Effect of aging on left ventricular diastolic filling in normal subjects

Can salivary and skin microbiome become a biodetector for aging-associated diseases? Current insights and future perspectives

Growth and aging are fundamental elements of human development. Aging is defined by a decrease in physiological activities and higher illness vulnerability. Affected by lifestyle, environmental, and hereditary elements, aging results in disorders including cardiovascular, musculoskeletal, and neurological diseases, which accounted for 16.1 million worldwide deaths in 2019. Stress-induced cellular senescence, caused by DNA damage, can reduce tissue regeneration and repair, promoting aging. The root cause of many age-related disorders is inflammation, encouraged by the senescence-associated secretory phenotype (SASP). Aging's metabolic changes and declining immune systems raise illness risk via promoting microbiome diversity. Stable, individual-specific skin and oral microbiomes are essential for both health and disease since dysbiosis is linked with periodontitis and eczema. Present from birth to death, the human microbiome, under the influence of diet and lifestyle, interacts symbiotically with the body. Poor dental health has been linked to Alzheimer's and Parkinson's diseases since oral microorganisms and systemic diseases have important interactions. Emphasizing the importance of microbiome health across the lifetime, this study reviews the understanding of the microbiome's role in aging-related diseases that can direct novel diagnosis and treatment approaches.

Independent Relationship between Ankylosing Spondylitis and Presystolic Wave Detected on Echocardiography

Objective

Ankylosing spondylitis (AS) is a persistent inflammatory disease affecting the axial skeleton which may lead to cardiovascular involvement. We examined the relationship between the presystolic wave (PW), which is frequently encountered in the evaluation of the left ventricular (LV) outflow tract, and AS.

Methods

The study included 117 consecutive patients with 73 of them being male. Demographic and clinical characteristics of the participants were recorded and echocardiographic examination was performed.

Results

Patients were categorized into two groups: patients diagnosed with AS (n = 64) and patients without AS (n = 53). LV ejection fraction (P = 0.014), LV mass index (P < 0.001), mitral E wave velocity (P = 0.002), and PW (P = 0.014) were independently linked with AS.

Conclusion

A substantial correlation was found between PW and AS.

Presystolic wave as a predictor of interatrial block in patients with supraventricular tachycardia

The identification of interatrial block (IAB) through electrocardiography (ECG) has been correlated with an elevated likelihood of developing atrial fibrillation (AF) and stroke. IAB is diagnosed by evaluating P-wave prolongation on a surface ECG. The presystolic wave (PSW) is an echocardiographic marker determined by pulse-wave examination of the aortic root during late diastole. As IAB and PSW share similar pathophysiological mechanisms, we speculated that PSW, as a component of the P wave, might be useful in predicting IAB. In the present study, we aimed to determine the relationship between PSW and IAB. Patients with pre-diagnosis of supraventricular tachycardia (SVT) on electrocardiography or rhythm Holter monitoring between January 2021 and December 2022 were included in the study. Surface 12-lead ECG and transthoracic echocardiography (TTE) were performed for the diagnosis of IAB and PSW. Patients were divided into two groups based on the presence of IAB, and PSW was compared between the groups. In total, 104 patients were enrolled in this study. IAB was diagnosed in 16 patients (15.3%) and PSW was detected in 33 patients (31.7%). The PSW was higher in the IAB ( +) group than in the IAB ( -) group (10 patients (71.4%) vs. 23 patients (32.4%), p = 0.008). PSW may be a useful tool for predicting IAB in patients with SVT. Further studies are needed to determine the clinical utility of PSW in the diagnosis and management of IAB.

Study the relationship between left atrial (LA) volume and left ventricular (LV) diastolic dysfunction and LV hypertrophy: Correlate LA volume with cardiovascular risk factors

Heart failure (HF) with normal ejection fraction - the isolated diastolic heart failure, depicts increasing prevalence and health care burden in recent times. Having less mortality rate compared to systolic heart failure but high morbidity, it is evolving as a major cardiac concern. With increasing clinical use of Left atrial volume (LAV) quantitation in clinical settings, LAV has emerged as an important independent predictor of cardiovascular outcome in HF with normal ejection fraction. This article is intended to review the diastolic and systolic heart failure, their association with left atrial volume, in depth study of Left atrial function dynamics with determinants of various functional and structural changes.

Exercise and hypoxia unmask pulmonary vascular disease and right ventricular dysfunction in a 10- to 12-week-old swine model of neonatal oxidative injury

Prematurely born young adults who experienced neonatal oxidative injury (NOI) of the lungs have increased incidence of cardiovascular disease. Here, we investigated the long-term effects of NOI on cardiopulmonary function in piglets at the age of 10-12 weeks. To induce NOI, term-born piglets (1.81 ± 0.06 kg) were exposed to hypoxia (10-12%F iO 2 ${F}_{{\rm{iO}}_{\rm{2}}}$ ), within 2 days after birth, and maintained for 4 weeks or until symptoms of heart failure developed (range 16-28 days), while SHAM piglets were normoxia raised. Following recovery (>5 weeks), NOI piglets were surgically instrumented to measure haemodynamics during hypoxic challenge testing (HCT) and exercise with modulation of the nitric-oxide system. During exercise, NOI piglets showed a normal increase in cardiac index, but an exaggerated increase in pulmonary artery pressure and a blunted increase in left atrial pressure - suggesting left atrial under-filling - consistent with an elevated pulmonary vascular resistance (PVR), which correlated with the duration of hypoxia exposure. Moreover, hypoxia duration correlated inversely with stroke volume (SV) during exercise. Nitric oxide synthase inhibition and HCT resulted in an exaggerated increase in PVR, while the PVR reduction by phosphodiesterase-5 inhibition was enhanced in NOI compared to SHAM piglets. Finally, within the NOI piglet group, prolonged duration of hypoxia was associated with a better maintenance of SV during HCT, likely due to the increase in RV mass. In conclusion, duration of neonatal hypoxia appears an important determinant of alterations in cardiopulmonary function that persist further into life. These changes encompass both pulmonary vascular and cardiac responses to hypoxia and exercise. KEY POINTS: Children who suffered from neonatal oxidative injury, such as very preterm born infants, have increased risk of cardiopulmonary disease later in life. Risk stratification requires knowledge of the mechanistic underpinning and the time course of progression into cardiopulmonary disease. Exercise and hypoxic challenge testing showed that 10- to 12-week-old swine that previously experienced neonatal oxidative injury had increased pulmonary vascular resistance and nitric oxide dependency. Duration of neonatal oxidative injury was a determinant of structural and functional cardiopulmonary remodelling later in life. Remodelling of the right ventricle, as a result of prolonged neonatal oxidative injury, resulted in worse performance during exercise, but enabled better performance during the hypoxic challenge test. Increased nitric oxide dependency together with age- or comorbidity-related endothelial dysfunction may contribute to predisposition to pulmonary hypertension later in life.

