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

Tissue Doppler imaging a new prognosticator for cardiovascular diseases

Tissue Doppler imaging (TDI) is evolving as a useful echocardiographic tool for quantitative assessment of left ventricular (LV) systolic and diastolic function. Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as heart failure, acute myocardial infarction, and hypertension. In these conditions, myocardial mitral annular or basal segmental (Sm) systolic and early diastolic (Ea or Em) velocities have been shown to predict mortality or cardiovascular events. In particular, those with reduced Sm or Em values of <3 cm/s have a very poor prognosis. In heart failure and after myocardial infarction, noninvasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/Ea or E/Em) is a strong prognosticator, especially when E/Ea is > or =15. In addition, systolic intraventricular dyssynchrony measured by segmental analysis of myocardial velocities is another independent predictor of adverse clinical outcome in heart failure subjects, even when the QRS duration is normal. In heart failure patients who received cardiac resynchronization therapy, the presence of systolic dyssynchrony at baseline is associated with favorable LV remodeling, which in turn predicts a favorable long-term clinical outcome. Finally, TDI and derived deformation parameters improve prognostic assessment during dobutamine stress echocardiography. A high mean Sm value in the basal segments of patients with suspected coronary artery disease is associated with lower mortality rate or myocardial infarction and is superior to the wall motion score.

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

Diastolic heart failure (DHF) currently accounts for more than 50% of all heart failure patients. DHF is also referred to as heart failure with normal left ventricular (LV) ejection fraction (HFNEF) to indicate that HFNEF could be a precursor of heart failure with reduced LVEF. Because of improved cardiac imaging and because of widespread clinical use of plasma levels of natriuretic peptides, diagnostic criteria for HFNEF needed to be updated. The diagnosis of HFNEF requires the following conditions to be satisfied: (i) signs or symptoms of heart failure; (ii) normal or mildly abnormal systolic LV function; (iii) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV end-diastolic volume index (LVEDVI) <97 mL/m(2). Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler (TD) (E/E' > 15). If TD yields an E/E' ratio suggestive of diastolic LV dysfunction (15 > E/E' > 8), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, electrocardiographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma levels of natriuretic peptides are elevated, diagnostic evidence of diastolic LV dysfunction also requires additional non-invasive investigations such as TD, blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, or electrocardiographic evidence of atrial fibrillation. A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFNEF in patients with breathlessness and no signs of congestion. The updated strategies for the diagnosis and exclusion of HFNEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFNEF.

Impact of statin therapy on systemic inflammation, left ventricular systolic and diastolic function and prognosis in low risk ischemic heart disease patients without history of congestive heart failure

OBJECTIVES

The aim of this study was to investigate the impact of statin on systemic inflammation, left ventricular systolic and diastolic function and prognosis in low risk ischemic heart disease (IHD) patients.

METHODS

A total of 430 consecutive IHD patients without congestive heart failure were enrolled. One hundred and thirty-two patients (31%) were treated with statin (statin group) and 298 patients (69%) were not (no statin group). Echocardiographic indices, high sensitivity CRP, and prognosis were compared.

RESULTS

Ejection fraction (EF) was significantly higher in the statin group (p<0.01). The ratio of the early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/E') was significantly lower in the statin group than in the no statin group (p<0.01). Although LDL-cholesterol level did not differ, high sensitivity CRP level was significantly lower in the statin group (0.3+/-0.5 vs. 1.1+/-2.3 mg/dl, p=0.005). Cardiac event-(cardiac death and congestive heart failure)free survival rate was significantly higher in the statin group than in no statin group (Log-rank p<0.0001). By multivariate logistic regression analysis, E/E' > 15 (p=0.002), EF < 50% (p=0.003), lack of statin use (p=0.009), left atrial dimension (p=0.02), use of diuretics (p=0.03) and lack of beta-blockers (p=0.04) were independent predictors of cardiac events. In 248 patients matched by propensity scores, statin remained associated with better event-free survival (Log-rank p=0.006).

CONCLUSION

Statin may improve left ventricular function and thus improve the prognosis in low risk patients with IHD.

