Echocardiographic predictors of change in left ventricular diastolic pressure in heart failure patients receiving nesiritide

Background: To evaluate the usefulness of currently accepted echocardiographic parameters of diastolic function to assess the acute change in left ventricular end‐diastolic pressure (LVEDP) following the administration of nesiritide in a heart failure population. Methods: In 25 heart failure patients (15 with systolic dysfunction, 10 with preserved ejection fraction [EF]), Doppler echocardiography, right and left heart catheterization, and invasive biventricular pressure hemodynamics were obtained at baseline and 30 minutes after nesiritide infusion. Results: Twenty‐four patients had sufficient echocardiographic images for analysis. The mean age was 60 ± 11 years, 48% were male, 56% had coronary artery disease, and 64% had hypertension. Right ventricular systolic pressure (RVSP) had the highest correlation with LV filling pressure: pulmonary capillary wedge pressure (PCWP), pre‐A wave LV, and LVEDP (r = 0.66, P = 0.0009; r = 0.63, P = 0.002; r = 0.72, P = 0.0002, respectively). Following nesiritide administration, the mean PCWP decreased from 17.1 ± 7.8 mmHg at baseline to 9.6 ± 6.2 mmHg (P < 0.001). Change in RVSP had the highest correlation with change in PCWP (r =?0.67, P = 0.10) and change in LVEDP (r =?0.71, P = 0.07). Conclusion: Echocardiographic parameters are frequently assessed in attempts to estimate left heart diastolic pressures. In heart failure patients, RVSP appears to be the best predictor of LVEDP, outperforming tissue Doppler E/E′. RVSP was found to be the best echocardiographic predictor of change in LV filling pressure with intravenous vasodilator therapy in heart failure patients. RVSP may provide a noninvasive means of assessing response to cardiac therapy.     

Mismatch between arterial stiffness increase and left ventricular diastolic dysfunction

Previous studies which included patients with preserved left ventricular (LV) systolic function demonstrated that arterial stiffness progressively increased as LV diastolic function decreased. However, it was unknown whether this correlation was still present in a heterogeneous study population involving patients with a wide range of LV systolic function. Seventy-five patients with depressed LV systolic function were consecutively included and 192 patients with preserved LV systolic function were randomly selected from subjects arranged for echocardiography examination. Brachial–ankle pulse wave velocity (baPWV) was measured using an ABI-form device. Of the 267 subjects (mean age 58 ± 14 years) included in the study, 105 had normal diastolic function, 74 had impaired relaxation, and 60 had pseudonormal and 28 restrictive diastolic dysfunction. BaPWV was only lower in patients with normal diastolic function than in those with abnormal diastolic function (p ≤ 0.001). It did not gradually rise as diastolic dysfunction grade increased. Multivariate analysis showed that increased age and systolic blood pressure and decreased LV ejection fraction, transmitral A velocity, and left atrial volume index (p ≤ 0.039) were correlated with increased baPWV. Our study showed that there were no positive correlation between echocardiographic LV diastolic parameters and baPWV. BaPWV did not progressively rise with increasing LV diastolic dysfunction grade. Therefore, patients with advanced LV diastolic dysfunction may not have increased arterial stiffness.     

Pulmonary Venous Flow and Correlates in Patients with Aortic Stenosis

In order to determine the value of pulmonary venous flow (PVF) pulsed Doppler measurements in assessing filling pressures in aortic stenosis (AS), we studied 20 patients by transthoracic and transesophageal echocardiography and catheter examination. Peak systolic PVF correlated with pulmonary capillary wedge pressure (PCWP) (r =-0.67, P < 0.01), the ratio of peak systolic to diastolic PVF correlated with PCWP (r =-0.68, P < 0.01) and left ventricular end-diastolic pressure (r =-0.51, P < 0.01). Peak systolic PVF < 40 cm / sec was highly sensitive and specific in the detection of PCWP ≥ 15 mmHg (100% and 84%, respectively). Correlations between PVF and pulsed Doppler transmitral indices were also found (r = 0.66 between peak systolic to diastolic PVF and peak late transmitral velocity, P < 0.01); however, PVF indices predicted filling pressures better than Doppler transmitral indices. In conclusion PVF indices are accurate predictors of high filling pressures in AS patients.     

