Prevalence of left ventricular diastolic dysfunction in the community. Results from a Doppler echocardiographic-based survey of a population sample

Screening for ventricular remodeling

Current guidelines emphasize the importance of preventing heart failure (HF) by targeting people with preclinical forms of the disease. Accordingly, there is considerable interest in identifying left ventricular (LV) remodeling, the fundamental substrate for HF, in asymptomatic individuals in the community. Increased LV mass and asymptomatic LV systolic and LV diastolic dysfunction are the remodeling phenotypes that could be potentially considered for population-wide screening. Plasma levels of natriuretic peptides (NP) have been extensively investigated for such screening purposes. However, a majority of investigations suggest that their performance characteristics are suboptimal for identifying LV remodeling phenotypes unless high-risk individuals (eg, older men with hypertension) are targeted. In general, the prevalence of LV systolic dysfunction in women is too low to justify screening. In recent reports, sequential screening strategies combining urine and plasma NP or plasma NP and hand-held portable echocardiography have been advocated as potential approaches to identify asymptomatic LV systolic dysfunction in a cost-effective manner. Additional studies are warranted to confirm these findings.

Characteristics of left ventricular diastolic dysfunction in the community: an echocardiographic survey

OBJECTIVE

To determine the prevalence and predictors of left ventricular (LV) diastolic dysfunction in older adults.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey of 1275 randomly selected residents of Canberra, aged 60 to 86 years (mean age 69.4; 50% men), conducted between February 2002 and June 2003.

MAIN OUTCOME MEASURES

Prevalence of LV diastolic dysfunction as characterised by comprehensive Doppler echocardiography.

RESULTS

The prevalence of any diastolic dysfunction was 34.7% (95% CI 32.1% to 37.4%) and that of moderate to severe diastolic dysfunction was 7.3% (95% CI 5.9% to 8.9%). Of subjects with moderate to severe diastolic dysfunction, 77.4% had an LV ejection fraction (EF) > 50% and 76.3% were in a preclinical stage of disease. Predictors of diastolic dysfunction were higher age (p < 0.0001), reduced EF (p < 0.0001), obesity (p < 0.0001) and a history of hypertension (p < 0.0001), diabetes (p = 0.02) and myocardial infarction (p = 0.003). Moderate to severe diastolic dysfunction with normal EF, although predominantly preclinical, was independently associated with increased LV mass (p < 0.0001), left atrial volume (p < 0.0001), and circulating amino-terminal pro-B-type natriuretic peptide concentrations (p < 0.0001), and with decreased quality of life (p < 0.005).

CONCLUSION

Diastolic dysfunction is common in the community and often unaccompanied by overt congestive heart failure. Despite the lack of symptoms, advanced diastolic dysfunction with normal EF is associated with reduced quality of life and structural abnormalities that reflect increased cardiovascular risk.

Age-Related Hemodynamic and Morphologic Differences in Patients Undergoing Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy

BACKGROUND

Alcohol septal ablation (ASA) decreases the left ventricular (LV) outflow gradient and relieves symptoms in patients with highly symptomatic hypertrophic obstructive cardiomyopathy (HOCM). The aim of this study was to evaluate the early course of hemodynamic, morphologic and clinical changes in younger and elderly patients.

METHODS AND RESULTS

Forty-four consecutive patients (age, 24-81 years) underwent the ASA procedure for HOCM. Clinical and echocardiographic data were obtained at baseline and periodically up to 12 months after ASA. There was a significant correlation between septum thickness and age at baseline and in the early post procedural period (p = 0.004 at baseline, p = 0.0033 days postoperative, p = 0.0193 weeks pos operative). The dependence of septal thickness on the duration of follow-up (p < 0.001) was significantly influenced by age (p = 0.026), which retained statistical significance after multivariate adjustment (p = 0.031). A decrease in the gradient of the LV outflow was identified in all age-related groups of patients (p < 0.001). After multivariate adjustment, there was a significant influence of age (p = 0.003) and creatine kinase-MB peak (p = 0.016) on the course of outflow gradient reduction.

CONCLUSIONS

ASA is an effective treatment option for patients with HOCM, irrespective of their age. Younger patients are characterized by a thicker basal septum at baseline and a slower hemodynamic improvement within the early post procedural period.

