How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology

Diastolic dysfunction in diabetes and the metabolic syndrome: promising potential for diagnosis and prognosis

Cardiac disease in diabetes mellitus and in the metabolic syndrome consists of both vascular and myocardial abnormalities. The latter are characterised predominantly by diastolic dysfunction, which has been difficult to evaluate in spite of its prevalence. While traditional Doppler echocardiographic parameters enable only semiquantitative assessment of diastolic function and cannot reliably distinguish perturbations in loading conditions from altered diastolic functions, new technologies enable detailed quantification of global and regional diastolic function. The most readily available technique for the quantification of subclinical diastolic dysfunction is tissue Doppler imaging, which has been integrated into routine contemporary clinical practice, whereas cine magnetic resonance imaging (CMR) remains a promising complementary research tool for investigating the molecular mechanisms of the disease. Diastolic function is reported to vary linearly with age in normal persons, decreasing by 0.16 cm/s each year. Diastolic function in diabetes and the metabolic syndrome is determined by cardiovascular risk factors that alter myocardial stiffness and myocardial energy availability/bioenergetics. The latter is corroborated by the improvement in diastolic function with improvement in metabolic control of diabetes by specific medical therapy or lifestyle modification. Accordingly, diastolic dysfunction reflects the structural and metabolic milieu in the myocardium, and may allow targeted therapeutic interventions to modulate cardiac metabolism to prevent heart failure in insulin resistance and diabetes.

Clinicopathological profiles of progressive heart failure in hypertrophic cardiomyopathy

AIMS

Hypertrophic cardiomyopathy (HCM) is an important cause of heart failure-related disability over a wide range of ages. Profiles of severe progressive heart failure symptoms and death, or heart transplantation deserve more complete definition within large patient cohorts.

METHODS AND RESULTS

Clinical and morphological features of heart failure were assessed in 293 consecutive HCM patients over a median follow-up of 6 (inter-quartile range 2-11) years. Gross and histopathological features were analysed in 12 patients for whom the heart was available for inspection. Of the 293 patients, 50 (17%) developed severe progressive heart failure, including 18 who died or were transplanted. Three profiles of heart failure were identified predominantly associated with: (i) end-stage systolic dysfunction (ejection fraction <50%) (15; 30%); (ii) left ventricular (LV) outflow obstruction at rest (11; 22%); and (iii) non-obstructive with preserved systolic function (24; 48%). Overall, atrial fibrillation (AF) contributed to heart failure in 32 patients (64%) among the three profiles. Compared with other patients, those non-obstructive with preserved systolic function had earlier onset of heart failure symptoms mainly due to diastolic dysfunction, and the most accelerated progression to advanced heart failure and adverse outcome (P = 0.04). Thrombi were identified in the left atrial appendage of five gross heart specimens all belonging to patients with AF, including three of which were unrecognized clinically and had previously embolized. Extensive myocardial scarring with LV remodelling was evident in all end-stage patients; no or only focal scars were present in other patients.

CONCLUSION

Profiles of advanced heart failure in HCM are due to diverse pathophysiological mechanisms, including LV outflow obstruction and diastolic or global systolic ventricular dysfunction. Atrial fibrillation proved to be the most common disease variable associated with progressive heart failure. Recognition of the heterogeneous pathophysiology of heart failure in HCM is relevant, given the targeted management strategies necessary in this disease.

Global strain rate imaging for the estimation of diastolic function in HFNEF compared with pressure-volume loop analysis

AIMS

Strain rate imaging provides direct information on intrinsic myocardial function and may improve the diagnostic of diastolic dysfunction in heart failure with normal ejection fraction (HFNEF). We therefore correlated global strain with pressure-volume (PV) loop analysis and compared it with flow and tissue Doppler measurements.

METHODS AND RESULTS

Longitudinal two-dimensional strain rate and flow and tissue Doppler (TDI) indices were measured simultaneously and correlated with diastolic indices of PV relationship obtained by a conductance catheter in 21 patients with HFNEF and 12 controls. HFNEF patients showed a reduced global strain rate during isovolumetric relaxation (SR(IVR)) [0.27 (0.12-0.39) vs. 0.44 (0.29-0.56) s(-1), P = 0.028]. Global strain rate during early (SR(E)) and late (SR(L)) diastole did not defer from controls. Their ratios with early transmitral flow, E/SR(IVR) and E/SR(E), were both elevated in HFNEF [3.68 (2.57-7.52) vs. 1.73 (1.47-2.37) m, P = 0.007 and 1.13 (0.76-1.36) vs. 0.83 (0.57-1.04) m, P = 0.030]. SR(E) and SR(IVR) correlated with left ventricular (LV) relaxation τ (r = 0.40 and 0.47, P < 0.05); E/SR(IVR) and E/SR(E) with LV end-diastolic pressure (r = 0.49 and 0.57, P < 0.01) and LV stiffness constant β (r = 0.42 and 0.43, P < 0.01). Neither of the strain rate indices were significantly more accurate than TDI (area under the curve: SR(E) 0.55, SR(IVR) 0.70, E'/A' 0.72, E/SR(E) 0.75, E/SR(IVR) 0.80, and E/E' 0.83).

CONCLUSION

Strain rate imaging is accurate in detecting increased LV stiffness in HFNEF, but it is not superior to already established TDI analysis including E/E' in patients with only mild degree of disease.