Elevation of plasma brain natriuretic peptide is a hallmark of diastolic heart failure independent of ventricular hypertrophy

OBJECTIVES: We tested a hypothesis that elevation of the plasma level of brain natriuretic peptide (BNP) is one of the characteristics of patients with diastolic heart failure (DHF) independent of left ventricular (LV) hypertrophy. BACKGROUND: The clinical characteristics of DHF are not well acknowledged, although DHF has become a great social burden. Such a lack of clinical information leads to inaccuracy in the diagnosis of DHF. We have demonstrated enhancement of ventricular production of BNP with progression of maladaptive ventricular hypertrophy, but not with development of compensatory hypertrophy in an animal DHF model. METHODS: Of 372 patients who presented to the emergency department because of acute pulmonary congestion without acute coronary syndrome between January 1996 and May 2002, those with an ejection fraction > or =45% upon admission, who were stably controlled at least for a year in our outpatient clinics, comprised the DHF group (n = 19). A control group consisted of 22 hypertensive patients with a LV mass index greater than or equal to its minimum value of the DHF group and an ejection fraction > or =45%, in whom cardiac symptoms had not occurred. RESULTS: Despite a similar distribution of LV mass index, the BNP level was higher in the DHF group than in the control group (149 +/- 38 vs. 31 +/- 5 pg/ml, p < 0.01). There was no difference in LV cavity size or parameters derived from pulsed Doppler transmitral flow velocity curves. CONCLUSIONS: An elevation of BNP may be a hallmark of patients with or at risk of DHF among subjects with preserved systolic function independent of LV hypertrophy.     

Clinical Significance of Positive Isovolumetric Relaxation Velocity of Pulsed-Wave Tissue Doppler Imaging

Objective: Among the pulsed-wave tissue Doppler imaging (pw-TDI) parameters, there are two different pw-TDI velocities (IVRa and IVRb) after systolic velocity, but before Ea velocity. In our study, we investigated the clinical importance of these two velocities in left ventricular diastolic dysfunction (LVDDF) evaluation. Methods: One hundred and eighty cases without exclusion criteria were included in the study. Cases with a transmitral E to A flow (E/A) ratio below 1 were assigned to group 2. In cases with an E/A ratio between 1 and 2, the pw-TDI parameters were taken into consideration. Cases with an Ea/Aa ratio above 1 were assigned to group 1 and cases with an Ea/Aa ratio 1 or below than 1 were assigned to group 3. Group 1 (n: 68) represented normal diastolic left ventricular (LV) inflow while group 2 (n = 87) represented impaired relaxation and group 3 (n = 25) represented pseudonormal LV inflow. Results: In our study, we found that IVRa velocity was lower in group 1 compared to group 2 and group 3 (P < 0.001 and P = 0.038, respectively). Similarly, this velocity was significantly different in group 3 and group 2 such as it was higher in group 2 compared to group 3 (P = 0.022). There was no difference in IVRb velocity and IVRa/IVRb ratio among the groups. A negative correlation was found between IVRa velocity and Ea velocity (r = 44%, P < 0.001). Positive correlation was found between IVRa velocity and isovolumetric relaxation time (r = 18%, P = 0.014) and also between IVRa velocity and Aa velocity (r = 19%; P = 0.010). Conclusion: Based on the results of our study, we concluded that IVRa velocity is an important pw-TDI parameter in the evaluation of LVDDF, especially in differentiating pseudonormal LVDDF type from normal LV inflow.     

Postoperative outcome in aortic stenosis with diastolic heart failure compared to one with depressed systolic function

BACKGROUND: In patients with aortic stenosis (AS), the clinical outcome worsens after the development of angina, syncope, and heart failure. This study was performed to elucidate whether the outcome with AS was also poor in patients with diastolic heart failure. METHODS AND RESULTS: Fifty-two patients who had undergone aortic valve replacement (AVR) for AS were retrospectively classified into 3 groups (G) on the basis of LV ejection fraction (EF) and pulmonary wedge pressure (PWP): G-1) normal LVEF, low PWP (EF > or = 45% and PWP < 16 mmHg; n = 35), G-2) normal LVEF, high PWP (EF > or = 45% and PWP > or = 16 mmHg; n = 8), and G-3) low LVEF (EF < 45%; n = 9). Among these 3 groups, we compared the outcome after AVR. None of the patients died after the operation in AS with preserved LVEF irrespective of the PWP, whereas there were 3 cardiac deaths in AS with low EF irrespective of the PWP. CONCLUSIONS: In patients with AS, diastolic heart failure developed in addition to systolic heart failure. The development of LV systolic dysfunction in AS was regarded as poor during the postoperative course, but diastolic heart failure did not affect the outcome. The occurrence of heart failure with preserved systolic function may have a slightly better prognosis and may still be suitable for AVR.     