Left atrial size in patients with arterial hypertension

INTRODUCTION Left atrial size is increased in patients with arterial hypertension. Left atrial enlargement represents a risk factor of atrial fibrillation and stroke. Left atrial size depends on the effect of many other etiological factors, predominantly by body mass and the left ventricular mass. OBJECTIVE The objective of the study was to investigate the frequency of the left atrial enlargement in patients with arterial hypertension, in obese patients with arterial hypertension and in patients with arterial hypertension and left ventricular hypertrophy. In addition, the aim was to investigate the influence of diastolic function parameters on the left atrial dimension. METHOD The study included 93 patients with arterial hypertension (mean age of 46.9 ? 9.7 years, 50.5% of males) and 33 healthy subjects (mean age 45.6 ?10.6 yrs., 40% of males) who consisted the control group. There was no statistical difference of the age and sex between patients and healthy persons. All patients were examined by the echocardiographic ultrasound device HP Sonos 2500 by three echosonographers. RESULTS The patients with arterial hypertension compared to the control group had significantly higher: body mass index (27.8 ? 4.1 versus 24.3 ? 3.0) (p<0.001), the left ventricular mass (249.7 ? 79.1 versus 174.6 ? 47.7) (p<0,001), the left ventricular mass index (122.2 ? 34.3 versus 96.7 + 20.9)(p<0.001) and the left atrium (3.8 ? 0.7 versus 3.3 ? 0.5) (p<0.001). The frequency of the left atrial enlargement in patients with arterial hypertension was 44.1%. The frequency of the left atrial enlargement In patients with arterial hypertension and the left ventricular hypertrophy was 53.3%, and in obese patients with arterial hypertension was 58.3%. Left ventricular diastolic function parameters in patients with arterial hypertension in relation to control exhibited statistically significant differences: isovolumetric relaxation time (IVRT) was longer (193.2 ? 37.8 versus 175,8 ? 23,6) (p<0.001), deceleration time (DT) was longer (193.2 ?37,8 versus 175.8 ?23.6) (p<0.01) and peak early diastolic filling wave velocity /peak atrial diastolic filling wave velocity ratio (E/A ratio) was lower (1.0 ? 0.3 versus 1.2 ? 0.3) (p<0.01). The quotient of linear correlation of the left ventricular diastolic function parameters in patients with arterial hypertension with left atrial volume did not show any significant correlation. CONCLUSION The left atrial size was statistically bigger in patients with arterial hypertension in relation to healthy subjects. The biggest left atrial enlargement was in hypertensive patients with the left ventricular hypertrophy and obese hypertensive patients. Left ventricular diastolic function parameters in patients with arterial hypertension had no statistically significant influence on the left atrial size.

The emerging role of echocardiography in the screening of patients at risk of heart failure

A large number of patients without symptoms of heart failure (HF) have asymptomatic left ventricular (LV) dysfunction owing to the compensatory mechanisms acting through the autonomic nervous system and neurohormones. In the setting of screening for prevention, one must identify the subgroup of these patients at high risk for symptomatic HF to establish appropriate therapy. As a first step to identify the subgroup of patients at high risk, clinical screening scores and natriuretic peptide measurements are used. Second, the definite diagnosis of asymptomatic LV dysfunction must be confirmed with echocardiography, occasionally with the help of new technologic developments to establish prompt, appropriate treatment to prevent disease progression. Therefore, the screening role of echocardiography is the early identification of patients with structural cardiopathy who are at risk of developing symptomatic HF and detection of those without LV dysfunction (diabetic and hypertensive) whose condition is prone to advance rapidly to structural cardiopathy or to symptomatic HF.

Exercise effects on cardiac size and left ventricular diastolic function: relationships to changes in fitness, fatness, blood pressure and insulin resistance

OBJECTIVES

To determine exercise training effects on cardiac size and left ventricular (LV) diastolic function and relationships of exercise induced changes in physiological and body composition parameters with cardiac parameters.

DESIGN

Prospective, randomised controlled trial.

SUBJECTS

Men and women (63.6 (5.7) years, body mass index 29.5 (4.4) kg/m(2)) with untreated hypertension (systolic blood pressure (BP) 130-159 or diastolic BP 85-99 mm Hg).

