Insight into different phenotypic presentations of heart failure with preserved ejection fraction

Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for half of all HF diagnoses, and its prevalence is increasing at an alarming rate. Lately, it has been recognized as a clinical syndrome due to diverse underlying etiology and pathophysiological mechanisms. The classic echocardiographic features of HFpEF have been well described as preserved ejection fraction (≥50%), left ventricular hypertrophy, and left atrial enlargement. However, echocardiography can play a key role in identifying the principal underlying mechanism responsible for HFpEF in the individual patient. The recognition of different phenotypic presentations of HFpEF (infiltrative, metabolic, genetic, and inflammatory) can assist the clinician in tailoring the appropriate management, and offer prognostic information. The goal of this review is to highlight several key phenotypes of HFpEF and illustrate the classic clinical scenario and echocardiographic features of each phenotype with real patient cases.

Prevalence, Determinants, and Prognostic Value of Left Atrial Dysfunction in Patients With Chronic Coronary Syndrome and Normal Left Ventricular Ejection Fraction

Patients with chronic coronary syndrome (CCS), even when they have complete revascularization and normal left ventricular (LV) systolic function, experience subsequent cardiovascular disease (CVD), highlighting the importance of surrogate markers to prevent adverse consequences. Speckle-tracking echocardiography-derived left atrial (LA) reservoir strain has emerged as a sensitive marker for CVD in various clinical settings. The present study investigated the prevalence, determinants, and prognostic value of LA dysfunction in CCS. We included 278 consecutive patients with CCS with completed percutaneous coronary intervention and preserved LV ejection fraction who underwent follow-up echocardiography. Speckle-tracking analysis was performed to assess LA reservoir strain, and LA dysfunction was defined as LA reservoir strain ≤24%. The primary outcome comprised new-onset atrial fibrillation, heart failure hospitalization, acute coronary syndrome, stroke, or all-cause death. At baseline, 28 patients (10.1%) had LA dysfunction. Multivariable analysis identified age, hypertension, LV ejection fraction, and multivessel disease as independent determinants of LA reservoir strain (all p <0.05). During a median follow-up of 4.8 years, the primary outcome occurred in 60 patients (21.6%). LA dysfunction carried a significant risk for primary outcome independent of traditional risk factors, LV parameters, and LA size (adjusted hazard ratio 3.10, p = 0.003); the risk increase remained significant even after excluding atrial fibrillation from the primary outcome (adjusted hazard ratio 2.27, p = 0.043). In conclusion, approximately 10% of patients with CCS with normal LV ejection fraction had LA dysfunction associated with adverse cardiovascular outcomes. Further studies are needed to explore whether therapeutic interventions affecting LA remodeling may help prevent CVD events.

Deformability of ascending thoracic aorta aneurysms assessed using ultrafast ultrasound and a principal strain estimator: In vitro evaluation and in vivo feasibility

BACKGROUND

Noninvasive vascular strain imaging under conventional line-by-line scanning has a low frame rate and lateral resolution, and depends on the coordinate system. It is thus affected by high deformations due to image decorrelation between frames.

PURPOSE

To develop an ultrafast time-ensemble regularized tissue-Doppler optical-flow principal strain estimator for aorta deformability assessment in a long-axis view.

METHODS

This approach alleviated the impact of lateral resolution using image compounding and that of the coordinate system dependency using principal strain. Accuracy and feasibility were evaluated in two aorta-mimicking phantoms first, and then in four age-matched individuals with either a normal aorta or a pathological ascending thoracic aorta aneurysm (TAA).

RESULTS

Instantaneous aortic maximum and minimum principal strain maps and regional accumulated strains during each cardiac cycle were estimated at systolic and diastolic phases to characterize the normal aorta and TAA. In vitro, principal strain results matched sonomicrometry measurements. In vivo, a significant decrease in maximum and minimum principal strains was observed in TAA cases, whose range was respectively 7.9 ± 6.4% and 8.2 ± 2.6% smaller than in normal aortas.

CONCLUSIONS

The proposed principal strain estimator showed an ability to potentially assess TAA deformability, which may provide an individualized and reliable evaluation method for TAA rupture risk assessment. This article is protected by copyright. All rights reserved.