A presystolic wave could easily detect subclinical left ventricular dysfunction in prediabetic patients with no history of hypertension

BACKGROUND

Prediabetes is associated with left ventricular (LV) systolic and diastolic dysfunction. A presystolic wave (PSW) is detected on late diastole from the Doppler examination of the LV outflow tract and is related to LV dysfunction. LV dysfunction could be detected with different echocardiographic methods, including conventional Doppler and Tissue Doppler imaging (TDI), 2D speckle tracking echocardiography, and myocardial performance index (MPI). In this study, we aimed to investigate the association of the presence of PSW with LV dysfunction assessed by different echocardiographic methods.

METHODS

A total of 137 prediabetic normotensive patients were enrolled in this study. Eighty-one (59.1%) patients had a PSW and 36 (40.9%) patients had not PSW on the Doppler examinations. Echocardiographic features were compared between these groups. LV dysfunction was determined based on MPI, LV global longitudinal strain (LVGLS), and conventional Doppler and TDI measurements.

RESULTS

There were no differences between groups regarding clinical and laboratory parameters, except LDL, which was significantly higher in the PSW-positive group. The PSW-positive group had lower E, Em, Ea, E/A, Em/Am, Ea/Aa, LVGLS and higher A, Am, Aa, E/e', isovolumetric relaxation time, and MPI than PSW-negatives. PSW velocity was moderately correlated with MPI (R = .33, p = .003) and LVGLS (R = .35, p = .001). The presence of PSW was independently associated with LV dysfunction assessed by MPI (OR = 3.87, p < .001), LVGLS (OR = 10.29, p < .001), and conventional Doppler and TDI parameters (OR = 8.87, p < .001).

CONCLUSION

PSW was significantly associated with subclinical LV dysfunction in prediabetic normotensive patients assessed with three echocardiographic methods.

Effect of Levosimendan on Ventricular Systolic and Diastolic Functions in Heart Failure Patients: A Meta-Analysis of Randomized Controlled Trials

ABSTRACT

Levosimendan, a calcium sensitizer, exerts inotropic action through improving left ventricular ejection fraction. We noticed that only few clinical studies are published in which the effects of levosimendan on cardiac function are studied by echocardiography. When screening the literature (PubMed, Embase, and CENTRAL, from inception to August 2020), we found 29 randomized controlled trials on levosimendan containing echocardiographic data. We included those studies, describing a total of 574 heart failure patients, in our meta-analysis and extracted 14 ultrasonic parameters, pooling the effect estimates using a random-effect model. Our analysis of the diastolic parameters of the left ventricle shows that levosimendan reduce the early/late transmitral diastolic peak flow velocity ratio [standardized mean difference (SMD) -0.45 to 95% confidence interval (CI) (-0.87 to -0.03), P = 0.037] and E/e' (e': mitral annulus peak early diastolic wave velocity using tissue-doppler imaging) [SMD -0.59, 95% CI (-0.8 to -0.39), P < 0.001]. As it regards the systolic parameters of the right ventricle, levosimendan increased tricuspid annular plane systolic excursion [SMD 0.62, 95% CI (0.28 to 0.95), P < 0.001] and tricuspid annular peak systolic velocity [SMD 0.75, 95% CI (0.35 to 1.16), P < 0.001], and reduced systolic pulmonary artery pressure [SMD -1.02, 95% CI (-1.32, -0.73), P < 0.001]. As it regards the diastolic parameters of the right ventricle, levosimendan was associated with the decrease of Aa (peak late diastolic tricuspid annular velocity using tissue-doppler imaging) [SMD -0.38, 95% CI (-0.76 to 0), P = 0.047] and increase of Ea (peak early diastolic tricuspid annular velocity using tissue-doppler imaging) [SMD 1.03, 95% CI (0.63 to 1.42), P < 0.001] and Ea/Aa [SMD 0.86, 95% CI (0.18 to 1.54), P = 0.013]. We show that levosimendan is associated with an amelioration in the diastolic and systolic functions of both ventricles in heart failure patients.

Relation of p - wave dispersion with presystolic a - wave and aortic valve sclerosis in asymptomatic subjects

BACKGROUND

P-wave duration and P-wave dispersion (PWD) are thought to be the surrogate marker of devoloping atrial fibrillation (AF). The main purpose of present study was to investigate the association between presystolic wave (PSW), aortic valve sclerosis, and PWD.

PATIENTS AND METHODS

Patients with sinus rhythm admitted to the cardiology outpatient clinic were consecutively enrolled. Maximum (Pmax) and minimum (Pmin) P-wave duration and PWD were measured. Echocardiography was used to assess the aortic valve morphology and presence of PSW. The patients were divided into two groups according to presence or absence of AVSc and PSW.

RESULTS

A total of 100 patients were enrolled consecutively. Patients with both PSW and AVSc had higher PWD values compared with those without PSW (42 ± 15 vs 65 ± 20) and AVSc (52 ± 21 vs 69 ± 19). The patients were categorized on the basis of median PWD values. According to univariate analysis, there was significant association between PWD and presence of PSW (P: .004), presence of AVS (P: .011), hypertension (P: .01) interventricular septal thickness (IVST) (P: .026), and posterior wall thickness (PWT) (P: .022). Multivariate logistic regression analyses demonstrated presence of PSW (95% confidence interval (1.058-6.505, P: .037) as an independent determinant of PWD.