MAIN OUTCOME MEASURES

Cardiac size and LV diastolic function, peak oxygen uptake (Vo(2)), muscle strength, general and abdominal fatness, and insulin resistance.

INTERVENTIONS

6 months of exercise training versus usual care.

RESULTS

When analysed by group at six months, cardiac size and LV diastolic function did not differ between exercisers (n = 51) and controls (n = 53), whereas exercisers had significantly higher peak Vo(2) (28 v 24 ml/kg/min) and strength (383 v 329 kg), and lower fatness (34% v 37%), diastolic BP (73 v 75 mm Hg) and insulin resistance (quantitative insulin sensitivity check index 0.35 v 0.34) versus controls (all p <or= 0.05). By regression analysis, among six month changes, increased peak Vo(2) and reduced abdominal fat were associated with increased cardiac size. Increased peak Vo(2) and reduced abdominal fat, BP and insulin resistance were associated with improved LV diastolic function. r Values ranged from 0.20 to 0.32 (p <or= 0.05).

CONCLUSIONS

When examined by group assignment, exercise had no effect on cardiac size or LV diastolic function. When individual variations in six month changes were examined, participants attaining the greatest increases in fitness and reductions in abdominal fatness, insulin resistance and BP showed a modest trend towards physiological hypertrophy characterised by increased cardiac size and improved LV diastolic function. These results suggest that decreased abdominal fatness may have a role in improving cardiovascular health.

Impact of obstructive sleep apnea on right ventricular global function: sleep apnea and myocardial performance index

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by repetitive upper airway obstructions during sleep, and it might cause cardiovascular complications such as heart failure, arrhythmias, myocardial infarction, systemic and pulmonary hypertension.

OBJECTIVES

To determine right ventricular diameters and myocardial performance index (MPI) reflecting ventricular global function in uncomplicated OSA patients.

METHODS

49 subjects without hypertension, diabetes mellitus, or any cardiac or pulmonary disease referred for evaluation of OSA had overnight polysomnography and complete echocardiographic assessment. According to the apnea-hypopnea index (AHI), subjects were divided into three groups: group 1: control subjects (AHI <5, n = 20), group 2: patients with mild OSA (AHI: 5-14, n = 11), and group 3: moderate-severe OSA (AHI > or = 15, n = 18). Right ventricular free wall diameter was measured by M mode, and right ventricular MPI was calculated as (isovolumic contraction time + isovolumic relaxation time)/pulmonary ejection time.

RESULTS

There were no differences of age, body mass index, heart rates, systolic and diastolic blood pressures among the groups (p > 0.05). Right ventricular end-diastolic and end-systolic diameters were not statistically different between the groups, and were within normal limits. Also, right ventricular free wall diameter was not significantly different between the groups of control, mild OSA and moderate-severe OSA (6.7 +/- 0.9, 6.9 +/- 1.0, 7.1 +/- 1.1 mm, p > 0.05). Right ventricular diastolic dysfunction was shown only in group 3 patients. Right ventricular MPI was statistically higher in group 3 (0.62 +/- 0.18) than in group 2 patients (0.50 +/- 0.10), and group 1 patients (0.48 +/- 0.08, p < 0.001).

CONCLUSIONS

It was suggested that patients with moderate-severe OSA had a right ventricular global dysfunction, in addition to the presence of a diastolic dysfunction.

BNP as a marker of diastolic dysfunction in the general population: Importance of left ventricular hypertrophy

BNP is a marker of systolic left ventricular dysfunction (LVSD) and heart failure. To assess BNP for the detection of diastolic dysfunction in the general population, we examined 1678 subjects within an age- and sex-stratified survey (MONICA Augsburg). BNP was measured using a commercially available RIA (Shionogi). BNP increased in subjects with diastolic dysfunction (mean 20.3+/-4.7 pg/ml vs. control 9.6+/-0.5 pg/ml, p<0.001), but to a lesser extent than in subjects with LV hypertrophy (LVH, mean 37.3+/-49.1 pg/ml, p<0.001 vs. control) or LVSD (mean 76.2+/-23.2 pg/ml, p<0.001 vs. control). Individuals with sole diastolic abnormality displayed BNP concentrations at the control level (mean 9.7+/-1.7 pg/ml). In univariate analysis, age, BMI, systolic blood pressure, left atrial size, LV mass index, diastolic dysfunction and EF displayed a significant correlation with BNP (p<0.001). However, LV mass index displaced diastolic dysfunction as a significant predictor of BNP in multivariate analysis. Upon ROC analysis, sensitivity and specificity for the detection of diastolic dysfunction by BNP were only 61% and 55%, respectively. Nevertheless, a normal BNP test virtually excluded the presence of diastolic dysfunction and concomitant LVH (NPV 99.9%). Increased BNP concentrations in subjects with diastolic dysfunction are strongly related to LVH. Population-wide screening for diastolic dysfunction with BNP cannot be recommended although a normal BNP test usually excludes diastolic dysfunction and LV hypertrophy.