Prognostic Value and Interplay Between Myocardial Tissue Velocities in Patients Undergoing Coronary Artery Bypass Grafting

Early diastolic tissue velocity (e') by tissue Doppler imaging represents an early marker of left ventricular (LV) dysfunction in ischemic heart disease. We assessed the value of e' for predicting mortality in patients undergoing coronary artery bypass grafting (CABG). We retrospectively investigated patients treated with CABG between 2006-2011. Before surgery, all patients underwent an echocardiogram with tissue Doppler imaging to measure tissue velocities: systolic (s'), e', and late diastolic (a'). The primary outcome was all-cause mortality. Survival analysis was applied. Improvement of EuroSCORE-II was assessed by net reclassification index. Of 660 patients, 72 (11%) died during a median follow-up time of 3.8 years. Mean age was 68 years, LVEF 50%, and 84% were men. All tissue velocities showed a significant negative association with outcome and e' provided highest Harrell's C-statistics (c-stat=0.68). After multivariable adjustment for EuroSCORE-II, LV hypertrophy, LV internal diameter, and global longitudinal strain, declining e' was associated with a higher risk of mortality (HR=1.35 (1.12 to 1.61), p = 0.001, per 1cm/s absolute decrease). LVEF≤40% modified the relationship between both s' and e' and outcome (p for interaction=0.021 and 0.024, respectively), such that neither predicted mortality when LVEF was ≤40%. In patients with LVEF>40%, only e' remained a predictor after multivariable adjustments (HR=1.36 (1.10 to 1.69), p = 0.005, per 1cm/s absolute decrease). A net reclassification index improvement of 0.14 was observed when adding global e' to the EuroSCORE-II. In conclusion, e' is an independent predictor of all-cause mortality in patients undergoing CABG, especially in patients with LVEF>40%, and improves the predictive value of EuroSCORE-II.

Additional roles of diastolic parameters in the diagnosis of obstructive coronary artery disease

BACKGROUND

A recent guideline emphasizes the role of four indicators, including annular e´ velocity, E/e´, left atrial (LA) size, and peak tricuspid regurgitation (TR) velocity, in the assessment of left ventricular (LV) diastolic dysfunction. This study was performed to determine the relationships among these four parameters and obstructive coronary artery disease (CAD).

METHODS

The study data were obtained from a nation-wide registry, composed of 1307 patients (age, 60.4 ± 10.8 years; 964 women) with normal LV ejection fraction (LVEF) who underwent invasive coronary angiography in the suspicion of CAD. Septal e´, E/e´, LA dimension (LAd), and TR velocity were assessed by transthoracic echocardiography.

RESULTS

Compared with patients without obstructive CAD, those with obstructive CAD showed changes in diastolic parameters indicating more progressed LV diastolic dysfunction in univariate analyses. In multiple logistic regression analysis, low septal e´ velocity (<7 cm/s) was identified as an independent risk factor associated with obstructive CAD (odd ratio, 1.91; 95% confidence interval, 1.08-3.36; P = 0.026). Receiver-operating characteristic curve analysis showed that septal e´ velocity had the most powerful value in the detection of obstructive CAD than the other three diastolic parameters (P < 0.01 for each comparison). Septal e´ velocity significantly increased diagnostic value of treadmill exercise test (TET) in the detection of obstructive CAD (P < 0.001 for integrated discrimination improvement index).

CONCLUSIONS

Among the four diastolic parameters, septal e´ velocity had the most powerful relationship with obstructive CAD in stable patients with normal LVEF. The addition of septal e´ velocity could improve the diagnostic value of TET.

Echocardiographic predictors of cardiovascular morbidity and mortality in women from the general population

AIMS

Global longitudinal strain (GLS) is a strong predictor of adverse cardiovascular outcome in men. However, studies have indicated that GLS may not predict cardiovascular outcomes as effectively in women. The aim of this study was to identify echocardiographic predictors of cardiovascular morbidity and mortality in women from the general population.

