Practical Impact of New Diastolic Recommendations on Noninvasive Estimation of Left Ventricular Diastolic Function and Filling Pressures

Hypertension-specific association of cardio-ankle vascular index with subclinical left ventricular function in a Chinese population: Danyang study

The association of cardio-ankle vascular index (CAVI), with subclinical cardiac dysfunction in hypertensive patients is unclear. We aim to examine their relationship in hypertensive patients compared with that in normotensive subjects. Our study included 1887 subjects enrolled from Danyang between 2018 and 2019. CAVI was measured using VaSera VS-1500A device. We performed conventional echocardiography to measure ejection fraction (EF) and E/A, tissue Doppler to measure mitral annular early diastolic velocities (e'), and speckle-tracking to estimate left ventricular (LV) global longitudinal strain (GLS). LV mass index (76.3, 80.0, and 84.0 g/m2), and E/e' (7.6, 8.2, and 8.8) were increased and GLS (21.1, 21.0, and 20.4%), E/A (1.2, 1.0, and 0.8) and e' velocity (11.2, 9.4, and 8.2 cm/s) was decreased from tertiles 1-3 of CAVI on unadjusted analyses (P < .001). After adjustment for covariates, GLS, E/A, and e' were still significantly decreased from tertiles 1-3 of CAVI (P ≤ .04). Further sensitive analyses revealed a similar association pattern for diastolic function but not systolic function. Compared with the lowest tertile, subjects with a top tertile of CAVI were at higher risk of subclinical LV systolic dysfunction in hypertensive patients (OR = 2.61; P = .005). Increased CAVI is associated with worse subclinical diastolic function. However, this relationship of CAVI to subclinical systolic function was more prominent in hypertensive patients.

Novel Strategies in Diagnosing Heart Failure with Preserved Ejection Fraction: A Comprehensive Literature Review

Heart failure (HF) with preserved ejection fraction (HFpEF) is a prevalent global condition affecting approximately 50% of the HF population. With the aging of the worldwide population, its incidence and prevalence are expected to rise even further. Unfortunately, until recently, no effective medications were available to reduce the high mortality and hospitalization rates associated with HFpEF, making it a significant unmet need in cardiovascular medicine. Although HFpEF is commonly defined as HF with normal ejection fraction and elevated left ventricular filling pressure, performing invasive hemodynamic assessments on every individual suspected of having HFpEF is neither feasible nor practical. Consequently, several clinical criteria and diagnostic tools have been proposed to aid in diagnosing HFpEF. Overall, these criteria and tools are designed to assist healthcare professionals in identifying and evaluating patients who may have HFpEF based on a combination of signs, symptoms, biomarkers, and non-invasive imaging findings. By employing these non-invasive diagnostic approaches, clinicians can make informed decisions regarding the best pharmacological and rehabilitation strategies for individuals with suspected HFpEF. This literature review aims to provide an overview of all currently available methods for diagnosing and monitoring this disabling condition.

Left ventricular structural abnormalities in the assessment of diastolic function in the elderly: source of discrepancies between the 2009 and 2016 criteria

Diastolic dysfunction (DD) is routinely evaluated in echocardiography to support diagnosis, prognostication, and management of heart failure, a condition highly prevalent in elderly patients. Clinical guidelines were published in 2009, and updated in 2016, pursuing to standardize and improve DD categorization. We aimed to assess the concordance of DD between these two documents in an elderly population and to investigate how left ventricular structural abnormalities (LVSA) impact the reclassification. To evaluate this we analyzed the 308 consecutive transthoracic echocardiograms in patients older than 60 years (70.4 ± 7.7 years-old, 59% women) that fulfilled the inclusion criteria out of the 1438 echocardiograms performed in a tertiary hospital. We found that the prevalence of DD was lower according to the 2016 criteria (64% vs. 91%; p < 0.001), with 207 (67.2%) patients changing category, indicating poor agreement between the guidelines (kappa = 0.21). There were 188 (61%) patients with LVSA, which drove most of the reclassifications in 2016 Grade I DD cases. The prevalence of elevated filling pressures by Doppler halved in this elderly population using the updated recommendations (20.9% vs. 39.2%; p < 0.001). In conclusion the prevalence of DD was lower applying the 2016 guidelines, with a poor agreement with 2009 guidelines in all DD grades. The role of LVSA in reclassifications was particularly evident in Grade I DD, while Doppler parameters drove reclassifications among the more severe grades. If not properly addressed, these discrepancies may undermine the reliance on DD as a diagnostic and prognostic tool, particularly in an elderly population at a higher risk of heart failure.

Exploring the prospect of intrinsic wave propagation in evaluating myocardial stiffness among patients with type 2 diabetes

Background

Diabetes predisposes affected individuals to impaired myocardial perfusion and ischemia, leading to cardiac dysfunction. Increased myocardial stiffness is an independent and significant risk factor in diastolic dysfunction. This study sought to estimate myocardial stiffness in Type 2 diabetes (T2DM) patients using the intrinsic wave velocity propagation (IVP) along the longitudinal wall motion during late diastole and evaluate the value of IVP in assessing cardiac function and structure.