[Characteristics of hypertensive cardiomyopathy in a population of hypertensive patients never treated]

BACKGROUND AND OBJECTIVE

Although impaired diastolic function is frequently found in systemic hypertension, the diagnosis of hypertensive heart disease (HHD) is based on the demonstration of left ventricular (LV) growth. The aim of the current work was to investigate the potential interactions between diastolic function and LV growth in patients with arterial hypertension.

PATIENTS AND METHOD

One hundred and sixteen never-treated asymptomatic hypertensives underwent an echocardiographic evaluation. Classification of diastolic dysfunction (DD) was based on alterations in parameters assessing transmitral inflow, Doppler tissue imaging of mitral annular motion, and color M-mode propagation velocity. Classification of LV growth was based on alterations in left ventricular mass index and/or relative will thickness.

RESULTS

Ninety-four patients (81%) exhibited DD and 22 (19%) exhibited normal diastolic function. Amongst patients with DD, 79 (84%) exhibited a pattern of impaired relaxation and 15 (16%) a pseudonormal pattern. The presence of LV growth was documented in 41% of patients without DD and 75% of patients with DD (p < 0.05). None of the studied patients exhibited echocardiographic signs of systolic dysfunction.

CONCLUSIONS

These findings indicate that DD is an early and highly frequent cardiac alteration in arterial hypertension. In addition, our data show that one fifth of hypertensive patients have DD in the absence of LV growth. It is thus suggested that the diagnosis of HHD can not be further based exclusively on morphologic criteria and should include also the evaluation of alterations in LV filling.

Usefulness of atrial size inequality as an indicator of abnormal left ventricular filling

Although pulsed Doppler echocardiography estimates current left ventricular (LV) filling, left atrial (LA) size reflects LV filling and pressure over time. However, the wide normal LA size range may blunt this diagnostic tool. Our objective was to compare the intraindividual atrial area difference (LA--right atrial [RA] area) and absolute LA area in their detection of a LA enlargement with respect to the degree of current LV filling impairment. We examined patients with acute coronary syndromes in sinus rhythm and without valvular disease (n = 154), and age- and gender-matched healthy controls (n=50) with echocardiography, applying pulsed Doppler international recommendations to group the patients according to the LV filling pattern: 0, normal; 1, delayed relaxation; 2, an isolated abnormal mitral pulmonary venous A-wave duration difference; 3, pseudonormal; and 4, restrictive. The LA and RA areas were measured in the 4-chamber view. Control values defined the normal range of: absolute LA area, LA area adjusted for body height, and LA-RA area. These areas indicated a LA enlargement in: (1) controls, 2%, 2%, and 4%, respectively; (2) patients with LV filling graded as normal/mildly impaired (groups 0 and 1), 15%, 17%, and 46%, respectively; moderately impaired (group 2), 26%, 29%, and 52%, respectively; and severely impaired (group 3 and 4), 42%, 38%, and 54%, respectively. Unequally sized atria appear to detect LA enlargement sensitively, especially when Doppler evidence of LV filling pathology is sparse. Clinically, with no obvious current cause for LA enlargement, a diagnosed "atrial size inequality" may still indicate a history of such causes.

Effects of age, gender, and left ventricular mass on septal mitral annulus velocity (E') and the ratio of transmitral early peak velocity to E' (E/E')

The ratio of the transmitral early peak velocity (E) evaluated by conventional Doppler imaging over early diastolic mitral annulus velocity (E') evaluated by tissue Doppler imaging has been proposed as a noninvasive marker for left ventricular filling pressure. We evaluated 174 normal patients and 86 patients with hypertension and LV hypertrophy to assess the effects of age, gender, and left ventricular hypertrophy on E' and E/E'. Age appeared to be the strongest determinant of E' and E/E', suggesting that in normal patients and in those with left ventricular hypertrophy, age-dependent cut-off values should be considered.