Determination of Left Ventricular Filling Pressure by Doppler Echocardiography in Patients With Coronary Artery Disease: Critical Role of Left Ventricular Systolic Function

Objectives. This study was designed to determine the usefulness of transthoracic Doppler measurements in detecting increased left ventricular (LV) end-diastolic pressure in patients with coronary artery disease, specifically examining the influence of systolic function on the accuracy of these methods.

Background. Studies that have correlated Doppler indexes with LV filling pressures primarily involved patients with LV systolic dysfunction. The reliability of Doppler indexes in estimating filling pressures in patients with coronary artery disease and preserved systolic function is unclear.

Methods. Pulsed wave Doppler transmitral and pulmonary venous flow velocity curves and LV pressure were recorded in 83 patients with coronary artery disease.

Results. Conventional Doppler indexes (deceleration time of mitral E wave velocity, ratio of peak mitral E to A wave velocities and pulmonary venous systolic fraction) correlated with LV filling pressure in patients with an ejection fraction (EF) ≤50% but not in those with an EF >50%. Previously published regression analysis for prediction of LV filling pressure was accurate in patients with an EF ≤50% but not in those with an EF >50%. The difference between flow duration with atrial contraction in the pulmonary veins and transmitral flow duration with atrial contraction correlated with LV filling pressure in both groups.

Conclusions. Analysis of the early diastolic portion of the transmitral or pulmonary venous flow velocity curves can be used to predict LV filling pressures in patients with systolic dysfunction, but are inaccurate in patients with preserved systolic function. The combined analysis of both flow velocity curves at atrial contraction is a reliable, feasible predictor of increased LV filling pressure, irrespective of systolic function.     

Longitudinal myocardial dysfunction in healthy older subjects as a manifestation of cardiac ageing

BACKGROUND: Abnormalities of longitudinal left ventricular (LV) contraction and relaxation may be early markers of cardiac disease. This study was designed to assess the relationship between long-axis LV function and age in healthy subjects. METHODS: 118 healthy individuals aged 57 +/-19 years (range 20-90 years) with no evidence of cardiovascular disease under-went echocardiography with Doppler examination of transmitral flow. To assess longitudinal LV function, systolic (S(m)), early diastolic (E(m)) and late diastolic (A(m)) mitral annular velocities were measured using colour-coded tissue Doppler imaging. RESULTS: The left atrium was enlarged (P<0.001) in subjects >/=60 years of age compared to those <60 years, but there were no differences in LV volumetric indices and ejection fraction. Peak E velocity was lower (P<0.001) and peak A velocity of transmitral flow was higher in older subjects (P<0.001) with a higher E/A ratio (P<0.001) and longer isovolumic relaxation time (P= 0.001) indicative of impaired ventricular relaxation. S m and E m mitral annular velocities decreased (P<0.001) and A m velocity increased (P=0.002) in the older group. E m velocity and E m /A m ratio showed a strong negative correlation with age (r= -0.80, P<0.001 and r=-0.78, P<0.001, respectively). CONCLUSIONS: Global LV systolic function is preserved but the velocity of long-axis systolic shortening is depressed in older individuals, indicating selective impairment of the longitudinal component of systolic contraction. The decline in the velocity of early diastolic long-axis LV lengthening and the changes in the pattern of transmitral flow suggest impaired ventricular relaxation. These measures of cardiac function may be a useful index of normal cardiac ageing.     

超声心动图对老年舒张性心力衰竭患者心脏结构和功能改变的评价

目的通过超声心动图检查探讨老年舒张性心力衰竭(diastolic heart failure,DHF)患者心脏结构及舒张和收缩功能的变化情况。方法对129例老年DHF患者(DHF组)和79例年龄匹配的健康老年人(对照组)进行超声心动图检查,测量左心室容积、左心房容积、左心室质量,获取二尖瓣血流、右上肺静脉血流频谱,用组织多普勒测量二尖瓣环心室长轴方向的收缩期心肌峰值运动速度(Sm)、舒张早期心肌峰值运动速度(Em)等值,并进行分析。结果与对照组比较,DHF组患者左心室舒张末容积指数轻度增大,左心室质量指数明显增大,左心房容积指数明显增大,Sm和Em均明显下降,差异均有统计学意义(P0.01)。相关分析显示,Sm与左心室质量指数独立相关(β=-0.018,P0.01),左心房容积指数与老年DHF患者舒张功能不全程度独立相关(β=0.002,P0.01)。结论老年DHF患者总体表现为显著的向心性增厚,左心房的大小与舒张功能受损程度相关;收缩与舒张功能的损害,可能共同参与老年DHF发生和发展的过程。     