CONCLUSION

Assessment of presystolic A-wave on echocardiography examination may provide important information regarding the atrial conduction velocities that is a electrophysiological cause of AF. While there was a significant association between AVSc and PWD in univariate analysis, this significance disappeared in multivariate analysis.

Echocardiographic evaluation of cardiac function in cynomolgus monkeys over a wide age range

Various cardiovascular diseases can be detected and diagnosed using echocardiography. The demand for cardiovascular system research using nonhuman primates is increasing, but echocardiographic references for nonhuman primates are limited. This report describes the first comparison of echocardiographic reference values in 247 normal cynomolgus monkeys (135 females, 112 males) over a wide age range. Echocardiography, electrocardiography, blood pressure and chest X-ray images were acquired under immobilization with intramuscular ketamine hydrochloride, then cardiac structure, function, and flow velocity were assessed. Cardiac hormone levels were also tested. We found that cardiac structures positively correlated with weight, that the size of these structures stabilized after reaching maturity and that cardiac output increased according to heart size. In contrast, fractional shortening of the left ventricle, ejection fraction and flow velocity showed no significant correlations with weight or age, and age and E wave correlated negatively. These findings appear sufficiently similar to those in humans to suggest that cynomolgus monkeys can serve as a suitable model of human cardiac disease. Our data should also prove useful for surveying cardiac dysfunction in monkeys.

As time flies by: Investigating cardiac aging in the short-lived Drosophila model

Aging is associated with a decline in heart function across the tissue, cellular, and molecular levels. The risk of cardiovascular disease grows significantly over time, and as developed countries continue to see an increase in lifespan, the cost of cardiovascular healthcare for the elderly will undoubtedly rise. The molecular basis for cardiac function deterioration with age is multifaceted and not entirely clear, and there is a limit to what investigations can be performed on human subjects or mammalian models. Drosophila melanogaster has emerged as a useful model organism for studying aging in a short timeframe, benefitting from a suite of molecular and genetic tools and displaying highly conserved traits of cardiac senescence. Here, we discuss recent advances in our understanding of cardiac aging and how the fruit fly has aided in these developments.

Heart failure with preserved ejection fraction and skeletal muscle physiology

Heart failure with preserved ejection fraction (HFpEF) accounts for half of all heart failure in the USA, increases in prevalence with aging, and has no effective therapies. Intriguingly, the pathophysiology of HFpEF has many commonalities with the aged cardiovascular system including reductions in diastolic compliance, chronotropic defects, increased resistance in the peripheral vasculature, and poor energy substrate utilization. Decreased exercise capacity is a cardinal symptom of HFpEF. However, its severity is often out of proportion to changes in cardiac output. This observation has led to studies of muscle function in HFpEF revealing structural, biomechanical, and metabolic changes. These data, while incomplete, support a hypothesis that similar to aging, HFPEF is a systemic process. Understanding the mechanisms leading to exercise intolerance in this condition may lead to strategies to improve morbidity in both HFpEF and aging.

A Test in Context: E/A and E/e' to Assess Diastolic Dysfunction and LV Filling Pressure

Diastolic dysfunction represents a combination of impaired left ventricular (LV) relaxation, restoration forces, myocyte lengthening load, and atrial function, culminating in increased LV filling pressures. Current Doppler echocardiography guidelines recommend using early to late diastolic transmitral flow velocity (E/A) to assess diastolic function, and E to early diastolic mitral annular tissue velocity (E/e') to estimate LV filling pressures. Although both parameters have important diagnostic and prognostic implications, they should be interpreted in the context of a patient's age and the rest of the echocardiogram to describe diastolic function and guide patient management. This review discusses: 1) the physiological basis for the E/A and E/e' ratios; 2) their roles in diagnosing diastolic dysfunction; 3) prognostic implications of abnormalities in E/A and E/e'; 4) special scenarios of the E/A and E/e' ratios that are either useful or challenging when evaluating diastolic function clinically; and 5) their usefulness in guiding therapeutic decision making.

Evidence of Left Ventricular Dysfunction in Asymptomatic Elderly Patients with Non-insulin-dependent Diabetes Mellitus

Diabetic cardiomyopathy is a distinct entity in diabetic patients with congestive heart failure, who have no angiographic evidence of significant coronary artery stenosis. The aim of this study was to evaluate left ventricular (LV) function in 24 elderly patients (mean age 67 ±2 years) with type 2 diabetes, who were asymptomatic and had no history of hypertension, or coronary or valvular heart disease. LV systolic indices (ejection fraction [EF] and fractional shortening [FS]), diastolic indices (E wave, A wave, E/A ratio, isovolumic relaxation time [IVRT] and deceleration time [DT]) and the myocardial performance index (MPI) were evaluated with echocardiography. Compared to controls (24 age- and gender-matched normal subjects), the E wave was reduced (0.60 ±0.10 m/sec vs 0.72 ±0.08 m/sec, p<0.05), the A wave was increased (0.77 ±0.07 m/sec vs 0.68 ±0.06 m/sec, p<0.05), the E/A ratio was decreased (0.78 ±0.20 vs 1.06 ±0.18, p<0.001) and both IVRT and DT were prolonged (0.115 ±0.01 sec vs 0.09 ±0.01 sec, p<0.001 and 0.240 ±0.04 sec vs 0.180 ±0.03 sec, p<0.001, respectively). The MPI was significantly increased (0.640 ±0.170 vs 0.368 ±0.098, p<0.001). LV diastolic function and the MPI are markedly impaired in asymptomatic elderly patients with type 2 diabetes.