Association of left ventricular diastolic dysfunction with elevated NT-pro-BNP in general intensive care unit patients with preserved ejection fraction: a complementary role of tissue Doppler imaging parameters and NT-pro-BNP levels for adverse outcome

The mechanisms of the N-terminal-pro-brain natriuretic peptide (NT-pro-BNP) release in intensive care unit (ICU) patients with preserved ejection fraction (EF) are unclear. We investigated whether left ventricular (LV) dysfunction, as assessed by tissue Doppler imaging (TDI), is related to NT-pro-BNP levels in ICU patients with preserved EF and has a complementary value to NT-pro-BNP in the determination of in-hospital mortality. We examined 58 mechanically ventilated patients with no history of heart failure (age, 60 +/- 18 years; EF, 63% +/- 7%). The systolic (S) and early diastolic (E') velocity of the mitral annulus by TDI and the E/E' as well as NT-pro-BNP, troponin, lactate acid, blood oxygen (P(O2)/Fi(O2)), sepsis, and ICU mortality were assessed. Systolic, E', and E/E' correlated with age, P(O2)/Fi(O2), lactate acid, NT-pro-BNP, troponin, history of arterial hypertension, and diabetes (P < 0.05). By multivariate analysis, the determinants of NT-pro-BNP were S (P = 0.024), E/E' (P = 0.017), and sepsis (P = 0.015). An NT-pro-BNP greater than 941 pg/mL was a reliable predictor of LV diastolic dysfunction defined as a composite of E' less than or equal to 8 cm/s and/or mean E/E greater than or equal to 13 (area under the curve, 75%; P = 0.03). Patients with combined NT-pro-BNP greater than 941 pg/mL and abnormal TDI markers had increased creatinine levels and a lower MAP, P(O2)/Fi(O2), and survival rate than those with abnormal TDI or NT-pro-BNP alone or patients with normal TDI markers and NT-pro-BNP (25%, 60%, 70%, and 84%, respectively; P < 0.05). The addition of abnormal TDI in a model including NT-pro-BNP and sepsis increased the model's value for in-hospital mortality (P for change = 0.01). In ICU patients with preserved EF, LV diastolic dysfunction and sepsis determine NT-pro-BNP levels. Tissue Doppler imaging markers and NT-pro-BNP have a complementary value for in-hospital mortality.

Do additional echocardiographic variables increase the accuracy of E/e' for predicting left ventricular filling pressure in normal ejection fraction? An echocardiographic and invasive hemodynamic study

BACKGROUND

There are few data on adding left atrial volume index (LAVi) or pulmonary artery systolic pressure (PAP) to the ratio of early mitral inflow to mitral annular velocity (E/e') for the estimation of left ventricular (LV) filling pressure in patients with preserved LV ejection fractions (LVEFs) (>50%).

METHODS

Patients underwent echocardiography within 20 minutes of cardiac catheterization. Echocardiographic variables were compared with invasively measured LV preatrial contraction pressure (pre-A).

RESULTS

Of the 122 patients studied (mean age, 55 +/- 9 years; mean LVEF, 61 +/- 6%), 67 (55%) were women, 108 (88%) had hypertension, and 79 (65%) had significant coronary artery disease at catheterization. E/e' was significantly correlated with pre-A (R = 0.63, P < .0001) compared with LAVi (R = 0.49, P < .001) and PAP (R = 0.48, P < .001). E/e' > 13 had sensitivity of 70% and specificity of 93% (area under the curve [AUC], 0.82; P < .0001), LAVi > 31 mL/m2 had sensitivity of 78% and specificity of 76% (AUC, 0.80, P < .001), and PAP > 28 mm Hg had sensitivity of 80% and specificity of 64% for pre-A > 15 mm Hg (AUC, 0.77, P < .001). Adding LAVi >31 mL/m2 for E/e' = 8 to 13 significantly increased the accuracy of E/e' > 13 alone (sensitivity, 87%; specificity, 88%; AUC, 0.89; P = .01 for comparison). However, adding PAP > 28 mm Hg for E/e' = 8 to 13 did not significantly increase the accuracy of E/e' > 13 alone (AUC, 0.82; sensitivity, 82%; specificity, 72%; P = NS for comparison).

CONCLUSIONS

In patients with preserved LVEFs, adding LAVi > 31 mL/m2 to E/e' (when E/e' was in the gray zone, but not when E/e' was >13) significantly increased the accuracy of E/e' alone for the estimation of LV filling pressure. These data support the notion of using several, rather than any single, Doppler echocardiographic parameter for the accurate assessment of LV diastolic function.

Normal values for longitudinal function of the right ventricle in healthy women >70 years of age

AIMS

The application of tricuspid annular plane systolic excursion (TAPSE) as an additional echocardiographic tool to analyse right ventricular (RV) systolic function has been recently established and two-dimensional-guided M-mode measurements of systolic long axis function of the RV are simple, repeatable, and highly reproducible. However, rare data are available on normal values. We aimed to analyse normal values in healthy women >70 years of age.

METHODS AND RESULTS

In a cross-sectional survey, we investigated a cohort of randomly selected, non-hospitalized women >70 years of age. History of myocardial infarction, valvular heart disease, and diastolic dysfunction were exclusion criteria. In order to rule out left ventricular or RV dysfunction, a normal left ventricular ejection fraction and normal values of B-type natriuretic peptide (BNP) were necessary prior to study inclusion. A detailed echocardiographic examination was performed. A total of 80 participants were included (mean age 75 +/- 2.6 years). Mean left ventricular ejection fraction was 63.8 +/- 5.7%. Tissue Doppler derived mean E/E' ratio was 10 +/- 2.3. Mean right atrial diameter was 31.3 +/- 4.7 mm. Mean values for RV outflow tract and RV dimension were 27.3 +/- 3.6 and 28.8 +/- 3.7 mm, respectively. Mean TAPSE was 23.7 +/- 3.5 mm. Mean value of BNP was normal (42.5 +/- 35.7 pg/mL).

CONCLUSION

In women >70 years of age without heart failure, structural heart disease, and neurohormonal activation, normal TAPSE values are approximately 24 mm.