Methods

87 and 53 participants with and without T2DM (control group) were enrolled. Of the 87 T2DM patients (DM group), 43 were complicated with hypertension (DM + H group), and 44 were not (DM-H group). Ultrasound parameters were measured and analyzed, including color M-mode flow propagation velocity, global longitudinal systolic strain (GLS), and IVP.

Results

IVP was higher in the DM group than in the control group (1.62 ± 0.25 m/s and 1.40 ± 0.19 m/s, P < 0.001). After stratification for hypertension, IVP in both DM + H (1.71 ± 0.25 m/s) and DM-H (1.53 ± 0.20 m/s) groups were found to be significantly higher than that in the control group (1.40 ± 0.19 m/s); also, the difference of IVP between DM + H and DM-H group reached statistical significance. Moreover, IVP was significantly correlated with flow propagation velocity during early diastole (Pve) (r = -0.580, P < 0.001), flow propagation velocity during late diastole (Pva) (r = 0.271, P < 0.001), GLS (r = 0.330, P < 0.001), interventricular septal thickness at end-diastole (IVSd) (r = 0.321, P < 0.001), blood glucose (r = 0.246, P < 0.003), systolic blood pressure (r = 0.370, P < 0.001) and diastolic blood pressure (r = 0.389, P < 0.001).

Conclusions

The results indicated the application potential of IVP in assessing the early detection of cardiac function changes noninvasively and sensitively. The correlation with myocardial stiffness warrants further studies to substantiate its potential clinical utility.

Imaging in Heart Failure with Preserved Ejection Fraction: A Multimodality Imaging Point of View

Heart failure with preserved ejection fraction (HFpEF) is an important global health problem. Despite increased prevalence due to improved diagnostic options, limited improvement has been achieved in cardiac outcomes. HFpEF is an extremely complex syndrome and multimodality imaging is important for diagnosis, identifying its different phenotypes and determining prognosis. Evaluation of left ventricular filling pressures using echocardiographic diastolic function parameters is the first step of imaging in clinical practice. The role of echocardiography is becoming more popular and with the recent developments in deformation imaging, cardiac MRI is extremely important as it can provide tissue characterisation, identify fibrosis and optimal volume measurements of cardiac chambers. Nuclear imaging methods can also be used in the diagnosis of specific diseases, such as cardiac amyloidosis.

Heart Failure with Preserved Ejection Fraction in Children

Diastolic dysfunction (DD) refers to abnormalities in the mechanical function of the left ventricle (LV) during diastole. Severe LVDD can cause symptoms and the signs of heart failure (HF) in the setting of normal or near normal LV systolic function and is referred to as diastolic HF or HF with preserved ejection fraction (HFpEF). Pediatric cardiologists have long speculated HFpEF in children with congenital heart disease and cardiomyopathy. However, understanding the risk factors, clinical course, and validated biomarkers predictive of the outcome of HFpEF in children is challenging due to heterogeneous etiologies and overlapping pathophysiological mechanisms. The natural history of HFpEF varies depending upon the patient's age, sex, race, geographic location, nutritional status, biochemical risk factors, underlying heart disease, and genetic-environmental interaction, among other factors. Pediatric onset HFpEF is often not the same disease as in adults. Advances in the noninvasive evaluation of the LV diastolic function by strain, and strain rate analysis with speckle-tracking echocardiography, tissue Doppler imaging, and cardiac magnetic resonance imaging have increased our understanding of the HFpEF in children. This review addresses HFpEF in children and identifies knowledge gaps in the underlying etiologies, pathogenesis, diagnosis, and management, especially compared to adults with HFpEF.

Prognostic Impact of Indeterminate Diastolic Function in Patients With Functionally Insignificant Coronary Stenosis

BACKGROUND

Cardiac diastolic dysfunction is an independent predictor of mortality, regardless of left ventricular (LV) systolic function. However, the current guidelines that define cardiac diastolic dysfunction may underrate the clinical implications of those with indeterminate diastolic function.

OBJECTIVES

We sought to evaluate the prognostic implications of indeterminate diastolic function on echocardiography and its association with coronary microvascular dysfunction (CMD).

METHODS

A total of 330 patients without LV systolic dysfunction and significant epicardial coronary stenosis (fractional flow reserve > 0.80) were analyzed from a prospective registry. Cardiac diastolic dysfunction was defined according to 2 algorithms depending on the presence of myocardial disease. First, the presence of myocardial disease and evidence of elevated LV filling pressure indicated diastolic dysfunction. Second, diastolic function in those without myocardial disease was defined using echocardiographic parameters (E/e', e' velocity, tricuspid regurgitation velocity, and left atrial volume index). Patients who did not meet half of the available criteria were classified as having indeterminate diastolic function. Coronary microvascular dysfunction was defined as coronary flow reserve < 2.0 and index of microcirculatory resistance ≥ 25 U. The primary outcome was cardiovascular death or admission for heart failure at 5 years.

