European multicentre validation study of the accuracy of E/e' ratio in estimating invasive left ventricular filling pressure: EURO-FILLING study

Natriuretic peptides and soluble ST2 improves echocardiographic diagnosis of elevated left ventricular filling pressures

Elevated filling pressure of the left ventricle (LV) defines diastolic dysfunction. The gold standard for diagnosis is represented by the measurement of LV end-diastolic pressure (LVEDP) during cardiac catheterization, but it has the disadvantage of being an invasive procedure. This study aimed to investigate the correlation between LVEDP and cardiac serum biomarkers such as natriuretic peptides (mid-regional pro-atrial natriuretic peptide [MR-proANP], B-type natriuretic peptide [BNP], and N-terminal prohormone BNP [NT-proBNP]), soluble ST2 (sST2), galectin-3 and mid-regional pro-adrenomedullin (MR-proAMD). Consecutive patients hospitalized in a tertiary center and undergoing left cardiac catheterization were included in the study. Diastolic dysfunction was considered present if the end-expiratory LVEDP was ≥ 15 mmHg. Cardiac biomarkers were determined from pre-procedural peripheral venous blood samples. A total of 110 patients were included, of whom 76 (69.0%) were males, with a median age of 65 (55-71) years. Median LVEDP was 13.5 (8-19) mmHg and diastolic dysfunction was present in 50 (45.4%) of the patients. LVEDP correlated with BNP (p < 0.0001, r = 0.39 [0.20-0.53]), NT-proBNP (p < 0.0001, r = 0.40 [0.22-0.55]), MR-proANP (p = 0.001, r = 0.30 [0.11-0.46]), sST2 (p < 0.0001, r = 0.47 [0.30-0.60]), but not with MR-proAMD (p = 0.77) or galectin-3 (p = 0.76). In the final stepwise multivariable binary logistic regression model, diastolic dysfunction was predicted by NT-proBNP, mitral average E/e', sST2, atrial fibrillation, and left atrium reservoir strain. BNP, NT-proBNP, MR-proANP, and sST2 had predictive value for diastolic dysfunction. In contrast, galectin-3 and MR-proAMD were not associated with increased filling pressures. Furthermore, NT-proBNP and sST2 significantly improved diastolic dysfunction prediction in the final multivariable model.

What Strain Analysis Adds to Diagnosis and Prognosis in Heart Failure Patients

Heart failure (HF) is a common disease that requires appropriate tools to correctly predict cardiovascular outcomes. Echocardiography represents the most commonly used method for assessing left ventricular ejection fraction and a cornerstone in the detection of HF, but it fails to procure an optimal level of inter-observer variability, leading to unsatisfactory prediction of cardiovascular outcomes. In this review, we discuss emerging clinical tools (global longitudinal strain of the left ventricle, the right ventricle, and the left atrium) that permitted an improvement in the diagnosis and ameliorated the risk stratification across different HF phenotypes. The review analyzes the speckle-tracking contributions to the field, discussing the limitations and advantages in clinical practice.

New insights into the potential utility of the left atrial function analysis in heart failure with preserved ejection fraction diagnosis

Aims

None of the conventional echocardiographic parameters alone predict increased NTproBNP level and symptoms, making diagnosis of heart failure with preserved ejection fraction (HFpEF) very difficult in some cases, in resting condition. We evaluated LA functions by 2D speckle tracking echocardiography (STE) on top of conventional parameters in HFpEF and preHF patients with diastolic dysfunction (DD), in order to establish the added value of the LA deformation parameters in the diagnosis of HFpEF.

Methods

We prospectively enrolled 125 patients, 88 with HFpEF (68±9 yrs), and 37 asymptomatic with similar risk factors with DD (preHF) (61±8 yrs). We evaluated them by NTproBNP, conventional DD parameters, and STE. Global longitudinal strain (GS) was added. LA reservoir (R), conduit (C), and pump function (CT) were assessed both by volumetric and STE. 2 reservoir strain (S) derived indices were also measured, stiffness (SI) and distensibility index (DI).

Results

LA R and CT functions were significantly reduced in HFpEF compared to preHF group (all p<0.001), whereas conduit was similarly in both groups. SI was increased, whereas DI was reduced in HFpEF group (p<0.001). By adding LA strain analysis, from all echocardiographic parameters, SR_CT<-1.66/s and DI<0.57 (AUC = 0.76, p<0.001) demonstrated the highest accuracy to identify HFpEF diagnosis. However, by multivariate logistic regression, the model that best identifies HFpEF included only SR_CT, GS and sPAP (R² = 0.506, p<0.001). Moreover, SR_CT, DI, and sPAP registered significant correlation with NTproBNP level.