Noninvasive prediction of the exercise-induced elevation in left ventricular filling pressure in post-heart transplant patients with normal left ventricular ejection fraction

OBJECTIVES:

At present, there are conflicting data on the ability of echocardiographic parameters to predict the exercise-induced elevation of left ventricular (LV) filling pressure. The purpose of the present study was to validate the ratio of early diastolic transmitral (E) to mitral annular velocity (e′) obtained at peak exercise in its capacity to determine the exercise-induced elevation of pulmonary capillary wedge pressure (PCWP) and to reveal new noninvasive parameters with such capacity.

METHODS:

Sixty-one patients who had undergone heart transplantation with normal LV ejection fraction underwent simultaneous exercise echocardiography and right heart catheterization.

RESULTS:

In 50 patients with a normal PCWP at rest, exercise E/e′ ≥8.5 predicted exercise PCWP ≥25 mmHg with a sensitivity of 64.3% and a specificity of 84.2% (area under the curve [AUC]=0.74). A comparable or slightly better prediction was achieved by exercise E/peak systolic mitral annular velocity (s′) ≥11.0 (sensitivity 79.3%; specificity 57.9%; AUC=0.75) and exercise E/LV systolic longitudinal strain rate ≤−105 cm (sensitivity 78.9%; specificity 78.6%; AUC=0.87). Combined, exercise E/s′ and exercise E/e′ resulted in a trend toward a slightly more precise prediction (sensitivity 53.6%; specificity 89.5%; AUC=0.78) than did either variable alone.

CONCLUSIONS:

Exercise E/e′, used as a sole parameter, is not sufficiently precise to predict the exercise-induced elevation of PCWP. Exercise E/s′, E/LV systolic longitudinal strain rate or combinations of these parameters may represent further promising possibilities for predicting exercise PCWP elevation.     

Diastolic and systolic heart failure: Different stages or distinct phenotypes of the heart failure syndrome?

It remains uncertain if diastolic heart failure (DHF) is a distinct HF phenotype or a precursor stage of systolic HF (SHF). The unimodal distribution of left ventricular ejection fraction (LVEF) in HF, depressed LV long-axis shortening in DHF, and progression to eccentric LV remodeling in hypertension favor DHF and SHF as successive stages. These arguments are countered by the bimodal distribution of LVEF after correction for gender, by the preserved LV twist in DHF and by the low incidence of eccentric LV remodeling in hypertension. Clinical features, LV anatomy and histology, cardiomyocyte stiffness, myocardial effects of diabetes, and the response to HF therapy support DHF and SHF as distinct phenotypes. Comparison of the myocardial signal transduction cascades that drive LV remodeling in DHF and SHF may solve the controversy. This review analyzes arguments supporting DHF and SHF as successive stages or distinct phenotypes of the HF syndrome.     

Evaluation of Subendocardial and Subepicardial Left Ventricular Functions Using Tissue Doppler Imaging after Complete Revascularization

Objective: We aim to evaluate subepicardial and subendocardial left ventricular (LV) functions in patient single coronary artery lesion at early stage after percutaneous coronary intervention (PCI). Additionally, a comparison of LV functions between patients and control cases was aimed. Method: Patients with culprit left anterior descending (LAD) lesion (n = 25) and subjects with normal coronary angiography (n = 25) were evaluated. Patients underwent PCI and at least one coronary stent was placed. After PCI, the pulsed-wave tissue Doppler imaging (pw-TDI) parameters taken from subepicardial and subepicardial layers were compared among the patients. Results: Left atrium (P = 0.050), LV end-diastolic (P = 0.049), and end-systolic (P = 0.006) diameters were larger compared to the control group. LV inflow velocities were not different between the patient and the control group. But, the myocardial performance index was different (P = 0.049). The systolic and diastolic pw-TDI parameters were apparently different between the patient and the control group. While the systolic pw-TDI parameters did not change, the diastolic pw-TDI parameters taken from both subepicardial (circumferential contraction) and subendocardial layers (longitudinal contraction) improved after PCI. After PCI, it was shown that while Ea velocity (P = 0.012) taken from the subendocardial layer increased, IVRa velocity (P < 0.001) taken from the subepicardial layer decreased. Conclusion: In our study, it could be said that LV, left atrium, and aortic valve diameter increase in patients with coronary artery disease. The systolic and diastolic functions were impaired at subendocardial and subepicardial layers. These dysfunctions can be easily presented with pw-TDI. Although systolic dysfunction persists, diastolic dysfunction improves at early stage after PCI.     