Left atrial volume combined with atrial pump function identifies hypertensive patients with a history of paroxysmal atrial fibrillation

Identifying patients at high risk for the occurrence of atrial fibrillation is one means by which subsequent thromboembolic complications may be prevented. Left atrial enlargement is associated with progression of atrial remodeling, which is a substrate for atrial fibrillation, but impaired atrial pump function is also another aspect of the remodeling. Our objective was to differentiate patients with a history of paroxysmal atrial fibrillation using echocardiography. We studied 280 hypertensive patients (age: 66+/-7 years; left ventricular ejection fraction: 65+/-8%), including 140 consecutive patients with paroxysmal atrial fibrillation and 140 age- and sex-matched control subjects. Left atrial volume was measured using the modified Simpson method at both left ventricular end systole and preatrial contraction and was indexed to body surface area. Peak late-diastolic mitral annular velocity was measured during atrial contraction using pulsed tissue Doppler imaging as an atrial pump function. Left atrial volume index measured at left ventricular end systole had a 74% diagnostic accuracy and a 71% positive predictive value for identifying patients with paroxysmal atrial fibrillation; these values for the ratio of left atrial volume index at left ventricular end systole to the peak late-diastolic mitral annular velocity were 82% and 81%, respectively, and those for the ratio of left atrial volume index at preatrial contraction to the peak late-diastolic mitral annular velocity were 86% and 90%, respectively. In conclusion, left atrial size combined with atrial pump function enabled a more accurate diagnosis of a history of paroxysmal atrial fibrillation than conventional parameters.

Pulmonary Vascular Response Patterns to Exercise: Is there a Role for Pulmonary Arterial Pressure Assessment during Exercise in the Post-Dana Point Era?

Pulmonary hypertension (PH) is often diagnosed late in its course when it purports a particularly poor prognosis. Exercise effectively unmasks early forms of several cardiopulmonary diseases but the role of performing pulmonary arterial pressure measurements during exercise in the evaluation of PH remains unclear. Whether pulmonary arterial pressure-flow relationships during exercise may provide a window into earlier diagnosis of functionally significant pulmonary arterial hypertension and left ventricular dysfunction,¹ or add incrementally to our armentarium of diagnostic tests and prognostic indicators in PH, is the topic of active ongoing investigation. Evidence is emerging that abnormal pulmonary arterial pressure response patterns to exercise, when properly indexed to increased blood flow, may help to identify early forms of heart failure and pulmonary arterial hypertension. This article will discuss approaches to performing hemodynamic measurements during exercise as well as the potential clinical utility of identifying normal and abnormal pulmonary vascular response patterns to exercise.

Maximum daily 6 minutes of activity: an index of functional capacity derived from actigraphy and its application to older adults with heart failure

OBJECTIVES

To compare the correlation between the maximum 6 minutes of daily activity (M6min) and standard measures of functional capacity in older adults with heart failure (HF) with that in younger subjects and its prognostic utility.

DESIGN

Prospective, cohort study.

SETTING

Tertiary care, academic HF center.

PARTICIPANTS

Sixty, ambulatory, adults, New York Heart Association (NYHA) Class I to III, stratified into young (50.9 +/- 9.4) and older cohorts (76.8 +/- 8.0).

MEASUREMENTS

Correlation between M6min and measures of functional capacity (6-minute walk test; 6MWT) and peak oxygen consumption (VO(2)) according to cardiopulmonary exercise testing in a subset of subjects. Survival analysis was employed to evaluate the association between M6min and adverse events.

RESULTS

Adherence to actigraphy was high (90%) and did not differ according to age. The correlation between M6min and 6MWT was higher in subjects aged 65 and older than in those younger than 65 (correlation coefficient (r=0.702, P<.001 vs r=0.490, P=.002). M6min was also significantly associated with peak VO(2) (r=0.612, P=.006). During the study, 26 events occurred (2 deaths, 10 hospitalizations, 8 emergency department visits, and 6 intercurrent illnesses). The M6min was significantly associated with subsequent events (hazard ratio=2.728, 95% confidence interval=1.10-6.77, P=.03), independent of age, sex, ejection fraction, NYHA class, brain natriuretic peptide, and 6MWT.

CONCLUSION

The high adherence to actigraphy and association with standard measures of functional capacity and independent association with subsequent morbid events suggest that it may be useful for monitoring older adults with HF.

Advances in diastolic heart failure

More than 50% of people living with congestive heart failure have diastolic heart failure (DHF). Most of them are older than 70 years, and female. The prevalence of DHF has increased with time. DHF is caused by left ventricular (LV) diastolic dysfunction (DD) which is induced by diastolic dyssynchrony. Cardiac and extracardiac factors play important roles in the development of heart failure (HF) symptoms. The diagnosis of DHF is generally based on typical symptoms and signs of HF, preserved or normal LV ejection fraction, DD and no valvular abnormalities on examination, using noninvasive and invasive methodologies. The outcomes with pharmacological therapy in patients with DHF are frequently neutral in clinical trials, and prognosis still remains poor with a 5-year mortality of 42.3% after hospitalization for HF. Further trials are necessary.

Treatment of heart failure with normal ejection fraction: an inconvenient truth!

Despite use of similar drugs, outcomes of recent heart failure (HF) trials were frequently neutral in heart failure with normal left ventricular ejection fraction (HFNEF) and positive in heart failure with reduced left ventricular ejection fraction (HFREF). The neutral outcomes of HFNEF trials were often attributed to deficient HFNEF patient recruitment with inclusion of many HFREF or noncardiac patients. Patient recruitment criteria of 21 HFNEF trials were therefore reviewed in reference to diagnostic guidelines for HFNEF. In the 4 published sets of guidelines, a definite diagnosis of HFNEF required the simultaneous and obligatory presence of signs and/or symptoms of HF and evidence of normal systolic left ventricular (LV) function and of diastolic LV dysfunction. In 3 of 4 sets of guidelines, normal systolic LV function comprised both a left ventricular ejection fraction (LVEF) >50% and an absence of LV dilation. Among the 21 HFNEF trials, LVEF cutoff values ranged from 35% to 50%, with only 8 trials adhering to an LVEF >50%. Furthermore, only 1 trial specified a normal LV end-diastolic dimension as an enrollment criterion and only 7 trials required evidence of diastolic LV dysfunction. Nonadherence to diagnostic guidelines induced excessive enrollment into HFNEF trials of HF patients with eccentric LV remodeling and ischemic heart disease compared with HF patients with concentric LV remodeling and arterial hypertension. Nonadherence to guidelines also led to underpowered HFNEF trials with a low incidence of outcome events such as death or HF hospitalizations. Future HFNEF trials should therefore adhere to diagnostic guidelines for HFNEF.