METHODS AND RESULTS

A total of 1245 women from the general population free of heart failure (HF) and atrial fibrillation had an echocardiographic examination performed including tissue Doppler imaging. In this subset, 747 women had images eligible for strain analysis. Endpoint was a composite of acute myocardial infarction, HF, and cardiovascular death. During follow-up (median 12.5 years), 162 women (13.0%) reached the composite outcome. These women had higher left ventricular (LV) mass index (LVMI), more LV hypertrophy, lower E/A, higher E/e', larger LV dimensions, and longer deceleration time. LVMI and e' remained as significant predictors of the composite outcome [LVMI: hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.03-1.17, P = 0.004, per 5 g/m2 increase] (e': HR 1.53, 95% CI 1.07-2.20, P = 0.020, per 1 cm/s decrease) after adjusting for age, hypertension, systolic blood pressure, diabetes mellitus, total cholesterol, smoking status, prevalent ischaemic heart disease, LV ejection fraction, E/e', E, E/A, interventricular septum thickness in diastole, left ventricular posterior wall in diastole, a', body surface area, and pro-brain natriuretic peptide. GLS was not an independent predictor of outcome after multivariable adjustment.

CONCLUSION

The degree of LV hypertrophy assessed as LVMI and diastolic dysfunction evaluated by e' are associated with adverse cardiovascular outcome in women from the general population.

Letter by Garcia A, et al. regarding article: Coronary artery disease risk reclassification by a new acoustic-based score

The best cost-effective non-invasive test for the diagnosis of coronary artery disease (CAD) in patients with intermediate pre-test probability (PTP) is unknown. Nevertheless one of the most common non invasive test used is the exercise treadmill testing (ETT) that is the less expensive non-invasive test but with the lowest sensitivity for the diagnosis of CAD, therefore many patients with intermediate PTP will required another non-invasive test with a higher cost and some of them require exposure to radiation. Despite all these measures, an estimated $108.9 billion is spent annually on CAD treatment. Some studies had showed that diastolic dysfunction is associated to CAD. A novel signal-processed surface ECG (MyoVista hsECG) can detection the abnormal myocardial relaxation and therefore identified CAD. The non-invasive acoustic device CADScore V3 algorithm had lower cost compared with any noninvasive test, with a high negative predictive value but not good enough specificity to diagnose CAD, hence should be the first approach in patients with a low and intermediate probability of CAD, and if to this evaluation will added the Myovista hs ECG to detection of CAD, therefore some patients with intermediate PTP could be reclassified into high risk and a better cost-effective decisions could be taken as referring directly to coronary angiography.

Evaluation of Coronary Artery Disease Using Myocardial Elastography with Diverging Wave Imaging: Validation against Myocardial Perfusion Imaging and Coronary Angiography

Myocardial elastography (ME) is an ultrasound-based technique that can image 2-D myocardial strains. The objectives of this study were to illustrate that 2-D myocardial strains can be imaged with diverging wave imaging and differ, on average, between normal and coronary artery disease (CAD) patients. In this study, 66 patients with symptoms of CAD were imaged with myocardial elastography before a nuclear stress test or an invasive coronary angiography. Radial cumulative strains were estimated in all patients. The end-systolic radial strain in the total cross section of the myocardium was significantly higher in normal patients (17.9 ± 8.7%) than in patients with reversible perfusion defect (6.2 ± 9.3%, p < 0.001) and patients with significant (-0.9 ± 7.4%, p < 0.001) and non-significant (3.7 ± 5.7%, p < 0.01) lesions. End-systolic radial strain in the left anterior descending, left circumflex and right coronary artery territory was found to be significantly higher in normal patients than in CAD patients. These preliminary findings indicate that end-systolic radial strain measured with ME is higher on average in healthy persons than in CAD patients and that ME has the potential to be used for non-invasive, radiation-free early detection of CAD.

Echocardiographic markers of inducible myocardial ischemia at baseline evaluation preparatory to exercise stress echocardiography

BACKGROUND

Tissue Doppler Imaging (TDI) is a sensible and feasible method to detect longitudinal left ventricular (LV) systolic dysfunction (LVSD) in patients with diabetes mellitus, hypertension or ischemic heart disease. In this study, we hypothesized that longitudinal LVSD assessed by TDI predicted inducible myocardial ischemia independently of other echocardiographic variables (assessed as coexisting potential markers) in patients at increased cardiovascular (CV) risk.

