Progression of systolic abnormalities in patients with "isolated" diastolic heart failure and diastolic dysfunction

Reduced systolic performance by tissue Doppler in patients with preserved and abnormal ejection fraction: New insights in chronic heart failure

BACKGROUND

Tissue Doppler imaging (TDI) is useful in the evaluation of systolic and diastolic function. It allows assessment of ventricular dynamics in its longitudinal axis. We sought to investigate the difference in systolic and diastolic longitudinal function in patients with chronic heart failure (CHF) with normal and reduced ejection fraction.

METHODS AND RESULTS

One hundred ten outpatients with CHF and 68 controls were included. Ejection fraction (EF) was obtained and longitudinal systolic (S) and diastolic (E' and A') wall velocities were recorded from basal septum. Group A (controls) were normal and CHF patients were classified by EF in Group B1: > 45% and B2: < or = 45%. In A, B1 and B2 the mean S peak was 7.74; 5.45 and 4.89 cm/s (p<0.001); the mean E' peak was 8.56; 5.72 and 6.1 cm/s (p<0.001); and the mean A' peak was 10.2; 7.3 and 5.3 cm/s (p<0.001). Also, isovolumic contraction and relaxation time were different among control and CHF groups, (both p<0.001). The most useful parameters for identifying diastolic CHF were IVRT and S peak, with area under ROC curves of 0.93 and 0.89. The cut-off of 115 ms for IVRT and 5.8 cm/s for S peak showed a sensitivity of 94 and 97%, with a specificity of 82 and 73%, respectively.

CONCLUSION

These findings suggest that impairment of left ventricular systolic function is present even in those with diastolic heart failure, and that abnormalities may have an important role to identifying the condition.

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.

The diabetic myocardium

Heart failure and diabetes mellitus are frequently associated, with diabetes potentiating the development of heart failure after other myocardial insults. This review documents the evidence in support of a specific primary myocardial disease in diabetes. The strongest clinical evidence relates to the detection of otherwise unexplained diastolic dysfunction in apparently healthy diabetic subjects, but recent studies with sensitive echocardiographic markers have shown systolic disturbances as well. The mechanism of this myocardial disease is multifactorial, with contributions from metabolic effects on the myocyte, structural changes in the myocardium and interstitium, autonomic neuropathy, and perhaps coronary vascular disease. The common pathway appears to be related to glycemic control and new evidence suggests better metabolic control to be beneficial, as well as angiotensin-converting enzyme inhibition and cross-link breakers.

Controversies in ventricular remodelling

Ventricular remodelling describes structural changes in the left ventricle in response to chronic alterations in loading conditions, with three major patterns: concentric remodelling, when a pressure load leads to growth in cardiomyocyte thickness; eccentric hypertrophy, when a volume load produces myocyte lengthening; and myocardial infarction, an amalgam of patterns in which stretched and dilated infarcted tissue increases left-ventricular volume with a combined volume and pressure load on non-infarcted areas. Whether left-ventricular hypertrophy is adaptive or maladaptive is controversial, as suggested by patterns of signalling pathways, transgenic models, and clinical findings in aortic stenosis. The transition from apparently compensated hypertrophy to the failing heart indicates a changing balance between metalloproteinases and their inhibitors, effects of reactive oxygen species, and death-promoting and profibrotic neurohumoral responses. These processes are evasive therapeutic targets. Here, we discuss potential novel therapies for these disorders, including: sildenafil, an unexpected option for anti-transition therapy; surgery for increased sphericity caused by chronic volume overload of mitral regurgitation; an antifibrotic peptide to inhibit the fibrogenic effects of transforming growth factor beta; mechanical intervention in advanced heart failure; and stem-cell therapy.

Progression of preserved systolic function heart failure to systolic dysfunction — A natural history study

OBJECTIVES

To assess the natural history of left ventricular (LV) structure and function in sequential heart failure admissions with preserved systolic function.

BACKGROUND

Heart failure (HF) with preserved LV systolic function accounts for between 20% and 30% of typical HF populations. Few data are available concerning the natural history of structural and functional changes in the LV in this patient population.

METHODS

We consented sequential admissions from the community with confirmed heart failure to participate in this study. Doppler-echocardiography was used to assess Ejection Fraction (EF), LV structure, regional wall motion and parameters of diastolic function including E:A ratio, E-wave deceleration time (DtE) and isovolumic relaxation time (IVRT). Follow-up echocardiography was carried out at three months (mean 103+/-13 days) from discharge.

RESULTS

Of 210 sequential admissions with primary heart failure 56 had preserved systolic function (LVEF> or =45%). Follow-up data at three months were available in 38 patients (mean age 72 years) with preserved LV systolic function. Of the group, 9 had been admitted within three months of discharge, 5 for recurrent HF. Eight patients (21%) exhibited significant decline in LV systolic function at follow-up, all with LVEF<45%. Three exhibited regional wall-motion abnormalities with the remainder showing dilatation and global reduction in function. None of these eight had presented to hospital for any cause other than routine outpatient department (OPD) visits during the 3 months.

CONCLUSION

Patients with preserved systolic function HF, a significant number may progress to systolic dysfunction with or without clinical events.

Heart failure with a normal ejection fraction

Nearly half of patients with symptoms of heart failure are found to have a normal left ventricular (LV) ejection fraction. This has variously been labelled as diastolic heart failure, heart failure with preserved LV function or heart failure with a normal ejection fraction (HFNEF). As recent studies have shown that systolic function is not entirely normal in these patients, HFNEF is the preferred term. The epidemiology, aetiology and possible pathophysiology of this contentious condition are reviewed. The importance of the remodelling process in determining whether a patient presents with systolic heart failure or HFNEF is emphasised and this can be used to classify patients in a more rational manner.

The Effects of Maintenance Recombinant Human Erythropoietin Therapy on Ambulatory Blood Pressure Recordings: Conventional, Doppler, and Tissue Doppler Echocardiographic Parameters

Cardiovascular disease is the major cause of mortality in maintenance hemodialysis patients. Left ventricular dysfunction is present in approximately 80% of these patients and is highly predictive of future ischemic heart disease, cardiac failure, and death. Anemia has been identified as one of several risk factors responsible for cardiac complications. The treatment of renal anemia with recombinant human erythropoietin (rHuEpo) and consequent improvement of cardiac performance may reverse pathological changes in left ventricular geometry. In this study, the acute and chronic effects of rHuEpo administration on 24-hour ambulatory blood pressure recordings and echocardiographic parameters in 30 rHuEpo-naïve maintenance hemodialysis patients were examined. Twenty-four-hour ambulatory blood pressure monitoring was performed prior to and after 1 week and 6 months of rHuEpo administration. The patients underwent echocardiographic examination prior to and after 6 months of rHuEpo administration. One week treatment with rHuEpo did not cause any significant change in 24-hour ambulatory blood pressure recordings. After 6 months of therapy, serum hemoglobin levels increased from 8.8 +/- 0.66 g/dL to 10.8 +/- 0.70 g/dL (P < 0.05). Echocardiographic examination revealed elevation in ejection fraction (62.26 +/- 6.84% vs. 69.90 +/- 8.98%, P < 0.05) with reductions in fractional shortening (36.70 +/- 4.96% vs. 35.96 +/- 6.32%, P < 0.05), interventricular septum thickness (1.21 +/- 0.16 vs. 1.00 +/- 0.16 cm, P < 0.05), and left ventricular mass index (148.2 +/- 46.5 g/m2 vs. 93.6 +/- 17.2 g/m2, P < 0.05). Doppler echocardiography and tissue Doppler imaging provided additional information in comparison with conventional echocardiography. Before treatment, mitral flow E wave (E, 0.64 +/- 0.27 vs. 0.82 +/- 0.17 cm/s), mitral flow A wave (A, 0.80 +/- 0.21 vs. 0.70 +/- 0.21 cm/s), early diastolic velocity of lateral wall (Lateral E', 11.2 +/- 2.8 vs. 12.4 +/- 2.3 cm/s), late diastolic velocity of lateral wall (Lateral A', 6.7 +/- 2.5 vs. 7.8 +/- 2.1 cm/s), early diastolic velocity of septal wall (Septal E', 9.7 +/- 2.9 vs. 11.3 +/- 1.1 cm/s), and late diastolic velocity of septal wall (Septal A', 6.4 +/- 2.1 vs. 7.8 +/- 2.0 cm/s) were significantly lower in patients than in the controls. Patients and controls have similar deceleration time of mitral flow E wave (E Dec, 186 +/- 57.8 vs. 192 +/- 62.4 ms), isovolumic left ventricular relaxation time (IVRT, 111.9 +/- 30.7 vs. 91.1 +/- 32 ms), systolic velocity of lateral wall (Lateral S', 7.8 +/- 2.3 vs. 8.1 +/- 2.0 cm/s), and systolic velocity of septal wall (Septal S', 7.5 +/- 1.9 vs. 7.7 +/- 1.4 cm/s) values. Therapy with rHuEpo did not cause significant changes in E (0.64 +/- 0.27 vs. 0.76 +/- 0.29 cm/s), A (0.80 +/- 0.21 vs. 0.79 +/- 0.23 cm/s), E Dec (186 +/- 57.8 vs. 165.8 +/- 60.1 ms), IVRT (111.9 +/- 30.7 vs. 101.6 +/- 36.2 ms), Lateral E' (11.2 +/- 2.8 vs. 11.5 +/- 4.4 cm/s), Lateral A' (6.7 +/- 2.5 vs. 7.4 +/- 2.1 cm/s), Lateral S' (7.8 +/- 2.3 vs. 8.1 +/- 2.0 cm/s), Septal E' (9.7 +/- 2.9 vs. 10.0 +/- 1.1 cm/s), Septal A' (6.4 +/- 2.1 vs. 6.6 +/- 2.0 cm/s), and Septal S' (7.5 +/- 1.9 vs. 7.9 +/- 1.4 cm/s) indicating persistence of diastolic dysfunction. In 6 months time, 24-hour ambulatory blood pressure recordings, however, tended to be higher (systolic: 125.16 +/- 21.02 mm Hg vs. 134.36 +/- 23.98 mm Hg; diastolic: 77.40 +/- 14.47 mm Hg vs. 83.26 +/- 14.89 mm Hg, P < 0.05). Correction of anemia with rHuEpo results in the elevation of blood pressure and reduction in left ventricular mass index. Myocardial contraction and relaxation velocities did not improve following regression of left ventricular hypertrophy, suggesting the persistance of diastolic dysfunction. Doppler echocardiography with tissue Doppler imaging reflects the real situation of diastolic function in patients on maintenance hemodialysis.

