What Do You Want From Your Echocardiogram?

Tissue Doppler indices of diastolic function as prognosticator in patients without heart failure in primary care

BACKGROUND

Tissue Doppler imaging (TDI) indices of left ventricular (LV) diastolic function provide incremental prognostic information on mortality and morbidity in the general population and in several clinical scenarios. Their independent, additional role in outpatients with normal LV ejection fraction (LVEF) and without heart failure (HF) is undefined.

METHODS

We reviewed clinical and echocardiographic records of 2628 consecutive outpatients 52.8% male, median age 71 years) with LVEF > 50% without concurrent or prior HF, from the Cardiovascular Center of Trieste. We analyzed septal early mitral annular velocity (e') and its combination with mitral peak early filling velocity (E/e') in relation to the composite end-point of death and cardiovascular hospitalizations.

RESULTS

During follow-up of 26 months (interquartile range: 12-41), 392 (15%) patients experienced the endpoint (88 deaths). Increasing E/e' showed an overall association with the clinical end-point (log rank p < 0.02), but with no prognostic difference between the middle and upper tertile. Decreasing e' also showed an association with the end-point, with a more balanced stepwise risk increase for increasing tertiles (log rank p < 0.01 for all contrasts). At multivariable analysis, E/e' (either in tertiles or dichotomized according to the threshold of 15) was no longer associated with clinical outcome, whereas e' independently predicted the combined endpoint [hazard ratio 0.73 (0.53-0.94), p = 0.04]. The prognostic value of e' was incremental to that of other clinical and echocardiographic variables (p = 0.04).

CONCLUSIONS

In outpatients with normal LVEF and without HF, e' and E/e' are both associated with clinical end-points, though only e' is an independent and incremental predictor of outcome. These findings suggest a potential role for e' as a prognosticator, and spread a cautionary word about the utilization of septal E/e' alone as a surrogate for a comprehensive assessment of diastolic function in this context.

The Role of Echocardiography in Heart Failure with Preserved Ejection Fraction: What Do We Want from Imaging?

Noninvasive imaging, particularly echocardiography, plays a central role in the evaluation for heart failure with preserved ejection fraction (HFpEF). Echocardiography helps to rule in HFpEF among patients with unexplained dyspnea when the diagnosis is uncertain. In established HFpEF, echocardiography provides important insights into pathophysiology and phenotyping, such as isolated left ventricular diastolic dysfunction, left atrial dysfunction, abnormal right ventricular-pulmonary artery coupling, ischemia, or obesity phenotypes. In addition, imaging enables risk stratification for HFpEF. This article provides a critical appraisal of the role of echocardiography in the diagnosis and evaluation of HFpEF.