Conclusions

By adding LA functional analysis, we might improve the HFpEF diagnosis accuracy, compared to present guidelines. LA pump function is the only one able to differentiates preHF from HFpEF patients at rest. A value of SR_CT < -1.66/s outperformed conventional parameters from the scoring system, reservoir strain, and LA overload indices in HFpEF diagnosis. We suggest that LA function by STE could be incorporated in the current protocol for HFpEF diagnosis at rest as a major functional criterion, in order to improve diagnostic algorithm, and also in the follow-up of patients with risk factors and DD, as a prognostic marker. Future studies are needed to validate our findings.

Butyrate modulates adipose-derived stem cells isolated from polygenic obese and diabetic mice to drive enhanced immunosuppression

BACKGROUND AIMS

Adipose-derived stem cells (ASCs) offer promising therapeutic possibilities for immunomodulation. Butyrate (BA) exerts potent anti-inflammatory effects and exhibits multiple regulatory functionalities in adipose tissue (AT). The authors aimed to explore whether BA modulates ASCs to augment their immunosuppressive capabilities.

METHODS

The authors examined the potency of BA and ASCs for controlling anti-CD3 plus CD28-stimulated splenocyte proliferation in vitro, both in combination and with pre-treatment. Further, the authors investigated genes specifically upregulated by BA-treated ASCs, which were harvested from ASC-splenocyte co-culture after the removal of floating splenocytes. In addition, the authors investigated the influence of oral BA supplementation on the ex vivo immunosuppressive potency of ASCs from BALB/c and Tsumura, Suzuki, obese, diabetes (TSOD) mice.

RESULTS

BA enhanced the immunosuppressive potency of ASCs when directly added to ASC-splenocyte co-cultures or via pre-conditioning treatment. The percentages of ASC-induced Foxp3⁺ regulatory T cells increased, whereas the numbers of ASC-suppressed T helper 17 cells further decreased after BA exposure. The messenger RNA expression levels of inducible nitric oxide (NO) synthase (iNOS), chemokines, IL-10 and amphiregulin in ASCs co-cultured with activated splenocytes were upregulated after incubation with BA. This was accompanied by an amplification of iNOS-inducing cytokines, interferon gamma and tumor necrosis factor alpha in the ASC-splenocyte co-culture, triggering ASCs to produce high NO levels under the influence of BA. Mechanistically, the authors detected BA-mediated acetylated histone H3 in ASCs. BA treatment consistently improved the immunosuppressive potency of ASCs derived from both BALB/c and TSOD mice.

CONCLUSIONS

The use of BA to counteract metaflammation by restoring the defective immunomodulation of ASCs from dysregulated AT in obese donors is recommended.

The venous contribution to cardiovascular performance: From systemic veins to left ventricular function: A review

The venous system contains ≈ 70 % of the total blood volume and is responsible in heart failure for key symptoms of congestion. It is active: it can increase or relax its tone with physiologic or pharmacologic stimuli. It is heterogeneous, behaves as a two-compartment model, compliant (splanchnic veins) and noncompliant (nonsplanchnic veins). It is dynamic in health and disease: in heart failure the vascular capacitance (storage space) is decreased and can result in volume redistribution from the abdominal compartment to the thoracic compartment (heart and lungs), which increases pulmonary pressures and precipitates pulmonary congestion. A noninvasive assessment of venous function, at rest and dynamically during stress, is warranted. The systemic haemodynamic congestion is assessed with inferior vena cava diameter and collapsibility. The pulmonary congestion is assessed with B-lines and pleural effusion. The contribution of left ventricular filling is assessed with end-diastolic volume, integrated with left ventricular function.

Association of echocardiographic measures of left ventricular diastolic dysfunction and hypertrophy with presence of coronary microvascular dysfunction

Background

Coronary microvascular dysfunction (CMD) is a common disorder, leading to symptoms similar to obstructive coronary artery disease. We aimed to determine whether measures of left ventricular (LV) diastolic function and hypertrophy may predict presence of CMD.

Methods

We retrospectively included patients undergoing diagnostic coronary angiography and transthoracic echocardiography, excluding patients with obstructive coronary artery disease, previous revascularization therapy, moderate or severe mitral valve disease, or atrial fibrillation. The following markers of LV diastolic function and hypertrophy were assessed: E- and A-wave velocity, E-wave deceleration time, E/A- and E/E′-ratio, left atrial area, left LV mass index, LV ejection time (LVET) and mitral valve closure to opening time. Logistic regression analysis was used to determine the association of echocardiographic parameters with presence of CMD.