Analysis of left ventricular systolic function using midwall mechanics in patients >60 years of age with hypertensive heart disease and heart failure

Normal ejection fraction (EFs) is often equated with normal systolic function. However, midwall mechanics reveal systolic dysfunction in hypertensive heart disease accompanied by hypertrophic remodeling. Midwall mechanics are unstudied in patients with acute diastolic heart failure (HF). This study analyzed left ventricular (LV) midwall stress-shortening relations in 61 patients aged >60 years with hypertensive heart disease, HF, and normal EF. Sixty-one hypertensive patients (mean age 78 +/- 10 years) who presented with HF, each with an EF >50%, underwent echocardiography. Midwall mechanics were compared with those of 79 controls (mean age 75 +/- 8 years) without structural heart disease. Relative wall thickness (0.63 +/- 0.11 vs 0.46 +/- 0.10 mm) and LV mass (237 +/- 67 vs 177 +/- 57 g) were significantly greater in patients with HF compared with controls. Mean EFs were similar in patients with HF and controls (64 +/- 9% vs 67 +/- 9%). Although mean endocardial fractional shortening (35 +/- 7% vs 37 +/- 7%) was not significantly different, midwall shortening in patients with HF was significantly less compared with controls (16 +/- 2% vs 19 +/- 3%, p <0.05). Eighteen of the 61 patients with HF (30%) had midwall shortening that was <95% confidence intervals of the normal midwall stress-shortening relations. By this criterion, these patients had systolic dysfunction despite normal EF; they had smaller LV chambers (in dimension and volume), greater relative wall thickness, and smaller stroke volumes. In conclusion, almost 1/3 of patients hospitalized with diastolic HF had systolic dysfunction, characterized by abnormal midwall stress-shortening relations.

Oxygen pulse during exercise is related to resting systolic and diastolic left ventricular function in older persons with mild hypertension

BACKGROUND

The mechanisms responsible for impaired cardiovascular hemodynamics during exercise among persons with milder forms of hypertension are not well documented. We examined the relationship of oxygen pulse during exercise, a correlate of stroke volume, with echocardiographic indices of resting left ventricular function to determine whether abnormal contractility and relaxation are related to abnormal cardiovascular dynamics during exercise among such persons.

METHODS

Subjects were 44 men and 55 women ages 55 to 75 years with mild hypertension but who were otherwise healthy. Resting left ventricular systolic and diastolic functions were assessed with 2-dimensional Doppler echocardiography and tissue Doppler imaging. Oxygen pulse (millimeters per beat) at rest and during multistage treadmill testing was derived from measurements of oxygen consumption and heart rate. The slope of oxygen pulse between successive exercise stages was calculated.

RESULTS

After a steep rise in oxygen pulse from rest to stage 1 of exercise, a markedly diminished oxygen pulse slope was seen between subsequent exercise stages. In stepwise regression analysis, the increase in the slope of oxygen pulse from rest to stage 1 was explained by a greater lean body mass (57%, P < .001) and a larger left atrial size (2%, P < .001). After exercise stage 1, the increase in the slope of oxygen pulse was explained by sex (24%, P < .001), higher mitral E/A ratio (6%, P < .001), and higher mitral annular systolic velocity (6%, P < .001).

CONCLUSIONS

These results suggest that a blunted oxygen pulse response to exercise among older persons with milder forms of hypertension may reflect impaired left ventricular stroke volume changes during exercise secondary to subtle abnormalities in both systolic and diastolic left ventricular functions.

Sex differences in left ventricular function in older persons with mild hypertension

BACKGROUND

Epidemiologic studies suggest that women are at increased risk of developing heart failure secondary to hypertension. Other studies have documented sex differences in left ventricular systolic and diastolic function in the presence of pressure overload states such as seen in aortic stenosis and hypertension. It is less clear if sex differences are present among older persons with mild hypertension.

METHODS

One hundred seven healthy subjects, aged 55 to 75 years, with blood pressures ranging from 130 to 159 mm Hg systolic and/or 85 to 99 mm Hg diastolic, were examined by standard echocardiography and the newer modalities of tissue Doppler and color M-mode imaging.

RESULTS

Women had a lower peak mitral annular systolic velocity (Sm), 8.9 (95% CI 8.4-9.5) cm/s versus 10.2 (95% CI 9.6-11.0) cm/s, (P < .01) than men. Among women, increasing age was associated with a reduction in diastolic function. For every decade of age, peak early mitral annular diastolic velocity (Em) declined by 1.6 cm/s (P < .01), mitral inflow velocity of propagation (Vp) declined by 26% (P < .01), E/Vp ratio increased by 20% (P = .03), and E/Em ratio increased by 11% (P = .04) in women. No age-associated changes were seen in men.

CONCLUSIONS

As revealed by newer echocardiographic imaging modalities, women with mild hypertension showed greater reductions in systolic and diastolic function as they aged compared with men. Our findings are consistent with the increased risk older women have of developing heart failure because of hypertension.

Impaired tissue Doppler diastolic function in patients with coronary artery disease: relationship to endothelial damage/dysfunction and platelet activation

BACKGROUND

Pulsed tissue Doppler imaging (TDI) allows direct measurement of systolic and diastolic function of the left ventricle. In patients with coronary artery disease (CAD), myocardial ischemia-related impaired diastolic function may be linked to systemic endothelial damage/dysfunction and increased thrombogenesis. We hypothesized relationships between TDI-defined diastolic dysfunction and plasma von Willebrand factor (vWf, marking endothelial damage/dysfunction), soluble P-selectin (sP-sel, reflecting platelet activation), fibrin D dimer (an index of fibrin turnover and thrombogenesis), fibrinogen, and plasma viscosity (PV) in CAD.

METHODS

Conventional 2-dimensional Doppler echocardiography and TDI were performed in 75 stable CAD patients (55 men, 59 +/- 11 years) and 40 age- and sex-matched healthy controls. Peak systolic (Sm), peak early (Em), and late (Am) diastolic mitral annular velocities measured at 4 sites (septal, lateral, inferior, and anterior) were averaged as global systolic and diastolic left ventricular function, respectively. The mean TDI velocities were dichotomized into low and high (below/above median) groups. Plasma vWf, sP-sel, D dimer (enzyme-linked immunosorbent assay), fibrinogen (modified Clauss), and PV levels were measured.

RESULTS

CAD patients had significantly lower Sm, Em, Em/Am ratio, and a higher ratio of early transmitral flow E-velocity over Em (E/Em) when compared with controls (all P < .05). On multivariate analysis, adjusted for age, ejection fraction, and clinical variables, the differences in the group means of vWf, sP-sel, and fibrinogen remained significantly different between the low and high TDI indexes. D-dimer levels were unrelated to any TDI indexes. None of the transmitral flow indexes were independently related to the research indexes.