Arterial Stiffness, Central Pulsatile Hemodynamic Load, and Orthostatic Hypotension

The association between central pulsatile hemodynamic load, arterial stiffness, and orthostatic hypotension (OH) is unclear. The authors recruited 1099 participants from the community. Questionnaire, physical examination, and laboratory tests were performed. To assess the correlation between central pulsatile hemodynamic load, arterial stiffness, and OH, multiple logistic regression analysis was performed, and the discriminatory power was assessed by the area under the receiver operating curve. The prevalence of OH in this population was 5.6%. After adjusting for potential confounders, brachial-ankle pulse wave velocity (BaPWV) was significantly and positively correlated with OH in both the hypertension and nonhypertension groups (all P<.05), while central systolic blood pressure (CSBP) was only significantly associated with OH in the hypertension subgroup. In addition, BaPWV seemed to have a better discriminatory power than CSBP in both subgroups. BaPWV appears to be a better indicator of OH than CSBP in routine clinical practice.

Relationship of promising methods in the detection of anthracycline-induced cardiotoxicity in breast cancer patients

Purpose

It remains challenging to identify patients at risk of anthracycline-induced cardiotoxicity. To better understand the different risk-stratifying approaches, we evaluated ¹²³I-metaiodobenzylguanidine (¹²³I-mIBG) scintigraphy and its interrelationship with conventional echocardiography, 2D strain imaging and several biomarkers.

Methods

We performed ¹²³I-mIBG scintigraphy, conventional and strain echocardiography and biomarker (NT-proBNP, TNF-α, galectin-3, IL-6, troponin I, ST-2 and sFlt-1) assessment in 59 breast cancer survivors 1 year after anthracycline treatment. Interobserver and intermethod variability was calculated on planar and SPECT ¹²³I-mIBG scintigraphy, using the heart/mediastinum (H/M) ratio and washout (WO). Pearson’s r and multivariate analyses were performed to identify correlations and independent predictors of ¹²³I-mIBG scintigraphy results.

Results

Delayed planar anterior whole-heart ROI (WH) H/M ratios and WO were the most robust ¹²³I-mIBG parameters. Significant correlations were observed between ¹²³I-mIBG parameters and several conventional echo parameters, global longitudinal and radial strain (GLS and GRS) and galectin-3. The highest Pearson’s r was observed between delayed H/M ratio and GRS (Pearson’s r 0.36, p = 0.01). Multivariate analysis showed that GRS was the only independent predictor of the delayed WH H/M ratio (p = 0.023).

Conclusion

The delayed planar H/M ratio is the most robust ¹²³I-mIBG parameter. It correlates with several conventional echocardiographic parameters, GLS, GRS and galectin-3. Of these, only GRS predicts the H/M ratio.

Presystolic flow in ascending aorta in a case of left ventricular diastolic dysfunction

A 65 years old hypertensive presented with effort breathlessness. Echocardiography revealed significant concentric remodeling of left ventricle. (relative wall thickness - 0.86) with significantly impaired relaxation (E/A - 0.54 and Ea/Aa - 0.52). Doppler evaluation of flow in ascending aorta revealed a presystolic flow which coincided with P wave of ECG and A wave of mitral flow. This finding suggests increased stiffness of left ventricle resulting in significant increase in left ventricular pressure during left atrial contraction and presystolic flow in aorta. Our case shows that all cases of grade 1 diastolic dysfunction are not alike. Presystolic flow in ascending aorta suggests greater degree of diastolic dysfunction than what is apparent from conventional criteria.

Left Atrial Longitudinal Speckle Tracking Echocardiography in Healthy Aging Heart

Background:

Left atrial volume (LAV) and function are connected to the left ventricular (LV) haemodynamic patterns. To define the changes of LAV and functions to counterbalance age-related LV diastolic impairment, this study was undertaken.

Methods:

2D-Left Atrial Speckle Tracking Echocardiography (2D-LASTE) was used to define both LAV and functions in an aged healthy population (group II) respect to adult healthy controls (group I).

Results:

Results showed an increasing of left atrial volume indices (LAVI) (maximum, minimum, pre-a) in old subjects in comparison with those obtained in adult healthy controls. On the contrary, LAVI passive emptying unchanged and LAVI passive fraction reduced with advanced age. Finally, LAVI active emptying increased with advancing age to compensate the age-dependent left ventricular diastolic dysfunction. The values of global systolic strain (S); systolic strain rate (SrS); early diastolic strain rate (SrE), and late diastolic strain rate (SrA) were also calculated. With reference to the function, our study confirmed that LA conduit function deteriorates with age while booster pump increases respect to adult controls and reservoir phase is maintained.

Conclusions:

The echocardiographic findings obtained with conventional and tissue Doppler confirmed the connection between LA functions and volumes and age-related LV dysfunction. Conclusively, 2D-LASTE appears to be a reliable tool to evaluate the role of LA to compensate the derangement of left ventricle happening with ageing.

Age-related changes to cardiac systolic and diastolic function during whole-body passive hyperthermia

NEW FINDINGS

What is the central question of this study? The effect of ageing on hyperthermia-induced changes in cardiac function is unknown. What is the main finding and its importance? Using echocardiography, we show that during hyperthermia the systolic and diastolic function can be appropriately augmented to meet cardiac demand in healthy older adults, although overall age-related impairments remain. One exception was late diastolic ventricular filling [i.e. E/A ratio and A/(A + E) ratio], which in the older adults was not further augmented during hyperthermia, unlike their young counterparts. To meet cardiac demand, therefore, healthy older adults appear to depend on an increased left ventricular systolic strain and proportion of their cardiac reserve. The effect of ageing on hyperthermia-induced changes in cardiac function is unknown. This study tested the hypothesis that hyperthermia-induced changes in left ventricular systolic and diastolic function are attenuated in older adults when compared with young adults. Eight older (71 ± 5 years old) and eight young adults (29 ± 5 years old), matched for sex, physical activity and body mass index, underwent whole-body passive hyperthermia. Mean arterial pressure (Finometer Pro), heart rate, forearm vascular conductance (venous occlusion plethysmography) and echocardiographic indices of diastolic and systolic function were measured during a normothermic supine period and again after an increase in internal temperature of ∼1.0 °C. Hyperthermia decreased mean arterial pressure and left ventricular end-diastolic volumes and increased heart rate to a similar extent in both groups (P > 0.05). Ageing did not alter the magnitude of hyperthermia-induced changes in indices of systolic (lateral mitral annular S' velocity) or diastolic function (lateral mitral annular E' velocity, peak early diastolic filling and isovolumic relaxation time; P > 0.05). However, with hyperthermia the global longitudinal systolic strain increased in the older group, but was unchanged in the young group (P = 0.03). Also, older adults were unable to augment late diastolic ventricular filling [i.e. E/A ratio and A/(A + E) ratio] during hyperthermia, unlike the young (P < 0.05). These findings indicate that older adults depend on a greater systolic contribution (global longitudinal systolic strain) to meet hyperthermic demand and that the atrial contribution to diastolic filling was not further augmented in older adults when compared with young adults.

