Predictive Value of C-Reactive Protein and Left Ventricular Diastolic Filling Pattern after a Non-ST Elevation Myocardial Infarction

Relationship of left ventricular hypertrophy and diastolic function with cardiovascular and renal outcomes in African Americans with hypertensive chronic kidney disease

African Americans with hypertension are at high risk for adverse outcomes from cardiovascular and renal disease. Patients with stage 3 or greater chronic kidney disease have a high prevalence of left ventricular (LV) hypertrophy and diastolic dysfunction. Our goal was to study prospectively the relationships of LV mass and diastolic function with subsequent cardiovascular and renal outcomes in the African American Study of Kidney Disease and Hypertension cohort study. Of 691 patients enrolled in the cohort, 578 had interpretable echocardiograms and complete relevant clinical data. Exposures were LV hypertrophy and diastolic parameters. Outcomes were cardiovascular events requiring hospitalization or causing death; a renal composite outcome of doubling of serum creatinine or end-stage renal disease (censoring death); and heart failure. We found strong independent relationships between LV hypertrophy and subsequent cardiovascular (hazard ratio, 1.16; 95% confidence interval, 1.05-1.27) events, but not renal outcomes. After adjustment for LV mass and clinical variables, lower systolic tissue Doppler velocities and diastolic parameters reflecting a less compliant LV (shorter deceleration time and abnormal E/A ratio) were significantly (P<0.05) associated with future heart failure events. This is the first study to show a strong relationship among LV hypertrophy, diastolic parameters, and adverse cardiac outcomes in African Americans with hypertension and chronic kidney disease. These echocardiographic risk factors may help identify high-risk patients with chronic kidney disease for aggressive therapeutic intervention.

Prediction of heart failure and adverse cardiovascular events in outpatients with coronary artery disease using mitral E/A ratio in conjunction with e-wave deceleration time: the heart and soul study

BACKGROUND

Deceleration time (DT) of early mitral inflow (E) is a marker of diastolic left ventricular (LV) chamber stiffness that is routinely measured during the quantitation of LV diastolic function with Doppler echocardiography. Shortened DT after myocardial infarction predicts worse cardiovascular outcome. Recent studies have shown that indexing DT to peak E-wave velocity (pE) augments its prognostic power in a population with a high prevalence of coronary risk factors and in patients with hypertension during antihypertensive treatment. However, in ambulatory subjects with stable coronary artery disease (CAD), it is not known whether DT predicts cardiovascular events and whether DT/pE improves its prognostic power.

METHODS

The ability of DT and DT/pE to predict heart failure (HF) hospitalizations and other major adverse cardiovascular events (MACEs) was studied prospectively in 926 ambulatory patients with stable CAD enrolled in the Heart and Soul Study. Unadjusted and multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for HF and other MACEs.

RESULTS

During a mean of 6.3 ± 2.0 years, there were 124 hospitalizations for HF and 198 other MACEs. Relative to participants with mitral E/A ratios in the normal range (0.75 < E/A < 1.5; n = 604), those with E/A ratios ≥ 1.5 (n = 107) had an increased risk for HF (HR, 2.54; 95% CI, 1.52-4.25, P < .001) but not for other MACEs (HR, 1.00; 95% CI, 0.60-1.68; P = 1.00), while those with E/A ratios ≤ 0.75 (n = 215) were not at increased risk for either outcome. Among patients with normal E/A ratios, lower DT/pE predicted HF (HR, 0.47; 95% CI, 0.23-0.97, P = .04 per point increase in ln{msec/[cm/sec]}), while DT alone did not. However, in this group with normal E/A ratios, neither DT/pE nor DT alone was predictive of other MACEs. In patients with E/A ratios ≤ 0.75 (n = 215) and those with E/A ratios ≥ 1.5 (n = 107), neither DT nor DT/pE predicted either end point.

CONCLUSIONS

In ambulatory patients with stable CAD, restrictive filling (E/A ratio ≥ 1.5) is a powerful predictor of HF. Among those with normal mitral E/A ratios (0.75-1.5), only DT/pE predicts HF, while neither DT nor DT/pE predicts other MACEs. This suggests that mitral E/A ratio has significant prognostic value in patients with CAD, and in those with normal mitral E/A ratios, the normalization of DT to pE augments its prognostic power.