RESULTS

Coronary flow reserve was lower in patients with indeterminate diastolic function compared with those with no diastolic dysfunction (3.5 ± 1.6 vs 3.2 ± 1.6, P = .002). The prevalence of CMD was also higher in patients with indeterminate diastolic function than in those with no diastolic dysfunction (10.6% vs 4.9%, P < .034). Patients with indeterminate diastolic function showed significantly higher risk of cardiovascular death or admission for heart failure than those without indeterminate diastolic function but not greater than those with definite diastolic dysfunction (cumulative incidence: 12.6%, 27.2%, and 32.7%, respectively, log-rank P < .001). Presence of CMD and elevated LV filling pressure (E/e' > 14) were independent predictors for cardiovascular death or admission for heart failure in patients with indeterminate diastolic function.

CONCLUSIONS

Patients with indeterminate diastolic function on echocardiogram showed higher risk of cardiovascular death or admission for heart failure than those with no diastolic dysfunction. Presence of CMD and elevated LV filling pressure were independent predictors for cardiovascular death or admission for heart failure among patients with indeterminate diastolic function.

Subclinical HMOD in Hypertension: Left Ventricular Diastolic Dysfunction

Arterial hypertension represents an important risk factor for the development of cardiac, vascular and renal events, predisposing to heart failure, acute coronary syndromes, peripheral artery disease, stroke, and chronic renal disease. Arterial hypertension leads to the development of subclinical hypertension mediated organ damage (HMOD) which has prognostic relevance and may influence the choice of treatment options. Alterations of cardiac structure and function represent the more widely assessed form of HMOD. This manuscript will focus on the diagnostic opportunities, prognostic significance and treatment of diastolic dysfunction alterations.

From Structural to Functional Hypertension Mediated Target Organ Damage—A Long Way to Heart Failure with Preserved Ejection Fraction

Arterial hypertension (AH) is a major risk factor for the development of heart failure (HF) which represents one of the leading causes of mortality and morbidity worldwide. The chronic hemodynamic overload induced by AH is responsible for different types of functional and morphological adaptation of the cardiovascular system, defined as hypertensive mediated target organ damage (HMOD), whose identification is of fundamental importance for diagnostic and prognostic purposes. Among HMODs, left ventricular hypertrophy (LVH), coronary microvascular dysfunction (CMVD), and subclinical systolic dysfunction have been shown to play a role in the pathogenesis of HF and represent promising therapeutic targets. Furthermore, LVH represents a strong predictor of cardiovascular events in hypertensive patients, influencing per se the development of CMVD and systolic dysfunction. Clinical evidence suggests considering LVH as a diagnostic marker for HF with preserved ejection fraction (HFpEF). Several studies have also shown that microalbuminuria, a parameter of abnormal renal function, is implicated in the development of HFpEF and in predicting the prognosis of patients with HF. The present review highlights recent evidence on the main HMOD, focusing in particular on LVH, CMD, subclinical systolic dysfunction, and microalbuminuria leading to HFpEF.

Left Ventricular Diastolic Dysfunction Screening by a Smartphone-Case Based on Single Lead ECG

Aims

To investigate the potential of a signal processed by smartphone-case based on single lead electrocardiogram (ECG) for left ventricular diastolic dysfunction (LVDD) determination as a screening method.

Methods and Results

We included 446 subjects for sample learning and 259 patients for sample test aged 39 to 74 years for testing with 2D-echocardiography, tissue Doppler imaging and ECG using a smartphone-case based single lead ECG monitor for the assessment of LVDD. Spectral analysis of ECG signals (spECG) has been used in combination with advanced signal processing and artificial intelligence methods. Wavelengths slope, time intervals between waves, amplitudes at different points of the ECG complexes, energy of the ECG signal and asymmetry indices were analyzed. The QTc interval indicated significant diastolic dysfunction with a sensitivity of 78% and a specificity of 65%, a Tpeak parameter >590 ms with 63% and 58%, a T value off >695 ms with 63% and 74%, and QRSfi > 674 ms with 74% and 57%, respectively. A combination of the threshold values from all 4 parameters increased sensitivity to 86% and specificity to 70%, respectively (OR 11.7 [2.7-50.9], P < .001). Algorithm approbation have shown: Sensitivity-95.6%, Specificity-97.7%, Diagnostic accuracy-96.5% and Repeatability-98.8%.

Conclusion

Our results indicate a great potential of a smartphone-case based on single lead ECG as novel screening tool for LVDD if spECG is used in combination with advanced signal processing and machine learning technologies.