Results

From 378 patients (mean age ± SD 59.7 ± 13.6 years, 45.6% male) included, the majority had CMD (n = 293, 77.5%). Patients with CMD were older (60.5 ± 13.4 years vs. 56.9 ± 14.3 years, p = 0.03), were less frequent male (42.3% vs. 57.0%, p = 0.02), and had higher systolic blood pressure (137.9 ± 25.7 mmHg vs. 124.7 ± 25.6 mmHg, p < 0.0001). LVET was significantly associated with CMD (1.42 [1.02–1.96], p = 0.04), while a non-statistically significant link was observed for A-wave velocity and E/E′-ratio (1.39 [0.96–2.00], p = 0.08 and 1.40 [0.92–2.13], p = 0.1, respectively). For all other echocardiography-derived measures, odds ratio for the association with CMD was <1.3 per each SD increase.

Conclusions

In this cross-sectional single-center cohort study, CMD was a frequent finding in patients undergoing coronary angiography for suspected obstructive coronary artery disease. LVET from transthoracic echocardiography is associated with the presence of CMD.

Echocardiographic Evaluation of Left Ventricular Filling Pressure in Patients With Heart Failure With Preserved Ejection Fraction: Usefulness of Inferior Vena Cava Measurements and 2016 EACVI/ASE Recommendations

CONTEXT

The left ventricular filling pressure (LVFP) is correlated to right atrial pressure (RAP) in heart failure. We compared diagnostic value of the inferior vena cava (IVC) measurements to the one of the 2016 echocardiographic recommendations to estimate LVFP in patients with suspected heart failure with preserved ejection fraction (HFpEF).

METHODS

Invasive hemodynamics and echocardiography were obtained within 48 hours in 132 consecutive patients with left ventricular ejection fraction ≥50%, and suspected pulmonary hypertension. Increased LVFP was defined by a pulmonary artery wedge pressure (PAWP) >15 mmHg.

RESULTS

Of 83 patients in sinus rhythm, a score of the 2016 recommendations ≥ 2 (E/e' ratio >14 and/or tricuspid regurgitation velocity >2.8 m/s and/or indexed left atrial volume>34 mL /m²) had a positive predictive value (PPV) of 63% for PAWP>15 mmHg, whereas a dilated IVC (>2.1 cm) and/or non-collapsible (≤50%) had a PPV of 82%. The net reclassification improvement was 0.39 (P < .05). In atrial fibrillation (AF), a dilated and/or non-collapsible IVC had an 86% PPV for PAWP>15 mmHg. The correlation between RAP and PAWP was 0.60, with 75.7% concordance (100/132) between dichotomized pressures (both RAP>8 mmHg and PAWP>15 mmHg and vice versa).

CONCLUSION

The IVC size and collapsibility is valuable to identify patients with HFpEF with high LVFP in both sinus rhythm and AF.

The value of exercise echocardiography in heart failure with preserved ejection fraction

Diastolic stress test is something that is now acknowledged in the recommendations and guidelines for diagnosing heart failure with preserved ejection fraction. This is mainly a submaximal exercise stress test, while the maximal exercise stress test is used in the research of ischemia. Echocardiography can be performed at rest and during submaximal exercise stress test. Few papers have proposed exercise echocardiography as a relevant diagnostic tool in heart failure with preserved ejection fraction. The E/e’ ratio and the estimated pulmonary artery pressure by maximal tricuspid regurgitation velocity should be measured during standardized exercise. Stroke volume and its change during exercise should be also assessed. In fact, unlike in a normal compliant heart, there is no increase in left ventricular end-diastolic volume during exercise and consequently no increase in cardiac output in heart failure with preserved ejection fraction. The absence of increased cardiac output during exercise is, like E/e’ and estimated pulmonary artery pressure, a major parameter to be investigated during submaximal exercise performed to confirm the diagnosis of heart failure with preserved ejection fraction as an etiology of dyspnea.

Rapid cardiothoracic ultrasound protocol for diagnosis of acute heart failure in the emergency department

OBJECTIVES

The aim of this study was to evaluate the performance of a rapid cardiothoracic ultrasound protocol (CaTUS), combining echocardiographically derived E/e' and lung ultrasound (LUS), for diagnosing acute heart failure (AHF) in patients with undifferentiated dyspnea in an emergency department (ED).