METHODS

Two hundred one patients at high CV risk defined according to the ESC Guidelines 2012 underwent exercise stress echocardiography (ExSEcho) for primary prevention. Echocardiographic parameters were measured at rest and peak exercise.

RESULTS

ExSEcho classified 168 (83.6 %) patients as non-ischemic and 33 (16,4 %) as ischemic. Baseline clinical characteristics were similar between the groups, but ischemic had higher blood pressure, received more frequently beta-blockers and antiplatelet agents than non-ischemic patients. The former had greater LV size, lower relative wall thickness and higher left atrial systolic force (LASF) than the latter. LV systolic longitudinal function (measure as peak S') was significantly lower in ischemic than non-ischemic patients (8.7 ± 2.1 vs 9.7 ± 2.7 cm/sec, p = 0.001). The factors independently related to myocardial ischemia at multivariate logistic analysis were: lower peak S', higher LV circumferential end-systolic stress and LASF.

CONCLUSIONS

In asymptomatic patients at increased risk for adverse CV events baseline longitudinal LVSD together with higher LV circumferential end-systolic stress and LASF were the factors associated with myocardial ischemia induced by ExSEcho. The assessment of these factors at standard echocardiography might help the physicians for improving the risk stratification among these patients for ExSEcho.

Tissue Doppler echocardiography predicts acute myocardial infarction, heart failure, and cardiovascular death in the general population

AIMS

To improve risk prediction of cardiovascular morbidity and mortality, we need sensitive markers of cardiac dysfunction; Echocardiographic Tissue Doppler Imaging (TDI) is feasible and harmless and may be ideal for this purpose.

METHODS AND RESULTS

Within the community-based Copenhagen City Heart Study, 2064 participants were examined by echocardiography including TDI and followed (median 10.9 years) with regard to cardiovascular death, heart failure, or acute myocardial infarction (n = 277). Impaired systolic (s') and diastolic (e' and a') function according to age and sex as assessed by TDI was associated with increased risk of the combined end point, even in the subgroup of persons with a normal conventional echocardiographic examination [per 1 cm/s decrease: s': HR 1.32 (1.12-1.57), P < 0.001; e': HR 1.17(1.04-1.31), P < 0.01; a': HR 1.17 (1.06-1.30), P < 0.005]. Interestingly, reduced early diastolic myocardial velocity (e') was associated with risk of acute myocardial infarction, whereas reduced systolic (s') or late diastolic function (a') was associated with heart failure and cardiovascular death independently of traditional risk factors, plasma proBNP, and conventional echocardiographic measures. Combining information on early and late diastolic function by TDI provided incremental prognostic information and improved risk classification (net reclassification improvement: 27%; P < 0.001) and remained a significant predictor of the combined end point even in the subgroup with a normal conventional echocardiographic examination [per cm/s decrease: HR 1.18 (1.08-1.28), P < 0.001].

CONCLUSION

In the general population, TDI identifies individuals with cardiac dysfunction and high risk of cardiovascular morbidity and mortality independently of traditional risk factors, even in persons with a normal conventional echocardiographic examination.

The Utility of Systolic and Diastolic Echocardiographic Parameters for Predicting Coronary Artery Disease Burden as Defined by the SYNTAX Score

BACKGROUND

Early identification of high-grade ischemia based on echocardiographic diastolic abnormalities may be clinically useful in the acute coronary syndrome (ACS) setting. This could provide the clinician with an awareness of the burden of coronary artery disease (CAD) before angiography is performed to allow for early intervention of suspected ischemic lesions. The objective of the study was to assess whether 2D transthoracic echocardiography (TTE)-derived tissue Doppler imaging parameters can predict the severity of CAD in comparison with the cardiac catheterization-derived SYNTAX score.

METHODS

A retrospective study of 74 stable angina or patients with ACS was performed in 2012 at a single tertiary care center. In all study subjects, TTE and angiography were performed within 6 months of each other without revascularization in the interim.