Ex Vivo measurements of myocardial viscoelasticity using Shearwave Dispersion Ultrasound Vibrometry (SDUV)

Stiffening of the left ventricle can compromise the ability of the heart to pump sufficient amounts of blood into the systemic circulation and could lead to heart failure. Quantifying mechanical properties of the left ventricular (LV) myocardium using a noninvasive technique would be of great benefit in clinical settings. We investigated the feasibility of using Shearwave Dispersion Ultrasound Vibrometry (SDUV) to measure viscoelasticity of the myocardium. A mechanical actuator was used to induce shear waves at multiple frequencies (40-500 Hz) in excised LV myocardium and urethane rubber samples, and a pulse echo ultrasound transducer was used to detect the motion at each frequency. An anti-symmetric Lamb wave model was fit to the shear wave dispersion curves in four orthogonal directions to obtain elastic and viscous moduli.

Diastolic function measurements and diagnostic consequences: a comparison of pulsed wave- and color-coded tissue Doppler imaging

INTRODUCTION

Tissue Doppler imaging (TDI) plays an important role in assessing diastolic function using echocardiography. However, two different methods [pulsed wave (PW-TDI) and color-coded (CC-TDI)] are currently used. We aimed to compare both measurements.

METHODS

We included 114 patients that were referred to our echocardiography department for evaluation of diastolic left ventricular function. In these patients, we sequentially measured tissue velocities of basal lateral and septal myocardium of the left ventricle in an apical four-chamber view with both PW-TDI and CC-TDI.

RESULTS

Our cohort consisted of a heterogeneous group of patients with and without a history of cardiac disease. Mean age of the patients was 52 +/- 16.7 years, and 62% were males. We found a strong correlation between PW-TDI- and CC-TDI-derived myocardial velocities (r = 0.93; p = 0.001). However, E' (mean of lateral and septal) velocities measured with PW-TDI were consistently higher compared to CC-TDI values [PW-TDI E' 10.3 +/- 3.9 (SD) cm/s vs. CC-TDI E' 7.7 +/- 3.1 cm/s; p < 0.001]. From these data, we calculated that the relation between E' measured with PW-TDI and CC-TDI can be described as: E' (PW-TDI) = 1.25 + 1.17 x E' (CC-TDI). Consequently, E/E' measured with PW-TDI was consistently lower compared with CC-TDI (9.1 +/- 3.1 vs. 12.5 +/- 5.7; p < 0.001) From these data, we calculated that the relation between E/E' measured with PW-TDI and CC-TDI can be described as: E/E' (PW-TDI) = 2.13 + 0.56 x E/E' (CC-TDI).

CONCLUSIONS

Despite a strong correlation, tissue velocities measured with PW-TDI will yield higher values as compared with CC-TDI. This should be taken into account when defining cut-off values for the evaluation of diastolic function.

How to diagnose cardiac amyloidosis early: impact of ECG, tissue Doppler echocardiography, and myocardial biopsy

AIMS

To detect cardiac amyloidosis (CA) earlier, it is inevitable to improve diagnostic strategies.

METHODS AND RESULTS

The impact of ECG, echocardiography including tissue Doppler imaging (TDI) and strain, and myocardial biopsies was evaluated in 30 patients (63% (n = 19) men, mean age 66 +/- 8 years, NYHA 3.0 +/- 0.5, 73% with prior myocardial decompensation), in whom we proved CA. Amyloid was confirmed by apple-green birefringence under polarised light, and the causing protein by immunohistochemical examinations. Genetic analyses excluded familial CA. All patients (AL-lambda (n = 22), AL-kappa (n = 3), senile amyloidosis (n = 5)) had echocardiographic signs of restrictive cardiomyopathy (RCM), typical TDI and strain parameters (E'septal; E' lateral < 8 cm/s; E/E' > 8; S' < or =9 cm/s; global longitudinal strain (GLS) -7.9 +/- 3.8%). Pericardial effusions were present in 63% of patients. ECGs were suspicious in many patients: 19 (63%) had low-voltage, 23 (77%) reduced R waves in V(1)-V(4), and 57% both. Abnormalities, retrospectively had been present for 0.5-4 years. Twenty (67%) patients died 232 +/- 268 [2-1020] days after CA was diagnosed, but 502 +/- 333 [30-1440] days after the first symptom.

CONCLUSION

Accurate ECG evaluations, careful echocardiographic search for RCM, reduced strain/strain rates, and general indications to myocardial biopsies with correct analyses are needed to diagnose CA.

Impact of a high-dose nitrate strategy on cardiac stress in acute heart failure: a pilot study

BACKGROUND

Intravenous nitrate therapy has been shown to improve short-term outcome of acute heart failure patients treated in the intensive care unit. The potential of a noninvasive high-dose nitrate strategy in the Emergency Department and the general ward remains unknown.

METHODS

A total of 128 consecutive acute heart failure patients were either treated with standard therapy or high-dose sublingual and transdermal nitrates on top of standard of care treatment. Cardiac recovery, quantified by B-type natriuretic peptide (BNP) levels during the first 48 h, was the primary endpoint. Secondary endpoints ascertained the safety of the nitrate therapy.

RESULTS

The high nitrate group received higher doses of nitrates during the first 48 h compared to the standard therapy group [82.4 mg (46.2-120.6) vs. 20 mg (10-30) respectively, P < 0.001]. The amount of diuretics given in both groups was similar. BNP levels decreased in all patients (P < 0.0001). However, the BNP decrease was larger in the high-dose nitrate group (P < 0.0001). The larger decrease in BNP in the high-dose nitrate group was already apparent 12 h after the initiation of treatment. After 48 h BNP values decreased by an average of 29 +/- 4.9% in the high-dose nitrate strategy group compared to 15 +/- 5.4% during standard therapy. There was a strong trend towards fewer ICU admissions in the high-dose nitrate group [high-dose nitrates: 2 cases (4%) vs. standard therapy: 9 cases (13%); P = 0.06]. During the study period, no intergroup changes were observed in blood pressure, RIFLE classes of acute kidney injury or troponin T. In-hospital and 90-day outcome was similar amongst the two groups.