PATIENTS AND RESULTS

We enrolled 100 patients with undifferentiated dyspnea from a tertiary care ED, who all had CaTUS done immediately upon arrival in the ED. CaTUS was positive for AHF with an E/e' > 15 and congestion, that is bilateral B-lines or bilateral pleural fluid, on LUS. In addition, an inferior vena cava index was also recorded to analyze whether including a central venous pressure estimate would add diagnostic benefit to the CaTUS protocol. All 100 patients had a brain natriuretic peptide (BNP) sample withdrawn, and 96 patients underwent chest radiography in the ED, which was analyzed later by a blinded radiologist. The reference diagnosis of AHF consisted of either a BNP of more than 400 ng/l or a BNP of less than 100 ng/l in combination with congestion on chest radiography and structural heart disease on conventional echocardiography.CaTUS had a sensitivity of 100% (95% confidence interval: 91.4-100%), a specificity of 95.8% (95% confidence interval: 84.6-99.3%), and an area under the curve of 0.979 for diagnosing AHF (P<0.001). The diagnostic accuracy of CaTUS was higher than of either E/e' or LUS alone. Adding the inferior vena cava index to CaTUS did not improve diagnostic accuracy. CaTUS seemed helpful also for differential diagnostics of dyspnea, mainly regarding pneumonias and pulmonary embolisms.

CONCLUSION

CaTUS, combining E/e' and LUS, provided excellent accuracy for diagnosing AHF.

Management of acute heart failure: Contribution of daily bedside echocardiographic assessment on therapy adjustment with impact measure on the 30-day readmission rate (JECICA)

There are currently one million heart failure (HF) patients in France and the rate is progressively increases due to population aging. Acute decompensation of HF is the leading cause of hospitalization in people over 65 years of age with a 25% re-hospitalization rate in the first month. Expenses related to the management of HF in France in 2013 amounted to more than one billion euros, of which 65% were for hospitalizations alone. The management of acute decompensation is a challenge, due to the complexity of clinical and laboratory evaluation leading to therapeutic errors, which in turn leads to longer hospitalization, high early re-hospitalization and complications. Therapeutic adjustment, especially diuretic, in the acute phase (during hospitalization) affects early re-hospitalization rates (within 30 days). These adjustments can be based on clinical estimation and laboratory parameters, but echocardiography has been shown to be superior in estimating filling pressures (FP) compared to clinical and laboratory parameters.

We hypothesize that a simple daily bedside echocardiographic assessment could provide a reproducible estimation of FP with an evaluation of mitral inflow and the inferior vena cava (IVC). This could allow a more reliable estimate of the true blood volume of the patient and thus lead to a more suitable therapeutic adjustment. This in turn should lead to a decrease in early re-admission rate (primary endpoint) and potentially decrease six-month mortality and rate of complications.

Echo-Doppler estimation of left ventricular filling pressure: results of the multicentre EACVI Euro-Filling study

Aims

The present Euro-Filling report aimed at comparing the diagnostic accuracy of the 2009 and 2016 echocardiographic grading algorithms for predicting invasively measured left ventricular filling pressure (LVFP).

Method and results

A total of 159 patients who underwent simultaneous evaluation of echo estimates of LVFP and invasive measurements of LV end-diastolic pressure (LVEDP) were enrolled at nine EACVI centres. Thirty-nine (25%) patients had a reduced LV ejection fraction (<50%), 77 (64%) were in NYHA ≥ II, and 85 (53%) had coronary artery disease. Sixty-four (40%) patients had elevated LVEDP (≥15 mmHg). Taken individually, all echocardiographic Doppler estimates of LVFP (E/A, E/e', left atrial volume, tricuspid regurgitation jet velocity) were marginally correlated with LVEDP. By using the 2016 recommendations, 65% of patients with normal non-invasive estimate of LVFP had normal LVEDP, while 79% of those with elevated non-invasive LVFP had elevated invasive LVEDP. By using 2009 recommendations, 68% of the patients with normal non-invasive LVFP had normal LVEDP, while 55% of those with elevated non-invasive LVFP had elevated LVEDP. The 2016 recommendations (sensitivity 75%, specificity 74%, positive predictive value 39%, negative predictive value 93%, AUC 0.78) identified slightly better patients with elevated invasive LVEDP (≥ 15 mmHg) as compared with the 2009 recommendations (sensitivity 43%, specificity 75%, positive predictive value 49%, negative predictive value 71%, AUC 0.68).

Conclusion

The present Euro-Filling study demonstrates that the new 2016 recommendations for assessing LVFP non-invasively are fairly reliable and clinically useful, as well as superior to the 2009 recommendations in estimating invasive LVEDP.

