Evaluating left atrial strain and left ventricular diastolic strain rate as markers for diastolic dysfunction in patients with mitral annular calcification

BACKGROUND

Mitral annular calcification (MAC) poses many challenges to the evaluation of diastolic function using standard echocardiography. Left atrial (LA) strain and left ventricular early diastolic strain rate (DSr) measured by speckle-tracking echocardiography (STE) are emerging techniques in the noninvasive evaluation of diastolic function. We aim to evaluate the utility of LA strain and early DSr in predicting elevated left ventricular filling pressures (LVFP) in patients with MAC and compare their effectiveness to ratio of mitral inflow velocity in early and late diastole (E/A).

METHODS

We included adult patients with MAC who presented between January 1 and December 31, 2014 and received a transthoracic echocardiogram (TTE) and cardiac catheterization with measurement of LVFP within a 24-h period. We used Spearman's rank correlation coefficient to assess associations of LA reservoir strain and average early DSr with LVFP. Receiver operating characteristic (ROC) curves were computed to assess the effectiveness of LA strain and DSr in discriminating elevated LVFP as a dichotomized variable and to compare their effectiveness with E/A ratio categorized according to grade of diastolic dysfunction.

RESULTS

Fifty-five patients were included. LA reservoir strain demonstrated poor correlation with LVFP (Spearman's rho = 0.03, p = 0.81) and poor discriminatory ability for detecting elevated LVFP (AUC = 0.54, 95% CI 0.38-0.69). Categorical E/A ratio alone also demonstrated poor discriminatory ability (AUC = 0.53, 95% CI 0.39-0.67), and addition of LA reservoir strain did not significantly improve effectiveness (AUC = 0.58, 95% CI 0.42-0.74, p = 0.56). Average early DSr also demonstrated poor correlation with LVFP (Spearman's rho = -0.19, p = 0.16) and poor discriminatory ability for detecting elevated LVFP (AUC = 0.59, 95% CI 0.44-0.75). Addition of average early DSr to categorical E/A ratio failed to improve effectiveness (AUC = 0.62, 95% CI 0.46-0.77 vs. AUC = 0.54, 95% CI 0.39-0.69, p = 0.38).

CONCLUSIONS

In our sample, LA reservoir strain and DSr do not accurately predict diastolic filling pressure. Further research is required before LA strain and early DSr can be routinely used in clinical practice to assess filling pressure in patients with MAC.

Left atrial diastasis strain slope is a marker of hemodynamic recovery in post-ST elevation myocardial infarction: the Laser Atherectomy for STemi, Pci Analysis with Scintigraphy Study (LAST-PASS)

Background

Left atrial (LA) mechanics are strongly linked with left ventricular (LV) filling. The LA diastasis strain slope (LADSS), which spans between the passive and active LA emptying phases, may be a key indicator of the LA-LV interplay during diastole.

Aim

This study aimed to investigate the LA-LV interdependencies in post-ST elevation myocardial infarction (STEMI), with particular focus on the LADSS.

Materials and methods

Patients with post-anterior STEMI who received primary percutaneous coronary intervention underwent contrast cardiac magnetic resonance imaging (MRI) during acute (5-9 days post-STEMI) and chronic (at 6 months) phases. The LADSS was categorized into three groups: Groups 1, 2, and 3 representing positive, flat, and negative slopes, respectively. Cross-sectional correlates of LADSS Group 2 or 3 compared to Group 1 were identified, adjusting for demographics, LA indices, and with or without LV indices. The associations of acute phase LADSS with the recovery of LV ejection fraction (LVEF) and scar amount were investigated.