Assessment of left atrial input impedance in normal subjects and in hypertensive patients

BACKGROUND: To assess left atrial (LA) input impedance in patients with signs and/or symptoms of heart failure and normal left ventricular ejection fraction, transesophageal Doppler pulmonary venous (PV) flow velocity and pulmonary capillary wedge pressure (PCWP) were studied in 20 patients and compared to 20 matched normal controls. METHODS: LA impedance was calculated as the ratio of harmonic terms of the PCWP (measured by right heart catheterization) to the corresponding harmonic terms of PV flow (measured by transesophageal Doppler echocardiography). Eight harmonics were analyzed. RESULTS: Left ventricular mass index (LVMI, p<0.001), heart rate (p<0.05), systolic and diastolic blood pressure (p<0.001), isovolumic relaxation time (IVRT, p<0.001), peak A transmitral flow velocity (p<0.001), peak reversal atrial PV flow velocity (p<0.001) and LA diameter (p<0.001) were increased in patients compared to controls. Spectra of impedance moduli were displaced upwards and to the right. The increase in the impedance moduli was observed at all frequencies of the first to seventh harmonic components (p<0.001). In multivariate tests LVMI (p=0.003), IVRT (p=0.001), and LA diameter (p=0.007) had a significant effect on all harmonic components of the impedance moduli (adjusted R2=0.970 to 0.999, p<0.001). CONCLUSIONS: LA input impedance derived from data obtained invasively and semi-invasively represents left ventricular diastolic function. Resistance to left ventricular filling is increased in hypertensive patients.     

Clinical value of B-type natriuretic peptide for the assessment of left ventricular filling pressures in patients with systolic heart failure and inconclusive tissue Doppler indexes

Invasive hemodynamic monitoring with Swan-Ganz catheterization to guide treatment decisions in heart failure may be hazardous and may lack prognostic value. We assessed the clinical utility of B-type natriuretic peptide (BNP) in estimating left ventricular filling pressures in patients with inconclusive tissue Doppler indexes. In this study, 50 patients with systolic heart failure and an early transmitral velocity to early diastolic mitral annular velocity ratio (E/Ea) between 8 and 15 were studied. Among them, 25 had been admitted for acutely decompensated heart failure (group A) and the remainder were clinically stable outpatients (group B). All patients underwent simultaneous invasive pulmonary capillary wedge pressure (PCWP) determination, BNP measurement, and echocardiography. In group A, BNP correlated with PCWP (r = 0.803, P < 0.001), deceleration time (DT, r = -0.602, p = 0.001), and end-systolic wall stress (SWS, r = 0.565, P = 0.003). In multivariate analysis, BNP was the only parameter independently associated with PCWP (P = 0.023). In group B, no correlation was found between BNP and PCWP or SWS, while DT correlated significantly with both PCWP (r = -0.817, P < 0.001) and BNP (r = -0.8, P < 0.001). We conclude that BNP may be a useful noninvasive tool for the assessment of left ventricular filling pressures in patients with acutely decompensated heart failure and inconclusive tissue Doppler indexes.     