Left ventricular diastolic function following myocardial infarction

An acute myocardial infarction causes a loss of contractile fibers which reduces systolic function. Parallel to the effect on systolic function, a myocardial infarction also impacts diastolic function, but this relationship is not as well understood. The two physiologic phases of diastole, active relaxation and passive filling, are both influenced by myocardial ischemia and infarction. Active relaxation is delayed following a myocardial infarction, whereas left ventricular stiffness changes depending on the extent of infarction and remodeling. Interstitial edema and fibrosis cause an increase in wall stiffness which is counteracted by dilation. The effect on diastolic function is correlated to an increased incidence of adverse outcomes. Moreover, patients with comorbid conditions that are associated with worse diastolic function tend to have more adverse outcomes after infarction. There are currently no treatments aimed specifically at treating diastolic dysfunction following a myocardial infarction, but several new drugs, including aldosterone antagonists, may offer promise.

Validity of Revised Doppler Echocardiographic Algorithms and Composite Clinical and Angiographic Data in Diagnosis of Diastolic Dysfunction

BACKGROUND

Commonly used echocardiographic indices for grading diastolic function predicated on mitral inflow Doppler analysis have a poor diagnostic concordance and discriminatory value. Even when combined with other indices, significant overlap prevents a single group assignment for many subjects. We tested the relative validity of echocardiographic and clinical algorithms for grading diastolic function in patients undergoing cardiac catheterization.

METHOD

Patients (n = 115), had echocardiograms immediately prior to measuring left ventricular (LV) diastolic (pre-A, mean, end-diastolic) pressures. Diastolic function was classified into the traditional four stages, and into three stages using a new classification that obviates the pseudonormal class. Summative clinical and angiographic data were used in a standardized fashion to classify each patient according to the probability for abnormal diastolic function. Measured LV diastolic pressure in each patient was compared with expected diastolic pressures based on the clinical and echocardiographic classifications.

RESULT

The group means of the diastolic pressures were identical in patients stratified by four-stage or three-stage echocardiographic classifications, indicating that both classifications schemes are interchangeable. When severe diastolic dysfunction is diagnosed by the three-stage classification, 88% and 12%, respectively, were clinically classified as high and intermediate probability, and the mean LV pre-A pressures was >12 mmHg (P < 0.005). Conversely, the mean LV pre-A pressure in the clinical low probability or echocardiographic normal groups was <11 mmHg.

CONCLUSION

Use of a standardized clinical algorithm to define the probability of diastolic function identifies patients with elevated LV filing pressure to the same extent as echocardiographic methods.

Relation of left atrial volume to B-type natriuretic peptide levels in patients with stable chronic heart failure

This study assessed the relation between B-type natriuretic peptide (BNP) and echocardiographic indexes of left ventricular (LV) filling pressure in 53 patients with stable heart failure and without significant valvular dysfunction. Left atrial volume indexed to body surface area (LAVi), an indicator of chronic LV filling pressure, was correlated with BNP (r = 0.692, p <0.001) and was the strongest independent predictor of elevated levels in this cohort. LAVi was also the best predictor of BNP >or=100 pg/ml, with an area under the receiver-operating characteristic curve of 0.85 (95% confidence interval 0.74 to 0.96, p <0.001). Using the optimal cutoff of >31 ml/m(2), LAVi had a sensitivity of 92% and a specificity of 65% for BNP >or=100 pg/ml. Patients with LAVi >31 ml/m(2) had a median BNP of 122 pg/ml, compared with 21 pg/ml in patients with LAVi <or=31 ml/m(2) (p <0.001). These findings suggest that in patients with stable heart failure, BNP levels are related to chronic LV filling pressures. This may help explain the relatively modest correlation between BNP and acute measures of LV filling and the heterogeneity in BNP levels in patients with stable heart failure.

Restrictive diastolic filling predicts death after acute myocardial infarction: systematic review and meta-analysis of prospective studies

OBJECTIVE

To determine, through a systematic review and meta-analysis, the magnitude of the survival deficit associated with a restrictive filling pattern after acute myocardial infarction (AMI).

METHODS

Online databases were searched for prospective echocardiography outcome studies of patients after AMI. All authors were contacted to seek confirmation of their data. Restrictive filling was compared with all non-restrictive filling patterns. Review Manager Version 4.2.7 software was used for analysis.

RESULTS

3855 patients in 16 studies were identified. Follow up varied from two weeks to five years (> 1 year, 10 studies; and > 4 years, four studies). 776 (20%) of patients had a restrictive filling pattern at baseline. 580 patients died (247 in the restrictive group), and the overall odds ratio for death (restrictive filling worse) was 4.10 (95% confidence interval 3.38 to 4.99).