CONCLUSIONS

In patients with CAD, diastolic dysfunction was closely associated with increased platelet activation and endothelial damage/dysfunction independent of systolic function. TDI-derived indexes are more sensitively related to plasma hemostatic markers than transmitral indexes in middle-aged patients with CAD.

Systolic and diastolic functions in elderly patients with and without heart failure

BACKGROUND

A considerable number of patients with heart failure (HF) have a normal left ventricular ejection fraction (LVEF). In these subjects, HF has usually been related to diastolic heart failure (DHF), still a frequently overlooked clinical entity.

METHODS

This study reports the clinical, instrumental, and conventional echocardiographic evaluation of 159 consecutive, hospitalized elderly patients, 87 admitted with HF and 72 admitted for other reasons without overt HF.

RESULTS

All of the 87 HF patients had signs of diastolic dysfunction (DDYS), yet 44.8% of them had a normal LVEF. Forty-four of the 72 patients admitted without overt HF (61.1%) had mild DDYS and 14 (19.5%) also had a reduced LVEF. There was a clear relationship between LVEF reduction and the severity of DDYS.

CONCLUSIONS

HF is often a combination of diastolic and systolic function abnormalities. DHF may be difficult to detect in HF subjects with normal LVEF because their DDYS is often mild. However, there are signs of DDYS in all HF patients that increase in severity as LVEF decreases. DDYS could be considered a marker for all forms of HF, especially in elderly patients.

Left heart failure with a normal ejection fraction: identification of different pathophysiologic mechanisms

BACKGROUND

Although heart failure with a normal ejection fraction (HFNEF) is a clinically heterogeneous syndrome, a single pathophysiologic mechanism, diastolic dysfunction, is often ascribed to explain this condition. In view of the clinical heterogeneity of these patients, we hypothesized that subgroups of HFNEF patients may have different underlying pathophysiologic mechanisms.

METHODS AND RESULTS

Freehand 3-dimensional echocardiography was used to measure left ventricular end-systolic and end-diastolic volumes in 99 asymptomatic normal controls and 2 groups with chronic heart failure: 35 patients with normal ejection fraction with longstanding hypertension (hypertensive HFNEF) and 11 patients with hypertrophic cardiomyopathy without a history of hypertension (nonhypertensive HFNEF). These data, combined with cuff sphygmomanometry and Doppler estimates of LV end-diastolic pressure (EDP) yielded estimated pressure-volume loops and slope (E es,sb ) of the end-systolic pressure-volume relationship, a load independent index of chamber contractility. Nonhypertensive HFNEF patients required high EDPs (21 +/- 2 versus 15 +/- 3 mm Hg in normals, P < .0001) to achieve normal EDVs (98 +/- 25 versus 95 +/- 21 mL in normals, P = NS). Although systolic function (E es,sb ) did not differ from normal, systolic blood pressure was lower than normal in these patients (114 +/- 10 versus 124 +/- 14 mm Hg in normals, P < .05). Hypertensive HFNEF patients also had increased EDP (20 +/- 2 mm Hg), but this was observed at higher than normal EDVs (118 +/- 29 mL, P < .05). Among patients with hypertensive HFNEF, 2 subgroups emerged, 1 with a high E es,sb (4.23 +/- 0.54 versus 2.1 +/- 0.7 mm Hg/mL) and 1 with normal E es,sb (2.31 +/- 0.51 mm Hg/mL). The former group was composed of elderly women with small body size (body surface area 1.7 +/- 0.2 versus 1.9 +/- 0.2 m 2 , P = .02) who had concentrically remodeled ventricles and low stroke volumes. The latter group was more diverse in age, body size, and included patients of both genders with increases in ventricular volumes, stroke volume, and mass consistent with a volume overload state.

CONCLUSION

Although HFNEF is commonly thought of as being the result of a single hemodynamic mechanism, these data indicate that subgroups exist with distinctly different underlying pathophysiologies.

Close Coupling of Systolic and Diastolic Function: Combined Assessment Provides Superior Prediction of Exercise Capacity

BACKGROUND

Isolated diastolic dysfunction is thought to account for approximately 50% of cases of heart failure. We tested the hypotheses that (1) the use of different methods for assessing systolic and diastolic function may contribute to the apparent frequency with which they are dissociated and (2) that combined assessment of systolic and diastolic function is superior to either one alone.

METHODS AND RESULTS

A total of 110 patients underwent echocardiography with tissue Doppler imaging (TDI) of the mitral annulus before maximal exercise testing. The correlation between left ventricular (LV) ejection fraction (EF) and exercise capacity was weak (r = 0.199). Among patients with EF greater than 55%, those with normal exercise capacity (>7 METs) had a higher systolic velocity of the mitral annulus than those achieving less than 7 METs (9.6 +/- 0.3 versus 7.5 +/- 0.4 cm/s, P = .001). The mitral annular systolic (Sa) and early diastolic (Ea) velocities each correlated moderately with exercise tolerance (r = 0.40 and 0.49, respectively). Sa and Ea correlated highly with each other (r = 0.79, P < .001). The sum of isovolumic contraction and relaxation times measured from TDI correlated moderately with exercise duration (r = -0.59). A combined index of systolic and diastolic function that includes isovolumic contraction and relaxation times and ejection time had the best correlation with achieved METs (r = -0.73, P < .001). A TDI index of cardiac performance higher than 0.52 had excellent sensitivity (86%) and specificity (100%) for predicting reduced exercise tolerance lower than 7 METs.

CONCLUSION

When assessed with the same technique, LV systolic and diastolic function are tightly linked. A TDI-derived combined index of myocardial performance is the best predictor of exercise capacity.

“Pure” diastolic dysfunction is associated with long-axis systolic dysfunction. Implications for the diagnosis and classification of heart failure

AIMS

To investigate regional systolic function of the left ventricle, to test the hypothesis that "pure" diastolic dysfunction (impaired global diastolic filling, with a preserved ejection fraction > or = 50%) is associated with longitudinal systolic dysfunction.

METHODS AND RESULTS

One hundred thirty subjects (31 patients with asymptomatic diastolic dysfunction, 30 with diastolic heart failure, 30 with systolic heart failure; and 39 age-matched normal volunteers) were studied by conventional and tissue Doppler echocardiography. Global diastolic function was assessed using the flow propagation velocity, and by estimating left ventricular filling pressure from the ratio of transmitral E and mitral annular E(TDE) velocities (E/E(TDE)); and global systolic function by measurement of ejection fraction. Radial and longitudinal functions were assessed separately from posterior wall and mitral annular velocities. Global and radial systolic function were similar in patients with "pure" diastolic dysfunction and normal subjects, but patients with either asymptomatic diastolic dysfunction or diastolic heart failure had impaired longitudinal systolic function (mean velocities: 8.0+/-1.2 and 7.7+/-1.5 cm/s, respectively, versus 10.1+/-1.5 cm/s in controls; p<0.001). In subjects with normal ejection fraction, global diastolic function correlated with longitudinal systolic function (r=0.56 for flow propagation velocity, and r=-0.53 for E/E(TDE) ratio, both p<0.001), but not with global systolic function.

CONCLUSION

Worsening global diastolic dysfunction of the left ventricle is associated with a progressive decline in longitudinal systolic function. Diastolic heart failure as conventionally diagnosed is associated with regional, subendocardial systolic dysfunction that can be revealed by tissue Doppler of long-axis shortening. Diagnostic algorithms and definitions of heart failure need to be revised.

Expiratory Flow Limitation Is Associated With Orthopnea and Reversed by Vasodilators and Diuretics in Left Heart Failure

BACKGROUND

In patients with acute left heart failure (LHF), orthopnea has also been related to the occurrence or worsening of expiratory flow limitation (EFL) in the supine position. We wished to assess whether short-term treatment with vasodilators and diuretics was able to abolish supine EFL and whether this could help to control orthopnea in patients with acute LHF.

METHODS

In nine nonobese (ie, mean [+/- SD] body mass index, 24 +/- 5 kg/m2), never-smoker patients (two men and seven women; mean age, 77 +/- 7 years) with acute LHF (mean ejection fraction, 43 +/- 15%), we assessed EFL by the negative expiratory pressure method and dyspnea by the Borg scale, with patients in both the seated and supine positions, before and after short-term treatment with vasodilators and diuretics until hospital discharge. Orthopnea was defined as a positive difference in the Borg score between measurements made with the patient in the supine and seated positions. Postural variations in the end-expiratory lung volume were inferred from changes in inspiratory capacity (IC) that were measured under the same circumstances.