RESULTS

The study population included a total of 74 patients (mean age 67 ± 12 years) with 77% presenting with an ACS. The median SYNTAX score was 24.0 (6.0-35.0). The E-wave velocity was higher, and deceleration time (DT) was lower in the high SYNTAX group in comparison with the low/intermediate SYNTAX group (P = 0.045 and P = 0.001, respectively). Septal mitral annular S' was lower in the high SYNTAX group (P = 0.02). After multivariate analysis, E/A ratio (OR 0.03, 95% 0.00-0.36, P = 0.0067), DT (OR 0.93, 95% CI 0.89-0.97, P = 0.0001) and septal annular S'-wave velocity (OR 0.34, 95% CI 0.16-0.71, P = 0.0038) remained strong predictors of a high SYNTAX score.

CONCLUSION

Early identification of systolic and diastolic dysfunction based on echocardiographic parameters may be of important clinical significance for predicting CAD burden prior to invasive angiography.

Left atrial enlargement and reduced physical function during aging

Diastolic dysfunction, often seen with increasing age, is associated with reduced exercise capacity and increased mortality. Mortality rates in older individuals are linked to the development of disability, which may be preceded by functional limitations. The goal of this study was to identify which echocardiographic measures of diastolic function correlate with physical function in older subjects. A total of 36 men and women from the Louisiana Healthy Aging Study, age 62-101 yr, received a complete echocardiographic exam and performed the 10-item continuous-scale physical-functional performance test (CS-PFP-10). After adjustment for age and gender, left atrial volume index (ρ = -0.59; p = .0005) correlated with the total CS-PFP-10 score. Increased left atrial volume index may be a marker of impaired performance of activities of daily living in older individuals.

Tissue Doppler imaging for diagnosis of coronary artery disease: a systematic review and meta-analysis

Global and regional left ventricular (LV) systolic dysfunction is a marker of coronary artery disease (CAD), which is conventionally assessed using two-dimensional echocardiography. Tissue Doppler imaging (TDI) has emerged as an adjunct tool in the diagnosis of regional wall motion abnormalities from CAD. We performed a systematic review and meta-analysis to assess the efficacy of TDI indices in the diagnosis of CAD. We searched MEDLINE and the Cochrane Library for controlled studies comparing TDI measurements in those with and without CAD as confirmed by coronary angiography. Meta-analyses of mean differences in TDI velocities between these populations were performed. Screening of titles and abstracts followed by full-text screening identified 8 studies. At rest, TDI was associated with a significant decrease in the pooled maximum systolic velocity among CAD patients compared to those without CAD [mean difference (MD): -0.66; 95% confidence interval (CI): -0.98 to −0.34]. There were no significant differences in maximum early and late diastolic velocities. Post-stress, TDI was associated with a significant decrease in maximum early diastolic velocity (MD: -1.91; 95% CI: -2.74 to −1.09) and maximum late diastolic velocity (MD: -1.57; 95% CI: -2.95 to −0.18) among CAD patients compared to those without CAD. There was no significant difference in maximum systolic velocity post-stress. Our results suggest that TDI may have a role in the evaluation of CAD. Future studies should evaluate the incremental value of TDI velocities over LV ejection fraction and two dimensional wall motion analysis in the detection of CAD and assessment of its severity. (Word Count: 249)

Tissue Doppler echocardiography improves the diagnosis of coronary artery stenosis in stable angina pectoris

Aim To determine if colour tissue Doppler imaging (TDI) performed at rest in patients with suspected stable angina pectoris (SAP) is able to predict the presence of significant coronary artery disease (CAD).

METHODS AND RESULTS

This study comprises 296 consecutive patients with clinically suspected SAP, no previous cardiac history, and a normal ejection fraction. All patients were examined by colour TDI, exercise electrocardiogram (ECG), and coronary angiography (CAG). Regional longitudinal systolic (s'), early diastolic (e'), and late diastolic (a') myocardial velocities were measured by colour TDI at six mitral annular sites and averaged to provide global estimates. Duke score (DS), including ST depression, chest pain, and exercise capacity, was used as the outcome of the exercise ECG. Patients with an area stenosis of ≥70% in at least one epicardial coronary artery were categorized as having a significant CAD (n= 108) and were compared with patients without significant CAD (n= 188). Both e' [odds ratio (OR): 1.5 (1.1-1.9, P < 0.01) per cm/s decrease] and s' [OR: 1.7 (1.1-2.5, P < 0.05) per cm/s decrease] remained independent predictors of CAD after multivariable adjustment for baseline, exercise ECG, and conventional echocardiographic parameters. Area under the receiver operating characteristic curve (AUC) for exercise ECG and TDI in combination was significantly higher than AUC for exercise ECG alone (0.84 vs. 0.79, P < 0.01).