Results

Sixty-six acute phase (86.4% male, 63.1 ± 11.8 years) and 59 chronic phase cardiac MRI images were investigated. The distribution across LADSS Groups 1, 2, and 3 in the acute phase was 24.2%, 28.9%, and 47.0%, respectively, whereas in the chronic phase, it was 33.9%, 22.0%, and 44.1%, respectively. LADSS Group 3 demonstrated a higher heart rate than Group 1 in the acute phase (61.9 ± 8.7 vs. 73.5 ± 11.9 bpm, p < 0.01); lower LVEF (48.7 ± 8.6 vs. 41.8 ± 9.9%, p = 0.041) and weaker LA passive strain rate (SR) (-1.1 ± 0.4 vs. -0.7 [-1.2 to -0.6] s-1, p = 0.037) in the chronic phase. Chronic phase Group 3 exhibited weaker LA passive SR [relative risk ratio (RRR) = 8.8, p = 0.012] than Group 1 after adjusting for demographics and LA indices; lower LVEF (RRR = 0.85, p < 0.01), higher heart rate (RRR = 1.1, p = 0.070), and less likelihood of being male (RRR = 0.08, p = 0.058) after full adjustment. Acute phase LADSS Groups 2 and 3 predicted poor recovery of LVEF when adjusted for demographics and LA indices; LADSS Group 2 remained a predictor in the fully adjusted model (β = -5.8, p = 0.013).

Conclusion

The LADSS serves both as a marker of current LV hemodynamics and its recovery in post-anterior STEMI. The LADSS is an important index of LA-LV interdependency during diastole.

Clinical Trial Registration

https://clinicaltrials.gov/, identifier NCT03950310.

Ratio of transmitral early filling velocity to diastolic strain rate and prognosis in type-1 diabetes

BACKGROUND

Impaired diastolic function is a hallmark of diabetic cardiomyopathy and a common feature in type 1 diabetes mellitus (T1DM). The ratio of transmitral early filling velocity to early diastolic strain rate (E/e'sr) has in recent studies proved to have strong prognostic value. This study aimed to investigate the prognostic value of E/e'sr compared to E/e' in T1DM without known heart disease.

METHODS

In this prospective cohort of T1DM patients, echocardiography was performed including two-dimensional speckle tracking. Follow-up was performed using nationwide registries. Outcomes were all-cause mortality and major cardiovascular events (MACE).

RESULTS

In total 1079 patients (age: 49.6 ± 14.5 years, 52.5% male, duration of diabetes 25.8 ± 14.6 years) were included in the study. During follow-up (median 6.3 years, IQR:5.7-6.9) 13.2% experienced MACE and 5.8% died. Following multivariable adjustment, both E/e'sr and E/e' was significantly associated with both MACE (E/e'sr: HR 1.16 CI95%:[1.05-1.29], p = 0.005, per 10 cm increase) vs. (E/e': HR 1.09 CI95%:[1.03-1.15], p = 0.001, per 1 unit increase) and all-cause mortality (E/e'sr: HR 1.20 [1.03-1.40], p = 0.016) vs. (E/e': HR: 1.11 [1.02-1.20], p = 0.016). Sex modified the association between E/e'sr and MACE (p for interaction = 0.008) such that E/e'sr after multivariable adjustment only remained significantly associated with MACE in females (HR: 1.41 [1.19-1.67], p < 0.001) but not in males (HR: 1.06 [0.93-1.20], p = 0.42). In females, E/e'sr provided incremental information beyond the Steno T1 Risk Engine (Harrell's C-statistic: 0.78 (0.72-0.83) vs. 0.81 (0.75-0.86), p = 0.007).

CONCLUSION

In patients with T1DM, both E/e'sr and E/e' provides independent prognostic information regarding prognosis. E/e'sr seems to have stronger prognostic value in females with T1DM.

Normal Values and Reference Ranges for the Ratio of Transmitral Early Filling Velocity to Early Diastolic Strain Rate: The Copenhagen City Heart Study

BACKGROUND

The ratio of transmitral early filling velocity to early diastolic strain rate (E/e'sr) has recently emerged as a measure of left ventricular filling pressure. Reference values are needed for this new parameter for it to be used clinically.

METHODS

Healthy participants from a prospective general population study, the Fifth Copenhagen City Heart Study, were assessed to establish reference values for E/e'sr derived from two-dimensional speckle-tracking echocardiography. The prevalence of abnormal E/e'sr was assessed in participants with cardiovascular risk factors or specific diseases.