Epidemiology of Diastolic Heart Failure

Heart failure (HF) is a major public health problem. Clinical studies suggest that a significant proportion of patients with HF have preserved ejection fraction, a clinical syndrome commonly referred to as diastolic HF (DHF). One of the purposes of epidemiological studies is to identify unmet public health needs in a population and to quantify the magnitude of the problem in a manner that is free from the referral bias inherent in clinical studies. We review current epidemiological data estimating the prevalence of DHF, highlight the challenges posed by existing data, and suggest focus for future studies on the epidemiology of DHF. We limited the review to studies that met our definition of population-based studies (eg, studies drawing participants from a defined community or all consecutive referrals to a health facility that is the sole provider to a defined community). Studies relevant to the epidemiology of each stage of DHF (American College of Cardiology/American Heart Association stages A-D) were reviewed. These epidemiological studies clearly define the magnitude of this health care problem and underscore the urgent need for studies elucidating the natural history, pathophysiology, and optimal diagnostic and management strategy for this extremely common clinical syndrome.

Cardiovascular response to acute normovolemic hemodilution in patients with coronary artery diseases: Assessment with transesophageal echocardiography

OBJECTIVE

Preoperative acute normovolemic hemodilution induces an increase in circulatory output that is thought to be limited in patients with cardiac diseases. Using multiple-plane transesophageal echocardiography, we investigated the mechanisms of cardiovascular adaptation during acute normovolemic hemodilution in patients with severe coronary artery disease.

DESIGN

Prospective case-control study.

SETTING

Operating theater in a university hospital.

PATIENTS

Consecutive patients treated with beta-blockers, scheduled to undergo coronary artery bypass (n = 50).

INTERVENTIONS

After anesthesia induction, blood withdrawal and isovolemic exchange with iso-oncotic starch (1:1.15 ratio) to achieve a hematocrit value of 28%.

MEASUREMENTS AND MAIN RESULTS

In addition to heart rate and intravascular pressures, echocardiographic recordings were obtained before and after acute normovolemic hemodilution to assess cardiac preload, afterload, and contractility. In a control group, not subjected to acute normovolemic hemodilution, hemodynamic variables remained stable during a 20-min anesthesia period. Following acute normovolemic hemodilution, increases in cardiac stroke volume (+28 +/- 4%; mean +/- sd) were correlated with increases in central venous pressure (+2.0 +/- 1.3 mm Hg; R = .56) and in left ventricular end-diastolic area (+18 +/- 5%, R = .39). The unchanged left ventricular end-systolic wall stress and preload-adjusted maximal power indicated that neither left ventricular afterload nor contractility was affected by acute normovolemic hemodilution. Diastolic left ventricular filling abnormalities (15 of 22 cases) improved in 11 patients and were stable in the remaining four patients. Despite reduction in systemic oxygen delivery (-20.5 +/- 7%, p < .05), there was no evidence for myocardial ischemia (electrocardiogram, left ventricular wall motion abnormalities).

CONCLUSIONS

In anesthetized patients with coronary artery disease, moderate acute normovolemic hemodilution did not compromise left ventricular systolic and diastolic function. Lowering blood viscosity resulted in increased stroke volume that was mainly related to increased venous return and higher cardiac preload.

Cardiomyocyte stiffness in diastolic heart failure

BACKGROUND

Heart failure with preserved left ventricular (LV) ejection fraction (EF) is increasingly recognized and usually referred to as diastolic heart failure (DHF). Its pathogenetic mechanism remains unclear, partly because of a lack of myocardial biopsy material. Endomyocardial biopsy samples obtained from DHF patients were therefore analyzed for collagen volume fraction (CVF) and sarcomeric protein composition and compared with control samples. Single cardiomyocytes were isolated from these biopsy samples to assess cellular contractile performance.