CONCLUSION

In patients with suspected SAP colour TDI performed at rest is an independent predictor of significant CAD, and colour TDI improves the diagnostic performance of exercise ECG.

Tissue Doppler echocardiography reveals impaired cardiac function in patients with reversible ischaemia

AIMS

To determine if echocardiographic tissue Doppler imaging (TDI) performed at rest detects reduced myocardial function in patients with reversible ischaemia.

METHODS AND RESULTS

Eighty-four patients with angina pectoris, no previous history of ischaemic heart disease and normal left ventricular ejection fraction were examined with colour TDI, single-photon emission computed tomography (SPECT), and coronary angiography (CAG). Patients with a normal SPECT (n= 42) constituted the control group and patients with a positive SPECT (n= 42) were divided into patients with (true-positive SPECT, n= 30) or without (false-positive SPECT, n= 12) significant coronary stenoses assessed by CAG. Regional longitudinal systolic (s'), early diastolic (e'), and late diastolic (a') myocardial velocities were measured by colour TDI at six mitral annular sites and averaged to provide global estimates. In patients with reversible ischaemia both global systolic and diastolic function were impaired in terms of reduced average s' (5.6 ± 0.9 vs. 6.1 ± 1.1 cm/s; P< 0.05), reduced average e' (5.9 ± 1.8 vs. 7.0 ± 1.7 cm/s; P< 0.01) and increased average E/e' (14.2 ± 5.0 vs. 11.5 ± 3.9; P< 0.01). This impairment of the cardiac function was even more evident in patients with a true-positive SPECT with reduced average s' (5.5 ± 0.8 vs. 6.1 ± 1.1 cm/s; P< 0.01), reduced average e' (5.2 ± 1.5 vs. 7.0 ± 1.7 cm/s; P< 0.001), and increased average E/e' (15.5 ± 5.2 vs. 11.5 ± 3.9; P< 0.001), whereas no difference in myocardial velocities could be demonstrated in patients with a false-positive SPECT compared with controls.

CONCLUSION

In patients with stable angina pectoris, preserved ejection fraction, and reversible ischaemia assessed by SPECT, echocardiographic colour TDI performed at rest reveals impaired cardiac function. The impairment of the cardiac function seems to be evident only in patients with a true-positive SPECT and colour TDI may therefore increase its diagnostic value.

Metformin is associated with improved left ventricular diastolic function measured by tissue Doppler imaging in patients with diabetes

OBJECTIVE

To examine the association between selected glucose-lowering medications and left ventricular (LV) diastolic function in patients with diabetes.

DESIGN

Retrospective cohort study (years 2005-2008).

METHODS

Echocardiograms of 242 patients with diabetes undergoing coronary angiography were analyzed. All patients had an LV ejection fraction (LVEF) ≥20% and were without atrial fibrillation, bundle branch block, valvular disease, or cardiac pacemaker. Patients were grouped according to the use of metformin (n=56), sulfonylureas (n=43), insulin (n=61), and combination treatment (n=82).

RESULTS

Mean age (66±10 years) and mean LVEF (45±11%) were similar across the groups. Mean isovolumic relaxation time (IVRT) was 66±31, 79±42, 69±23, and 66±29 ms in metformin, sulfonylureas, insulin, and combination treatment groups respectively (P=0.4). Mean early diastolic longitudinal tissue velocity (e') was 5.3±1.6, 4.6±1.6, 5.3±1.8, and 5.4±1.7 cm/s in metformin, sulfonylureas, insulin, and combination treatment groups (P=0.04). In adjusted linear regression models, the use of metformin was associated with a shorter IVRT (parameter estimate -9.9 ms, P=0.049) and higher e' (parameter estimate +0.52 cm/s, P=0.03), compared with no use of metformin. The effects of metformin were not altered by concomitant use of sulfonylureas or insulin (P for interactions >0.4).

CONCLUSIONS

The use of metformin is associated with improved LV relaxation, as compared with no use of metformin.