New Possibilities in Heart Failure: The Effects of Tadalafil on Diastolic Function in Patients Undergoing Robot-Assisted Radical Prostatectomy

Inhibitors of phosphodiesterase type 5 (PDE5i) are the first-line treatment for erectile dysfunction and are also used to treat pulmonary hypertension. PDE5i impedes the breakdown of nitric oxide (NO)-driven cyclic guanosine monophosphate (cGMP) in smooth muscle cells of the vascular bed, acting as a potent vasodilator. In heart failure, cGMP signaling is altered. The modulation of cGMP has therefore emerged as a potential therapeutic option for heart failure. In this prospective observational study, we aim to investigate whether tadalafil, a long-acting PDE5i used for erectile dysfunction, could also improve diastolic function assessed by cardiac ultrasound. A total of 23 patients were enrolled, undergoing nerve-sparing robot-assisted radical prostatectomy for prostate cancer and treated with 20 mg tadalafil on alternate days to recover erectile function. All patients underwent tadalafil treatment for at least 6 months. Participants underwent a clinical and cardiac ultrasound with color Doppler assessment at baseline, after 3 months, and after 6 months. At 6 months, no significant difference was found apart from lower E/e’ ratio (7.4 ± 2.7 vs. 6.3 ± 1.3; p < 0.03), peak velocity of TR jet (2.4 ± 0.2 vs. 2.1 ± 0.2; p < 0.001), and PAPs (27.3 ± 3.6 vs. 22.9 ± 5.7; p < 0.005). Our prospective study shows that 6 months of erectile dysfunction therapy for secondary to radical prostatectomy is associated with a favorable effect on diastolic function, improving the E/e’ ratio and peak velocity of the TR jet.

Diastolic Dysfunction in Systemic Sclerosis: Risk Factors and Impact on Mortality

OBJECTIVE

To determine the independent risk factors for diastolic dysfunction (DD) in patients with systemic sclerosis (SSc) and to evaluate the impact of DD on mortality.

METHODS

SSc patients enrolled in the Johns Hopkins Scleroderma Center Cohort between November 1, 2006 and November 1, 2017 with ≥1 analyzable 2-dimensional (2-D) echocardiogram in our system were included (n = 806). DD risk factors and SSc disease characteristics were prospectively obtained, and the presence or absence of DD was determined using the most recent 2-D echocardiogram. Logistic regression models examined associations between clinical risk factors and DD, and Cox proportional hazards models were used to assess survival.

RESULTS

DD was present in 18.6% of participants. The majority of participants were female (84%) with a median age of 58.4 years (interquartile range 48.8-68.1). Older age (odds ratio [OR] 1.12 [95% confidence interval (95% CI) 1.09-1.15], P < 0.001), coronary artery disease (OR 3.69 [95% CI 1.52-8.97], P = 0.004), obesity (OR 4.74 [95% CI 2.57-8.74], P < 0.001), longer SSc disease duration (OR 1.04 [95% CI 1.01-1.06], P = 0.004), diffusing capacity for carbon monoxide ≤60% of predicted (OR 2.41 [95% CI 1.40-4.16], P = 0.002), and history of scleroderma renal crisis (OR 3.18 [95% CI 1.12-9.07], P = 0.031) were all independently associated with an increased risk of DD. Anti-Scl-70 positivity (OR 0.49 [95% CI 0.26-0.93], P = 0.03) and severe gastrointestinal disease (OR 0.48 [95% CI 0.30-0.79], P = 0.004) were associated with a reduced risk of DD. The presence of DD was independently associated with an increase in the risk of mortality (hazard ratio 1.69 [95% CI 1.07-2.68], P = 0.027).

CONCLUSION

DD is independently associated with an increased risk of mortality in patients with SSc. Potentially modifiable risk factors, including coronary artery disease and obesity, should be addressed in patients with SSc to reduce mortality risk.

Can echocardiographic assessment of diastolic function be automated?

Echocardiographic evaluation of left ventricular diastolic function relies on a multi-pronged algorithm, which incorporates Doppler-based and volumetric parameters. Integration of clinical data in diastolic assessment is recommended, though not clearly outlined. We sought to develop an automated tool for diastolic function, compare its performance to human-generated diagnoses and identify the common sources of error. Our software tool is based on the 2016 diastolic guidelines algorithm, which uses 8 parameters as input, with 10 conditions as the logic and 5 possible outputs as final diagnoses. Initially, we prospectively studied 563 patients whose diastolic function was independently evaluated by an expert echocardiographer and by the automated tool. Incongruent cases were further analyzed, after which features of myocardial disease were integrated into a refined version of the software that was tested in an independent cohort of 1106 patients. In the initial analysis, 202/563 grades (36%) were incongruent between the automated and human reads, with the highest rate of discordance for mild and indeterminate categories. In 17% of cases, human diagnoses differed from that dictated by the algorithm due to integration of clinical factors. Follow-up analysis using the refined automated tool did not improve the discordance rate (440/1106; 40%). There was more discordance in cases of: age > 40 years, impaired mitral inflow patterns (E/A < 0.8) and reduced mitral e' values. Further analysis revealed differences in how readers interpreted the interaction between these factors and diastolic function, which could not be incorporated into the automated tool. In conclusion, although assessment of diastolic function relies on an algorithm that can be automated, this algorithm does not include clear guidance on how to incorporate age, or age-related changes in Doppler-based parameters, often resulting in discordant diagnoses. Standardized interpretation of these factors is needed to improve the reproducibility of diastolic function grading by human readers and the accuracy of the automated classification.