METHODS AND RESULTS

DHF patients (n=12) had an LVEF of 71+/-11%, an LV end-diastolic pressure (LVEDP) of 28+/-4 mm Hg, and no significant coronary artery stenoses. DHF patients had higher CVFs (7.5+/-4.0%, P<0.05) than did controls (n=8, 3.8+/-2.0%), and no conspicuous changes in sarcomeric protein composition were detected. Cardiomyocytes, mechanically isolated and treated with Triton X-100 to remove all membranes, were stretched to a sarcomere length of 2.2 microm and activated with solutions containing varying [Ca2+]. Compared with cardiomyocytes of controls, cardiomyocytes of DHF patients developed a similar total isometric force at maximal [Ca2+], but their resting tension (F(passive)) in the absence of Ca2+ was almost twice as high (6.6+/-3.0 versus 3.5+/-1.7 kN/m2, P<0.001). F(passive) and CVF combined yielded stronger correlations with LVEDP than did either alone. Administration of protein kinase A (PKA) to DHF cardiomyocytes lowered F(passive) to control values.

CONCLUSIONS

DHF patients had stiffer cardiomyocytes, as evident from a higher F(passive) at the same sarcomere length. Together with CVF, F(passive) determined in vivo diastolic LV dysfunction. Correction of this high F(passive) by PKA suggests that reduced phosphorylation of sarcomeric proteins is involved in DHF.

Effect of obesity and being overweight on long-term mortality in congestive heart failure: influence of left ventricular systolic function

AIMS

Previous studies have suggested that a high body mass index (BMI) is associated with an improved outcome in congestive heart failure (CHF). However, the studies addressing this problem have not included enough patients with non-systolic heart failure to evaluate how left ventricular systolic function interacts with obesity on prognosis in CHF. The aim of this study was to evaluate how BMI influences mortality in patients hospitalized with CHF, and to address in particular whether the effect of BMI is influenced by left ventricular (LV) systolic function.

METHODS AND RESULTS

Retrospective analysis of baseline and survival data for 4700 hospitalized CHF patients for whom BMI was available. LV systolic function, as assessed by wall motion index was available for 95% of the patients. Follow-up time ranged from 5 to 8 years. In the total population, the risk of death decreased steadily with increasing BMI from the underweight to the obese. Compared with normal weight, and adjusted for sex and age, risk ratios (RR) and 95% confidence limits were: underweight 1.56 (1.33-1.84), overweight 0.90 (0.83-0.97), obese 0.77 (0.70-0.86). Being underweight conferred a greater risk in CHF patients with normal systolic function [RR 1.66 (1.29-2.14), compared with normal weight] than in patients with reduced systolic function [RR 1.11 (0.87-1.42), P for interaction 0.03]. In patients with systolic dysfunction, obesity was associated with increased risk compared with normal weight [RR 1.21 (1.01-1.45)].

CONCLUSION

Increasing BMI in CHF is associated with a lower mortality, but the influence is complex and depends on left ventricular systolic function. Hence, in patients with systolic dysfunction obesity may indicate an increased risk.

Sex-related differences in outcome after ST-segment elevation myocardial infarction treated by primary angioplasty: data from the Zwolle Myocardial Infarction study

BACKGROUND

Several studies have found that among patients with ST-elevation myocardial infarction (STEMI) treated by thrombolysis, female sex is associated with a worse outcome. The aim of this study was to investigate sex-related differences in clinical and angiographic findings and in long-term outcome in patients with STEMI treated with primary angioplasty.

METHODS

Our population is represented by 1548 consecutive patients with STEMI treated by primary angioplasty from April 1997 to October 2001. All clinical, angiographic, and follow-up data were prospectively collected.

RESULTS

Among 1548 patients, 353 were women (22.8%). Female sex was associated with more advanced age, higher prevalence of diabetes, hypertension, more advanced Killip class, longer ischemia time, and smaller vessel caliber. No difference was observed in terms of procedural success, postprocedural epicardial flow, myocardial perfusion, ST-segment resolution, and enzymatic infarct size. At 1-year follow-up, female sex was associated with a significantly higher 1-year mortality rate at univariate (9.3% vs 4.9 %, RR [95% CI] = 1.79 [1.14 to 2.8], P = .002) but not at multivariate analysis (RR [95% CI] = 1.41 [0.86 to 2.32], P = NS).