Diastolic ventricular function improves during the first 48-hours-of-life in infants weighting <1250 g

AIM

Few studies have focused on cardiac ventricular diastolic function in preterm neonates in the immediate post-natal period. This study evaluated Doppler-derived parameters of diastolic ventricular function in infants with birth weights of <1250 g during the transitional period.

METHODS

This was a prospective observational study conducted in the Coombe Women and Infants University Hospital in Dublin, Ireland. Flow patterns on the mitral and tricuspid valve, isovolumic relaxation time (IVRT), left and right ventricular output and superior vena cava flow were measured in 22 infants with a birth weight of below 1250 g at six, 12, 24 and 48 h of age.

RESULTS

Early filling peak velocity of the left and right ventricle increased significantly from 30.3 to 39.5 cm/sec and 26.6 to 32.1 cm/sec, respectively. IVRT of the right ventricle decreased from 70 to 57 ms, and there was a nonsignificant decrease in IVRT of the left ventricle from 61.6 to 54 ms over the first 48 h.

CONCLUSION

We have demonstrated that parameters of diastolic ventricular function change significantly over the first 48 h of life in preterm infants <1250 g and that these changes may represent early diastolic dysfunction during the transitional period.

Clinical significance of a presystolic wave on Doppler examination of the left ventricular outflow tract

A presystolic wave (PSW) is commonly seen on Doppler examination of the left ventricular outflow tract (LVOT), but is little studied. We conducted a retrospective study to assess the prevalence of the PSW, correlations with various Doppler parameters, and its clinical significance. Two hundred echocardiograms, 100 with ejection fraction (EF) >55% and 100 with EF <45%, were reviewed. Mitral inflow velocities, septal annular velocities, LVOT, and PSW velocities were measured. Major adverse cardiovascular events (MACE [death, heart failure hospitalization, atrial fibrillation, and stroke]) were compared between those with and without a PSW, in both EF groups. Mean age was 58 ± 15 years; 56% were men and 69% were African-American. PSW prevalence was similar between normal (68%) and reduced EF groups (62%). However, its velocity was less in the low EF group (37 ± 10 vs 48 ± 16 cm/s, p <0.0001). In subjects with normal EF PSW velocity correlated with mitral A velocity (rho = 0.43, p = 0.0003). In subjects with reduced EF the association with A velocity was not significant (rho = 0.22, p = 0.09), but there was a significant association with annular a' velocity (rho = 0.38, p = 0.002). Over a mean follow-up of 1.7 ± 0.3 years, 57 subjects (28%) experienced MACE. Those without a PSW had more MACE (39% vs 23%, p = 0.02); PSW absence remained predictive of MACE after adjustment for multiple variables, especially in patients with reduced EF. In conclusion, PSW is common in the LVOT. Its presence and magnitude are associated with measures of atrial contraction. Its absence is associated with increased rates of adverse events, especially in patients with low EF.

Physical fitness and risk for heart failure and coronary artery disease

BACKGROUND

Multiple studies have demonstrated strong associations between cardiorespiratory fitness and lower cardiovascular disease mortality. In contrast, little is known about associations of fitness with nonfatal cardiovascular events.

METHODS AND RESULTS

Linking individual participant data from the Cooper Center Longitudinal Study with Medicare claims files, we studied 20642 participants (21% women) with fitness measured at the mean age of 49 years and who survived to receive Medicare coverage from 1999 to 2009. Fitness was categorized into age- and sex-specific quintiles (Q) according to Balke protocol treadmill time with Q1 as low fitness. Fitness was also estimated in metabolic equivalents according to treadmill time. Associations between midlife fitness and hospitalizations for heart failure and acute myocardial infarction after the age of 65 years were assessed by applying a proportional hazards model to the multivariate failure time data. After 133514 person-years of Medicare follow-up, we observed 1051 hospitalizations for heart failure and 832 hospitalizations for acute myocardial infarction. Compared with high fitness (Q4-5), low fitness (Q1) was associated with a higher rate of heart failure hospitalization (14.3% versus 4.2%) and hospitalization for myocardial infarction (9.7% versus 4.5%). After multivariable adjustment for baseline age, blood pressure, diabetes mellitus, body mass index, smoking status, and total cholesterol, a 1 unit greater fitness level in metabolic equivalents achieved in midlife was associated with ≈20% lower risk for heart failure hospitalization after the age of 65 years (men: hazard ratio [95% confidence intervals], 0.79 [0.75-0.83]; P<0.001 and women: 0.81 [0.68-0.96]; P=0.01) but just a 10% lower risk for acute myocardial infarction in men (0.91 [0.87-0.95]; P<0.001) and no association in women (0.97 [0.83-1.13]; P=0.68).

CONCLUSIONS

Fitness in healthy, middle-aged adults is more strongly associated with heart failure hospitalization than acute myocardial infarction outcomes decades later in older age.