Low mechano-energetic efficiency is associated with future left ventricular systolic dysfunction in hypertensives

Aims

In a hypertensive population with optimal blood pressure control with a long‐term follow‐up, we aimed at analysing possible predictors of left ventricular (LV) ejection fraction (LVEF) reduction, including indexed mechano‐energetic efficiency (MEEi), a well‐recognized echo‐derived parameter of LV performance.

Methods and results

The study population included 5673 hypertensive patients from the Campania Salute Network with a long‐term follow‐up, normal baseline LVEF (≥50%), and no prevalent cardiovascular (CV) disease. Patients developing LVEF impairment (LVEF < 50% or a reduction of at least 10 percentage points compared with baseline) were compared with patients with persistently normal LVEF. Optimal blood pressure control was achieved in about 80% of patients. Patients who experienced LVEF reduction were 2.41% during a long‐term follow‐up (mean duration 5.6 ± 3.9 years). At baseline, they were older (59.46 ± 11.58 vs. 53.40 ± 11.41, P < 0.0001) and showed higher LV mass index (53.3 ± 12.83 vs. 47.56 ± 9.58, P < 0.0001), left atrial (LA) volume index (14.4 ± 4.2 vs. 13.1 ± 2.8, P < 0.0001) and carotid intima–media thickness (1.99 ± 0.86 vs. 1.61 ± 0.73, P < 0.0001), lower MEEi (0.32 ± 0.08 vs. 0.34 ± 0.07, P = 0.037), and higher prevalence of CV events during follow‐up (13.9% vs. 3%, P < 0.0001) compared with patients with persistently normal LVEF. A logistic regression analysis, performed after running univariate analyses and selecting parameters significantly associated with LVEF reduction, showed that having a CV event [odds ratio (OR) 7.57, P < 0.0001], being in the lowest MEEi quartile (OR 2.43, P = 0.003), and having a larger LA volume index (OR 1.08, P = 0.028) were all parameters independently associated with the development of LV systolic dysfunction. A further logistic regression model, performed by excluding patients experiencing CV events, demonstrated that the lowest MEEi quartile was independently associated with the evolution towards LVEF reduction (OR 2.35, P = 0.004), despite significant impact of LA volume index (OR 1.08, P = 0.023) and antiplatelet therapy (OR 1.89, P < 0.01). Receiver operating characteristic curves showed that the model including MEEi had higher accuracy than the model without MEEi in predicting LVEF reduction (areas under the curve 0.68 vs. 0.63, P = 0.046).

Conclusions

Lower values of MEEi at baseline identify hypertensive patients more liable to develop LVEF reduction. In hypertensive setting, MEEi evaluation improves risk stratification for development of LV systolic dysfunction during long‐term follow‐up.

Association of Echocardiographic Measures of Left Atrial Function and Size With Incident Dementia

IMPORTANCE

Atrial myopathy-characterized by alterations in left atrial (LA) function and size-is associated with ischemic stroke, independent of atrial fibrillation (AF). Electrocardiographic markers of atrial myopathy are associated with dementia, but it is unclear whether 2-dimensional echocardiographic (2DE)-defined LA function and size are associated with dementia.

OBJECTIVE

To examine the association of LA function and size with incident dementia.

DESIGN, SETTING, AND PARTICIPANTS

The Atherosclerosis Risk in Communities (ARIC) study is a community-based prospective cohort. An exploratory, retrospective analysis was conducted. ARIC centers are located in Forsyth County, North Carolina; Jackson, Mississippi; Washington County, Maryland; and suburban Minneapolis, Minnesota. For this analysis, visit 5 (2011-2013) served as the baseline. Participants without prevalent AF and stroke and who had 2DEs in 2011-2013 were included and surveilled through December 31, 2019.

EXPOSURES

LA function (reservoir strain, conduit strain, contractile strain, emptying fraction, passive emptying fraction, and active emptying fraction), and LA size (maximal and minimal volume index) as evaluated by 2DE.

MAIN OUTCOMES AND MEASURES

Dementia cases were identified using in-person and phone cognitive assessments, hospitalization codes, and death certificates. Cox proportional hazards models were used.

RESULTS

Among 4096 participants (mean [SD] age, 75 [5] years; 60% women; 22% Black individuals), 531 dementia cases were ascertained over a median follow-up of 6 years. Dementia incidence for the lowest LA quintile was 4.80 for reservoir strain, 3.94 for conduit strain, 3.29 for contractile strain, 4.20 for emptying fraction, 3.67 for passive emptying fraction, and 3.27 for active emptying fraction per 100 person-years. After full-model adjustments, there were statistically significant associations between measures of LA function and dementia; the hazard ratios (HRs) from the lowest vs highest quintile for reservoir strain were 1.98 (95% CI, 1.42-2.75); for conduit strain, 1.50 (95% CI, 1.09-2.06); for contractile strain, 1.57 (95% CI, 1.16-2.14); for emptying fraction, 1.87 (95% CI, 1.31-2.65); and for active emptying fraction, 1.43 (95% CI, 1.04-1.96). LA passive emptying fraction was not significantly associated with dementia (HR, 1.26 [95% CI, 0.93-1.71]). Dementia incidence for the highest LA maximal volume index quintile was 3.18 per 100 person-years (HR for highest vs lowest quintile, 0.77 [95% CI, 0.58-1.02]) and for the highest minimal volume index quintile was 3.50 per 100 person-years (HR for the highest vs lowest quintile, 0.95 [95% CI, 0.71-1.28]). Both measures were not significantly associated with dementia. These findings were robust to sensitivity analyses that excluded participants with incident AF or stroke.