RESULTS

Before treatment, with the patient in the seated position the mean dyspnea score was 1.5 +/- 0.5, the mean IC was 1.49 +/- 0.38 L, seven patients were non-flow-limited, and two patients were flow-limited. During recumbency, the mean dyspnea score was 2.7 +/- 0.5 (p < 0.01 vs seated position values), the mean IC was 1.66 +/- 0.45 L, and seven patients exhibited EFL. After a mean duration of 17 +/- 8 days of treatment (range, 7 to 28 days), EFL was detected in two patients only in the supine position, IC increased both in the seated position (1.65 +/- 0.34 L; p < 0.01) and the supine position (1.81 +/- 0.41 L; p = 0.07) position, and, although only two patients denied orthopnea, the mean dyspnea score during recumbency actually decreased to 1.9 +/- 1.0 (p < 0.05).

CONCLUSIONS

Our results indicate that short-term treatment with vasodilators and diuretics is able to control orthopnea and to remove supine EFL in most patients with acute LHF, suggesting a posture-related increase in bronchial obstruction as the main mechanism of EFL, which appears to play a role in the occurrence and severity of orthopnea in these circumstances.

Effect of age on left ventricular systolic function in humans: a study of systolic isovolumic acceleration rate

The aim of this study was to examine the effect of age on left ventricular (LV) systolic function in normal healthy adults. Eighty consecutive subjects without cardiovascular disease underwent standard and tissue Doppler (TD) echocardiographic imaging. LV systolic function was assessed by load-dependent indices as ejection fraction (EF) and myocardial systolic velocities by TD as well as by the load-independent index, systolic isovolumic acceleration rate (IVA). None of the echocardiographic measurements of systolic function declined with age (mean IVA for the group, 286 +/- 123 cm s(-2); IVA vs. age, r = 0.21, P = 0.1). Likewise, LV end diastolic dimension, wall thickness, mass and left atrial maximum volume were not significantly related to age. On the other hand, as previously reported, echocardiographic indices of diastolic function showed a significant decline with age (P < 0.05). When the group was stratified by gender, isovolumic velocity and acceleration were higher in men than women, but the differences were not significant (P = 0.12 and 0.37, respectively). No significant relation was observed between age and measurements of LV systolic function by regression analysis in women (P > 0.1). However, in men, a positive correlation was noted between average IVA and age (r = 0.63, P = 0.007). In conclusion, age is not associated with a change in cardiac structure and LV systolic function, but is accompanied by a decline in echocardiographic indices of diastolic function. With respect to gender, age does not appear to influence LV systolic function in women, but is associated with an increase in IVA and septal systolic ejection in men.

Losartan improves regional left ventricular systolic and diastolic function in patients with hypertension: accurate evaluation using a newly developed color-coded tissue doppler imaging technique

BACKGROUND

Angiotensin II receptor antagonists have recently been accepted as antihypertensive therapy. Tissue Doppler imaging (TDI) has been developed as a noninvasive tool to assess quantitatively regional myocardial motion abnormalities. This study was designed to determine whether our newly developed technique of color-coded TDI may be a useful means of quantifying the improvement in regional left ventricular (LV) myocardial contractility and relaxation after treatment with losartan in patients with hypertension.

METHODS AND RESULTS

Losartan (50 to 100 mg) was administered for 6 months to 37 previously untreated patients with essential hypertension. Averaged myocardial velocity profiles (MVPs) for color-coded TDI were recorded in the ventricular septum and LV posterior wall before and after treatment. Peak myocardial velocities and peak myocardial velocity gradients (MVGs) in the LV walls were determined during systole and early diastole. The plasma concentration of transforming growth factor (TGF)-beta1 also was measured in all patients. Blood pressure and plasma TGF-beta1 level decreased after initiation of losartan therapy. The LV mass index and LV meridional end-systolic wall stress also decreased after treatment with losartan. LV geometry changed from a pattern consistent with concentric hypertrophy to normal geometry in 10 patients and to a pattern consistent with concentric remodeling in 5 patients, and from concentric remodeling to normal geometry in 5 patients after treatment with losartan. The ratio of early to late diastolic filling for the transmitral flow velocity increased after losartan treatment. The peak systolic and early diastolic myocardial velocities and MVGs in the ventricular septum and LV posterior wall increased after treatment with losartan, although the values 6 months after treatment with losartan were still lower than those in normal individuals. There were good correlations between changes in plasma TGF-beta1 level and changes in systolic and early diastolic MVGs 6 months after losartan. However, there were no significant correlations between changes in the systolic blood pressure and LV end-systolic wall stress and changes in the TDI parameters.

CONCLUSION

Losartan improves regional LV function in patients with hypertension. Our newly developed averaged MVP and MVG measurements may be useful for accurately evaluating regional LV myocardial contractility and relaxation in these patients.

Left ventricular diastolic dysfunction in patients with chronic renal failure: impact of diabetes mellitus

AIMS

Left ventricular (LV) hypertrophy and LV diastolic dysfunction are cardiac changes commonly observed in patients with chronic renal failure (CRF) as well as hypertension. Although the impairment of LV diastolic function in patients with diabetes mellitus has been shown, little is known about the specific effect of diabetes on LV diastolic function in patients with CRF. The present study was designed to investigate the impact of diabetic nephropathy on LV diastolic dysfunction, independent of LV hypertrophy, in CRF patients.

METHODS

In 67 patients with non-dialysis CRF as a result of chronic glomerulonephritis (n = 33) or diabetic nephropathy (n = 34), and 134 hypertensive patients with normal renal function, two-dimensional and Doppler echocardiographic examinations were performed, and LV dimension, mass, systolic function, and diastolic function were evaluated.

RESULTS

LV mass was increased and LV diastolic dysfunction was advanced in subjects with CRF compared with hypertensive controls. In the comparison of echocardiographic parameters between the two groups of CRF patients, i.e. chronic glomerulonephritis and diabetic nephropathy groups, all indices of LV diastolic function were more deteriorated in the diabetic nephropathy group than in the chronic glomerulonephritis group, although LV structure including hypertrophy and systolic function did not differ between the groups. In a multiple regression analysis, the presence of diabetes (i.e. diabetic nephropathy group) was a significant predictor of LV diastolic dysfunction in CRF subjects, independent of other influencing factors such as age, blood pressure, renal function, anaemia and LV hypertrophy.

CONCLUSION

The present findings suggest that LV diastolic dysfunction, independent of LV hypertrophy, is specifically and markedly progressed in patients with CRF as a result of diabetic nephropathy.

Reduced myocardial velocities of left ventricular long-axis contraction identify both systolic and diastolic heart failure-a comparison with brain natriuretic peptide

BACKGROUND

Echocardiographic diagnosis of radial fractional shortening or global ejection fraction fails to diagnose all patients with heart failure; about 40%, with apparently normal global systolic function, will have elevated brain natriuretic peptide (BNP) concentrations and "pure" diastolic dysfunction. Screening methods do not include assessment of left ventricular (LV) longitudinal function, however, which is a more sensitive marker of subclinical disease.

AIMS

We investigated the diagnostic potential of assessment of LV longitudinal function in suspected heart failure, in a comparison against BNP.

METHODS

Fifty consecutive subjects (aged 65+/-12 years; 30 men) referred to a heart failure clinic with unexplained breathlessness were examined by echocardiography and had plasma BNP measured by fluorescence immunoassay.

RESULTS

Global systolic function (ejection fraction) correlated moderately with log-transformed BNP (r=-0.54), as did global diastolic function (r=0.55 for estimated LV filling pressure, and r=-0.51 for transmitral flow propagation velocity), and radial systolic function (r=-0.60) (all p<0.001). The echocardiographic parameter that correlated best with BNP, however, was LV longitudinal systolic function (r=-0.78, p<0.001). By stepwise multiple regression analysis, BNP was predicted by longitudinal systolic velocity, in association with LV mass index and radial systolic velocity (r=0.81, r(2)=0.66, p<0.0001). The sensitivity and specificity of a longitudinal systolic velocity of </=5.5 cm/s (mean of 4 basal segments) to diagnose heart failure (defined as an elevated BNP) were 94% and 85%, respectively; the negative predictive value was 97%.

CONCLUSION

Non-invasive diagnosis or exclusion of suspected heart failure, whether systolic or diastolic, can be performed accurately by echocardiographic measurement of LV longitudinal systolic function.

Combined systolic and diastolic dysfunction in the presence of preserved left ventricular ejection fraction

BACKGROUND

Heart failure with preserved left ventricular ejection fraction (LVEF) suggests isolated diastolic dysfunction.

AIM

The purpose of this study was to determine if systolic and diastolic dysfunction occurred with preserved LVEF.