CONCLUSIONS

A noninvasive high-dose nitrate strategy on top of standard therapy is safe and notably accelerates cardiac recovery in patients observed on the general ward.

Prediction of transition to chronic atrial fibrillation in elderly patients with nonvalvular paroxysmal atrial fibrillation by transthoracic Doppler echocardiography

BACKGROUND

It is well known that paroxysmal atrial fibrillation (PAF) often precedes the development of chronic atrial fibrillation (CAF).

HYPOTHESIS

The purpose of this study was to determine prospectively whether transthoracic echocardiography is useful for the prediction of the transition to CAF in elderly patients with nonvalvular PAF.

METHODS

Forty-two consecutive elderly patients (> or =65 years) with nonvalvular PAF were prospectively evaluated after undergoing transthoracic echocardiography. The study endpoint was the transition to CAF (AF; > or = 6 mo).

RESULTS

During a follow-up period of 32 +/- 24 mo, 12 patients developed CAF. Patients with CAF had a significantly lower peak A velocity (A) and a higher E/A ratio of the transmitral inflow (TMF) such as a pseudonormalization pattern, and a lower peak atrial reversal wave velocity, higher peak diastolic wave velocity (D), and lower peak systolic/diastolic wave velocity ratio (S/D ratio) of the pulmonary venous flow (PVF). Kaplan-Meier analysis revealed that the transition to CAF was observed more often when A was < or = 70 cm/sec and E/A ratio was > or = 1.07 of TMF, and D was > or = 44 cm/sec and the S/D ratio was < or = 1.34 of PVF. All patients developed CAF when the E/A ratio was > or = 1.15 or the S/D ratio was < or = 0.75.

CONCLUSIONS

This prospective study suggests that elderly patients at high risk for transition to CAF have a pseudonormalization pattern of TMF and a diastolic dominant pattern of PVF, and that transthoracic Doppler estimation of TMF and PVF may be useful in identifying elderly patients at high risk for the transition from nonvalvular PAF to CAF.

Uncoupled cardiac nitric oxide synthase mediates diastolic dysfunction

BACKGROUND

Heart failure with preserved ejection fraction is 1 consequence of hypertension and is caused by impaired cardiac diastolic relaxation. Nitric oxide (NO) is a known modulator of cardiac relaxation. Hypertension can lead to a reduction in vascular NO, in part because NO synthase (NOS) becomes uncoupled when oxidative depletion of its cofactor tetrahydrobiopterin (BH(4)) occurs. Similar events may occur in the heart that lead to uncoupled NOS and diastolic dysfunction.

METHODS AND RESULTS

In a hypertensive mouse model, diastolic dysfunction was accompanied by cardiac oxidation, a reduction in cardiac BH(4), and uncoupled NOS. Compared with sham-operated animals, male mice with unilateral nephrectomy, with subcutaneous implantation of a controlled-release deoxycorticosterone acetate pellet, and given 1% saline to drink were mildly hypertensive and had diastolic dysfunction in the absence of systolic dysfunction or cardiac hypertrophy. The hypertensive mouse hearts showed increased oxidized biopterins, NOS-dependent superoxide production, reduced NO production, and dephosphorylated phospholamban. Feeding hypertensive mice BH(4) (5 mg/d), but not treating with hydralazine or tetrahydroneopterin, improved cardiac BH(4) stores, phosphorylated phospholamban levels, and diastolic dysfunction. Isolated cardiomyocyte experiments revealed impaired relaxation that was normalized with short-term BH(4) treatment. Targeted cardiac overexpression of angiotensin-converting enzyme also resulted in cardiac oxidation, NOS uncoupling, and diastolic dysfunction in the absence of hypertension.

CONCLUSIONS

Cardiac oxidation, independently of vascular changes, can lead to uncoupled cardiac NOS and diastolic dysfunction. BH(4) may represent a possible treatment for diastolic dysfunction.

Heart failure burden and therapy

Heart failure (HF) is a syndrome with a broad spectrum of heterogeneous symptoms and signs resulting in a wide range of clinical expressions. The prevalence of HF is estimated to be 1-2% in developed countries, increasing with age. Heart failure is the leading cause of hospitalization for patients older than 65 years, raising concerns about the economic burden of this syndrome. This article provides a critical review of epidemiological and clinical aspects for HF; causes, comorbidities, and types of HF are also described. The systolic vs. diastolic, the acute vs. chronic approaches, and the connections between HF and left bundle branch block or atrial fibrillation are further detailed. In addition, a synthesis of the latest results and recommendations concerning the indication and the prescription of pharmacological (such as diuretics or rennin-angiotensin-aldosterone system inhibitors) and non-pharmacological treatments (particularly device therapy) is proposed.

Exercise and Weight Loss Improve Exercise Capacity Independent of Cardiac Function in Metabolic Syndrome

Hypertension, diabetes and obesity cause cardiac diastolic dysfunction (DD) which could reduce exercise capacity. Our aim was to determine if 10% weight loss by exercise at 60% VO2max five days/week (~-375 kcal/session) and caloric restriction (~-600 kcal/d) over 6 months improves exercise capacity and DD in Metabolic syndrome (MetS). Eighteen subjects (40 ± 1y, women = 6, BMI = 33.5 ± 1.0 kg/m2) successfully completed the study. Maximal treadmill stress echocardiography was performed at baseline and post weight loss to determine VO2max, resting and stress DD as the ratio of peak early diastolic mitral inflow velocity (E) to tissue Doppler early diastolic annular decent (E’). After weight loss (mean = 9.5 ± 0.2%), all metabolic parameters improved. Resting and stress E/E’ values remained normal before and after weight loss. Exercise intolerance is likely due to general deconditioning and not cardiac dysfunction in early MetS as VO2max increases significantly with lifestyle while cardiac function remains unchanged.