Clinical Utility of Left Atrial Strain in Children in the Acute Phase of Kawasaki Disease

BACKGROUND

We aimed to evaluate the diagnostic utility of peak left atrial longitudinal strain (PALS) during left ventricular (LV) systole to differentiate children in the acute phase of Kawasaki disease (aKD) from controls. We also aimed to compare the diagnostic utility of PALS with those of conventional echocardiographic indices of diastolic function.

METHODS

Retrospectively measured PALS, LV longitudinal peak systolic strain, and strain rate obtained via velocity vector imaging were compared in a derivation cohort comprising 95 aKD and 67 controls. The utility of PALS in differentiating aKD from controls was compared with those of E/E', E/A, and maximum left atrial volume index (LAVImax). Derived cutoffs from receiver operating characteristic curves were validated in a separate validation cohort comprising 37 aKD and 19 controls.

RESULTS

In the derivation cohort, PALS was significantly decreased in aKD as compared with in controls. For differentiating aKD from controls, PALS outperformed E/E', E/A, and LAVImax. However, cutoffs of PALS (≤40% and ≤39%, before and after adjusting for the presence of significant mitral regurgitation and LV systolic dysfunction, respectively), like those of E/E', E/A, and LAVImax, showed low sensitivity and poor discriminative ability for differentiating aKD from controls. In the validation cohort, for differentiating aKD from controls, both cutoffs of PALS showed low sensitivity, like those of E/E', E/A, and LAVImax.

CONCLUSION

In aKD, impaired left atrial reservoir function could be detected as decreased PALS. For differentiating aKD from controls, PALS outperforms E/E', E/A, and LAVImax. However, like E/E', E/A, and LAVImax, PALS as a single parameter is limited in its clinical utility to differentiate aKD from controls because of its low sensitivity and poor discriminative ability.

Left Ventricular Torsion Shear Angle Volume Approach for Noninvasive Evaluation of Diastolic Dysfunction in Preserved Ejection Fraction

BACKGROUND

Accurate noninvasive diagnostic tools for evaluating left ventricular (LV) diastolic dysfunction (LVDD) are limited in preserved LV ejection fraction. We previously proposed the relationship of normalized rate of change in LV torsion shear angle (φ') to corresponding rate of change in LV volume (V') during early diastole (represented as -dφ'/dV') as a measure of LV diastolic function. We prospectively evaluated diagnostic accuracy of -dφ'/dV' in respect to invasive LV parameters.

METHODS AND RESULTS

Participants (n=36, age 61±7 years) with LV ejection fraction ≥50% and no acute myocardial infarction undergoing coronary angiography for chest pain and/or dyspnea evaluation were studied. High-fidelity invasive LV pressure measurements and cardiac magnetic resonance imaging with tissue tagging were performed. τ, the time constant of LV diastolic relaxation, was 58±10 milliseconds (mean±SD), and LV end-diastolic pressure was 14.5±5.5 mm Hg. Cardiac magnetic resonance imaging-derived -dφ'/dV' was 5.6±3.7. The value of -dφ'/dV' correlated with both τ and LV end-diastolic pressure (r=0.39 and 0.36, respectively, P<0.05). LVDD was defined as τ>48 milliseconds and LV end-diastolic pressure >12 mm Hg (LVDD1), or, alternatively, τ>48 milliseconds and LV end-diastolic pressure >16 mm Hg (LVDD2). Area under the curve (AUC) of -dφ'/dV' for identifying LVDD1 was 0.83 (0.67-0.98, P=0.001), with sensitivity/specificity of 72%/100% for -dφ'/dV' ≥6.2. AUC of -dφ'/dV' for identifying LVDD_2 was 0.82 (0.64-1.00, P=0.006), with sensitivity/specificity of 76%/85% for -dφ'/dV' ≥6.9. There were good limits of agreement between pre- and post-nitroglycerin -dφ'/dV'.

CONCLUSIONS

The -dφ'/dV' obtained from the LV torsion volume loop is a promising parameter for assessing global LVDD with preserved LV ejection fraction and requires further evaluation.

E/a´ ratio a simple detector of left ventricular dysfunction in patients with decreased ejection fraction

OBJECTIVES

Could a diastolic dysfunction and an increased LV-filling pressure according to ASE/EACVI guidelines be detected or ruled out by the E/a´ratio in patients with decreased ejection fraction.

DESIGN

We retrospectively evaluated the diastolic function of 113 unselected in-hospital patients, aged 40-84 years, in sinus rhythm and with no or mild valve disease, having a decreased systolic function (EF ≤50%) using the new ASE/EACVI guidelines and compared these results with the E/a´ratio derived from the E wave in the mitral flow and the a´velocity in the tissue Doppler.