RESULTS

The population comprised 1,623 healthy participants (median age, 45; interquartile range, 32-56; 61% female). The upper reference limit for E/e'sr in the population was 79.6 cm. Following multivariable adjustment, male participants exhibited significantly higher E/e'sr than female participants (upper reference limit for male participants, 83.7 cm; for female participants, 76.5 cm). For both sexes, E/e'sr increased in a curvilinear fashion with age such that the largest increases in E/e'sr were observed in participants >45 years. In the entire CCHS5 population with E/e'sr available (n = 3,902), increasing age, body mass index, systolic blood pressure, male sex, estimated glomerular filtration rate, and diabetes were associated with E/e'sr (all P < .05). Total cholesterol was associated with a less steep increase in E/e'sr. Abnormal E/e'sr was seldomly observed in participants with normal diastolic function but became more frequent in participants with increasing grades of diastolic dysfunction (normal, mild, moderate, severe [abnormal E/e'sr for each grade: 4.4% vs 20.0% vs 16.2% vs 55.6%, respectively]).

CONCLUSION

The E/e'sr differs between sexes and is age dependent such that E/e'sr increases with advancing age. Therefore, we established sex- and age-stratified reference values for E/e'sr.

Early diastolic strain rate in relation to long term prognosis following isolated coronary artery bypass grafting

BACKGROUND

The ratio of early mitral inflow velocity to early diastolic strain rate (E/e'sr) is a novel echocardiographic measure to estimate early left ventricular (LV) filling pressure. We hypothesize that E/e'sr is a predictor of outcome following coronary artery bypass grafting (CABG) and that it is superior to the conventionally used E/e'.

METHODS & RESULTS

Consecutive patients undergoing isolated CABG at Gentofte Hospital (n = 652) were included. The mean age of the study population was 67 ± 9 years, 84% were male, mean LVEF was 50 ± 11%. Prior to surgery, all patients underwent an extensive echocardiographic examination. The outcome was all-cause mortality. During follow-up (median 3.8 years [IQR: 2.7; 4.9 years]), a total of 73 (11.2%) died. Both E/e' and E/e'sr were significant predictors in univariable models. In a multivariable model, E/e'sr remained an independent predictor of outcome (HR:1.05 [1.01-1.10], p = 0.049, per 10 cm increase) whereas E/e' did not (HR:1.05 [0.99-1.11], p = 0.053, per 1-unit increase). The relationship between E/e'sr, and the outcome was significantly modified by GLS (p for interaction = 0.043). In the multivariable model, E/e'sr was still significantly associated with the outcome in patients with high GLS (≥13.6%) (HR:1.18 [1.02-1.36], p = 0.029) but not in patients with low GLS (HR 1.04 CI95%: [0.99-1.10], p = 0.14). E/e' was not a significant predictor of all-cause mortality after multivariable adjustment in neither of the groups. E/e'sr improved net reclassification with 33% when added to EuroSCOREII.

CONCLUSION

Following CABG, preoperative E/e'sr is an independent predictor of all-cause mortality, especially in patients with preserved systolic function and superior to E/e'.

Incremental prognostic value of global myocardial work over ejection fraction and global longitudinal strain in patients with heart failure and reduced ejection fraction

AIMS

Left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) help identify heart failure (HF) patients who are at risk for adverse outcomes. This study aimed to determine whether global myocardial work (GMW), derived from non-invasive LV pressure-strain loops, can provide incremental prognostic information over EF and GLS in patients with HF and reduced EF (HFrEF).

METHODS AND RESULTS

We retrospectively analysed 508 patients (age 62.9 ± 15.8 years, 29.1% female) with LVEF ≤40%. The study endpoint was a composite of all-cause death and HF hospitalization. The incremental value of GMW over clinical and echocardiographic variables including EF and GLS for the association with the composite endpoint was assessed using Cox regression analyses. Over a 1-year follow-up, 183 patients reached the endpoint. Baseline variables associated with the endpoint were age, haemoglobin, LV end-systolic volume, New York Heart Association Class III or IV, E/e' ratio, pulmonary artery systolic pressure, EF, and GLS. Cox regression analysis revealed that GMW [hazard ratio (HR) 1.15, 95% confidence interval (CI) 1.05-1.25, per 100-mmHg% decrease] added incremental prognostic value over these variables. Both EF and GLS were not independent variables when GMW was included in the model. Patients with GMW <750 mmHg% were associated with a significantly higher risk of all-cause death and HF hospitalization (HR 3.33, 95% CI 2.31-4.80) than patients with GMW ≥750 mmHg%.