Left ventricular hypertrophy increases cardiovascular risk independently of in-office and out-of-office blood pressure values

OBJECTIVES

Previous studies have shown that left ventricular hypertrophy (LVH) represents a cardiovascular risk factor independently of clinic blood pressure (BP). The present study was aimed at determining the impact of LVH on the incidence of cardiovascular morbid and fatal events taking into account not only classical risk factors but also home and ambulatory BP values, which have been shown to have an important independent prognostic impact.

METHODS

In 1716 patients belonging to the 'Pressioni Arteriose Monitorate E Loro Associazioni' population of Monza, we quantified left ventricular mass index and identified LVH by standard cutoff values. We also measured clinic, home and 24-h ambulatory BPs together with serum glucose and lipids.

RESULTS

During a follow-up of 148 months, the rate of fatal and nonfatal (hospitalizations) cardiovascular events as well as of all-cause death was markedly greater (four-fold to five-fold) in patients as compared with those without LVH. In LVH individuals, the increased risk remained significant even when data were adjusted for a large number of other confounding factors including home BP, 24-h mean BP and ambulatory BP. Results were similar when left ventricular mass was indexed by height and body surface area. A 10% increase in left ventricular mass index was associated with a significant increase in cardiovascular risk or all-cause deaths. In multivariate analysis, left ventricular mass index was always an independent predictor of cardiovascular events and death for any cause.

CONCLUSION

Our data provide evidence that LVH is an important risk factor even when the contribution of different BPs to risk is fully taken into account.

Cardiac diastolic dysfunction and metabolic syndrome in young women after placental syndrome

OBJECTIVE

To estimate whether women with a recent history of a placental syndrome and concomitant metabolic syndrome have reduced cardiac diastolic function.

METHODS

In this cohort study, women with a history of a placental syndrome were included. We assessed body mass index, blood pressure, fasting serum lipids, glucose and insulin levels, and 24-hour urinary protein and albumin output after an interval of at least 6 months postpartum. Cardiac diastolic function was assessed by echocardiography.

RESULTS

Metabolic syndrome was found in 22% of the women evaluated. Diastolic dysfunction was seen in 24% of the women with the metabolic syndrome compared with 6.3% in those without (odds ratio 4.77, 95% confidence interval 2.18-10.41; adjusted odds ratio 6.09, 95% confidence interval 2.64-14.04). Univariable analysis showed that all the constituents of the metabolic syndrome related to diastolic dysfunction.

CONCLUSION

In women with a history of placental syndrome complicating pregnancy, the presence of metabolic syndrome increases the risk of cardiac diastolic dysfunction fourfold.

LEVEL OF EVIDENCE

II.

Brain natriuretic peptide is related to diastolic dysfunction whereas urinary albumin excretion rate is related to left ventricular mass in asymptomatic type 2 diabetes patients

Background

The aims of this study were to estimate the prevalence of left ventricular systolic (LVSD) and diastolic (LVDD) dysfunction, and to test if BNP and urinary albumin excretion rate (AER) are related to LVSD, LVD and left ventricular mass (LVM) in asymptomatic type 2 diabetes patients.

Methods

Presence of LVSD, LVDD and LVM, determined with echocardiography, was related to levels of BNP and AER in 153 consecutive asymptomatic patients with type 2 diabetes.

Results

LVSD was present in 6.1% of patients whereas 49% (29% mild, 19% moderate and 0.7% severe) had LVDD and 9.4% had left ventricular hypertrophy. Increasing age (P < 0.0001) was the only independent variable related to mild LVDD whereas increasing BNP (P = 0.01), systolic blood pressure (P = 0.01), age (P = 0.003) and female gender (P = 0.04) were independent determinants of moderate to severe LVDD. AER (P = 0.003), age (P = 0.01) and male gender (P = 0.006) were directly and independently related to LVM.

Conclusion

About half of asymptomatic type 2 diabetes patients have LVDD. Of those, more than one third display moderate LVDD pattern paralleled by increases in BNP, suggesting markedly increased risk of heart failure, especially in females, whereas AER and male sex are related to LVM.

Myocardial fibrosis and diastolic dysfunction in patients on chronic haemodialysis

BACKGROUND

Left ventricular (LV) diastolic dysfunction is linked to myocardial collagen content in many cardiac diseases. There are no data regarding such relationship in patients with end-stage renal disease (ESRD) undergoing haemodialysis.

METHODS

Twenty-five patients with ESRD undergoing haemodialysis were studied by echocardiography. LV diastolic function was investigated by Doppler echocardiography, by analysing LV filling velocities at rest and during loading manoeuvres, which represent an estimate of LV filling pressure. According to the Doppler pattern, LV filling pressure in a given patient was judged to be normal or slightly increased or to be moderately or severely increased. The presence of myocardial fibrosis was estimated by ultrasound tissue characterization with integrated backscatter, which in diastole correlates with the collagen content of the myocardium.

RESULTS

Integrated backscatter was higher in patients with moderate or severely increased than in patients with normal or slightly increased LV filling pressure (integrated backscatter: 51.0 +/- 9.8 vs 41.6 +/- 5.6%; P = 0.008). Integrated backscatter was a strong and independent determinant of diastolic dysfunction (odds ratio = 1.212; P = 0.040).

CONCLUSION

Our data support the hypothesis that, in a selected population of patients with ESRD undergoing haemodialysis, myocardial fibrosis is associated with LV diastolic myocardial properties.

Left ventricular torsion parameters are affected by acute changes in load

BACKGROUND

Quantification of left ventricular torsion may provide new indices of systolic and diastolic function. We sought to characterize the effect of acute manipulation of load on cardiac torsion, plecotropy in human subjects.

METHODS

Simultaneous Millar LV pressure, micromanometry, and echocardiograms were performed on 18 patients (10 male, mean age 66 years) with normal systolic function. Loading was altered sequentially by the administration of glyceryl trinitrate (GTN) and saline fluid loading. Echocardiographic speckle tracking imaging was used to quantify LV torsion and event timing was recorded relative to mitral valve opening (MVO).