CONCLUSIONS AND RELEVANCE

In this exploratory analysis of a US community-based cohort, several echocardiographic measures of lower LA function were significantly associated with an increased risk of subsequent dementia. Measures of LA size were not significantly associated with dementia risk. These findings suggest that impaired LA function may be a risk factor associated with dementia.

Left atrial strain improves echocardiographic classification of diastolic function in patients with metabolic syndrome and overweight-obesity

BACKGROUND

Current recommendations for echocardiographic assessment of diastolic function (2016 guidelines of the American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) in patients with metabolic syndrome and overweight/obesity result in a significant number of patients with indeterminate diastolic dysfunction (LVDD). The aim of this article is to study whether the use of the left atrial strain criterion (LALS) reduces the number of indeterminate patients.

METHODS

229 patients were studied with a complete echocardiographic study that included left ventricular longitudinal strain (LVLS) analysis, LALS and a maximal ergospirometry test with assessment of oxygen uptake (VO_2max).

RESULTS

The mean age was 65 ± 5 years, 153 (67%) males, with a mean EF of 60 ± 5%. The mean LVLS was -19.4 ± 2% and the LALS Reservoir was 23.8 ± 7%. There were 140 patients who did not meet LVDD criteria and 82 who did meet the indeterminate LVDD criterion. When the left atrial volume index (LAVI) >34 ml/m² criterion was replaced in the 2016 ASE/EACVI algorithm by LALS Reservoir ≤20%, the number of indeterminate patients was reduced from 36% to 23% (p < 0.001) at the expense of increasing normal studies (61% and 74%). Adding the LALS Reservoir criterion ≤23% in the 82 patients of the indeterminate group resulted in two groups with a different VO_2max (11.6 ± 3 and 18 ± 5 ml/kg/min, p:0.081).

CONCLUSIONS

This study confirms the low prevalence of diastolic dysfunction in overweight/obese patients with metabolic syndrome. Adding left atrial strain criterion to the current recommendations significantly reduces the number of indeterminate patients by reclassifying them as normal.

Multimodality imaging in patients with heart failure and preserved ejection fraction: an expert consensus document of the European Association of Cardiovascular Imaging

Nearly half of all patients with heart failure (HF) have a normal left ventricular (LV) ejection fraction (EF) and the condition is termed heart failure with preserved ejection fraction (HFpEF). It is assumed that in these patients HF is due primarily to LV diastolic dysfunction. The prognosis in HFpEF is almost as severe as in HF with reduced EF (HFrEF). In contrast to HFrEF where drugs and devices are proven to reduce mortality, in HFpEF there has been limited therapy available with documented effects on prognosis. This may reflect that HFpEF encompasses a wide range of different pathological processes, which multimodality imaging is well placed to differentiate. Progress in developing therapies for HFpEF has been hampered by a lack of uniform diagnostic criteria. The present expert consensus document from the European Association of Cardiovascular Imaging (EACVI) provides recommendations regarding how to determine elevated LV filling pressure in the setting of suspected HFpEF and how to use multimodality imaging to determine specific aetiologies in patients with HFpEF.

Advanced imaging tools for evaluating cardiac morphological and functional impairment in hypertensive disease

Arterial hypertension represents a systemic burden, and it is responsible of various morphological, functional and tissue modifications affecting the heart and the cardiovascular system. Advanced imaging techniques, such as speckle tracking and three-dimensional echocardiography, cardiac magnetic resonance, computed tomography and PET-computed tomography, are able to identify cardiovascular injury at different stages of arterial hypertension, from subclinical alterations and overt organ damage to possible complications related to pressure overload, thus giving a precious contribution for guiding timely and appropriate management and therapy, in order to improve diagnostic accuracy and prevent disease progression. The present review focuses on the peculiarity of different advanced imaging tools to provide information about different and multiple morphological and functional aspects involved in hypertensive cardiovascular injury. This evaluation emphasizes the usefulness of the emerging multiimaging approach for a comprehensive overview of arterial hypertension induced cardiovascular damage.

Assessment of diastolic function in aortic stenosis: A comparison between 2009 and 2016 guidelines

AIMS

New diastolic dysfunction (DD) guidelines were introduced in 2016 to replace the 2009 guidelines, but have not yet been evaluated in aortic stenosis (AS). We aimed to compare the 2009 and 2016 DD guidelines in severe AS patients in terms of association with left ventricular (LV) and left atrial (LA) remodeling, with pulmonary capillary wedge pressure (PCWP) at rest and exercise, and with prognosis.