CONCLUSION

In patients with HFrEF, GMW provides incremental prognostic information over EF and GLS regarding risk of all-cause death and HF hospitalization.

Diastolic function assessed with speckle tracking over a decade and its prognostic value: The Copenhagen City Heart Study

BACKGROUND

The ratio of transmitral early filling velocity to early diastolic strain rate (E/e'sr) may be a more accurate measure of LV filling pressure then ratio of early filling pressure to early tissue velocity. The aim of the study was to investigate the impact of age, sex, obesity, smoking, hypertension, hypercholesterolemia, diabetes, physical activity level, socioeconomic, and psychosocial status on E/e'sr over a decade. Additionally, the predictive value of ΔE/e'sr on future major adverse cardiovascular events (MACE) has never been explored.

METHOD

The study included 623 participants from the general population, who participated in the 4th and 5th Copenhagen City Heart Study (CCHS4 and CCHS5). Examinations were median 10 years apart. MACE was the composite endpoint of heart failure, myocardial infarction, and all-cause death.

RESULTS

Follow-up time was median 5.7 years, and 43 (7%) experienced MACE. Mean age was 51 ± 14 years, and 43% were male. Mean ΔE/e'sr was 2.1 ± 23.0 cm. After multivariable adjustment for demographic, clinical, and biochemistry variables, high age (stand. β-coef. = .24, P < .001) and mean arterial blood pressure (MAP) (stand. β-coef. = .17, P < .001) were significantly associated with an accelerated increase in E/e'sr In multivariable Cox regression, E/e'sr at CCHS5 and ΔE/e'sr were independent predictors of MACE (HR = 1.20, 95% CI [1.01; 1.42] per 10 cm increase for both). ΔE/e'sr did only provide incremental prognostic value to change in left atrial volume index of the conventional diastolic measurements.

CONCLUSION

In the general population, age and MAP were predictors of an accelerated increase in E/e'sr over a decade. E/e'sr at CCHS5 and ΔE/e'sr were independent predictors of future MACE.

Prognostic value of ratio of transmitral early filling velocity to early diastolic strain rate in patients with Type 2 diabetes

AIMS

The ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) has recently emerged as a novel measure of left ventricular filling pressure. E/e'sr has in previous studies demonstrated to have good prognostic value in various patient populations. The aim of this study is to investigate the prognostic value of E/e'sr in a large cohort of patients with Type 2 diabetes in relation to cardiovascular morbidity and mortality.

METHODS AND RESULTS

In this prospective study, 848 Type 2 diabetic patients (mean age 63.6 ± 10.3 years, 64.7% male) underwent comprehensive echocardiographic examination including 2D speckle tracking in which E/e'sr along with novel and conventional echocardiographic variables were obtained. During follow-up (median: 4.8 years, interquartile range: 4.0-5.3), 122 (14.1%) met the composite outcome of cardiovascular disease, hospitalization, and mortality. Both E/e'sr and E/e' were significantly associated with the outcome [E/e'sr: hazard ratio (HR) 1.07, 95% confidence interval (CI): 1.05-1.10; P < 0.001, per 0.10 m increase] and (E/e': HR 1.07, 95% CI: 1.05-1.10; P = 0.001, per 1 unit increase). E/e'sr remained an independent predictor after multivariable adjustment for demographical, clinical, and echocardiographic parameters (HR 1.06, 95% CI: 1.01-1.12; P = 0.032, per 10 cm increase). The same was true for E/e' (HR 1.09, 95% CI: 1.04-1.14; P < 0.001, per 1 unit increase). Additionally, E/e'sr provided incremental prognostic information beyond the UK 'Prospective Diabetes Study risk engine' 0.72 (0.68-0.77) vs. 0.74 (0.70-79), P = 0.040.