RESULTS

The average E/a´ ratio is a strong predictor of a grade II-III diastolic dysfunction and an elevated left atrial pressure according to ASE/EACVI guidelines with an AUC of 0.92. An average E/a´ ratio with a cut-off >10 had a sensitivity of 97.6% and a negative predictive value of 98.2% in detecting or ruling out a grade II-III diastolic dysfunction and an elevated left atrial pressure according to the current guidelines.

CONCLUSION

The average E/a´ ratio might be useful as a fast screening tool of a left ventricular dysfunction and an increased left ventricular filling pressure in patients with a decreased ejection fraction.

Assessment of early treatment response by rapid cardiothoracic ultrasound in acute heart failure: Cardiac filling pressures, pulmonary congestion and mortality

Background:

It is unclear how to optimally monitor acute heart failure (AHF) patients. We evaluated the timely interplay of cardiac filling pressures, brain natriuretic peptides (BNPs), lung ultrasound (LUS) and symptoms during AHF treatment.

Methods:

We enrolled 60 patients who had been hospitalised for AHF. Patients were examined with a rapid cardiothoracic ultrasound (CaTUS) protocol, combining LUS and focused echocardiographic evaluation of cardiac filling pressures (i.e. medial E/e’ and inferior vena cava index [IVCi]). CaTUS was done at 0, 12, 24 and 48 hours (±3 hours) and on the day of discharge, alongside clinical evaluation and laboratory samples. Patients free of congestion (B lines or pleural fluid) on LUS at discharge were categorised as responders, whereas the rest were categorised as non-responders. Improvement in congestion parameters was evaluated separately in these groups. The effect of congestion parameters on prognosis was also analysed.

Results:

Responders experienced a significantly larger decline in E/e’ (2.58 vs. 0.38, p = 0.037) and dyspnoea visual analogue scale (1–10) score (7.68 vs. 3.57, p = 0.007) during the first 12 hours of treatment, while IVCi and BNPs declined later without no such rapid initial decline. Among patients experiencing a >3 U decline in E/e’ during the first 12 hours of treatment, 18/21 were to become responders ( p < 0.001). LUS response was the only congestion parameter independently predicting both 6-month survival regarding all-cause mortality and the composite endpoint of all-cause mortality or rehospitalisation for AHF.

Conclusion:

E/e’ seemed like the most useful congestion parameter for monitoring early treatment response, predicting prognostically beneficial resolution of pulmonary congestion.

What Is the Evidence That the Tissue Doppler Index E/e' Reflects Left Ventricular Filling Pressure Changes After Exercise or Pharmacological Intervention for Evaluating Diastolic Function? A Systematic Review

Background

Noninvasive echocardiographic tissue Doppler assessment (E/e′) in response to exercise or pharmacological intervention has been proposed as a useful parameter to assess left ventricular (LV) filling pressure (LVFP) and LV diastolic dysfunction. However, the evidence for it is not well summarized.

Methods and Results

Clinical studies that evaluated invasive LVFP changes in response to exercise/other interventions and echocardiographic E/e′ were identified from PubMed, Scopus, Embase, and Cochrane Library databases. We grouped and evaluated studies that included patients with preserved LV ejection fraction (LVEF), patients with mixed/reduced LVEF, and patients with specific cardiac conditions. Overall, we found 28 studies with 9 studies for preserved LVEF, which was our primary interest. Studies had differing methodologies with limited data sets, which precluded quantitative meta‐analysis. We therefore descriptively summarized our findings. Only 2 small studies (N=12 and 10) directly or indirectly support use of E/e′ for assessing LVFP changes in preserved LVEF. In 7 other studies (cumulative N=429) of preserved LVEF, E/e′ was not useful for assessing LVFP changes. For mixed/reduced LVEF groups or specific cardiac conditions, results similar to preserved LVEF were found.

Conclusions

We find that there is insufficient evidence that E/e′ can reliably assess LVFP changes in response to exercise or other interventions. We suggest that well‐designed prospective studies should be conducted for further evaluation.