The Tei index and asymptomatic myocarditis in children with severe dengue

This study aimed to assess myocardial involvement in infants and children with severe dengue (as per the new World Health Organization [WHO] classification 2009) using the Tei index. This prospective observational study was conducted in the Department of Pediatrics, PGIMER and the associated Dr. RML Hospital, New Delhi from August to December 2010. The study included 67 children (ages 3 months-14 years) who satisfied the WHO criteria for the diagnosis of probable dengue fever with warning signs or severe dengue and tested positive for dengue via immunoglobulin-M (IgM) capture enzyme-linked immunoassay (MAC-ELISA). The patients were subjected to a complete blood count, liver function tests, renal profile, electrocardiography, myocardial band enzymes of creatine phosphokinase (CPK-MB), chest x-ray, abdomen ultrasonography, and two-dimensional echocardiography with color-flow Doppler mapping. Ejection fraction and Tei index measurements were performed. Significantly fewer patients with severe dengue were found to have myocardial involvement at admission by ejection fraction (48 %) and E/E' (37 %), than by the Tei index (70 %). Of the 67 patients with severe dengue, one died, giving a case fatality rate of 1.5 %. At discharge, the Tei index persisted on the high side for patients with myocardial involvement, whereas the ejection fraction improved for the majority of them. Most of the patients with severe dengue had asymptomatic myocarditis, as evident by a deranged Tei index, which improved but did not normalize by the time of discharge, necessitating a longer follow-up period. For the majority of the patients, inotropic support was not required to maintain hemodynamic stability.

Aerobic interval training compensates age related decline in cardiac function

OBJECTIVES

To study the effect of aerobic interval training (AIT) on myocardial function in sedentary seniors compared to master athletes (MA) and young controls.

DESIGN

Sixteen seniors (72 ± 1 years, 10 men) performed AIT (4 × 4 minutes) at ≈ 90% of maximal heart rate three times per week for 12 weeks. Results were compared with 11 male MA (74 ± 2 years) and 10 young males (23 ± 2 years).

RESULTS

Seniors had an impaired diastolic function compared to the young at rest. AIT improved resting diastolic parameters, increased E/A ratio (44%, p <0.01), early diastolic tissue Doppler velocity (e') (11%, p <0.05) and e' during exercise (11%, p <0.01), shortened isovolumic relaxation rate (IVRT) (13%, p <0.01). Left ventricle (LV) systolic function (S') was unaffected at rest, whereas S' during stress echo increased by 29% (p <0.01). Right ventricle (RV) S' and RV fractional area change (RFAC) increased (9%, p <0.01, 12%, p =0.01, respectively), but not RV e'. MA had the highest end-diastolic volume, stroke volume, diastolic reserve and RV S'.

CONCLUSION

AIT partly reversed the impaired age related diastolic function in healthy seniors at rest, improved LV diastolic and systolic function during exercise as well as RV S' at rest.

Aging-associated cardiovascular changes and their relationship to heart failure

Aging represents a convergence of declining cardioprotective systems and increasing disease processes that is fertile ground for the development of heart failure. Fifty percent of all heart failure diagnoses and 90% of all heart failure deaths occur in individuals older than 70. This article discusses the microscopic and macroscopic changes in cardiovascular structure, function, protective systems, and disease associated with aging. In addition to outlining important clinical considerations and conditions in older persons, the link between normal aging and the elevated risk for development of stage B heart failure is explained and potential therapeutic pathways are highlighted.

Exercise Tolerance and the Post Exercise Diastolic Filling Pattern in Patients With the Resting Impaired Relaxation

Background

In patients with normal LV systolic function, cardiac output increases with exercise mediated by increased stroke volume early in exercise and an increase in heart rate later in exercise. Despite normal LV systolic function, patients who display an impaired relaxation pattern may have a reduced exercise tolerance. We hypothesized that the resting impaired relaxation pattern that persists during exercise results in reduced LV filling volume and reduced exercise tolerance.

Methods

We evaluated consecutive exercise echocardiograms performed at Harper Hospital from 1998-2000 for patients with sinus rhythm, normal resting wall motion and ejection fraction (> 55%), evidence of resting impaired relaxation, and a negative exercise echocardiogram. There were 49 patients fitting the above criteria who were compared with a group of age and sex matched patients (43 patients) with a normal rest and exercise echocardiogram with normal resting transmitral Doppler. Rest and post exercise echocardiography and Doppler parameters were obtained.

Results

Patients in the impaired relaxation group demonstrated shorter exercise times as compared to the normal control group (8.8 ± 1.6 versus 9.7 ± 2.0 minutes, P < 0.001). In patients with normal resting transmitral diastolic filling, there was an increased the extent of atrial contribution to LV filling volume post exercise associated with shortening of isovolumic relaxation. Two patterns were seen in the impaired relaxation group post exercise. In 1 subgroup in which E/A ratio decreased post exercise, exercise duration was reduced (7.4 ± 1.3 minutes, P < 0.001) as compared to the subgroup with E/A increase (9.6 ± 1.2 minutes) post exercise which was similar to normal controls. Forward stepwise regression indicated that exercise time was primarily related to E/A change post exercise for all patient groups (r = 0.625, P = 0.0008). Specifically, this was true for patients with E/A reversal at rest (r = 0.584, P = 0.0028). However, for patients with normal diastolic filling at rest, the diastolic velocity integral was the major predictor (r = 0.695, P < 0.0084).

Conclusion

We conclude that the transmitral Doppler pattern post exercise provides insight into the mechanism of reduced exercise tolerance in some patients with the resting impaired relaxation pattern. Preservation of this pattern post exercise is associated with reduced exercise tolerance.

Can an elderly woman's heart be too strong? Increased mortality with high versus normal ejection fraction after an acute coronary syndrome. The Global Registry of Acute Coronary Events

BACKGROUND

Coronary artery disease is the leading cause of death in women. We sought to validate previous clinical experience in which we have observed that elderly women with a very high left ventricular ejection fraction (LVEF) are at increased risk of death compared with elderly women with acute coronary syndromes with a normal LVEF.

METHODS

Data from 5,127 elderly female patients (age >65 years) enrolled in the Global Registry of Acute Coronary Events were collected. Patients were divided into 3 groups based on their LVEF: group I had a low ejection fraction (<55%), group II had a normal ejection fraction (55%-65%), and group III had a high ejection fraction (>65%). χ² test and multiple logistic regression analysis were performed. The main outcome measures were death in-hospital and death, stroke, rehospitalization, and myocardial infarction at 6-month follow-up.