CONCLUSION

In patients with Type 2 diabetes, E/e'sr provides independent and incremental prognostic information regarding cardiovascular morbidity and mortality.

Echocardiography to estimate high filling pressure in patients with heart failure and reduced ejection fraction

AIMS

Echocardiographic assessment of left ventricular filling pressures is performed using a multi-parametric algorithm. Unselected sample of patients with heart failure with reduced ejection fraction (HFrEF) patients may demonstrate an indeterminate status of diastolic indices making interpretation challenging. We sought to test improvement in the diagnostic accuracy of standard and strain echocardiography of the left ventricle and left atrium (LA) to estimate a pulmonary capillary wedge pressure (PCWP) > 15 mmHg in patients with HFrEF.

METHODS AND RESULTS

Out of 82 consecutive patients, 78 patients were included in the final analysis and right heat catheterization, and echocardiogram was performed simultaneously. According to the univariable analysis, E wave velocity, the ratio between E-wave/A-wave (E/A, area under the curve [AUC] = 0.81, respectively), isovolumic relaxation time (AUC = 0.83), pulmonary vein D wave (AUC = 0.84), pulmonary vein S/D Ratio (AUC = 0.85), early pulmonary regurgitation velocity (AUC = 0.80), and accelerationa time at right ventricular out-flow tract (RVOT AT, AUC = 0.84) identified with the highest accuracy PCWP > 15 mmHg. They were all tested in multivariate analysis, and they were not independently correlated with PCWP. Tricuspid regurgitation (TR) velocity was measurement with the highest predictive value in identifying PCWP > 15 mmHg (AUC = 0.89), compared with other established parameters such as the ratio between e-wave velocity divided by mitral annular e' velocity (E/e'), deceleration time, or LA indexed volume (LAVi), which all reached a lower accuracy level (AUC = 0.75; 0.78; 0.76). Among strain measures, global longitudinal strain in four chamber view (GLS 4ch), the ratio between e-wave velocity divided by mitral annular e' strain rate (E/e'sr), and LA longitudinal strain at the reservoir phase were helpful in estimating elevated PCWP (AUC = 0.77; 0.76; 0.75). According to multivariable analysis, the following two models had the greatest accuracy in detecting PCWP > 15 mmHg: (i) TR velocity, LAVi, and E wave velocity (receiver operating characteristic [ROC]-AUC = 0.98), (ii) AT RVOT, LAVi and GLS 4ch (ROC-AUC = 0.96). Neither E/A (ROC-AUC = 0.81) nor E/e' (ROC-AUC = 0.75) was an independent predictor when included in the model. The two MODELS were applicable to the entire population and demonstrated better agreement with the invasive reference (91% and 88%) than the guidelines algorithm (77%) regardless of the type of rhythm.

CONCLUSIONS

Our suggested echocardiographic approach could be used to potentially reduce the frequency of "doubtful" classification and increase the accuracy in predicting elevated left ventricular filling pressure leading to a decrease in the number of invasive assessment made by right heart catheterization.

Global diastolic strain rate for the assessment of left ventricular diastolic dysfunction in young peritoneal dialysis patients: a case control study

Background

Left ventricular (LV) myocardial longitudinal diastolic strain rate measured by two-dimensional speckle tracking imaging (2D-STI) was proved to have a better correlation with the LV diastolic function. We aimed to use this sensitive tool to predict LV myocardial diastolic dysfunction in young peritoneal dialysis (PD) patients with preserved LV ejection fraction (LVEF).

Methods

We enrolled 30 PD patients aged ≤60 with LVEF ≥54% and classified as normal LV diastolic function by conventional echocardiography, and 30 age- and sex-matched healthy people as the control group. The left atrial maximum volume index (LAVI), LV mass index (LVMI), LVEF, LV posterior wall thickness (LVPWT), interventricular septal thickness (IVST), peak velocity of tricuspid regurgitation (TR), peak early diastolic velocity/late diastolic velocity (by Pulsed Doppler) (E/A) and E/peak velocity of the early diastolic wave (by Pulsed-wave tissue Doppler) (E/e’) were recorded by conventional echocardiographic. Next, the average LV global longitudinal systolic strain (GLS avg) and the average LV global longitudinal diastolic strain rate (DSr avg) during early diastole (DSrE avg), late diastole (DSrA avg) and isovolumic relaxation period (DSrIVR avg) were obtained from 2D-STI. Combined them with E, the new noninvasive indexes (E/DSrE avg., E/DSrA avg. and E/DSrIVR avg) were derived.