Prognostic value of pulmonary congestion assessed by lung ultrasound imaging during heart failure hospitalisation: A two-centre cohort study

Pulmonary congestion assessed at discharge by lung ultrasonography predicts poor prognosis in heart failure (HF) patients. We investigated the association of B-lines with indices of hemodynamic congestion [BNP, E/e', pulmonary systolic arterial pressure (PAPs)] in HF patients, and their prognostic value overall and according to concomitant atrial fibrillation (AF), reduced (≤40%) ejection fraction (EF), and timing of quantification during hospitalisation for heart failure (HHF). In 110 HHF patients, B-lines were highly discriminative of BNP >400 pg/ml (AUC ≥ 0.80 for all), and moderately discriminative of PAPs >50 mmHg (AUC = 0.68, 0.56 to 0.80); conversely, B-lines poorly discriminated average E/e' ≥ 15, except at discharge. B-line count significantly predicted mid-term recurrent HHF or death (overall and in subgroups), regardless of AF status, EF, and timing of quantification during HHF (all p for interaction >0.10). regardless, B-lines ≥30 at discharge were most predictive of outcome (HR = 7.11, 2.06-24.48; p = 0.002) while B-lines ≥45 early during HHF were most predictive of outcome (HR = 9.20, 1.82-46.61; p = 0.007). Lung ultrasound was able to identify patients with high BNP levels, but not with increased E/e', also showing a prognostic role regardless of AF status, EF or timing of quantification; best B-line cut-off appears to vary according to the timing of quantification during hospitalization.

Diagnostic Accuracy of Tissue Doppler Index E/e' for Evaluating Left Ventricular Filling Pressure and Diastolic Dysfunction/Heart Failure With Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

Background

Tissue Doppler index E/è is used clinically and in multidisciplinary research for estimation of left ventricular filling pressure (LVFP) and diastolic dysfunction (DD)/heart failure with preserved ejection fraction (HFpEF). Its diagnostic accuracy is not well studied.

Methods and Results

From the PubMed, Scopus, Embase, and Cochrane databases, we identified 24 studies reporting E/è and invasive LVFP in preserved EF (≥50%). In random‐effects models, E/è had poor to mediocre linear correlation with LVFP. Summary sensitivity and specificity (with 95% CIs) for the American Society of Echocardiography–recommended E/è cutoffs (lateral, mean, and septal, respectively) to identify elevated LVFP was estimated by using hierarchical summary receiver operating characteristic analysis. Summary sensitivity was 30% (9–48%), 37% (13–61%), and 24% (6–46%), and summary specificity was 92% (82–100%), 91% (80–99%), and 98% (92–100%). Positive likelihood ratio (LR+) was <5 for lateral and mean E/è. LR+ was slightly >10 for septal E/è obtained from 4 studies (cumulative sample size <220). For excluding elevated LVFP, summary sensitivity for E/è (lateral, mean, and septal, respectively) was 64% (38–86%), 36% (3–74%), and 50% (14–81%), while summary specificity was 73% (54–89%), 83% (49–100%), and 89% (66–100%). Because of data set limitations, meaningful inference for identifying HFpEF by using E/è could not be drawn. With the use of quality assessment tool for diagnostic accuracy studies (Quality Assessment of Diagnostic Accuracy Studies questionnaire), we found substantial risks of bias and/or applicability.

Conclusions

There is insufficient evidence to support that E/è can reliably estimate LVFP in preserved EF. The diagnostic accuracy of E/è to identify/exclude elevated LVFP and DD/HFpEF is limited and requires further validation in a well‐designed prospective clinical trial.

The year 2014 in the European Heart Journal--Cardiovascular Imaging: part II

The European Heart Journal-Cardiovascular Imaging, created in 2012, has become a reference for publishing multimodality cardiovascular imaging scientific and review papers. The impressive 2014 impact factor of 4.105 confirms the important position of our journal. In this part, we summarize the most important studies from the journal's third year, with specific emphasis on cardiomyopathies, congenital heart diseases, valvular heart diseases, and heart failure.

Relation between E/e' ratio and NT-proBNP levels in elderly patients with symptomatic severe aortic stenosis

BACKGROUND

Symptoms in the elderly patients with severe aortic stenosis (AS) and co-morbidities seem to lack in specificity. Therefore, objective parameters for increased left ventricular(LV) filling pressures are needed. The aim of this study was to investigate the correlation between the septal, lateral and average E/e' ratio and the value of the N-terminal pro-hormone of brain natriuretic peptide (NT-proBNP).

METHODS

Two-hundred-fifty consecutive symptomatic patients (mean age 80 ± 8 years, 52% men) with severe AS underwent transthoracic echocardiography and NT-proBNP measurement.

RESULTS

In the overall population the septal E/e' (r = 0,459, r(2) = 0,21, P <0,0001), lateral E/e' (r = 0,322, r(2) = 0,10, P <0,0001), and the average E/e' (r = 0,432, r(2) = 0,18, P <0,0001) were all significantly correlated to NT-proBNP. After the exclusion of patients with confounders (more than mild aortic or mitral regurgitation, severe renal dysfunction, obesity or severe COPD) the septal E/e' (r = 0,584, r(2) = 0,34, P <0,0001), lateral E/e' (r = 0,377, r(2) = 0,14, P <0,0001), and the average E/e' (r = 0,487, r(2) = 0,24, P <0,0001) were all significantly better correlated to NT-proBNP. In obese patients no significant correlations were seen. Previous bypass surgery did not alter the correlations.