CONCLUSIONS

This study shows that in patients with STEMI treated by primary angioplasty, women are associated with higher mortality rate in comparison with men, mainly because of their high-risk profile and angiographic features. Female sex did not emerge as an independent predictor of death.

The diagnosis of heart failure in the community

OBJECTIVES

We sought to compare construct and predictive validity of four sets of heart failure (HF) diagnostic criteria in an epidemiologic setting.

BACKGROUND

The prevalence estimates of HF vary broadly depending on the diagnostic criteria.

METHODS

Data were collected in a survey of community dwellers who were > or =65 years of age living in Dicomano, Italy. At baseline, HF was diagnosed with the criteria of the Framingham, Boston, and Gothenburg studies and of the European Society of Cardiology (ESC). Left ventricular mass index and ejection fraction, left atrium systolic dimension, lower extremity mobility disability, summary physical performance score, and 6-min walk test were compared between HF and non-HF participants to test for construct validity of each set of criteria. Predictive validity was evaluated with follow-up assessment of cardiovascular mortality, incident disability, and HF-related hospitalizations. Comparisons were adjusted for demographics, comorbidity, and psychoaffective status.

RESULTS

Of 553 participants, 11.9%, 10.7%, 20.8%, and 9.0% had HF, according to Framingham, Boston, Gothenburg, and ESC criteria, respectively. In terms of construct validity, Framingham and Boston criteria discriminated HF from non-HF participants better than Gothenburg and ESC criteria across the measures of cardiac function and global performance. The Boston criteria showed a superior predictive validity because they indicated a significantly greater adjusted risk of cardiovascular death (hazard ratio3.9, 95% confidence interval 1.2 to 13.2), incident disability, and hospitalizations in participants with HF.

CONCLUSIONS

The Boston criteria are preferable to Framingham, Gothenburg, and ESC criteria for the diagnosis of HF in older community dwellers because they have good construct validity and more accurately predict cardiovascular death, incident disability, and hospitalizations.

Impact of obesity on the risk of heart failure and survival after the onset of heart failure

Obesity has reached epidemic proportions in the United States and worldwide. Heart failure (HF) is also a major public health problem, which, despite therapeutic advances, is associated with substantial mortality. The adverse impact of obesity on the cardiovascular system is being increasingly recognized, and includes a hyperdynamic circulation, subclinical cardiac structural and functional changes, and overt HF. At the same time, the possible protective effect of obesity in patients with established HF has been emphasized in recent studies. This article reviews evidence from epidemiologic studies evaluating the impact of overweight and obesity on the risk of HF, appraises published data on the prognostic significance of overweight and obesity after the onset of HF, describes the potential mechanisms underlying these associations,speculates on the clinical implications of current evidence, and suggests directions for future research.

Elevated plasma levels of Nt-proBNP in patients with type 2 diabetes without overt cardiovascular disease

OBJECTIVE

The NH(2)-terminal portion of the precursor of brain natriuretic peptide (Nt-proBNP) has been reported to be elevated in left ventricular dysfunction. This peptide is a split product from the proBNP molecule, and its level in the circulation is not, as the mature BNP peptide, dependent on the peripheral number of BNP receptors. We aimed to test the hypothesis that asymptomatic left ventricular dysfunction (ALVD), as estimated by Nt-proBNP, would be more prevalent in patients with type 2 diabetes without overt cardiovascular disease in comparison with matched control subjects.

RESEARCH DESIGN AND METHODS

The study population consisted of 253 patients with type 2 diabetes and 230 matched control subjects aged 40-70 years without any overt heart disease from primary care centers in Western Finland and Southern Sweden. Nt-proBNP was measured in plasma by competitive enzyme immunosorbent assay.

RESULTS

Patients with type 2 diabetes were shown to have higher Nt-proBNP values (360.9 pmol/l [262.6-467.9]) than control subjects (302.7 pmol/l [215.4-419.2]) (P < 0.001). Nt-proBNP levels were independently related to diabetes after adjustment for age, sex, systolic and diastolic blood pressure, BMI, heart rate, drug treatment, serum creatinine, and cystatin C.

CONCLUSIONS

Our data suggest that the secretion of Nt-proBNP is increased in type 2 diabetic patients with no overt heart disease, suggesting that type 2 diabetes is associated with a higher prevalence of ALVD than hitherto thought. Nt-proBNP may thus serve as a screening instrument to select patients with type 2 diabetes who could benefit from an echocardiographical examination.