METHODS

Equilibrium resting radionuclide ventriculograms from 439 patients with an LVEF >/=0.50 were used to determine LV peak filling rate (PFR) and peak ejection rate (PER) in end-diastolic volumes per second and LV end-systolic volume (ml). Patients with low-normal (n=147; range, 0.50-0.58; mean+/-S.D., 0.53+/-0.02), intermediate-normal (161, 0.59-0.64, 0.61+/-0.02), and high-normal (131, 0.65-0.94, 0.72+/-0.06) LVEF were compared.

RESULTS

From low-normal to intermediate-normal to high-normal LVEF, LV end-systolic volume decreased (93+/-36, 71+/-33, 43+/-26, respectively, P<0.0001), PFR increased (2.31+/-0.74, 2.58+/-0.74, 3.15+/-0.94, P<0.0001), PER increased (-2.78+/-0.50, -3.13+/-0.47, -3.83+/-0.84, P<0.0001), the percentages of patients with abnormal PFR decreased (66, 56, 40, P<.0001), and the percentage with abnormal PER decreased (47, 14, 5, P<0.0001). Of 193 patients with preserved LVEF and abnormally low PFR, 65 (34%) had abnormally low PER.

CONCLUSIONS

The results indicate that a preserved LVEF was often associated with LV systolic dysfunction (enlarged LV end-systolic volume and low PER) and LV diastolic dysfunction (decreased PFR).

Usefulness of tissue Doppler imaging in the diagnosis and prognosis of acute right ventricular infarction with inferior wall acute left ventricular infarction

Tissue Doppler (TD) imaging is a novel echocardiographic technique that measures myocardial velocities. However, there are sparse data on TD imaging of the right ventricular (RV) free wall in the diagnosis and prognosis of RV myocardial infarction (MI) in inferior wall left ventricular MI. Fifty patients who had left ventricular MI underwent TD echocardiography and angiography within 48 hours of MI. For diagnosis, the ability of RV TD imaging to detect RV MI was assessed using coronary angiography as the reference standard. For prognosis, the ability of TD detection of RV dysfunction to predict cardiac death or rehospitalization at 1 year was determined. For diagnosis, the univariate predictors of RV MI included RV diastolic dimension (p = 0.001), TD imaging of tricuspid annular systolic velocity (p = 0.001), and early diastolic velocity (p = 0.002). On multivariate analysis, systolic annular velocity (p = 0.04) and RV dimension (p = 0.05) predicted RV MI. For prognosis, nonculprit coronary artery disease (p = 0.003), TD imaging of RV systolic annular velocity (p = 0.005), and early diastolic velocity (p = 0.01) were among the univariate predictors of cardiac death or rehospitalization. On multivariate analysis, nonculprit coronary artery disease (p = 0.02) and TD imaging of systolic annular velocity (p = 0.04) were independent predictors of outcome. Decreased RV systolic annular velocity on TD images detects RV MI in first left ventricular acute inferior MI and predicts cardiac death or rehospitalization at 1 year.

Tissue Doppler echocardiographic quantification. Comparison to coronary angiography results in Acute Coronary Syndrome patients

Background

Multiples indices have been described using tissue Doppler imaging (DTI) capabilities. The aim of this study was to assess the capability of one or several regional DTI parameters in separating control from ischemic myocardium.

Methods

Twenty-eight patients with acute myocardial infarction were imaged within 24-hour following an emergent coronary angioplasty. Seventeen controls without any coronary artery or myocardial disease were also explored. Global and regional left ventricular functions were assessed. High frame rate color DTI cineloop recordings were made in apical 4 and 2-chamber for subsequent analysis. Peak velocity during isovolumic contraction time (IVC), ejection time, isovolumic relaxation (IVR) and filling time were measured at the mitral annulus and the basal, mid and apical segments of each of the walls studied as well as peak systolic displacement and peak of strain.

Results

DTI-analysis enabled us to discriminate between the 3 populations (controls, inferior and anterior AMI). Even in non-ischemic segments, velocities and displacements were reduced in the 2 AMI populations. Peak systolic displacement was the best parameter to discriminate controls from AMI groups (wall by wall, p was systematically < 0.01). The combination IVC + and IVR< 1 discriminated ischemic from non-ischemic segments with 82% sensitivity and 85% specificity.

Conclusion

DTI-analysis appears to be valuable in ischemic heart disease assessment. Its clinical impact remains to be established. However this simple index might really help in intensive care unit routine practice.

Diastolic dysfunction and diastolic heart failure: diagnostic, prognostic and therapeutic aspects

Left ventricular (LV) diastolic dysfunction (DD) and diastolic heart failure (HF), that is symptomatic DD, are due to alterations of myocardial diastolic properties. These alterations involve relaxation and/or filling and/or distensibility. Arterial hypertension associated to LV concentric remodelling is the main determinant of DD but several other cardiac diseases, including myocardial ischemia, and extra-cardiac pathologies involving the heart are other possible causes. In the majority of the studies, isolated diastolic HF has been made equal to HF with preserved systolic function (= normal ejection fraction) but the true definition of this condition needs a quantitative estimation of LV diastolic properties. According to the position of the European Society of Cardiology and subsequent research refinements the use of Doppler echocardiography (transmitral inflow and pulmonary venous flow) and the new ultrasound tools has to be encouraged for diagnosis of DD. In relation to uncertain definitions, both prevalence and prognosis of diastolic heart failure are very variable. Despite an apparent lower death rate in comparison with LV systolic HF, long-term follow-up (more than 5 years) show similar mortality between the two kinds of HF. Recent studies performed by Doppler diastolic indexes have identified the prognostic power of both transmitral E/A ratio < 1 (pattern of abnormal relaxation) and > 1.5 (restrictive patterns). The therapy of LV DD and HF is not well established but ACE-inhibitors, angiotensin inhibitors, aldosterone antagonists and β-blockers show potential beneficial effect on diastolic properties. Several trials, completed or ongoing, have been planned to treat DD and diastolic HF.

Contribution of left ventricular diastolic dysfunction to heart failure regardless of ejection fraction

Heart failure (HF) has been classified as systolic and diastolic based on the left ventricular ejection fraction. We hypothesized that left ventricular diastolic dysfunction is an important element of HF regardless of ejection fraction. Two hundred six patients who had clinical HF were compared with 72 age-matched controls. Diastolic dysfunction, as assessed by the mitral filling pattern and tissue Doppler imaging, was present in >90% of patients who had HF regardless of ejection fraction and was more frequent and severe than in age-matched controls (p <0.001). In patients who had HF, B-type natriuretic peptide correlated with diastolic dysfunction (r = 0.62, p <0.001) but not with ejection fraction or end-diastolic volume index (EDVI). The degree of diastolic dysfunction influenced survival rate (risk ratio 1.64, p <0.05), whereas ejection fraction and EDVI did not. Systolic function measured by systolic mitral annular velocity was decreased in patients who had HF and an ejection fraction </=0.40 (4.8 +/- 1.1 cm/s) and, to a lesser extent, an ejection fraction >/=0.50 (6.6 +/- 1.8 cm/s) compared with control subjects (8.0 +/- 2.1 cm/s, p <0.01). Patients who had HF and an ejection fraction >/=0.50 had an increased ratio of ventricular mass to EDVI. Patients who had HF and an ejection fraction </=0.40 had increased left ventricular EDVI. Thus, regardless of ejection fraction, patients who have HF also have diastolic dysfunction. Diastolic dysfunction is a better predictor of B-type natriuretic peptide levels and mortality than ejection fraction or left ventricular EDVI. In addition to diastolic dysfunction, HF with an ejection fraction >/=0.50 is associated with mild systolic dysfunction and an increased ratio of left ventricular mass to EDVI. In HF with an ejection fraction </=0.40, systolic dysfunction and left ventricular dilation accompany diastolic dysfunction.

Diastolic Heart Failure: Definitions and Terminology

Patients with chronic heart failure can be divided into 2 broad categories: systolic heart failure and diastolic heart failure. There are significant differences in demographics, prognosis, left ventricular structure, as well as systolic and diastolic function between these 2 groups of patients. The purpose of this presentation is to define the terminology used to describe these 2 broad categories of heart failure and to characterize the functional measurements that constitute their pathophysiological mechanisms.

Impact of left ventricular diastolic function on exercise capacity in patients with chronic mitral regurgitation: an exercise echocardiography study

BACKGROUND

Mitral regurgitation (MR) is known as one of the most frequent causes of heart failure and sudden death. In spite of increasing prevalence of MR, there have been no available data on cardiac determinants of exercise capacity in patients with chronic MR.

HYPOTHESIS

This study aimed to investigate cardiac determinants of exercise capacity in patients with chronic MR.

