Clinical Relevance of the Spectral Tissue Doppler E/e' Ratio in the Management of Patients with Atrial Fibrillation: a Comprehensive Review of the Literature

Case report: Diagnosis of apical hypertrophic cardiomyopathy that escaped clinical and echocardiographic investigations for twenty years: Reasons and clinical implications

Background

Apical hypertrophic cardiomyopathy (ApHCM) is a rare form of hypertrophic cardiomyopathy which predominantly affects the apex of the left ventricle. The diagnosis can be challenging due to several factors, ranging from no typical clinical and electrocardiogram (EKG) findings to potential difficulties in executing and interpreting the echocardiographic examination.

Case presentation

We report the case of an 84-year-old woman who came to our echo-lab to undergo a routine echocardiogram. She had a history of permanent atrial fibrillation, paced rhythm and previous episodes of heart failure (HF), allegedly explained by a diagnosis of hypertensive heart disease that had been confirmed many times over the previous 20 years. The clinical examination and the EKG were unremarkable. The echocardiographic images were poor quality. But a senior cardiologist, expert in imaging and echocardiography, noted the lack of delineation of the endocardial border of the left ventricular (LV) apex region. Contrast echocardiography was performed and severe apical hypertrophy discovered.

Conclusion

ApHCM can be a challenging diagnosis. Contrast echocardiography must always be applied in cases of poor delineation of the LV apical endocardial border at baseline echocardiography. Timely detection and appropriate lifestyle intervention might slow the development of LV hypertrophy, and possibly minimize and delay heart failure (HF) related symptoms and arrhythmias. The prognosis remains relatively benign during long term follow-up.

Early Echocardiographic Predictors for Atrial Fibrillation Propensity: The Left Atrium Oracle

Atrial fibrillation (AF) results from structural and electrical remodeling of the atria, primarily of the left atrium (LA); therefore, LA changes, both anatomical and functional are recognized as proarrhythmic markers with a powerful prognostic value. Being widely available and noninvasive, echocardiography is used to monitor LA form and function in clinical practice. Early functional (electrical) remodeling of the LA precedes anatomical alterations. Impaired LA functions and reduced atrial compliance due to atrial fibrosis may be evaluated using novel echocardiographic techniques, such as tissue Doppler analysis and speckle tracking. Functional evaluation of the LA conveys prognostic information about the risk of AF, as the severity of the impairment is an independent predictor of new-onset AF and AF recurrence. However, specific parameters are still investigated for incorporation into algorithms to predict future AF occurrence. The aim of the review is to summarize echocardiographic parameters, their predicting value and applicability in practice.

Diastolic function in patients with heart failure with preserved ejection fraction and atrial fibrillation: impact of diabetes

INTRODUCTION

The objective of our study was to evaluate the severity of diastolic dysfunction in patients with heart failure with preserved ejection fraction (HFpEF), atrial fibrillation (AF) and type 2 diabetes mellitus (T2DM) compared to those with HFpEF and AF without DM.

MATERIAL AND METHODS

This is an observational, prospective, case-control study. We selected 720 patients with heart failure consecutively admitted between March 2019-December 2020, of whom 253 patients with AF. After applying the inclusion/exclusion criteria, 105 subjects remained in the study. The patients were divided into two groups, according to the presence of T2DM: group A (39 patients with T2DM, 37.14%), group B (66 patients without T2DM, 62.85%). 2D transthoracic echocardiography was performed in all patients. The study was approved by the Ethics Committee of the hospital. Statistical analysis was performed using R software, version 4.0.2.

RESULTS

Patients with HFpEF, AF, and T2DM had higher LV filling pressures compared to those without DM (OR = 5.00, 95% CI: 1.77-15.19). Moreover, patients with insulin-requiring T2DM (OR = 6.25, 95% CI: 1.50-25.98) had higher LV filling pressures than those treated with oral antidiabetic drugs (OR = 4.44, 95% CI: 1.37-15.17). We demonstrated that patients with T2DM had higher E/e' ratio (difference -2.78, P 0.0003, 95% CI: -4.24 to -1.31) and lower deceleration time (DT) (difference 23.04, P 0.0002, 95% CI: 11.10-34.97) than those without T2DM.

CONCLUSIONS

Patients with HFpEF, AF and T2DM have higher LV filling pressures than those without T2DM, suggesting that the presence of T2DM leads to a more severe diastolic dysfunction.