Results

The PD group ‘s LVEF, E/e′, TR and LAVI were in the normal range compared with the controls, and only e′ (p < 0.001) was decreased. The LVMI (p < 0.001), LVPWT (p < 0.001), IVST (p < 0.001) increased while E/A (p < 0.001) decreased. The GLS avg. (p = 0.008) was significantly decreased in PD patients compared with the controls. DSrA avg. (p = 0.006) and E/DSrE avg. (p = 0.006) were increased, while DSrE avg. (p < 0.001), DSrIVR avg. (p = 0.017) and E/DSrA avg. (p < 0.001) decreased. After the multivariable regression analysis, the correlation between DSrE and the conventional parameters including LVPWT (p < 0.001), E/A (p < 0.001) still remained significant.

Conclusions

Young PD patients with preserved LVEF already exhibited myocardial diastolic dysfunction. Global diastolic strain rate indexes were valuable parameters to evaluate diastolic dysfunction. Additionally, LVPWT was highly correlated with DSrE, such parameter should be taken into account for predicting the early LV diastolic dysfunction in clinical practice.

Short-term effects of angiotensin receptor-neprilysin inhibitors on diastolic strain and tissue doppler parameters in heart failure patients with reduced ejection fraction: A pilot trial

OBJECTIVE

Although sacubitril/valsartan has recently shown its long-term benefits on morbidity and mortality in symptomatic patients with chronic heart failure with reduced ejection fraction (HFrEF), its short-term effects on diastolic function remain uncertain. We sought to assess 30-day effects of sacubitril/valsartan on left ventricular (LV) diastolic paremeters determined by speckle tracking and tissue Doppler imaging (STI and TDI respectively) as well as their association with functional capacity change evaluated by peak oxygen uptake (VO₂max) in stable patients with symptomatic HFrEF.

METHODS

A total of 35 patients (aged 61 ± 9 years) eligible for sacubitril/valsartan underwent a complete two-dimension (2D) echocardiographic study and a cardiopulmonary exercise test at baseline and 30 days after the initiation of therapy.

RESULTS

Significant improvements in ratio of trans-mitral inflow early diastolic velocity E to mitral annulus early diastolic velocity E' (ΔΕ//Ε' = -35.9%, p = 0.001), peak early diastolic strain rate SRE (ΔSRE = +22.5%, p = 0.024) and ratio E/SRE (ΔE/SRE = -33.2%, p = 0.025) were observed after 1-month therapy. Compared with baseline, VO₂max also increased significantly by 16.7 % (p = 0.001). Baseline E/SRE and ΔE/SRE were the strongest independent predictors of VO₂max improvement (beta = -0.43, p = 0.004 and beta = 0.45, p = 0.021 respectively) in the multivariate analysis.

CONCLUSION

Sacubitril/valsartan was associated with early improvement in LV diastolic function determined by TDI and 2D STI. Baseline E/SRE was stronger than standard echocardiographic parameters in predicting the early benefit of sacubitril/valsartan therapy.

Ratio of Early Mitral Inflow Velocity to the Global Diastolic Strain Rate and Global Left Ventricular Longitudinal Systolic Strain Predict Overall Mortality and Major Adverse Cardiovascular Events in Hemodialysis Patients

Background

The ratio of early mitral inflow velocity to the global diastolic strain rate (E/E'sr) and global longitudinal systolic strain (GLS) of the left ventricle (LV) are emerging indices of diastolic and systolic functions, respectively, for the LV. Their prognostic significance in the prediction of mortality and cardiovascular (CV) outcomes remains underexplored in hemodialysis (HD) patients.