RESULTS

Hospital mortality was 12% in group I. Patients in group III were more likely to die in-hospital than those in group II (P = .003). Multivariable logistic regression showed that high ejection fraction was an independent predictor of hospital death (odds ratio [OR] 2.5, 95% CI [CI] 1.2-5.2, P = .01), 6-month death (OR 2.0, 95% CI 1.1-3.4, P = .01), and cardiac arrest/ventricular fibrillation (OR 2.5, 95% CI 1.2-5.0, P = .01) compared with the normal ejection fraction group.

CONCLUSIONS

Having a very high LVEF (> 65%) is associated with worse survival and higher rates of sudden cardiac death than an LVEF considered to be in the reference range.

Does coronary calcium score predict future cardiac function? Association of subclinical atherosclerosis with left ventricular systolic and diastolic dysfunction at MR imaging in an elderly cohort

PURPOSE

To evaluate subclinical atherosclerosis measured by using coronary artery calcium (CAC) as a predictor of future left ventricular (LV) systolic and diastolic function in asymptomatic elderly participants.

MATERIALS AND METHODS

The institutional review boards of the University of Southern California and the Harbor University of California Los Angeles Research and Education Institute (where the South Bay Heart Watch study was initially conducted) approved this HIPAA-compliant study of 386 participants (mean age, 75.2 years) from among the original 1461 participants in the longitudinal South Bay Heart Watch prospective investigation of subclinical atherosclerosis. CAC at computed tomography was correlated with LV ejection fraction (LVEF), regional wall motion abnormalities (RWMAs), and peak filling rate (PFR) assessed a mean of 11.4 years ± 0.6 (standard deviation) later with cardiac magnetic resonance imaging. Analysis of variance and covariance testing was performed with the Wald test, testing for trends across the CAC groups. Covariates included age, level of total cholesterol, level of high-density lipoprotein cholesterol, systolic blood pressure, use of lipid-lowering medication, and smoking status.

RESULTS

Mean LVEF was 60.3% ± 9.9, with 11 (2.8%) of 386 participants having an LVEF of less than 40%. Forty-six (11.9%) of 386 participants had RWMAs. Higher CAC scores were associated with slightly lower LVEF (P for trend = .04) and a greater percentage of participants with decreased PFR (P for trend = .47) and RWMAs (P for trend = .01). After age- and risk factor-adjustment, only RWMA (P = .05) was associated with higher CAC. RWMAs were associated with significantly (P < .001) lower mean LVEF and PFR. Nineteen (41%) of 46 participants with RWMAs had documented Q-wave myocardial infarction, and three (7%) underwent coronary revascularization. CAC scores of 100 or greater were associated with a 2.2-fold (95% confidence interval: 1.30, 3.75) increase in RWMA (P < .001).

CONCLUSION

Subclinical atherosclerosis assessed by using CAC is associated with an increased future likelihood of RWMA, as a marker of previous and possible subclinical coronary artery disease.

The use of E/A ratio as a predictor of outcome in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt

OBJECTIVES

The clinical significance of diastolic dysfunction in cirrhosis, a feature of cirrhotic cardiomyopathy, is unclear. The aim of this study was to assess the utility of E/A ratio, an indicator of diastolic dysfunction, to predict ascites clearance and mortality after transjugular intrahepatic portosystemic stent shunt (TIPS) insertion.

METHODS

A total of 101 cirrhotic patients who received TIPS had pre-TIPS assessments of demographics, severity of liver dysfunction (Child-Pugh and Model for End-Stage Liver Disease (MELD) scores), renal function, hemodynamics, and cardiac function (two-dimensional echocardiography). An E/A ratio of < or =1 was used to indicate diastolic dysfunction. Patients were followed-up for a mean period of 24.6+/-2.4 months post TIPS.

RESULTS

A total of 41 patients with an E/A ratio of < or =1 (group A), and 60 patients with an E/A ratio of >1 (group B) were studied. Group A had significantly higher MELD scores (14.0+/-1.0 vs. 11.4+/-0.8; P=0.03), because of higher serum creatinine levels (107+/-5 vs. 86+/-6 micromol/l; P<0.01). There was no difference in pre-TIPS systemic hemodynamics, systolic function, or portal pressure between the two groups. After TIPS, more patients in group B had ascites clearance (log rank, P=0.038), and the same patients had a higher probability of survival (log rank, P=0.046). There were three post-TIPS cardiac deaths in group A only. A multivariate analysis showed that an E/A of ratio < or =1 was predictive of slow ascites clearance (hazard ratio=7.3, 95% confidence interval=1.3-40.7, P=0.021) and death after TIPS (hazard ratio=4.7, 95% confidence interval=1.1-20.2, P=0.035).

CONCLUSIONS

Diastolic dysfunction, indicated by reduced E/A ratio, is prevalent in advanced cirrhosis and is associated with reduced ascites clearance and increased mortality post TIPS, possibly related to worsening of hemodynamic dysfunction in the post-TIPS period.

Impact of Mild Hypertension on Left Atrial Size and Function

Background— Left atrial (LA) enlargement has been documented to occur in moderate and severe hypertension.

Methods and Results— One hundred twelve mild hypertension patients were prospectively recruited and compared with 198 healthy volunteers. All recruits had a transthoracic echocardiogram. Maximum LA biplane volume, minimum LA biplane volume, and pre ‘p’-LA biplane volume were measured, and left atrial passive, active emptying, and conduit volumes were calculated at baseline and in a subgroup of patients after 12 months. After adjusting for age, gender, and body mass index, maximum LA biplane volume, pre ‘p’-LA biplane volume, and their indexed volumes were increased in the hypertension group. Active emptying volume and fraction were significantly increased in the hypertension group, with no change in conduit and passive volumes. Subgroup analysis comparing hypertensives with normal/mildly increased left ventricular mass (group 1) with those with moderate/severely increased left ventricular mass (group 2) at baseline demonstrated that maximum LA biplane volume (62.8�17.9 mL versus 45.4�13.7 mL; P <0.001) was significantly increased in group 2. Active emptying volume was also increased.