METHODS

We consecutively enrolled 32 patients (11 men, mean age: 44 +/- 14 years) who had greater than moderate MR with normal left ventricular (LV) systolic function (LV ejection fraction >50%). Conventional echocardiographic indices and parameters measured by Doppler tissue imaging at septal side of mitral annulus were obtained before exercise. Mitral regurgitation fraction, forward stroke volume, pulmonary venous flow velocities, and systolic pulmonary artery pressure (sPAP) were also obtained with standard methods.

RESULTS

Left ventricular ejection fraction was 61 +/- 6% and MR fraction was 48 +/- 13%. All patients finished a symptom-limited treadmill exercise test with a peak heart rate of >85% of predicted maximum heart rate. Mean exercise time was 9.95 +/- 2.17 min, corresponding to 11 +/- 2 metabolic equivalents. Among pre-exercise echocardiographic variables, only early diastolic mitral annulus velocity (E') and pulmonary venous reversal flow velocity (PVa) showed a significant correlation with exercise time (r = 0.44, p = 0.011, and r = -0.40, p = 0.040, respectively), which persisted after multivariate analysis (p = 0.011 and 0.038, respectively). Other parameters such as systolic mitral annulus velocity, resting and postexercise sPAP, forward stroke volume, LV size, LV ejection fraction, left atrial size, and regurgitant fraction showed no significant correlation.

CONCLUSIONS

Left ventricular diastolic function is an important determinant of exercise capacity in patients with chronic MR. Both E' and PVa, accepted surrogate estimates for LV diastolic function, may be useful for identifying patients with chronic MR and with poor exercise capacity.

Ventricular structure and function in aged dogs with renal hypertension: a model of experimental diastolic heart failure

BACKGROUND

Heart failure (HF) with normal ejection fraction (diastolic HF [DHF]) usually occurs in elderly patients with hypertension. The presence and significance of altered systolic and diastolic ventricular function in DHF is increasingly controversial. Our objective was to develop a clinically relevant large-animal model to better understand the pathophysiology of DHF.

METHODS AND RESULTS

Ventricular structure and function were characterized in young control (YC group; n=6), old control (OC group; n=7), and old dogs made hypertensive by renal wrapping (experimental DHF [ExDHF] group; n=8). The ExDHF group was associated with normal left ventricular (LV) volume, increased LV mass, and myocardial fibrosis. LV relaxation was impaired in ExDHF (tau=53+/-6 ms) compared with OC (tau=35+/-3 ms; P<0.05) and YC (tau=33+/-6 ms; P<0.05) dogs. The percent diastole at which relaxation is complete was increased in ExDHF (116+/-30%) compared with OC (69+/-8%; P<0.05) and YC (35+/-5%; P<0.05) dogs. The coefficient of LV diastolic stiffness was similar in OC, YC, and ExDHF dogs. Diastolic pressures increased dramatically in response to increases in blood pressure. End-systolic LV stiffness was enhanced in ExDHF dogs and after load enhancement of myocardial performance was maintained. Arterial stiffness was increased in ExDHF dogs.

CONCLUSIONS

Aged dogs with chronic hypertension exhibit LV hypertrophy and fibrosis with impaired LV relaxation but no increase in the coefficient of LV diastolic stiffness. LV systolic and arterial stiffness are increased, which may exacerbate load-dependent impairment of relaxation and contribute to increased filling pressures with hypertensive episodes. This model mimics many of the structural and functional characteristics described in the limited studies of human DHF and provides insight into the pathogenesis of DHF.

Tissue Doppler imaging for the detection and quantitation of myocardial dysfunction in patients with type 2 diabetes mellitus

The prevalence of type 2 diabetes mellitus is rapidly increasing. Myocardial dysfunction may be a consequence of diabetic cardiomyopathy and it contributes to the poor prognosis of diabetic patients.

AIMS

This study was designed to test whether tissue Doppler imaging might be a suitable tool for early detection of myocardial dysfunction in diabetic patients.

METHODS

Forty-three diabetic patients and 33 non-diabetic controls, including age-matched subgroups without evidence of coronary artery disease (n=12), were recruited if they had normal LV-function by standard 2-D echocardiography and no clinical signs of heart failure. They were investigated with tissue Doppler imaging at rest and during pharmacological stress with dipyridamole and/or dobutamine. Myocardial function was calculated as the mean value from six basal myocardial segments for peak velocity at systole (Vs), early diastole (Ve) and atrial contraction (Va).

RESULTS

Compared to controls, diabetic patients had compromised Ve at rest (8.5 +/- 1.7 vs. 9.6 +/- 1.9 cm/sec, p < 0.02), as did the subgroups without coronary artery disease (9.3 +/- 1.7 vs. 10.7 +/- 1.5 cm/sec, p < 0.05). Dobutamine stress resulted in lower Vs (10.7 +/- 2.7 vs. 13.6 +/- 3.4 cm/sec, p < 0.05) and Ve (10.0 +/- 2.1 vs. 13.1 +/- 3.8 cm/sec, p < 0.05) in the diabetic patients, demonstrating an impaired increase of Vs, Vd and Va (p < 0.05, p < 0.0003 and p < 0.03, respectively). An inverse correlation was observed between Ve and age in both control and diabetic individuals. Thus, abnormal values were defined in relation to age.

CONCLUSIONS

Diastolic and systolic myocardial dysfunction in patients with type 2 diabetes may be identified by quantitative tissue Doppler imaging before the onset of clinical signs of heart failure and before the appearance of traditional echocardiographic indices of systolic myocardial dysfunction.

Detection of early systolic dysfunction with strain rate imaging in a patient with light chain cardiomyopathy

Congestive heart failure (CHF) in cardiac amyloidosis has been attributed to the development of diastolic dysfunction, because severe CHF symptoms have been observed despite a normal or only mildly reduced LV ejection fraction (EF). An early impairment of longitudinal systolic function has been described by means of tissue Doppler-derived myocardial deformation imaging ('strain rate imaging', SRI). Our patient presented with signs of CHF and significantly increased brain-natriuretic peptide (BNP) levels. Conventional measures of systolic contractile function were within the normal range and mitral inflow Doppler showed only moderate diastolic dysfunction. Histopathological examination by endomyocardial biopsy revealed interstitial deposition of amyloid fibers. Quantitative assessment of myocardial velocities (TDI) and deformation properties (Strain) from the apical view demonstrated a significant impairement of systolic longitudinal myocardial function. In patients with isolated diastolic dysfunction detected by conventional Doppler echocardiography, the quantitative assessment of myocardial strain and strain rate can be helpful in the early detection of systolic dysfunction.

Tissue Doppler imaging in the evaluation of left ventricular diastolic function

PURPOSE OF REVIEW

Describe the rationale behind, and clinical use of, tissue Doppler (TD) imaging in the assessment of left ventricular (LV) diastolic function, with a focus on recent developments.

RECENT FINDINGS

Tissue Doppler imaging is a novel echocardiographic technique that directly measures myocardial velocities. Systolic TD measurements assess left and right ventricular myocardial contractile function. Diastolic TD values reflect myocardial relaxation, and in combination with conventional Doppler measurements, ratios (E/Ea) have been developed to estimate LV filling pressures. TD values and derived ratios have been demonstrated to be valuable in the diagnosis of elevated LV filling pressures, clinical congestive heart failure (CHF), and the prognosis of patients with cardiac disease and CHF. New TD indices have now been developed to assess myocardial relaxation and LV filling pressures, and the impact of LV systolic function on the use of TD imaging has recently been described. TD echocardiography is being used in an ever-widening group of patients for the assessment of LV diastolic function, and its correlation to, and comparison with, B-type natriuretic peptide is an active area of current investigation.

SUMMARY

This review focuses on new developments in the clinical use of TD echocardiography in the evaluation of left ventricular diastolic function.

A new Doppler tissue ratio to revisit systole: The pre-ejectional isovolumic to ejectional velocity ratio–application to aging

Most diagnostic applications of Doppler tissue echocardiography rely on peak (Pk) velocity (V) values of single variables or myocardial V gradient. Whereas age-related changes in diastolic V are well-known, previous Doppler tissue echocardiography studies of systolic function showed no age effect for pre-ejectional (Ej) isovolumic (PEI) and Ej inward wall motion Pk V. In addition to myocardial V gradient, ratios were calculated between PEI and Ej Pk V, and mean V averaged over systole (PEI/Ej V ratios) at each layer of the posterior wall using M-mode color on two control groups: A (27 +/- 5 years) and B (54 +/- 10 years). The only changes were for PEI/Ej V ratios (mean V endocardial 21 +/- 7% vs 34 +/- 20%, P = .01; mean V epicardial 27 +/- 8% vs 40 +/- 18%, P = .006; Pk epicardial V 21 +/- 10% vs 30 +/- 16%, P = .04 for groups A and B, respectively). Correlation versus age were r = 0.52 and P = .005 (mean V endocardial), r = 0.50 and P = .007 (mean V epicardial), and r = 0.32 and P = .03 (Pk epicardial V). PEI/Ej V ratios and mean V studied in separate layers showed that the new systolic approach had advantages over single variable or Pk V to study age-related changes.