CONCLUSIONS

Mortality is about four times higher in patients with a restrictive filling pattern than in those with non-restrictive filling patterns after AMI. Echocardiographic assessment of diastolic filling pattern is an important part of the echocardiographic assessment of patients after myocardial infarction and provides important prognostic information about such patients.

Effect of ischemic mitral regurgitation on the ratio of early transmitral flow velocity to mitral annulus early diastolic velocity in patients with stable coronary artery disease

The present study evaluated the prevalence of ischemic mitral regurgitation (MR) in a large population of patients with documented coronary artery disease who had been referred for echocardiography and assessed whether ischemic MR is an independent determinant of echocardiographically estimated left ventricular (LV) filling pressures. We studied 849 consecutive patients with coronary artery disease (67 +/- 10 years; 76% men) without organic valvular disease. Ischemic MR was semiquantitatively graded as absent or trace or grades 1 to 3/4 by assessment of the color flow jet in relation to the left atrium in multiple orthogonal views. The ratio of early transmitral flow velocity to mitral annulus early diastolic velocity was determined to estimate LV filling pressures. Ischemic MR was absent in 25% of patients and 28% had grade > or = 2 ischemic MR. Only 18% of patients with preserved LV function had a significant ischemic MR, but up to 66% of patients with poor LV function had grade > or = 2 MR. The ratio of early transmitral flow velocity to mitral annulus early diastolic velocity was independently predicted by age, gender, LV ejection fraction, and ischemic MR severity. Even mild ischemic MR was associated with an increase in this noninvasive marker of LV filling pressures.

Risk Stratification in Chronic Heart Failure: Independent and Incremental Prognostic Value of Echocardiography and Brain Natriuretic Peptide and its N-terminal Fragment

BACKGROUND

It was the aim of this study to compare the prognostic impact of echocardiography and brain natriuretic peptide and its N-terminal fragment (NT-proBNP) in patients with chronic heart failure (CHF).

METHODS

In all, 73 patients with CHF underwent conventional 2-dimensional/Doppler echocardiography and Doppler tissue analysis of systolic, early and late diastolic mitral annular velocities. The mitral filling pattern was classified as restrictive or nonrestrictive. NT-proBNP measurements were carried out on a bench-top analyzer. A cardiac event (rehospitalization caused by worsening CHF, cardiac death, urgent cardiac transplantation) was defined as combined study end point.

RESULTS

During follow-up of 226 +/- 169 days, 27 patients had an event (rehospitalization because of CHF, n = 18; cardiac death, n = 7; urgent transplantation, n = 2). On multivariate Cox regression analysis, a restrictive filling pattern, NT-proBNP, the ratio of peak early diastolic mitral flow to mitral annular E' velocity were independent prognostic predictors. A risk stratification model based on the 3 strongest independent predictors separated groups into those with good, intermediate, and poor outcome (event-free survival of 78%, 46%, and 0%, respectively).

CONCLUSIONS

In patients with CHF, Doppler echocardiography, Doppler tissue imaging, and NT-proBNP provide independent and incremental prognostic information. A combined use of echocardiography and NT-proBNP may help to improve risk stratification in this patient population.

Diastolic stress echocardiography: hemodynamic validation and clinical significance of estimation of ventricular filling pressure with exercise

OBJECTIVES

Our study attempted to validate a Doppler index of diastolic filling (E/E') during exercise with simultaneously measured left ventricular diastolic pressure (LVDP), investigate its association with exercise capacity, and understand which patients to select for testing.

BACKGROUND

The ratio of early diastolic transmitral velocity to early diastolic tissue velocity approximates LVDP at rest, but there is limited validation of exercise E/E' with invasive hemodynamic measurement, and its clinical implications are unclear.

METHODS

The ratio of early diastolic transmitral velocity to early diastolic tissue velocity was measured at rest and during supine cycle ergometry in 37 patients undergoing left heart catheterization. In addition to correlation between invasive and estimated LVDP, the accuracy of different cutoffs for identification of elevated LVDP (>15 mm Hg) was determined at both rest and exercise. Doppler index of diastolic filling was also measured at rest and immediately after maximal treadmill exercise in 166 patients to investigate the association between exercise E/E' and exercise capacity (<8 metabolic equivalents [METs]).