Clinical relevance of spectral tissue Doppler-derived E/e' in older patients with preserved ejection fraction

BACKGROUND

The E/e' index measured in spectral tissue Doppler is included in the recommendations for the diagnosis by transthoracic Doppler echocardiography of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction. While E/e' is influenced by age in healthy individuals, no studies have evaluated this index in elderly patients. This study addressed the clinical relevance of E/e' in assessment of left ventricular diastolic function in elderly patients with preserved ejection fraction and its relevance from both a diagnostic and prognostic perspective based on the existing literature.

METHODS

A total of 76 patients≥70years of age were prospectively included. The analysis of left ventricular diastolic function was adapted from the 2016 ASE/EACVI recommendations without consideration of E/e'.

RESULTS

The mean age was 85years. In all, 42 patients had moderate-to-severe diastolic dysfunction (elevated left atrial pressure). Mean E/e' was significantly correlated with diastolic function (r=0.58, P<0.001). Mean E/e'>13.3 had a sensitivity of 86% and a specificity of 91% in the diagnosis of moderate-to-severe diastolic dysfunction (AUC: 0.92). E/(e'xs') (AUC: 0.89) and NT pro-BNP (AUC: 0.80) did not perform better than E/e'. The existing literature offers large body of evidence that E/e' provides essential diagnostic and prognostic information in older patients with cardiovascular disease.

CONCLUSION

E/e' is accurate in the diagnosis of significant diastolic dysfunction, in the diagnosis of heart failure with preserved ejection fraction and in risk stratification in older patients with cardiovascular disease.

Approach to decongestion therapy in patients with acute decompensated heart failure: the echocardiography guided strategy

Goal The E / (Ea×Sa) index is an echocardiographic parameter to determine a patient's left ventricular filling pressure. This study aims to determine the safety and efficacy of the echocardiographic E / (Ea×Sa) index guided diuretic therapy compared to urine output (conventional) guided diuretic treatment.Material and Methods In this cross-sectional study, patients with heart failure with reduced ejection fraction (HFrEF) who were hospitalized due to acute decompensation episode were consecutively allocated in a 1:1 ratio to monitoring arms. The diuretic dose, which provided 20 % reduction in the E / (Ea×Sa) index value compared to initial value, was determined as adequate dose in echocardiography guided monitoring group. The estimated glomerular filtration rate (eGFR), change in weight, NT pro-BNP level and dyspnea assessment on visual analogue scale (VAS) were analyzed at the end of the monitoring.Results Although the similar doses of diuretics were used in both groups, the patients with E / (Ea×Sa) index guided strategy had the substantial lower NT pro-BNP level within 72 hours after diuretic administration (2172 vs.2514 pg / mL, p= 0.036). VAS score on dyspnea assessment was significantly better in the patients with E / (Ea×Sa) index guided strategy (52 vs. 65; p= 0.04). And, in term of body weight loss (4.93 vs.5.21 kg, p=0.87) and e-GFR (54.58±8.6 vs. 52.65±9.1 mL / min / 1.73 m2p=0.74) in both groups are associated with similar outcomes. In both groups, there was no worsening renal function and electrolyte imbalance that required stopping or decreasing loop diuretic dosing.Conclusions The E / (Ea×Sa) index guidance might be a safe strategy for more effective diuretic response that deserves consideration for selected a subgroup of acute decomposed HFrEF patients.

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.

Value of Index Beat in Evaluating Left Ventricular Systolic and Diastolic Function in Patients with Atrial Fibrillation: A Dual Pulsed-Wave Doppler Study

Atrial fibrillation (AF) poses challenges in use of the echocardiogram to assess left ventricular (LV) function. The index beat method has been found to agree well with the average method. We aimed to assess the value of the index beat method in evaluation of LV function using the dual pulsed wave Doppler technique. Peak early diastolic mitral inflow velocity (E) and diastolic (e') and systolic (s') mitral annulus velocity were simultaneously obtained and measured beat-to-beat in patients with AF. The index beat s' exhibited the best correlation (r = 0.96 and 0.92, respectively, for septal and lateral wall, both p values = 0.000) with the mean, while E/e' at the pre-index beat, rather than at the index beat-initiated cycle, had the best correlation with the mean (r = 0.88 for septal and 0.97 for lateral wall, both p values = 0.000).