Early predictors of alterations in left atrial structure and function related to left ventricular dysfunction in asymptomatic patients with hypertension

Our aim was to investigate the relationships between left atrial (LA) structural and functional changes and left ventricular (LV) dysfunction related to LV pressure overload in asymptomatic patients with hypertension. One hundred and twenty-six asymptomatic patients with hypertension and LV ejection fraction (EF) ≥60% were studied. Conventional, pulsed and tissue Doppler, and two-dimensional speckle-tracking echocardiography (2DSTE) were performed to seek the independent determinants for alterations in LA structure and function. LA volume index (LAVI) correlated with age, body mass index (BMI), end-diastolic ventricular septal thickness (VSth), end-diastolic LV posterior wall thickness, relative LV wall thickness (RWT), LV mass index, peak A velocity of transmitral flow, E/e’, and peak systolic and early diastolic LA strains and strain rates. Peak LA strain during ventricular systole (S-LAs) correlated with age, BMI, heart rate (HR), end-systolic LV diameter, LAVI, VSth, RWT, LVEF, e’, E/e’, peak systolic LV radial strain, and peak early diastolic LV longitudinal strain rate. Multivariate regression analyses indicated that LV mass index, peak A velocity, E/e’, and S-LAs are defined as strong predictors related to LAVI, and that BMI, HR, LAVI, and peak systolic LV radial strain are defined as strong predictors related to S-LAs. In conclusion, 2DSTE demonstrated that alterations in LA structure and function are mainly associated with LV diastolic and systolic dysfunction, respectively, in preclinical patients with hypertension.     

Correlation of Tei index obtained from tissue Doppler echocardiography with invasive measurements of left ventricular performance

BACKGROUND: The aim of this study is to correlate Tei index obtained from tissue Doppler echocardiography (TDE-Tei index) defined as the ratio of the sum of isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT) over the ejection time (ET) with invasive measurements of left ventricular (LV) performance. METHODS: Thirty-four patients who underwent an echocardiographic examination and cardiac catheterization were studied. Invasive measurements of peak +dp/dt, peak -dp/dt, and isovolumic relaxation constant of the left ventricle (tau) were obtained from a micromanometer-tipped catheter. RESULTS: After a multivariate analysis, TDE-Tei index had a negative correlation with ejection fraction (EF) (beta=-0.384, P = 0.046) and positive correlation with tau (beta= 0.397, P = 0.040). ET had a negative correlation with heart rate (beta=-0.446, P = 0.005) and positive correlation with EF (beta= 0.379, P = 0.015). ICT + IRT had a positive correlation with tau (beta= 0.512, P = 0.002). ICT/ET had a negative correlation with EF (beta=-0.657, P < 0.001) and positive correlation with peak early transmitral filling wave velocity (beta= 0.385, P = 0.001). IRT/ET had a positive correlation with tau (beta= 0.402, P = 0.018). CONCLUSIONS: TDE-Tei index exerts a correlation both with accepted indices of LV systolic and diastolic function acquired by cardiac catheterization. Hence, TDE-Tei index is a simple and feasible indicator in assessing overall LV function.     

Effects of carvedilol on left ventricular remodeling and systolic function in elderly patients with heart failure

BACKGROUND: Recent studies have shown that carvedilol therapy in patients with heart failure improves clinical outcome and survival, however, the effects of such treatment on left cardiac morphology and function in elderly patients with severe heart failure has not been widely studied. AIM: The purpose of this study was to establish the effect of carvedilol at short- and long-term on left ventricular size and performance with mono- and two-dimensional echocardiography, in subjects with dilated cardiomyopathy, NYHA III functional class, low LV ejection fraction (EF < 35%) and mean age of > 70 years. METHODS: We studied 48 patients, previously randomized to treatment with either carvedilol or placebo, and we performed echocardiographic evaluation at the start, and after 3 and 12 months. Left ventricular diameters, LV mass and fractional shortening were calculated by Deveraux formula; left ventricular volumes and ejection fraction were measured by area-length formula; pulmonary pressure was calculated by tricuspid reflow. RESULTS: After 3 months, only LV end-diastolic diameter was lower in the carvedilol group compared to the placebo group. Nevertheless, after 12 months, patients on carvedilol treatment showed a LV geometric and functional improvement compared to placebo. We found significant differences in: diastolic (P < 0.01) and systolic diameters (P < 0.001); on LV mass (P < 0.002); on LV systolic volume (P < 0.03); and on LV ejection fraction (P<0.01). Pulmonary pressure was also reduced in beta-blocker subjects (P < 0.001). CONCLUSIONS: Carvedilol therapy for 12 months reduced LV diameters and volumes. Thus, improving cardiac remodeling and LV systolic function in elderly patients with severe heart failure. Several months of therapy are required for these favorable effects to occur, as these changes do not occur in the short term.     