RESULTS

In patients undergoing invasive measurement, nine (24%) had elevation of LVDP only during exercise. There was a good correlation between E/E' and LVDP at rest (r = 0.67) and during exercise (r = 0.59), and the regressions at rest and exercise corresponded closely. Receiver-operator curve analysis indicated that a cutoff value of 13 for exercise E/E' identified patients with an elevated LVDP during exercise. A post-exercise E/E' >13 was highly specific (90%) for reduced exercise capacity, and even after classification of resting E/E', exercise E/E' permitted classification of patients with exercise capacity <8 METs or > or =8 METs.

CONCLUSIONS

The ratio of early diastolic transmitral velocity to early diastolic tissue velocity correlates with invasively measured LVDP during exercise. It can be used to reliably identify patients with elevated LVDP during exercise and reduced exercise capacity.

Echocardiographic Indices of Increased Left Ventricular Filling Pressure and Dilation After Acute Myocardial Infarction

The relationship between echocardiographic indicators of acute and chronic left ventricular (LV) filling pressure and LV dilation after acute myocardial infarction was assessed in 47 patients. The ratio of early transmitral flow velocity to early mitral annulus velocity (E/e') reflects acute LV filling pressure and the indexed volume of the left atrium is an indicator of chronic LV filling pressure. E/e' was higher (19 vs 10, P = .001) among patients who experienced a greater than 15% increase in indexed LV end-diastolic volume (remodeling group, n = 10). Receiver operating characteristic curve analysis confirmed that E/e' was a predictor of remodeling (area under the curve 0.83, P = .002). Patients with E/e' greater than 15 had a mean increase in indexed LV end-diastolic volume of 9.3 versus 1.7 mL/m2 in patients with E/e' 15 or less (P = .01). Multivariable regression analyses confirmed that E/e' was the strongest independent predictor of remodeling in this cohort (odds ratio 1.39, P = .01). There was no relationship between indexed volume of the left atrium and LV dilation. These data suggest that the E/e' ratio may be a useful predictor of LV dilation after acute myocardial infarction. In particular, an E/e' ratio greater than 15 identifies patients at increased risk.

Comparison of usefulness of echocardiographic Doppler variables to left ventricular end-diastolic pressure in predicting future heart failure events

We sought to determine whether the echocardiographic Doppler parameters of left ventricular diastolic dysfunction predict future heart failure (HF) events and, if so, which parameters best predict HF. We also examined whether the predictive ability of echocardiographic Doppler parameters was related to their prediction of left ventricular end-diastolic pressure (LVEDP). We studied patients who underwent cardiac catheterization and echocardiography performed within a 30-day period. The end point was HF, defined as new-onset or recurrent HF diagnosed by a physician and requiring the initiation or modification of treatment of HF. We identified 289 patients (mean age 63.5 +/- 12.6 years) with a mean follow-up of 10.9 +/- 10.2 months. A total of 24 HF events occurred. LVEDP was a significant predictor of HF univariately and independently in multiple regression models after adjustment for ejection fraction. In Cox models adjusted for age, gender, LVEDP, and ejection fraction, only the left atrial volume index and early mitral inflow to early diastolic tissue velocity (E/e') ratio remained predictive of HF. A multiple regression model, including all echocardiographic variables, showed a persistent, although attenuated, relation of early to late mitral inflow velocity (E/A) ratio and E/e' with LVEDP (p = 0.06 and p = 0.002, respectively). The addition of E/e' or the left atrial volume indexed to body surface area, but not E/A, to the clinical history and left ventricular ejection fraction provided incremental prognostic information. A LVEDP of > or =20 mm Hg, E/e' ratio of > or =15, and left atrial volume index of > or =23 ml/m(2) identified those with a higher risk of HF. In conclusion, invasively determined LVEDP is an independent predictor of future HF events. E/e' and the left atrial volume indexed to body surface area are the best independent predictors of future HF and provide prognostic information incremental to the clinical history and left ventricular ejection fraction.

Impact of intracoronary bone marrow cell transfer on diastolic function in patients after acute myocardial infarction: results from the BOOST trial

AIMS

We have recently shown in the randomized-controlled BOne marrOw transfer to enhance ST-elevation infarct regeneration (BOOST) trial that intracoronary autologous bone marrow cell (BMC) transfer improves left ventricular (LV) ejection fraction recovery in patients after acute myocardial infarction (AMI). However, the impact of BMC therapy on LV diastolic function in patients after AMI has remained uncertain.

