > or = 0.65 as the criteria for pseudonormal/restrictive mitral flow, this diagnosis had sensitivity, specificity, and accuracy of 82%, 96%, and 91%, respectively. TEI index allows noninvasive differentiation of pseudonormal /restrictive from normal mitral flow.

Relation of early changes of QT dispersion to changes in left ventricular systolic and diastolic function after a first acute myocardial infarction

OBJECTIVE

To describe the relation between changes of left ventricular systolic and diastolic function and changes of QT dispersion (difference in duration between longest and shortest QT interval) following acute myocardial infarction.

DESIGN

QT dispersion was determined at admission, hospital discharge, and 1 and 3 months following myocardial infarction in 64 consecutive 1-year survivors. Patients were divided into Group A where QT dispersion was < 52 ms at all recordings or initially > 52 ms but decreased during follow-up, and Group B where QT dispersion remained increased > or = 52 ms at all measurements. Doppler-Echocardiography was carried out on day 1, day 5, and after 1, 3, and 12 months.

RESULTS

In 26 patients QT dispersion remained increased > or = 52 ms during the first 3 months after infarction. Among these a significant increase of end-systolic volume was seen whereas low or rapid normalized QT dispersion was associated with a significant decrease of ventricular volumes. After 1 year end-systolic (70 +/- 32 ml vs 49 +/- 16 ml, p = 0.006) and end-diastolic volumes (138 +/- 41 ml vs 105 +/- 22 ml, p = 0.001) were higher in Group B. In a multivariate model Group B was significantly related to an increase of end-diastolic volume (p = 0.01). In Group A diastolic function improved in eight patients and in two it deteriorated, whereas improvement was seen in one patient and deterioration in nine patients from Group B (p < 0.01).

CONCLUSION

Following myocardial infarction low QT dispersion is associated with preserved left ventricular function, whereas persistently increased dispersion is associated with left ventricular dilation and deterioration of diastolic function.

Pseudonormal mitral filling pattern predicts hospital re-admission in patients with congestive heart failure

OBJECTIVES

We sought to investigate whether pseudonormal (PN) filling was associated with death or hospital admission in patients with congestive heart failure (CHF).

BACKGROUND

The high mortality rate associated with CHF is related to many clinical and echocardiographic variables. In particular, a short mitral deceleration time and restrictive diastolic filling predict death and/or hospital admission. We hypothesized that differentiating patients with nonrestrictive filling might identify an intermediate PN group that may be associated with intermediate risk.

METHODS

A total of 115 patients admitted to the hospital for exacerbation of CHF symptoms underwent pre-discharge Doppler echocardiography to determine mitral inflow (before and after preload reduction) and pulmonary venous return. Patients were followed up for one year, and all-cause mortality and re-admission data were analyzed.

RESULTS

The classification of filling patterns was: abnormal relaxation (AR) in 46 (40%) patients, pseudonormal (PN) filling in 42 (36.5%) patients and restrictive filling pattern (RFP) in 27 (23.4%) patients. When comparing the RFP group with the AR group, all-cause mortality was higher (38.4% vs. 17.4%, p = 0.033), hospital admission was higher (70.3% vs. 54.3%, p = 0.073), death/hospital admission was higher (77.8% vs. 56.5%, p = 0.02), CHF hospital admission was higher (40.7% vs. 15.2%, p = 0.01) and death/CHF hospital admission was higher (62.9% vs. 26.1%, p = 0.0005). Mortality in the PN group was not significantly different from that in the two other groups, but re-admissions were higher than the AR group (76.2% vs. 54.3%, p = 0.006), as was death/re-admission (78.6% vs. 56.5%, p = 0.004) and death/CHF re-admission (47.6% vs. 26.1%, p = 0.03). Re-admissions in the PN and RFP groups were comparable.

CONCLUSIONS

In a general hospital population of older patients with CHF, PN filling was associated with hospital admission rates similar to those seen with restrictive filling. The combined end point of death/CHF hospital admission was similar for restrictive filling and AR. Measurement of these variables is easy to add to routine clinical echocardiography and may provide important prognostic information in a wide range of patients with CHF.

Echocardiographic assessment of diastolic function

Abnormal diastolic function is increasingly appreciated as a major contributor to cardiac morbidity and mortality. Accurate noninvasive assessment of the presence and severity of diastolic impairment is crucial to the broad application and understanding of this common condition. Echocardiographic parameters have become the backbone of this noninvasive assessment. Active investigation into both old and new Doppler variables will provide the framework that can lead to a more uniform assessment and reporting that will be essential as we prepare to confront clinically the next frontier in cardiac pathophysiology. This review discusses the clinical impact of recent echocardiographic contributions to the field of diastology.