Methods

This prospective study included 190 maintenance HD patients. The E/E'sr ratio and GLS were assessed using two-dimensional speckle tracking echocardiography. The clinical outcomes included overall mortality, CV mortality, and major adverse cardiovascular events (MACE). The associations between the E/E'sr ratio, GLS, and clinical outcomes were evaluated using multivariate Cox regression analysis. The incremental values of the E/E'sr ratio and GLS in outcome prediction were assessed by χ ² changes in Cox models.

Results

Over a median follow-up period of 3.7 years, there were 35 overall deaths, 16 CV deaths, and 45 MACE. Impaired diastolic function with a higher E/E'sr ratio was associated with overall mortality (HR, 1.484; 95% CI, 1.201-1.834; p < 0.001), CV mortality (HR, 1.584; 95% CI, 1.058-2.371; p = 0.025), and MACE (HR, 1.205; 95% CI, 1.040-1.397; p = 0.013) in multivariate adjusted Cox analysis. Worsening GLS was associated with overall mortality (HR, 1.276; 95% CI, 1.101-1.480; p = 0.001), CV mortality (HR, 1.513; 95% CI, 1.088-2.104; p = 0.014), and MACE (HR, 1.214; 95% CI, 1.103-1.337; p < 0.001). The E/E'sr ratio and GLS had better outcome prediction than the E to early diastolic mitral annular velocity (E/E') ratio and left ventricular ejection fraction (LVEF). Moreover, adding the E/E'sr ratio and GLS to Cox models containing relevant clinical and conventional echocardiographic parameters improved the prediction of overall mortality (p < 0.001), CV mortality (p < 0.001), and MACE (p < 0.001).

Conclusion

The E/E'sr ratio and GLS, as emerging indices of LV diastolic and systolic functions, significantly predict mortality and CV outcomes and outperform conventional echocardiographic parameters in outcome prediction in HD patients.

Ratio of Transmitral Early Filling Velocity to Early Diastolic Strain Rate Predicts All-Cause Mortality in Heart Failure with Reduced Ejection Fraction

AIMS

The ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) has recently emerged as a novel measure of left ventricular (LV) filling pressure. This new measure has demonstrated to have prognostic value superior to E/e'. This study aimed to investigate the prognostic value of E/e'sr in a large cohort of patients with heart failure with reduced ejection fraction (HFrEF) in relation to all-cause mortality.

METHODS

We retrospectively studied 897 HFrEF (mean age 66 ± 12 years, 73% male, 59% ischemic cardiomyopathy) patients who underwent speckle tracking echocardiography where E/e'sr along with novel and conventional echocardiographic parameters were obtained. The primary endpoint was defined as all-cause mortality.

RESULTS

During follow-up (median: 40 months IQR: 22-57), 137 (15.3%) patients died. Both E/e'sr and E/e' were significantly associated with mortality (E/e'sr: HR 1.03 95%CI [1.02-1.04], p<0.001, per 0.10m increase) and (E/e': HR 1.04 95%CI [1.02-1.06], p = 0.001, per 1unit increase). E/e'sr remained an independent predictor in a multivariable model after adjusting for age, gender, mean arterial pressure, heart rate, BMI, total cholesterol, diabetes mellitus, ischemic cardiomyopathy, LVEF, LVIDd, LVMI, LAVI, TAPSE and LV-GLS (HR 1.02 95%CI [1.01-1.03], p = 0.007) whereas E/e' did not (HR 1.01 95%CI [0.98-1.04], p = 0.57). Furthermore, E/e'sr provided incremental prognostic information beyond a model including known risk factors: age, gender, total cholesterol, mean arterial pressure, heart rate, BMI, smoking status and E/e' (Harrell's C-statistics: 0.72 (0.68-0.77) vs 0.70 (0.66-0.75), p = 0.047).

CONCLUSIONS

In HFrEF patients, E/e'sr provides independent and incremental prognostic information regarding all-cause mortality superior to E/e'.