METHODS AND RESULTS

Using (tissue) Doppler echocardiography, we evaluated the effects of BMC transfer on LV diastolic function in patients enrolled in the BOOST trial. After successful primary percutaneous coronary intervention (PCI) for acute ST-elevation myocardial infarction (MI), patients were randomized to a control (n = 29) or BMC transfer group (n = 30). Diastolic function was determined 4.5+/-1.5 days after PCI, at 6 months, and at 18 months by measuring transmitral flow velocities (E/A ratio), diastolic myocardial velocities (Ea/Aa ratio), isovolumic relaxation time (IVRT), and deceleration time (DT). All analyses were performed in a blinded fashion. There was an overall effect of BMC transfer on E/A [0.33+/-0.12; 95% confidence interval (CI): 0.09-0.57; P = 0.008] and Ea/Aa ratios (0.29+/-0.14; 95% CI: 0.01-0.57; P = 0.04). In contrast, we found no effect of BMC transfer on DT (-5+/-14 ms; 95% CI: -33 to 22; P = 0.70), IVRT (-7+/-7 ms; 95% CI: -20 to 6; P = 0.29), and E/Ea ratio (0.35+/-0.14; 95% CI: -0.92 to 1.62; P = 0.57).

CONCLUSION

Intracoronary autologous BMC transfer improves echocardiographic parameters of diastolic function in patients after AMI.

Mitral Peak Doppler E-wave to Peak Mitral Annulus Velocity Ratio Is an Accurate Estimate of Left Ventricular Filling Pressure and Predicts Mortality in End-stage Renal Disease

OBJECTIVE

The study aimed to assess whether the mitral peak Doppler E-wave to peak mitral annulus velocity ratio (E/Ea) estimates left ventricular (LV) filling pressure (LVFP) and predicts mortality in end-stage renal disease.

METHODS

In all, 125 candidates for renal transplant were prospectively studied. LV end-diastolic pressure of 15 mm Hg or greater at cardiac catheterization was defined as elevated LVFP.

RESULTS

Severe coronary artery disease, N- terminal pro-B-type natriuretic peptide level, left atrial size, flow propagation velocity, mitral E/Ea ratio, pulmonary atrial reversal velocity, and pulmonary-mitral atrial wave duration predicted an increased LVFP. However, the mitral E/Ea ratio (odds ratio 8.1, 95% confidence interval 5.1-9.6, P = .003) was the only independent predictor. An E/Ea of 15 or more, seen in 31 (25%) patients, predicted increased LVFP with sensitivity of 82% and specificity of 88%, and was associated with increased mortality (P = .005).

CONCLUSIONS

In end-stage renal disease, mitral E/Ea ratio 15 or higher accurately predicts increased LVFP and mortality.

Prognostic value of a restrictive mitral filling pattern in patients with systolic heart failure and an implantable cardioverter-defibrillator

In patients with chronic heart failure and reduced systolic function, an implantable cardioverter-defibrillator (ICD) improves the prognosis, but morbidity and mortality remain high. We attempted to identify the prognostic impact of Doppler echocardiography and QRS duration in such patients. We prospectively enrolled 84 patients with chronic heart failure, an ICD, and impaired systolic function (mean ejection fraction 29 +/- 10%). Echocardiographic measurements included left ventricular dimensions/volumes, ejection fraction, mitral E/A ratio, deceleration time, and tissue Doppler analysis of mitral annular velocities (S', E', A'). A cardiac event (death from pump failure or appropriate ICD therapy, i.e., antitachycardia pacing/shock due to sustained ventricular tachycardia or ventricular fibrillation) was defined as the study end point. During a follow-up of 373 +/- 254 days, 22 patients (26%) had an event (death from pump failure, n = 7; patients who received an appropriate ICD therapy, n = 16). In patients with an event, the QRS duration was longer (169 +/- 41 vs 146 +/- 37 ms, p = 0.023), the mitral E/E' ratio was higher (16.0 +/- 6.5 vs 12.8 +/- 5.9, p = 0.044), and a restrictive filling pattern was more frequent (44% vs 9%, p = 0.017). Stepwise multivariate Cox regression analysis identified a restrictive filling pattern as the only independent predictor of an event (hazard ratio 3.65, 95% confidence interval 1.54 to 8.64, p = 0.003). For patients with a restrictive filling pattern, the outcome was markedly poorer than that for patients with a nonrestrictive pattern (event-free survival rate 38% vs 72%, p = 0.005). In conclusion, in patients with chronic heart failure, an ICD, and systolic dysfunction, a restrictive filling pattern is an independent predictor of adverse cardiac events.