Comparison of right and left ventricular function in obese and nonobese men

We studied systolic and diastolic function of the left and right ventricles in obese male subjects. Obese subjects had increased left ventricular mass and normal left ventricular systolic and diastolic function. They also had impaired right ventricular relaxation and right ventricular filling.

Poor concordance of commonly used echocardiographic measures of left ventricular diastolic function in patients with suspected heart failure but preserved systolic function: is there a reliable echocardiographic measure of diastolic dysfunction?

OBJECTIVE

To determine the concordance of different Doppler echocardiographic criteria for "diastolic dysfunction" in patients with suspected heart failure but preserved left ventricular systolic function.

DESIGN

Prospective, descriptive study.

SETTING

Outpatient based direct access echocardiography service.

PATIENTS

Consecutive patients referred with suspected heart failure but preserved left ventricular systolic function.

MEASUREMENTS

Echocardiographic measurements of systolic and diastolic function. Eight published studies giving age and sex specific ranges for measures of diastolic function in healthy subjects were reviewed and the proportion of patients outside the normal limits for each of these published ranges was calculated.

RESULTS

There was very poor concordance between measures with up to a 16-fold difference in the prevalence of diastolic dysfunction in the overall patient cohort. Even for a given measure, there was relatively poor agreement between the published reference ranges. In subsets likely to include patients at high risk of having diastolic dysfunction, an increased prevalence of diastolic dysfunction was not evident with any measure in any patient subset.

CONCLUSIONS

Our findings challenge the use of the diagnosis of diastolic heart failure based on the most commonly used echocardiographic criteria. Physicians should be cautious about echocardiographic reports describing diastolic dysfunction and only apply the diagnosis of diastolic heart failure with great care.

Heart failure with preserved left ventricular systolic function; epidemiology, clinical characteristics, and prognosis

Recent cross-sectional, population-based echocardiographic studies show that about half of all patients with heart failure have preserved left ventricular systolic function (HF-PSF). Cohort studies of hospitalized patients show a smaller proportion of HF-PSF. Compared to those with reduced systolic function, patients with HF-PSF are more often female, older, less likely to have coronary artery disease, and more likely to have hypertension. Patients with HF-PSF are less symptomatic and receive different pharmacologic therapy than patients with reduced systolic function. Morbidity and mortality rates in patients with HF-PSF are high but not quite as high as in patients with reduced systolic function. Though much has recently been learned about the syndrome of HF-PSF, many questions remain to be answered, not least how it should be treated.

[Diabetic cardiopathy: pathogenesis, diagnosis and therapy]

Diabetes mellitus is one of the most widespread metabolic diseases in Western industrial countries with increasing prevalence due to a progressively aging population that is also characterized by increasing obesity and a sedentary life style. Cardiovascular conditions are the major prognostic complications of diabetes. Cardiologically, diabetic cardiopathy may become manifest on different structural and functional levels of the heart. Disorders may involve the micro- and macrocirculation (angiopathy), ventricular function (cardiomyopathy) and the intracardial nervous system (autonomous neuropathy). The following survey summarizes the cardiovascular risk with particular attention to the pathogenesis, diagnostics and therapy of diabetes mellitus related coronary disease and diabetic cardiomyopathy.

Left ventricular diastolic dysfunction: risks, identification, and treatment

Risk factors of cardiovascular disease, such as hypertension, diabetes, and myocardial infarction, if left untreated, will increase the risk of the development of chronic heart failure. Much is known about the pathophysiology and effective treatments of chronic heart failure from left ventricular systolic dysfunction; however, little clinical trial evidence exists concerning benefits of treating patients with chronic heart failure and preserved systolic function, also known as left ventricular diastolic dysfunction. Rather, an understanding of the pathophysiology and patient signs and symptoms has usually dictated choice of treatments. With the results of ongoing trials, as well as the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM)-Preserved and the Digitalis Investigation Group (DIG) trials, clinical evidence is accumulating to support effective treatments in patients with left ventricular diastolic dysfunction. The focus of this review is to discuss the risks of, identification of, and rationale for therapeutic choices being employed for treating left ventricular diastolic dysfunction and implications from studies that may support these choices.