Mitral E wave deceleration time to peak E velocity ratio and cardiovascular outcome in hypertensive patients during antihypertensive treatment (from the LIFE echo-substudy)

The early mitral flow deceleration time (DTE) is a prognostically validated marker of left ventricular diastolic dysfunction. It has been reported that the DTE is influenced by the loading conditions, which can vary during antihypertensive treatment. We hypothesized that normalization of the DTE for mitral peak E-velocity (mitral deceleration index [MDI]) might better predict incident cardiovascular (CV) events in hypertensive patients during treatment compared to DTE alone or other traditional indexes of diastolic function, such as the mitral E/A ratio. We evaluated 770 hypertensive patients with electrocardiogram findings of left ventricular hypertrophy (age 66 +/- 7 years; 42% women) enrolled in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echocardiographic substudy. Echocardiographic examinations were performed annually for 5 years during intensive antihypertensive treatment. We examined the utility of the MDI at baseline and as a time-varying predictor of incident CV events. Of the 770 patients, 70 (9%) had CV events. The baseline MDI was positively associated with age and relative wall thickness and negatively associated with gender and heart rate (all p <0.01). Unadjusted Cox regression analysis showed a positive association between the baseline MDI and CV events (hazard ratio 1.21, 95% confidence interval 1.07 to 1.37, p = 0.002). In the time-varied Cox models, a greater in-treatment MDI was associated with a greater rate of CV events (hazard ratio 1.43, 95% confidence interval 1.05 to 1.93, p = 0.022), independently of the covariates. No significant association was found for in-treatment DTE or any of the prognostically validated indexes of diastolic function. In conclusion, in our population of patients with treated hypertension with electrocardiographic findings of left ventricular hypertrophy, the MDI independently predicted future CV events. Normalization of DTE for E velocity might be preferred to other traditional diastolic function indexes in evaluating diastolic function during antihypertensive treatment.

The Ratio of Mitral Deceleration Time to E-wave Velocity and Mitral Deceleration Slope Outperform Deceleration Time Alone in Predicting Cardiovascular Outcomes: The Strong Heart Study

BACKGROUND

The deceleration time of early mitral inflow (E) is shortened by left ventricular chamber stiffening and prolonged by impaired relaxation. For any given rate of deceleration of early mitral inflow, a higher E-wave velocity (E) is associated with a longer deceleration time. It is not known whether deceleration time normalized for E-velocity or its inverse (deceleration slope) better predicts cardiovascular (CV) events compared with deceleration time or E-velocity alone.

METHODS

We compared the prognostic value of deceleration time, E-velocity, deceleration time/E-velocity, and deceleration slope in 3102 American Indian participants in the Strong Heart Study, free of clinical CV disease and documented atrial fibrillation, in predicting fatal and nonfatal CV events.

RESULTS

During a mean of 8.5 +/- 2.4 years, there were 637 fatal and nonfatal CV events. After adjustment for traditional CV risk factors, deceleration time/E-velocity (adjusted hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.00-1.18; P = .04 for every 0.89 msec/[cm/s] [1 + standard deviation {SD}] increase) and deceleration slope (HR, 0.91; 95% CI, 0.82-1.00; P = .01 for every 91 msec [1 + SD] increase) predicted CV events, whereas deceleration time and E-velocity did not. When participants with restrictive-type filling (n = 74) were removed from the analysis, deceleration time/E-velocity (HR, 1.10; 95% CI, 1.01-1.20; P = .03 for every 0.89 msec/[cm/s] [1 + SD] increase) and deceleration slope (HR, 0.64; 95% CI, 0.36-0.91; P = .01 for every 91 msec [1 + SD] increase) predicted CV events even more strongly.

CONCLUSION

In a large population-based sample with high prevalences of hypertension and diabetes, free of prevalent CV disease, deceleration time/E-velocity and deceleration slope predict CV events, whereas their components (deceleration time and E-velocity) do not. This suggests normalization of deceleration time for E-velocity or using its inverse (deceleration slope) more precisely captures prognostically significant prolongation of deceleration than does deceleration time alone.