CONCLUSIONS

In elderly patients with severe symptomatic AS there is a significant correlation between the E/e' ratio and NT-proBNP, in particular after exclusion of confounders. The correlation was best for the septal E/e' ratio and was preserved in patients with a history of bypass surgery.

E/e' Ratio in Patients With Unexplained Dyspnea: Lack of Accuracy in Estimating Left Ventricular Filling Pressure

BACKGROUND

Elevated left ventricular filling pressure is a cardinal feature of heart failure with preserved ejection fraction. Mitral E/e' ratio has been proposed as a noninvasive measure of left ventricular filling pressure. We studied the accuracy of E/e' to estimate and track changes of left ventricular filling pressure in patients with unexplained dyspnea.

METHODS AND RESULTS

We performed supine and upright transthoracic echocardiography in 118 patients with unexplained dyspnea who underwent right heart catheterization. Supine E/e' ratio modestly but significantly correlated with supine pulmonary arterial wedge pressure (PAWP; r=0.36; P<0.001) and demonstrated poor agreement with PAWP values (Bland-Altman limits of agreement of -8.3 to 8.3 mm Hg; range, 6.5-21.2 mm Hg). Similarly, E/e' ratio cut off of 13 performed poorly in identifying patients with elevated left ventricular filling pressure (sensitivity 6%, specificity 90%). The receiver-operating characteristic area of E/e' was 0.65 (95% confidencce interval, 0.50-0.79). With change from the supine to upright position, PAWP decreased (-5±4 mm Hg; P<0.001) as did both E wave (-17±15 cm/s; P<0.001) and e' (-2.7±2.7 cm/s; P<0.001) velocities, whereas E/e' remained stable (+0.2±2.6; P=0.57). Positional change in PAWP correlated modestly with change in E-wave (r=0.37; P<0.001) velocity. There was no appreciable relationship between change in PAWP and change in average E/e' (r=-0.04; P=0.77) and in half the patients the change in PAWP and E/e' were directionally opposite.

CONCLUSIONS

In patients with unexplained dyspnea, E/e' ratio neither accurately estimates PAWP nor identifies patients with elevated PAWP consistent with heart failure with preserved ejection fraction. Positional changes in E/e' ratio do not reflect changes in PAWP.

New echocardiographic predictors of clinical outcome in patients presenting with heart failure and a preserved left ventricular ejection fraction: a subanalysis of the Ka (Karolinska) Ren (Rennes) Study

OBJECTIVES

To identify electrocardiographic and echocardiographic predictors of mortality and hospitalizations for heart failure (HF) in the KaRen study.

BACKGROUND

KaRen is a prospective, observational study of the long-term outcomes of patients presenting with heart failure and a preserved ejection fraction (HFpEF).

METHOD

We identified 538 patients who presented with acute cardiac decompensation, a >100 pg/mL serum b-type natriuretic peptide (BNP) or >300 pg/mL N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration and a left ventricular ejection fraction (LVEF) >45%. After 4-8 weeks of standard treatment, 413 patients (mean age = 76 ± 9 years, 55.9% women) returned for analyses of their clinical status, laboratory screen, and detailed electrocardiographic and Doppler echocardiographic recordings. They were followed for a mean of 28 months thereafter. The primary study endpoint was time to death from all causes or first hospitalization for heart failure.

RESULTS

Mean LVEF was 62.4 ± 6.9% and median NT-proBNP 1410 pmol/L. PR interval >200 ms was present in 11.2% of patients and 14.9% had a >120 ms QRS duration, with left bundle branch block in only 6.3%. Over a mean follow-up of 28 months, 177 patients (42.9%) reached a primary study endpoint, including 61 deaths and 116 hospitalizations for heart failure. After adjustment for age, gender, New York Heart Association class, atrial fibrillation history, creatinine, sodium, BNP, ejection fraction, and right ventricular fractional shortening, only E/e' remained as a predictor, with a hazard ratio = 1.49 and P = 0.0012.

CONCLUSION

The incidence of hospitalizations for HF and deaths in KaRen was high and E/e' predicted adverse clinical outcomes. These observations should help in the risk stratification and therapy of HFpEF.

The use of echocardiography in acute cardiovascular care: Recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/ critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.