RESULTS

GTN administration decreased preload (LV end diastolic pressure: 15.7 vs 8.4 mmHg, P < 0.001), and afterload (wall stress: 140 vs 84 x10(3)dyn/cm(2), P < 0.02). Administration of fluid increased preload (LVEDP 11.3 vs 18.1 mmHg, P < 0.001) and increased wall stress, but to a lesser extent (102 vs 117 x10(3)dyn/cm(2), P < 0.003). GTN administration augmented peak torsion (8.4 vs 11.0 deg, P < 0.05), increased systolic torsion velocity (46.6 vs 65.3deg/sec, P < 0.01) and resulted in earlier onset of untwisting (-105 vs -127ms, P < 0.05). Fluid loading decreased the proportion of untwisting prior to MVO (39.0 vs 31.0%, P < 0.05), untwisting acceleration (-750 vs -592deg/sec/sec, P < 0.05) and delayed the timing of peak untwisting (-37.0 vs 9.1ms, P < 0.01), but did not affect systolic torsion parameters.

CONCLUSIONS

Left ventricular torsion parameters are sensitive to acute changes in load and therefore need to be interpreted in the context of current loading conditions.

Simultaneous estimation of NT-proBNP on top to mitral flow Doppler echocardiography as an accurate strategy to diagnose diastolic dysfunction in HFNEF

BACKGROUND

Conventional echocardiography has limited accuracy in detecting diastolic dysfunction and NT-proBNP is known to be a reliable biomarker to rule out heart failure. Therefore NT-proBNP on top to conventional mitral flow Doppler might improve the diagnostic of diastolic dysfunction in patients with heart failure despite normal EF (HFNEF) without using tissue Doppler.

METHODS AND RESULTS

Diastolic function of 46 patients with HFNEF was determined by pressure-volume loop obtained by conductance-catheter measurements. LV stiffness correlated with the amount of collagen types I and III analyzed from endomyocardial biopsies (EMBs). NT-proBNP plasma levels correlated with LV stiffness, LVEDP and the collagen amount from EMBs (p<0.01). In another set of patients with HFNEF (n=107, 53 [45-62] years), diastolic dysfunction was confirmed by left and/or right heart catheterization. Their Doppler indices and plasma marker NT-proBNP values were compared with those of 73 controls (186 [70-342] vs 54[30-75] pg/ml, p<0.001). Mitral flow Doppler was impaired in 70/107 (65%) of the HFNEF. When additional criterium NT-proBNP>125 pg/ml was used 96/107 (90%) patients with impaired diastolic function were recognized. Sensitivity of tissue Doppler indices E'/A' and E/E' were improved by 4-6% using NT-proBNP on top. NT-proBNP recognized HFNEF patients with higher hospitalization rate indicated by phone questionnaire, whereas Doppler indices alone did not.

CONCLUSION

Plasma NT-proBNP levels are associated with increased LV stiffness and cardiac collagen content. On top measurements of plasma NT-proBNP improve the echocardiography diagnostic of diastolic function and prognostic of rehospitalization in HFNEF.

Natriuretic peptides in the detection of preclinical diastolic or systolic dysfunction

AIMS

The diagnostic value of natriuretic peptides in asymptomatic patients at risk for diastolic or systolic HF is controversial. We tested (1) the prevalence of preclinical LV dysfunction in an at-risk cohort; (2) the diagnostic accuracy of natriuretic peptides alone or in combination with clinical parameters for predicting asymptomatic left ventricular systolic or diastolic dysfunction.

METHODS

542 primary care patients (mean age 63 +/- 11 years, 42% female) without prediagnosed HF, but with risk factors for left ventricular dysfunction, underwent thorough cardiological workup, including echocardiography and analysis of natriuretic peptides.

RESULTS

23 patients (4%) showed reduced systolic function (EF < 50%), and 15 patients (3%) had severe diastolic dysfunction. All natriuretic peptides significantly increased with decreasing ejection fraction and with increasing degree of diastolic dysfunction. For natriuretic peptides, receiver operating characteristics analysis yielded good results for the detection of systolic dysfunction or severe diastolic dysfunction. Combining clinical parameters with natriuretic peptide data improved the diagnostic accuracy and largely reduced the number of needed screening echoes to identify patients with LV systolic or diastolic dysfunction.

CONCLUSIONS

The prevalence of preclinical diastolic dysfunction is high in primary care patients at risk, but the relative prevalence of severe diastolic dysfunction and systolic dysfunction is only 7%. High-risk individuals may be screened most efficiently by using a score system incorporating clinical data and NT-proBNP.

Combining blood flow and tissue Doppler imaging with N-terminal pro-type B natriuretic peptide for risk stratification of clinically stable patients with systolic heart failure

AIMS

This study was designed to ascertain whether the combination of Doppler assessment of the ratio of mitral blood flow to myocardial early diastolic velocities (E/E(m) ratio) and plasma N-terminal pro-type B natriuretic peptide (NT-proBNP) testing is useful to better stratify patients with stable systolic heart failure (HF).

METHODS AND RESULTS

A total of 362 outpatients with chronic systolic HF (left ventricular ejection fraction <or=45%) underwent clinical assessment, NT-proBNP testing, and comprehensive echo-Doppler study. The endpoint was all-cause mortality or HF-related hospital admissions (i.e. hospitalization for worsening HF, biventricular pacemaker implantation, or mitral valve surgery). Median follow-up duration was 25 months. Two hundred and fifty-nine patients were judged clinically stable by a Framingham's criteria-based HF score. In multivariate Cox's proportional hazards analysis, plasma NT-proBNP (P< 0.0001) and E/E(m) ratio (P= 0.04) were among the significant predictors of the combined endpoint. Survival free from cardiac mortality and HF-related hospitalization was 55% in patients with the E/E(m) ratio in the higher third (>or=12), 77% in those with the E/E(m) ratio in the intermediate third, and 86% in those with the E/E(m) ratio in the lower third (<or=7) (P< 0.0001). By stratifying patients according to NT-proBNP above the median, patients' outcome was predicted in 13 out of 17 in the intermediate third (P = 0.002) and in 9 out of 10 in the lower third of E/E(m) ratio (P= 0.005).