Three-dimensional assessment of left ventricular systolic strain in patients with type 2 diabetes mellitus, diastolic dysfunction, and normal ejection fraction

Left ventricular (LV) diastolic dysfunction often occurs in patients with type 2 diabetes mellitus (DM) independent of atherosclerotic coronary artery disease, myocardial ischemia, and regional wall motion anomalies. Limited information exists on LV myocardial tissue strain in this patient group. We measured 3-dimensional (3-D) parameters of LV systolic and diastolic functions in 28 patients who had type 2 DM (age 33 to 70 years), standard echocardiographic evidence of LV diastolic dysfunction, and normal LV ejection fraction, and 31 normal control subjects (age 19 to 74 years) who had no evidence of cardiac disease, with multislice cine anatomic and tagged magnetic resonance imaging. Three-dimensional analysis of the resulting images showed that peak systolic mitral valve plane displacement was 12% smaller (p = 0.040) and peak diastolic mitral valve plane velocity was 21% lower (p = 0.008) in patients who had DM than in normal controls. Peak systolic circumferential and longitudinal strains and principal 3-D shortening strain were 14%, 22%, and 10% smaller, respectively, in the DM group (p <0.001 for each). Peak diastolic rate of relaxation of circumferential and longitudinal strains and principal 3-D shortening strain were 35%, 32%, and 33% lower, respectively, in the DM group (p <0.001 for each). Thus, LV systolic circumferential, longitudinal and 3-D principal strains, and diastolic strain rates are impaired in patients who have type 2 DM, LV diastolic dysfunction, and normal LV ejection fraction.

Echocardiographic parameters of ventricular dyssynchrony validation in patients with heart failure using sequential biventricular pacing

OBJECTIVES

We sought to evaluate the relationship between hemodynamic and ventricular dyssynchrony parameters in patients undergoing simultaneous and sequential biventricular pacing (BVP).

BACKGROUND

Various echocardiographic parameters of ventricular dyssynchrony have been proposed to screen and optimize BVP therapy.

METHODS

Forty-one patients with heart failure undergoing BVP implantation were studied. Echocardiography coupled with tissue tracking and pulsed Doppler tissue imaging (DTI) was performed before and after BVP implantation and after three months of optimized BVP. Indexes of inter- or intraventricular dyssynchrony were correlated with hemodynamic changes during simultaneous and sequential BVP (10 intervals of right ventricular [RV] or left ventricular [LV] pre-excitation).

RESULTS

Variations in intra-LV delay(peak), intra-LV delay(onset), and index of LV dyssynchrony measured by pulsed DTI were highly correlated with those of cardiac output (r = -0.67, r = -0.64, and r = -0.67, respectively; p < 0.001) and mitral regurgitation (r = 0.68, r = 0.63, and r = 0.68, respectively; p < 0.001), whereas variations in the extent of myocardium displaying delayed longitudinal contraction (r = -0.48 and r = 0.51, respectively; p < 0.05) and the variations in septal-to-posterior wall motion delay (r = -0.41, p < 0.05 and r = 0.24, p = NS, respectively) were less correlated. The changes in interventricular dyssynchrony were not significantly correlated (p = NS). Compared with simultaneous BVP, individually optimized sequential BVP significantly increased cardiac output (p < 0.01), decreased mitral regurgitation (p < 0.05), and improved all parameters of intra-LV dyssynchrony (p < 0.01). At three months, a significant reverse mechanical LV remodeling was observed with significantly decreased LV volumes (p < 0.01) associated with an increased LV ejection fraction (p = 0.035).

CONCLUSIONS

Specific echocardiographic measurements of ventricular dyssynchrony are highly correlated with hemodynamic changes and may be a useful adjunct in the selection and optimization of BVP. Individually optimized sequential BVP provided a significant early hemodynamic improvement compared with simultaneous BVP.

Role of Diastole in Left Ventricular Function, II: Diagnosis and Treatment

Left ventricular diastolic dysfunction plays an important role in congestive heart failure. Although once thought to be lower, the mortality of diastolic heart failure may be as high as that of systolic heart failure. Diastolic heart failure is a clinical syndrome characterized by signs and symptoms of heart failure with preserved ejection fraction (0.50) and abnormal diastolic function. One of the earliest indications of diastolic heart failure is exercise intolerance followed by fatigue and, possibly, chest pain. Other clinical signs may include distended neck veins, atrial arrhythmias, and the presence of third and fourth heart sounds. Diastolic dysfunction is difficult to differentiate from systolic dysfunction on the basis of history, physical examination, and electrocardiographic and chest radiographic findings. Therefore, objective diagnostic testing with cardiac catheterization, Doppler echocardiography, and possibly measurement of serum levels of B-type natriuretic peptide is often required. Three stages of diastolic dysfunction are recognized. Stage I is characterized by reduced left ventricular filling in early diastole with normal left ventricular and left atrial pressures and normal compliance. Stage II or pseudonormalization is characterized by a normal Doppler echocardiographic transmitral flow pattern because of an opposing increase in left atrial pressures. This normalization pattern is a concern because marked diastolic dysfunction can easily be missed. Stage III, the final, most severe stage, is characterized by severe restrictive diastolic filling with a marked decrease in left ventricular compliance. Pharmacological therapy is tailored to the cause and type of diastolic dysfunction.

Diagnosing heart failure in aortic valve stenosis

OBJECTIVE

In aortic valve stenosis (AS), heart failure (HF) omens a high risk of death and is an indication for prompt valve replacement. We studied whether its detection can be facilitated by measuring plasma N-terminal B-type natriuretic peptide (Nt-BNP) or by estimating pulmonary capillary wedge pressure (PCWP) using echocardiography.

DESIGN AND SETTING

A cross-sectional cohort study in a university hospital.

SUBJECTS AND METHODS

We studied 137 consecutive adult patients referred to our unit for invasive evaluation of isolated AS. All patients underwent cardiac catheterization, measurement of plasma Nt-BNP and estimation of PCWP by Doppler echocardiography of transmitral and pulmonary venous flow velocities. The final diagnosis of HF was based on the combined criteria of dyspnoea on ordinary effort and PCWP >14 mmHg at cardiac catheterization. The performance of Nt-BNP and the PCWP estimate in the detection of HF were studied using receiver operating characteristic (ROC) analysis.

RESULTS

Totally 42 patients had HF. A cardiologist's clinical diagnosis of HF had high specificity (94%) but poor sensitivity (66%). With an optimized cut-off point, plasma Nt-BNP had moderate sensitivity (77%) and specificity (79%) for HF; the ROC area was 0.83. The echocardiographic PCWP estimate classified 90% of patients correctly as having normal or truly elevated (>14 mmHg) PCWP. Its sensitivity and specificity for the diagnosis of HF were 80 and 95% respectively; the ROC area was 0.88. With a cut-off point of 12 mmHg, the sensitivity of the PCWP estimate was 85% and specificity, 88%.

CONCLUSION

The recognition of HF in patients with AS can be improved by estimating PCWP using Doppler echocardiography of transmitral and pulmonary venous flow velocities.

Tissue Doppler imaging of the right and left ventricle in severe obesity (body mass index >35 kg/m2)

We investigated right and left heart function in 51 patients with a body mass index of >35 kg/m(2) who underwent evaluation for gastric bypass surgery using standard Doppler echocardiography and color tissue Doppler imaging. Left atrial diameter (3.7 +/- 0.5 vs 3.3 +/- 0.4 cm, p <0.001), left ventricular end-diastolic diameter (5.0 +/- 0.6 vs 4.5 +/- 0.4 cm, p <0.001), and left ventricular mass index (119 +/- 49 vs 76 +/- 26 g/m, p <0.001) were increased in patients with severe obesity. Early diastolic mitral annular velocity (7.5 +/- 2.1 vs 9.6 +/- 3.0 cm/s, p <0.001), early diastolic/late diastolic mitral annular velocity ratio (1.38 +/- 0.6 vs 1.94 +/- 1.3, p = 0.007), early diastolic tricuspid annular velocity (7.8 +/- 2.6 vs 9.5 +/- 2.4 cm/s, p = 0.002), early diastolic/late diastolic tricuspid annular velocity ratio (0.9 +/- 0.36 vs 1.1 +/- 0.4, p = 0.048), and mitral annular systolic velocity (5.7 +/- 1.3 vs 6.5 +/- 1.5 cm/s, p = 0.012) were significantly lower in obese patients. Early diastolic mitral inflow/mitral annular velocity ratio was increased in the obese (13.5 +/- 4.7 vs 9.1 +/- 3.6, p <0.001). Tricuspid annular systolic velocities did not differ.