Ratio of Transmitral Early Filling Velocity to Early Diastolic Strain Rate as a Predictor of Cardiovascular Morbidity and Mortality Following Acute Coronary Syndrome

The ratio of early mitral inflow velocity (E) to early diastolic strain rate (E/e'sr) is a significant predictor of cardiac outcomes in various patient populations. This study aims to evaluate the predictive value of E/e'sr for heart failure, acute myocardial infarction, and death due to cardiovascular disease following acute coronary syndrome (ACS). In total, 432 ACS patients underwent echocardiography following percutaneous coronary intervention. The end point was the composite of heart failure, acute myocardial infarction, and death due to cardiovascular disease. Median follow-up was 4.4 (interquartile range 0.2 to 6.3) years. During the follow-up period, 199 (46.1%) met the composite outcome. Mean value of E/e'sr in patients was 0.70 ± 0.37 m. In univariable Cox regression, E/e'sr was a predictor of the composite outcome (hazard ratio [HR] 1.05 95% confidence interval [CI] 1.03 to 1.07, p <0.001, per 0.10 m increase). After multivariable adjustment for demographic and clinical parameters, E/e'sr remained an independent predictor (HR 1.03; 95% CI 1.01 to 1.06; p = 0.013, per 0.10 m increase). Global longitudinal strain (GLS) modified the relation between E/e'sr and outcome (p value for interaction = 0.011). In ACS patients with a relatively preserved systolic function assessed by GLS (GLS ≥ 13.2%), E/e'sr showed to be a significant predictor (HR 1.20; 95% CI 1.06 to 1.36; p = 0.005, per 0.10 m increase). In contrast, E/e'sr was not a significant predictor in ACS patients with impaired systolic function (GLS < 13.2%; HR 1.02; 95% CI 0.99 to 1.04; p = 0.28). In conclusion, E/e'sr provides important prognostic information regarding cardiovascular morbidity and mortality in ACS patients. However, E/e'sr was not an independent predictor over that of echocardiographic parameters. Furthermore, E/e'sr is a stronger prognosticator in patients with relatively preserved systolic function as opposed to patients with impaired systolic function.

The year 2017 in the European Heart Journal-Cardiovascular Imaging: Part II

European Heart Journal - Cardiovascular Imaging was launched in 2012 as a multimodality cardiovascular imaging journal. It has gained an impressive impact factor of 8.366 during its first 5 years and is now established as one of the top 10 cardiovascular journals and has become the most important cardiovascular imaging journal in Europe. The most important studies from 2017 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.

Evolution of diastolic function algorithms: Implications for clinical practice

OBJECTIVE

We undertook this study of echocardiographic classification of diastolic function by three different algorithms to determine: (1) how frequently each algorithm classified patients and (2) how well the results agreed with one another.

BACKGROUND

Several algorithms exist to grade diastolic function (DF), the Mayo Clinic scheme of Redfield et al (Mayo 2003) and the 2 ASE guideline documents of 2009 and 2016 (ASE 2009 and ASE 2016).

METHODS

A total of 200 consecutive echocardiograms were retrospectively analyzed; mean age of patients 60.3 ± 3.5 years, 45% male. Echocardiograms were performed using Intersocietal Accreditation Commission guidelines. Diastolic function was assessed by Mayo 2003 and ASE 2009 and 2016. Coexisting conditions affecting DF analysis, such as mitral annular calcification (MAC), were tabulated. Data were compared using a paired t-test. Concordance between algorithms was assessed using the Kappa statistic.

RESULTS

A total of 117 of 200 studies (58.5%) were excluded for the presence of coexisting conditions (51.5%), poor image quality (2.5%), or incomplete data (4.5%). Thirty-three of the remaining 83 studies (40%) received the same grade of DF based on assessments made using the Mayo 2003 and ASE 2016 algorithms; the Kappa statistic was 0.20. 36 of the 83 studies (43%) received the same grade of DF based on assessments made using the ASE 2009 and ASE 2016 algorithms; the Kappa statistic was 0.25.

CONCLUSION

Assessment of diastolic function via echocardiography cannot be reliably accomplished in approximately 50% of patients using current guidelines. Further, when studies are suitable for assessment, widely used guidelines yield discordant results.