CONCLUSION

In patients with stable HF categorized according to the E/E(m) ratio, NT-proBNP testing improves risk stratification, particularly in those with minor degrees of diastolic dysfunction.

Echocardiography in 2009: the future of clinical diagnosis

Over the past 10 years we have observed a tremendous expansion on cardiovascular imaging with breathtaking images observing all aspects of the cardiac anatomy and functions. So much so that each imaging modality has grown to the point that one single individual cannot possess all the required expertise for its optimal use and the need for subspecialization in the various imaging modalities is crucial. Echocardiography has surprised many for its ability to adapt in the ever increasing demand and the discovery of the many new modalities. These include 3D and deformation imaging, as well as contrast utilization during the studies, which will continue to put echocardiography in a league of its own in terms of patients management. Some basic descriptions of the various modalities are summarized and their contribution to a number of clinical scenarios, today and in the future, are explored.

Current controversies in heart failure with a preserved ejection fraction

Heart failure with a preserved ejection fraction is a fascinating and multifaceted condition that has provoked enormous debate and a wealth of mechanistic studies. Controversies exist with regard to its nomenclature. If its nomenclature is questioned, one can be certain the pathogenesis is ill understood. If the pathogenesis is disputed, the diagnosis becomes difficult and inconsistent. These diagnostic challenges result in inappropriate recruitment to clinical trials. Therefore, the trials may be underpowered and difficult to interpret. This paper examines contemporary theories of heart failure with a preserved ejection fraction, clarifies the controversies and attempts to resolve the divergences of opinion.

Left ventricular function in gestational hypertension: serial echocardiographic study

BACKGROUND

Gestational hypertension (GH) is associated with hemodynamic changes, and alterations of systolic and diastolic left ventricular (LV) function. However, the magnitude and pattern of changes of different parameters of LV function and contractility in this patient population have not been fully clarified.

METHODS

Thirty-five pregnant women with GH underwent three echocardiographic examinations, in second and third trimester of pregnancy, and 1 month after delivery. Twelve normotensive pregnant women served as gestational age-matched controls. Hemodynamic parameters and standard indexes of LV systolic and diastolic function were analyzed. Additionally, we have measured peak systolic velocity of mitral annulus (S'), end-systolic elastance (Ees), and early transmitral to early lengthening velocity of mitral annulus ratio (E/E') as parameters of longitudinal function, contractility, and filling, respectively.

RESULTS

Women with GH had initially higher body weight, blood pressure, and heart rate (P < 0.005, P < 0.0001, and P = 0.011, respectively). Temporal analysis of different echocardiographic parameters revealed increase in wall thickness from baseline to second measurement, with consequential increase in LV mass in women with GH (P = 0.014 for septum, P = 0.010 for posterior wall, and P = 0.09 for LV mass). No significant changes of LV volumes, ejection fraction (EF), transmitral flow parameters, S', Ees, and E/E' were observed throughout the follow-up in both groups (P = nonsignificant for all). Importantly, pattern of changes was similar in both groups for all examined parameters (P = nonsignificant between groups, for all).

CONCLUSIONS

It appears that changes of LV longitudinal function, filling, and contractility during pregnancy are not significant and not influenced by GH.

Diagnostic accuracy of emergency Doppler echocardiography for identification of acute left ventricular heart failure in patients with acute dyspnea: comparison with Boston criteria and N-terminal prohormone brain natriuretic peptide

OBJECTIVES

Echocardiography is a fundamental tool in the diagnosis of acute left ventricular heart failure (aLVHF). However, a consultative exam is not routinely available in every emergency department (ED). The authors investigated the diagnostic performance of emergency Doppler echocardiography (EDecho) performed by emergency physicians (EPs) for the diagnosis of aLVHF in patients with acute dyspnea.

METHODS

A convenience sample of acute dyspneic patients was evaluated. For each patient, the Boston criteria score for heart failure was calculated, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) and EDecho were contemporaneously performed. Four investigators, after a limited echocardiography course, performed EDechos and evaluated for a "restrictive" pattern on pulsed Doppler analysis of mitral inflow and reduced left ventricular (LV) ejection fraction. The final diagnosis, established after reviewing all patient clinical data except NT-proBNP and EDecho results, served as the criterion standard.

RESULTS

Among 145 patients, 64 (44%) were diagnosed with aLVHF. The median time needed to perform EDecho was 4 minutes. Pulsed Doppler analysis was feasible in 125 patients (84%). The restrictive pattern was more sensitive (82%) and specific (90%) than reduced LV ejection fraction and more specific than the Boston criteria and NT-proBNP for the diagnosis of aLVHF. Considering noninterpretable values of the restrictive pattern and uncertain values ("gray areas") of Boston criteria (4 < Boston criteria score < 7) and of NT-proBNP (300 < NT-proBNP < 2,200 pg/mL) as false results, the accuracy of the restrictive pattern in the overall population was 75%, compared with accuracy of 49% for both NT-proBNP and Boston criteria.

CONCLUSIONS

EDecho, particularly pulsed Doppler analysis of mitral inflow, is a rapid and accurate diagnostic tool in the evaluation of patients with acute dyspnea.

Diastolic dysfunction, cardiovascular aging, and the anesthesiologist

As the number of persons aged 65 years and older continues to increase, the anesthesiologist will more frequently encounter this demographic. Cardiovascular changes that occur in this patient population present difficult anesthetic challenges and place these patients at high risk of perioperative morbidity and mortality. The anesthesiologist should be knowledgeable about these age-related cardiovascular changes, the pathophysiology underlying them, and the appropriate perioperative management. Whether presenting for cardiac or general surgery, the anesthesiologist must identify patients with altered physiology as a result of aging or diastolic dysfunction and be prepared to modify the care plan accordingly. With a directed preoperative assessment that focuses on certain aspects of the cardiovascular system, and the assistance of powerful echocardiographic tools such as tissue Doppler, this can be achieved.