Stroke volume and mitral annular velocities

The aim of this study was to assess the impact of stroke volume (SV) on mitral annular velocities derived from tissue Doppler imaging (TDI). To this end, conventional echocardiographic variables and TDI derived mitral annular velocities (S', E', A') were obtained in 14 patients (pts) with increased SV (due to primary mitral (n=12) (ISV group)), in 41 pts with reduced SV (due to ischemic (n=27) or dilated cardiomyopathy (n=9) or hypertensive heart disease (n=5) (RSV group)) and 29 asymptomatic controls with normal SV (CON group). Systolic (S') and early diastolic (E') mitral annular velocities were elevated in the ISV group in the comparison to the CON group, but were significantly reduced in the RSV group. Late diastolic annular velocities (A') did not differ between the ISV and the CON group, but were lowest in the RSV group. On simple linear regression analysis, SV was significantly related to S' (r=0.74, p<0.001), to E' (r=0.74, p<0.001) and to A' (r=0.43, p<0.01). On multiple regression analysis, SV was a stronger independent predictor of S' and E' than conventional systolic or diastolic echocardiographic variables. Thus, stroke volume has a significant impact on TDI derived systolic (S') and early diastolic (E') mitral annular velocities. This should be considered, when TDI is used in the evaluation of LV performance or in the estimation of filling pressures.

Comparison of Efficacy of Reverse Remodeling and Clinical Improvement for Relatively Narrow and Wide QRS Complexes After Cardiac Resynchronization Therapy for Heart Failure

INTRODUCTION

Cardiac resynchronization therapy (CRT) has been shown to reverse left ventricular (LV) remodeling and improve symptoms in heart failure patients with wide QRS complexes; however, its role in patients with mildly prolonged QRS complexes is unclear. This study investigated if CRT benefited patients with mildly prolonged QRS complexes >120 to 150 ms and explored if the severity of systolic asynchrony determined such a response.

METHODS AND RESULTS

Fifty-eight patients (age 66 +/- 11 years, 66% male) who had undergone CRT were studied prospectively. Of these patients, 27 had QRS duration between 120 and 150 ms (group A), and 31 had QRS duration >150 ms (group B). Tissue Doppler echocardiography and clinical assessment were performed at baseline and 3 months after CRT. Both groups had significant reduction of LV volume and increased ejection fraction, +dP/dt, and sphericity index (all P < 0.05). These improvements were greater in group B and were explained by the higher prevalence of systolic intraventricular asynchrony. Significant reverse remodeling (reduction of LV end-systolic volume >15%) was evident in 46% of group A patients and 68% of group B patients. Improvement in clinical endpoints was observed in both groups (all P < 0.01), although the changes in metabolic equivalent and New York Heart Association functional class were greater in group B. In both groups, systolic asynchrony index (TS-SD) was the most important predictor of reverse remodeling (r =-0.78, P < 0.001) and was the only independent predictor in the multivariate model (beta=-1.80, confidence interval =-2.18 to -1.42, P < 0.001); QRS duration was not. A predefined TS-SD value >32.6 ms had a sensitivity of 94% and specificity of 83% to predict reverse remodeling. Improvement of intraventricular asynchrony after CRT was evident only in responders (P = 0.01).

CONCLUSION

Improvement of LV remodeling and clinical status is evident after CRT in heart failure patients with QRS duration >120 to 150 ms. These responders are closely predicted by the severity of prepacing intraventricular asynchrony but not QRS duration.

Comparison of left ventricular function by tissue Doppler imaging in patients with diabetes mellitus without systemic hypertension versus diabetes mellitus with systemic hypertension

Because diabetes mellitus substantially increases the risk of development of heart failure, we sought to establish early alterations in left ventricular systolic and diastolic function in patients with diabetes mellitus with and without coexisting systemic hypertension. We studied 134 subjects using echocardiography comprising standard 2-dimensional and conventional Doppler as well as tissue Doppler imaging. Our study demonstrated the early appearance of both left ventricular systolic and diastolic dysfunction in diabetic patients at rest and the contributory effects of diabetes to myocardial impairment produced by hypertension, as well as the high usefulness of tissue Doppler imaging in detection and quantitation of myocardial dysfunction in diabetics. This method was superior to other echocardiographic techniques and plasma brain natriuretic peptide evaluation.

Beyond the measurement of QRS complex toward mechanical dyssynchrony: cardiac resynchronisation therapy in heart failure patients with a normal QRS duration

Mechanical systolic dyssynchrony exists in many patients with heart failure, irrespective of QRS duration, and so more patients may derive benefit from cardiac resynchronisation therapy than previously considered.

Effect of a cardiac rehabilitation program on left ventricular diastolic function and its relationship to exercise capacity in patients with coronary heart disease: experience from a randomized, controlled study

BACKGROUND

A cardiac rehabilitation and prevention program (CRPP) is a recognized nonpharmacological modality in the management of coronary heart disease (CHD). However, the effect of a CRPP on systolic function of the heart is controversial, and no data exists on diastolic function in CHD. A randomized, controlled study was conducted to address these issues.

METHODS

Patients (n = 269) with recent acute myocardial infarction (n = 193) or after percutaneous coronary intervention (PCI) (n = 76) were randomized to either CRPP (2-hour twice-weekly exercise program for 8 weeks) or conventional therapy (control group). Serial treadmill exercise testing and at-rest echocardiography were performed during phases 1 (baseline), 2 (post-exercise training), and 3 (8-month follow up).

RESULTS

The prevalence of left ventricular (LV) abnormal relaxation pattern (ARP) of diastolic dysfunction was increased in the control group only in phase 3 (65% vs 88%, chi2 = 7.6, P <.01). Significant improvement of individual LV diastolic parameters towards less severe delayed relaxation was also observed in the CRPP group, especially in those with recent acute myocardial infarction or ARP. The gain in exercise capacity was faster and more substantial in the CRPP than the control group (P <.001 for phase 2, P <.05 for phase 3), and was significantly correlated with LV diastolic indices in those with ARP. Exercise training had neutral effects on LV systolic function and rate-pressure product.

CONCLUSIONS

In patients with CHD, CRPP prevented the progression of resting LV diastolic dysfunction, without affecting systolic function. In those with ARP, the improvement of diastolic function predicted the gain in exercise capacity.

Elevation of plasma brain natriuretic peptide is a hallmark of diastolic heart failure independent of ventricular hypertrophy

OBJECTIVES

We tested a hypothesis that elevation of the plasma level of brain natriuretic peptide (BNP) is one of the characteristics of patients with diastolic heart failure (DHF) independent of left ventricular (LV) hypertrophy.

BACKGROUND

The clinical characteristics of DHF are not well acknowledged, although DHF has become a great social burden. Such a lack of clinical information leads to inaccuracy in the diagnosis of DHF. We have demonstrated enhancement of ventricular production of BNP with progression of maladaptive ventricular hypertrophy, but not with development of compensatory hypertrophy in an animal DHF model.

METHODS

Of 372 patients who presented to the emergency department because of acute pulmonary congestion without acute coronary syndrome between January 1996 and May 2002, those with an ejection fraction > or =45% upon admission, who were stably controlled at least for a year in our outpatient clinics, comprised the DHF group (n = 19). A control group consisted of 22 hypertensive patients with a LV mass index greater than or equal to its minimum value of the DHF group and an ejection fraction > or =45%, in whom cardiac symptoms had not occurred.

RESULTS

Despite a similar distribution of LV mass index, the BNP level was higher in the DHF group than in the control group (149 +/- 38 vs. 31 +/- 5 pg/ml, p < 0.01). There was no difference in LV cavity size or parameters derived from pulsed Doppler transmitral flow velocity curves.

CONCLUSIONS

An elevation of BNP may be a hallmark of patients with or at risk of DHF among subjects with preserved systolic function independent of LV hypertrophy.

Development of a depressed left ventricular ejection fraction in patients with left ventricular hypertrophy and a normal ejection fraction

The progression from concentric left ventricular (LV) hypertrophy to heart failure has not been well defined. Of 159 predominantly hypertensive African-American patients with LV hypertrophy and a normal ejection fraction (EF), 28 (18%) developed a reduced EF after a median follow-up of approximately 4 years. Risk factors for this outcome included a history of coronary artery disease, pulmonary edema seen on a chest x-ray, or a subsequent myocardial infarction.