Conclusion— Even mild hypertension seems to be associated with a reduction in early diastolic filling. This results in augmented late left ventricular diastolic filling due to active atrial contraction and may be the mechanism for the increase in left atrial size.

Approaching regional left atrial function by tissue Doppler velocity and strain imaging

Atrial function is an integral part for the proper performance of the circulatory system. Assessment of its haemodynamic and mechanical characteristics by use of non-invasive echocardiography, including tissue Doppler velocity and strain imaging, may provide a better insight into atrial function and its relationship with ventricular function. From an electromechanical perspective, this review summarizes not only the various methods for evaluating regional atrial function by tissue Doppler imaging, but also the normal findings in healthy subjects and the major clinical utilities in cardiac diseases, such as atrial fibrillation, ischaemic heart disease and heart failure.

Handheld echocardiography offers rapid assessment of clinical volume status

BACKGROUND

Assessment of volume status is vital for successful management of patients in heart failure (HF) programs. Bedside determination of elevated left-sided filling pressure (LFP) can be challenging and frequently inaccurate; therefore, incorporating technology such as handheld echocardiography, to aid in estimation of LFP, may improve patient care. In this study, we evaluated the feasibility and accuracy of handheld echocardiography by a nonexpert for potential use in the point of care evaluation of compensation.

METHODS

Subjects were recruited from the HF clinic or inpatient service at a single center. Each subject underwent a focused handheld transthoracic echocardiogram by a medical resident trained for 10 hours. Subjects were assigned to 1 of 4 filling patterns (1 = normal, 2 = abnormal relaxation, 3 = pseudonormal, 4 = restrictive) based on measurements by pulsed wave and tissue Doppler. A 3-step echocardiography test for congestion in HF (TEC-HF) was devised for estimation of LFP. The gold standard for determining elevated LFP was clinical evaluation by a HF specialist, who classified subjects as being euvolemic or hypervolemic.

RESULTS

A total of 100 consecutive subjects (72% male) were recruited, with average age of 60 years and left ventricular ejection fraction of 27%. All subjects had evaluable echocardiographic data. Based on TEC-HF, filling patterns 3 and 4 predicted hypervolemia and patterns 1 and 2 predicted euvolemia, with sensitivity and specificity of 86% and 92%, respectively, and positive and negative predictive values of 86% and 92%, respectively.

CONCLUSIONS

Applying TEC-HF with handheld echocardiography accurately reflects clinical LFP as assessed by HF specialists. This procedure was easily taught to nonexpert medical staff who obtained adequate images in all patients. Handheld echocardiography could be a useful tool for assessing volume status in nonspecialized community settings.

[Morphological and functional characteristics of the left ventricle in athletes of various ages, and performing at various levels]

One of the most important effects of regular physical training is the adaptation of the cardiovascular system. The basic importance of an "athlete's heart" is manifested in two fields, one is public health, the other competitive sport.

AIM

1. Can the higher E/A quotient of physically active persons be explained by the training bradycardia, or can it be supposed as an independent effect of regular physical exercise? 2. Which training-induced heart characteristics seem to be different in players of various ball-games? 3. How are cardiac data related to the relative aerobic power as most indicative index of endurance performance?

METHODS

Two-dimensionally guided M-mode and Doppler echocardiographic data of different athletic and non-athletic subjects were compared with each other, differences between data of different athletic groups were also analysed.

RESULTS

1. E/A quotient characterises left ventricular (LV) diastolic function, but it highly depends on the heart rate. The higher E/A found in young athletes does not seem to be an independent effect of the regular physical training. 2. Investigating the data of different ball-game-players, characteristic differences were seen. In the myocardial hypertrophy and in the resting heart rate water polo players were the best, volleyball players the worst, but the values of the latter were also better than those of non-athletes. 3. In the pooled group of non-athletes and of competitors of several kinds of sports (endurance athletes, ball-game-players, power-and-sprint-events athletes) all measured parameters correlated significantly with the relative maximal oxygen consumption.

CONCLUSIONS

1. The higher E/A in elderly subjects suggests that regular physical training can diminish the age-associated impairment of diastolic function. 2. For the high intensity training and for the long competition period a special endurance training program would be useful for volleyball players. 3. The higher was the proportion of endurance activity in the training and competitive program, the stronger were the correlations with the relative aerobic capacity.

Effects of aging on left atrioventricular coupling and left ventricular filling assessed using cardiac magnetic resonance imaging in healthy subjects

Left ventricular (LV) filling results from diastolic suction of the left ventricle and passive left atrial (LA) emptying at early diastole and LA contraction at end-diastole. Effects of aging on LA and LV geometric characteristics and function and its consequences for LV filling are incompletely understood. Insight into these effects may increase the understanding of diastolic function. Cardiac magnetic resonance imaging was used to study effects of aging on left atrioventricular coupling and LV filling. Forty healthy volunteers underwent cardiac magnetic resonance imaging and were subdivided into 2 age groups of 20 to 40 (younger group) and 40 to 65 years (older group). For the older group, LA volumes were larger (p <0.05) and LV volumes, including stroke volumes, were smaller (p <0.05), whereas ejection fraction remained constant. LA/LV volume ratios were larger (0.27 +/- 0.06 vs 0.19 +/- 0.03; p <0.001) and correlated with LV mass-volume ratio (r = 0.42, p <0.01). The older group also had lower LA passive emptying (15 +/- 3.0 vs 19 +/- 4.8 ml/m(2); p <0.05) and higher LA active emptying volumes (13 +/- 3.1 vs 11 +/- 3.9 ml/m(2); p <0.05). For both groups, conduit volume contributed most to LV filling, but was lower in the older group (21 +/- 5.1 vs 27 +/- 9.0 ml; p <0.05). In conclusion, changes in LA volume and function were age dependent and related to changes in LV mass-volume ratio. Conduit volume contributed most to LV filling and decreased with age, suggesting it to be an indicator of diastolic function.