METHODS AND RESULTS

We included 212 patients with severe AS (112 undergoing AVR, 100 asymptomatic). Echocardiography, magnetic resonance imaging, and brain natriuretic peptides (BNP) were performed/measured. Thirty-nine asymptomatic patients had PCWP measured during rest and maximal exertion. Asymptomatic patients were followed for 3.1 years for the combined endpoint of death, AVR or admission with heart failure. The 2009 and 2016 DD guidelines agreed poorly with each other (Cohens' κ = .15). 2009 guidelines showed many ambiguous DD findings. With the 2016 guidelines, 20% of patients had indeterminate DD. DD grade 2 according to 2016 guidelines showed stronger association with symptom status, BNP, global longitudinal strain (GLS) and peak exercise PCWP than 2009 guidelines. For indeterminate DD patients according to 2009 guidelines, GLS above the median was associated with event-free survival (HR .11 (95% CI .02-.53)). For neither guideline was DD associated with the combined endpoint in asymptomatic patients.

CONCLUSION

The 2016 guidelines show a stronger association with BNP, GLS, and exercise PCWP than the 2009 guidelines. The 2016 guidelines result in 20% of patients with indeterminate DD; however, these patients may possibly be stratified according to GLS.

Simple Two-Dimensional Echocardiographic Scoring System for the Estimation of Left Ventricular Filling Pressure

BACKGROUND

When left ventricular filling pressure (LVFP) increases, the mitral valve opens early and precedes tricuspid valve opening in early diastole. The authors hypothesized that a visually assessed time sequence of atrioventricular valve opening could become a new marker of elevated LVFP. The aim of this study was to test the diagnostic ability of a novel echocardiographic scoring system, the visually assessed time difference between mitral valve and tricuspid valve opening (VMT) score, in patients with heart failure.

METHODS

One hundred nineteen consecutive patients who underwent cardiac catheterization within 24 hours of echocardiographic examination were retrospectively analyzed as a derivation cohort. In addition, a prospective study was conducted to validate the diagnostic ability of the VMT score in 50 patients. Elevated LVFP was defined as mean pulmonary artery wedge pressure (PAWP) ≥ 15 mm Hg. The time sequence of atrioventricular valve opening was visually assessed and scored (0 = tricuspid valve first, 1 = simultaneous, 2 = mitral valve first). When the inferior vena cava was dilated, 1 point was added, and VMT score was ultimately graded as 0 to 3. Cardiac events were recorded for 1 year after echocardiography.

RESULTS

In the derivation cohort, PAWP was elevated with higher VMT scores (score 0, 10 ± 5; score 1, 12 ± 4; score 2, 22 ± 8; score 3, 28 ± 4 mm Hg; P < .001, analysis of variance). VMT score ≥ 2 predicted elevated PAWP with accuracy of 86% and showed incremental predictive value over clinical variables and guideline-recommended diastolic function grading. These observations were confirmed in the prospective validation cohort. Importantly, VMT score ≥ 2 discriminated elevated PAWP with accuracy of 82% in 33 patients with monophasic left ventricular inflow in the derivation cohort. Kaplan-Meier analysis demonstrated that patients with VMT scores ≥ 2 were at higher risk for cardiac events than those with VMT scores ≤ 1 (P < .001).

CONCLUSIONS

VMT scoring could be a novel additive marker of elevated LVFP and might also be associated with adverse outcomes in patients with heart failure.

Impact of Updated 2016 ASE/EACVI VIS-À-VIS 2009 ASE Recommendation on the Prevalence of Diastolic Dysfunction and LV Filling Pressures in Patients with Preserved Ejection Fraction

BACKGROUND

Assessment of diastolic dysfunction (DD) and left ventricular filling pressures (LVFP) by echocardiography is complex in patients with preserved ejection fraction (EF). The American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) jointly published recommendations in 2016 to simplify the diagnosis and classification of DD and the assessment of LVFP. We aimed to study the impact of the updated 2016 ASE/EACVI guidelines vis-à-vis the 2009 ASE recommendations on prevalence of DD and LVFP in patients with preserved EF.

METHODS

Five hundred patients referred to the echocardiography laboratory from March 2020 to May 2020 were analyzed. Patients with left ventricular ejection fraction (LVEF) < 50% were excluded. All patients underwent comprehensive transthoracic echocardiography. DD and LVFP were assessed by the 2016 ASE/EACVI and 2009 ASE recommendations. The concordance between the guidelines was analyzed by kappa coefficient and overall proportion of agreement.

RESULTS

Mean age was 53 ± 13 years and 63.4% were men. Prevalence of DD and abnormal LVFP were significantly lower with the 2016 recommendations than with the 2009 recommendations (9.4% vs. 16.8%, p < 0.001 and 8.4% vs. 12.8%, p < 0.05). Patients with Grade 1 DD (100%) and Grade 2 DD (46.4%) were reclassified by the 2016 recommendations. Indeterminate diastolic function (9.8%) was strikingly high according to the 2016 recommendations. The concordance between the two recommendations was moderate (kappa = 0.569). The overall proportion of agreement was 85.4%.