Diastolic Heart Failure Can Be Diagnosed by Comprehensive Two-Dimensional and Doppler Echocardiography

There are many myocardial and non-myocardial conditions that cause heart failure with normal left ventricular ejection fraction (LVEF). Among them, diastolic heart failure (heart failure due to diastolic dysfunction) is the most common cause of heart failure with normal LVEF. Diastolic heart failure easily can be diagnosed by comprehensive two-dimensional and Doppler echocardiography, which can demonstrate abnormal myocardial relaxation, decreased compliance, and increased filling pressure in the setting of normal LV dimensions and preserved LVEF. Therefore, diastolic heart failure should always be considered when LVEF is normal on two-dimensional echocardiography in patients with clinical evidence of heart failure. The diagnosis can be confirmed if Doppler echocardiography and myocardial tissue imaging provide evidence for impaired myocardial relaxation (i.e., decreased longitudinal velocity of the mitral annulus during early diastole and decreased propagation velocity mitral inflow), decreased compliance (shortened mitral A-wave duration and mitral deceleration time), and increased filling pressure (shortened isovolumic relaxation time and an increased ratio between early diastolic mitral and mitral annular velocities). Early identification of diastolic dysfunction in asymptomatic patients by the use of echocardiography may provide an opportunity to manage the underlying etiology to prevent progression to diastolic heart failure.

Tissue Doppler-derived index of left ventricular filling pressure, E/E', predicts survival of patients with non-valvular atrial fibrillation

OBJECTIVES

To investigate whether the ratio of early transmitral flow velocity (E) to early diastolic mitral annular velocity (E') predict prognosis in patients with non-valvular atrial fibrillation.

METHODS

230 patients with non-valvular atrial fibrillation were enrolled and studied. According to E/E' value, patients were divided into groups with lower (group A with E/E' <or= 15) and higher (group B with E/E' > 15) E/E'.

RESULTS

During follow up (average 245 days), 21 (9.1%) deaths were documented. All cause death (15/90 (16.7%) v 6/140 (4.3%)), cardiac death (10 (11.1%) v 2 (1.4%)) and congestive heart failure (16 (17.8%) v 8 (5.7%)) were more common in group B than in group A (all p < 0.01). A Kaplan-Meier survival curve showed that the cumulative survival rate was significantly lower in group B than in group A (log rank p = 0.0013). By multivariate logistic regression analysis, E/E' (chi(2) = 4.47, odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01 to 1.11, p = 0.03) and age (chi(2) = 6.45, OR 1.06, 95% CI 1.01 to 1.11, p = 0.02) were independent predictors of mortality.

CONCLUSION

The Doppler-derived index of left ventricular filling pressure, E/E', is a powerful predictor of the clinical outcome of patients with non-valvular atrial fibrillation.

Comparison of usefulness of left ventricular diastolic versus systolic function as a predictor of outcome following primary percutaneous coronary angioplasty for acute myocardial infarction

Left ventricular (LV) diastolic function is an important predictor of morbidity and mortality after acute myocardial infarction (AMI). We evaluated the role of diastolic function in predicting in-hospital events and LV ejection fraction (EF) 6 months after a first AMI that was treated with primary percutaneous coronary intervention (PCI). We prospectively enrolled 59 consecutive patients who were 60 +/- 15 years of age (48 men), presented at our institution with their first AMI, and were treated with primary PCI. Patients underwent 2-dimensional and Doppler echocardiography, including tissue Doppler imaging of 6 basal mitral annular regions within 24 hours after primary PCI and were followed until discharge. Clinical and echocardiographic variables at index AMI were compared with a combined end point of cardiac death, ventricular tachycardia, congestive heart failure, or emergency in-hospital surgical revascularization. Follow-up echocardiographic assessment was performed at 6 months in 24 patients. During hospitalization, 3 patients died, 7 developed congestive heart failure, 4 had ventricular tachycardia, and 1 required emergency surgical revascularization. Stepwise logistic regression analysis showed the ratio of early mitral inflow diastolic filling wave (E) to peak early diastolic velocity of non-infarct-related mitral annulus (p < 0.01) (E') and mitral inflow E-wave deceleration time (p < 0.02) to be independent predictors of in-hospital cardiac events (generalized R2 = 0.66). In a stepwise multiple linear regression model, independent predictors of follow-up LVEF were mitral inflow deceleration time (R2 = 0.39, p = 0.002), baseline LVEF (R2 = 0.54, p < 0.02), and mitral inflow peak early velocity/mitral annular peak early velocity (or E/E') of infarct annulus (R2 = 0.66, p = 0.02). In conclusion, in patients who are treated with primary PCI for a first AMI, E/E' velocity ratio and mitral inflow E-wave deceleration time are strong predictors of in-hospital cardiac events and of LVEF at 6-month follow-up.