Speckle tracking global strain rate E/E' predicts LV filling pressure more accurately than traditional tissue Doppler E/E'

Background: The ratio of early diastolic transmitral flow velocity (E) to tissue Doppler (TD) mitral annular early diastolic velocity (E/E′_VEL‐TD) has been widely used for the noninvasive assessment of LV diastolic filling pressures. However, it has been reported that E/E′_VEL‐TD is not accurate particularly when being applied to patients with advanced heart failure. Methods: Fifty‐six ICU patients with decompensated heart failure underwent simultaneous echocardiography and PCWP measurements. Patients with elevated PCWP (n = 41) were compared with patients normal PCWP (n = 15) as well as age‐matched healthy controls (n = 32). In the apical 4‐chamber view, the ratio of E to speckle tracking (ST) mitral annular velocity (E/E′_VEL‐ST) and early diastolic global LV longitudinal strain rate (E/E′_SR‐ST) were evaluated as new surrogate markers of elevated PCWP. Results: Correlations with PCWP were observed for speckle tracking derived E/E′_VEL‐ST (r = 0.40,P = 0.002) and E/E′_SR‐ST (r = 0.56, P < 0.001), although the traditional E/E′_VEL‐TD did not show a significant correlation (r = 0.23, P = 0.082). Compared with controls, patients with elevated PCWP had significant increases in all variables. The best cutoff values and diagnostic accuracies for identifying elevated PCWP were E/E′_VEL‐TD>12 (Sensitivity/Specificity/area under the ROC curve: 0.58/0.90/0.78), E/E′_VEL‐ST > 14 (0.60/0.85/0.80), and E/E′_SR‐ST > 93 (0.80/0.88/0.89). Conclusion: Speckle tracking derived E/E′_SR‐ST may be a robust surrogate marker of elevated LV filling pressure. In ICU patients, E/E′_SR‐ST showed better correlation with PCWP and higher diagnostic accuracy than the tissue Doppler approach. (Echocardiography 2012;29:404‐410)     

Contribution of systolic and diastolic abnormalities to heart failure with a normal and a reduced ejection fraction

Heart failure (HF) has traditionally been divided into HF with a reduced ejection fraction (EF; systolic HF) and HF with a normal EF (diastolic HF). Both groups have reductions in exercise tolerance, neurohumoral activation, and abnormal left ventricular (LV) filling dynamics and impaired relaxation. Although the normal EF indicates that pump performance is adequately compensated, some of the patients with HF and a normal EF have reduced longitudinal systolic velocity indicating cardiac muscular contractile dysfunction. Regardless of EF, the severity of HF and its prognosis and degree of exercise intolerance are closely related to the degree of diastolic filling abnormalities. Patients with HF and a reduced EF have ventricular dilatation and elongated myocytes, whereas patients with HF and a normal EF do not. Thus, patients with HF have diastolic abnormalities regardless of EF and many patients with HF and a normal EF have contractile abnormalities despite preserved systolic pump performance. Heart failure with a normal EF and a reduced EF differs in the systolic LV pump performance and the type of remodeling. The mechanism of the differing remodeling responses is not known, but aging, sex differences, and diabetes may contribute.     

Subclinical left ventricular longitudinal systolic dysfunction in hypertension with no evidence of heart failure

BACKGROUND: The prevalence of subclinical left ventricular (LV) systolic dysfunction in asymptomatic hypertensive patients was determined using tissue Doppler imaging (TDI). METHODS AND RESULTS: TDI-derived mitral annular velocities were acquired in 35 control subjects, 92 asymptomatic hypertensive patients with no heart failure (HHD), and 15 patients with diastolic heart failure (DHF). No significant intergroup differences in LV ejection fraction were noted. Peak systolic annular velocity was significantly reduced in the DHF group compared with the control and HHD group. Using peak systolic velocity <6.1 cm/s as a cut-off value for abnormal velocity, 10% of HHD patients and 53% of DHF showed impaired LV longitudinal systolic velocity. Peak early diastolic annular velocities were significantly reduced in both the HHD and DHF groups compared with the control group. With multivariable regression analysis, peak early and late diastolic annular velocities, female gender and deceleration time of the E wave velocity were selected as independent predictors for peak systolic annular velocities. CONCLUSIONS: Systolic long-axis LV function was impaired in 10% of asymptomatic hypertensive patients. Its reduction was closely correlated with impaired diastolic function. Assessment of LV longitudinal function by TDI plays an important role in identifying diastolic dysfunction and subclinical LV systolic dysfunction in asymptomatic hypertensive patients.