CONCLUSIONS

Prevalence of DD and abnormal LV filling pressures were lower with application of the 2016 ASE/EACVI recommendations in patients with preserved EF. There was moderate agreement between the 2009 and 2016 recommendations.

Functional capacity and left ventricular diastolic function in patients with type 2 diabetes

AIMS

The study sought to evaluate cardiorespiratory fitness in patients with type 2 diabetes mellitus (DM) with different levels of left ventricular (LV) diastolic dysfunction (LVDD).

METHODS

This investigation included 55 controls and 85 uncomplicated diabetic patients, who underwent laboratory analysis, echocardiographic evaluation and cardiopulmonary exercise testing. All DM subjects were separated into 3 groups using the level of LV diastolic function as main criterion: normal, intermediate and LVDD.

RESULTS

Echocardiographic parameters of LV hypertrophy were significantly higher in DM subjects, particularly those with intermediate LV diastolic function and LVDD comparing with controls. The same is valid for parameters of LV diastolic function (E/e', left atrial volume index and tricuspid regurgitation velocity). Peak oxygen uptake was lower, whereas ventilation/carbon dioxide slope was higher, in DM subjects with intermediate LV diastolic function and LVDD in comparison to controls. In the whole study population HbA1c, LV mass index and mitral E/e' were independently related with peak oxygen uptake and ventilation/carbon dioxide slope.

CONCLUSIONS

LVDD significantly impacted functional capacity in DM patients. Glycemic control, LV mass index and LVDD were independently related with peak oxygen consumption and ventilation/carbon dioxide slope in the study population. These results show that timely diagnosis of LVDD and more intensive antidiabetic treatment could prevent target organ damage in DM patients.

Discrepancies in Assessing Diastolic Function in Pre-Clinical Heart Failure Using Different Algorithms-A Primary Care Study

Background: Current guidelines on diastolic function (DF) by the American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) have been disputed and two alternative algorithms have been proposed by Johansen et al. and Oh et al. We sought (a) to assess the concordance of ASE/EACVI guidelines on DF using these proposed alternative approaches and (b) to evaluate the prevalence of indeterminate diastolic dysfunction (DD) by each method, exploring means for reducing their number. Methods: We retrospectively analyzed the echocardiographic reports of 1158 outpatients including subjects at risk of heart failure without (n = 644) or with (n = 241) structural heart disease, and 273 healthy individuals. Concordance was calculated using the k coefficient and overall proportion of DD reclassification rate. The effectiveness of pulmonary vein flow (PVF), Valsalva maneuver, and left atrial volume index/late diastolic a’-ratio (LAVi/a’) over indeterminate grading was assessed. Results: The DD reclassification rate was 30.1% (k = 0.35) for ASE/EACVI and OH, 36.5% (k = 0.27) for ASE/EACVI and JOHANSEN and 31.1% (k = 0.37) for OH and JOHANSEN (p < 0.0001 for all comparisons). DF could not be graded only by ASE/EACVI and OH in 9% and 11% patients, respectively. The majority of patients could be reclassified using PVF or Valsalva maneuver or LAVi/a’, with the latter being the single most effective parameter. Conclusion: Inconsistencies between updated guidelines and independent approaches to assess and grade DF impede their interchangeable clinical use. The inconclusive diagnoses can be reconciled by conventional echocardiography in most patients, and LAVi/a’ emerges as a simple and effective approach to this aim.

Diastology: 2020-A practical guide

Left ventricular (LV) diastolic function can be most conveniently assessed by echocardiography which provides reliable assessments of LV structure and function. Most patients with structural heart disease have variable degrees of myocardial dysfunction. LV structural changes as pathologic hypertrophy and systolic functional abnormalities as depressed LV long-axis systolic function are associated with diastolic dysfunction. The recognition of structural abnormalities and abnormal LV long-axis function as indices of diastolic dysfunction is an important difference between 2016 and 2009 guidelines. In addition, there are other Doppler findings indicative of diastolic dysfunction and abnormally elevated LV filling pressures. In the absence of clinical, 2D echocardiographic, and specific Doppler indices of diastolic dysfunction, mitral annulus early diastolic velocity (e'), left atrium (LA) maximum volume index, peak velocity of tricuspid regurgitation jet by continuous-wave Doppler, and ratio of mitral inflow early diastolic velocity to e' velocity can be used to draw inferences about LV diastolic function. In the presence of diastolic dysfunction, mean LA pressure and grade of diastolic dysfunction should be determined. When LA pressure at rest is normal, it is reasonable to proceed to diastolic stress testing in an attempt to identify patients with dyspnea due to heart failure. There are specific algorithms recommended in patients with atrial fibrillation, moderate or severe mitral annular calcification, and noncardiac pulmonary hypertension.