Transesophageal Echocardiographic Evaluation of Diastolic Function

Diastolic dysfunction is increasingly recognized as a cause of hemodynamic instability in the perioperative setting. Difficulty weaning from cardiopulmonary bypass and an increased need for inotropic support can occur in the absence of systolic impairment. Diastolic dysfunction can also impede hemodynamic stabilization and weaning progress in the mechanically ventilated critically ill patient. The use of transesophageal echocardiography in the ICU can assist in diagnosing the presence and progression of diastolic impairment, which may help to target therapeutic interventions that lead to positive outcomes. This review summarizes the conventional and new echocardiographic modalities for evaluating diastolic function in the perioperative setting.

Different prognostic impact of systolic function in patients with heart failure and/or acute myocardial infarction

AIMS

To study the prognostic importance of left ventricular systolic function in patients with heart failure (HF) and acute myocardial infarction (AMI) with respect to the presence of prior heart failure and known ischemic heart disease.

METHODS

In 13,084 consecutive patients diagnosed with either AMI or HF, a medical history and an echocardiographic assessment of left ventricular systolic function by wall motion index (WMI) were obtained. Patients were divided into four groups: AMI with or without a history of HF, and primary HF (no recent AMI) with or without a history of ischemic heart disease (IHD). Mortality was assessed after nine years of follow-up.

RESULTS

WMI stratified patients according to all-cause mortality in all four groups of patients (p<0.0001). For a decrease in WMI of 0.3 (corresponding to a decrease in left ventricular ejection fraction of 0.1), the hazard ratio was 1.61 (95% CI: 1.48-1.76) for AMI patients without prior HF, 1.43 (1.38-1.48) for AMI patients with prior HF, 1.26 (1.22-1.30) for primary HF patients with IHD and 1.23 (1.18-1.27) for HF patients without IHD.

CONCLUSION

WMI stratifies patients with IHD and/or HF according to risk of all-cause death. The presence of HF attenuates the prognostic power of WMI.

Usefulness of tissue doppler and color M-mode indexes of left ventricular diastolic function in predicting outcomes in systolic left ventricular heart failure (from the ADEPT study)

The prognostic values of tissue Doppler imaging and color M-mode diastolic indexes were studied in 225 patients who had symptomatic systolic heart failure in the ADEPT study. The primary end point of death, transplantation, or hospitalization due to heart failure occurred in 65 patients and was independently predicted by shorter deceleration time, lower ratio of pulmonary vein systolic to diastolic velocity, and increasing levels of the ratios of early transmitral velocity to early annular velocity or velocity of propagation. For the ratio of early transmitral velocity to early annular velocity, this prediction was additive to deceleration time. Newer diastolic indexes provide an independent prediction of clinical outcomes.

B-type natriuretic peptide and tissue Doppler study findings in elderly patients hospitalized for acute diastolic heart failure

The imbalance of Starling's forces was investigated in 25 elderly patients hospitalized for acute diastolic heart failure. Tissue Doppler evidence of elevated left ventricular filling pressures was present on admission in 17 patients with high B-type natriuretic peptide (BNP) levels. Serum proteins concentrations and colloid osmotic pressure, related to malnutrition and severe sepsis, were significantly less in the 8 patients without tissue Doppler evidence of elevated filling pressures, and a high level of BNP was consistent with paroxysmal elevation in filling pressures in this setting.

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.

Independent and incremental prognostic value of early mitral annulus velocity in patients with impaired left ventricular systolic function

OBJECTIVES

This study sought to investigate the incremental prognostic value of non-invasive measures of early myocardial relaxation and left ventricular diastolic pressure (LVDP) in patients with impaired left ventricular (LV) systolic function.

BACKGROUND

The early diastolic mitral annulus velocity (Em) reflects myocardial relaxation, and the combined ratio of the early transmitral flow velocity (E) to Em (E/Em) >15 correlates well with elevated mean LVDP. It is unknown if these new indexes will predict poorer survival in patients with LV systolic dysfunction.

METHODS

Echocardiograms were prospectively obtained in 182 patients with impaired LV systolic function, defined as an LV ejection fraction <0.50. The end point was cardiac mortality. The majority of this patient sample (80%) has been reported on in a previous publication.

RESULTS

After a median 48 months' follow-up, Em emerged as an independent predictor of survival (hazard ratio 0.61, 95% confidence interval 0.45 to 0.82). An Em <3 cm/s was associated with a significantly excess mortality (log-rank statistic 9.36, p = 0.002), and this measurement added incremental prognostic value to standard indexes of systolic or diastolic function, including a deceleration time <140 ms and an E/Em >15 (p = 0.038).

CONCLUSIONS

Early diastolic mitral annulus velocity is a powerful predictor of cardiac mortality in patients with LV systolic impairment; Em <3 cm/s emerged as the best prognosticator in long-term follow-up, incremental to other clinical or echocardiographic variables, including the ratio E/Em.

Tissue Doppler imaging provides incremental prognostic value in patients with systemic hypertension and left ventricular hypertrophy

OBJECTIVES

We sought to determine the prognostic value of left ventricular (LV) mitral annular velocities measured by tissue Doppler imaging (TDI) in hypertensive patients with echocardiographic evidence of LV hypertrophy.

BACKGROUND

Echo LV hypertrophy and LV geometry provide additional predictive value of all-cause mortality beyond traditional cardiovascular risk factors. Limited data exist regarding the predictive value of TDI velocities for cardiovascular risk stratification in treated hypertensive patients.

METHODS

Two-dimensional and Doppler echocardiograms were obtained in 252 consecutive subjects, including 174 subjects with systemic hypertension and 78 age-matched normal subjects. The end point was cardiac death in subsequent median follow-up of 19 months.

RESULTS

Nineteen patients (7.54%) died of cardiac causes. The TDI mitral annulus systolic velocity and the early diastolic mitral annular velocity (Em) were significantly lower in the non-survivors (all P < 0.001). The pseudonormal (PN) or restrictive filling pattern (RFP) was associated with cardiac mortality. The other parameters associated with cardiac mortality were LV ejection fraction, LV mass index, inter-ventricular septal wall thickness in diastole and the ratio of early mitral inflow to early myocardial velocity. In multivariate analysis, Em, inter-ventricular septal wall thickness in diastole and either PN or RFP were the strongest predictors. The addition of Em < 3.5 cm/s significantly improved the outcome of a model that contained clinical risk factors, inter-ventricular septal wall thickness in diastole > 1.4 cm and either PN or RFP (P = 0.043).

CONCLUSIONS

Early diastolic mitral annulus velocity measured by TDI provides prognostic information, incremental to clinical data and standard echocardiographic variables, for risk stratification of hypertensive patients under treatment.

Tissue Doppler imaging for predicting outcome in patients with cardiovascular disease

PURPOSE OF REVIEW

Tissue Doppler imaging is being increasingly used for assessing global ventricular function in systole and diastole, and for quantifying regional wall motion abnormalities both in systolic heart failure with mechanical dyssynchrony and ischemic heart disease. Its use as a predictive tool is recent and the authors review publications relating to this aspect.

RECENT FINDINGS

Peak early diastolic mitral annular velocity is a powerful predictor of outcome in a variety of cardiovascular conditions and adds incremental value to clinical parameters and standard mitral Doppler inflow velocities. Tissue Doppler imaging can also predict the development of hypertrophic cardiomyopathy in asymptomatic individuals carrying the genetic mutation even before the onset of overt left ventricular hypertrophy. In addition, the standard deviation of the time to peak systolic velocity is a good marker of mechanical asynchrony and can predict reverse remodeling. It may also be useful in identifying individuals with ischemic heart disease and regional wall motion abnormalities who have an adverse outcome.

SUMMARY

Tissue Doppler imaging is a powerful new echocardiographic tool that is now becoming the standard for assessing ventricular function in a variety of situations and diseases.