Pioglitazone improves left ventricular diastolic function in patients with essential hypertension

BACKGROUND: Left ventricular (LV) hypertrophy and diastolic dysfunction, which are common cardiac consequences of hypertension, are modified by insulin resistance. The present study assessed the hypothesis that primary treatment of insulin resistance may reverse such cardiac changes in hypertensive patients. METHODS: A total of 30 patients with essential hypertension were enrolled in this study. In echocardiographic examinations, LV mass index, the peak velocity ratio of early diastolic to atrial filling (E/A), and the E-wave deceleration time (DcT) were determined. Insulin sensitivity test with steady-state plasma glucose (SSPG) method, oral glucose tolerance test, and blood samplings for measurement of adiponectin and matrix metalloproteinase (MMP)-2 were also performed. Six months after treatment with pioglitazone (30 mg/day), an insulin sensitizer, these examinations were repeated. RESULTS: Pioglitazone significantly increased E/A and decreased DcT, without a change in LV mass index. These improvements in diastolic properties were much greater in subjects with a marked (>or==3.3 mmol/L) decrease in SSPG (n=11) than the others (n=19), although the decrease in glucose levels did not differ between the two groups. In addition, the changes in E/A and DcT were closely correlated with the decrease in SSPG. Pioglitazone treatment significantly elevated plasma adiponectin and MMP-2 levels, and the increase in MMP-2 was positively correlated with the increase in adiponectin. CONCLUSIONS: The present findings demonstrate that pioglitazone improves LV diastolic function without LV mass regression in hypertensive patients in proportion to the amelioration of insulin resistance. These findings suggest that increased adiponectin and MMP may be involved in the beneficial effect of pioglitazone on diastolic function.     

Fasting plasma glucose is an independent determinant of left ventricular diastolic dysfunction in nondiabetic patients with treated essential hypertension.

Left ventricular (LV) hypertrophy and LV diastolic dysfunction are common cardiac changes in hypertensive patients, and these changes are modified by various factors other than blood pressure. The present study was conducted to investigate the influence of mild abnormalities in glucose metabolism on LV structure and function in essential hypertension. In 193 nondiabetic patients with treated essential hypertension, two-dimensional and Doppler echocardiographic examinations were performed, and relative wall thickness (RWT), LV mass index (LVMI), fractional shortening, and the ratio of the peak velocity of atrial filling to early diastolic filling (A/E) were calculated. Fasting plasma glucose (FPG) and HbA1c levels were positively correlated with the A/E ratio and the deceleration time of the E wave. However, these plasma levels had no correlation with RWT, LVMI, or fractional shortening. Peak A wave velocity and the A/E ratio were significantly higher in patients who had FPG of > or = 100 mg/dl (and <126 mg/dl) than those who had FPG of <100 mg/dl, although age, blood pressure, RWT, LVMI, and fractional shortening did not differ between the two groups. In a multiple regression analysis of all subjects, only FPG and age were independent determinants of the A/E ratio. These observations suggest that FPG is a sensitive predictor for LV diastolic dysfunction in nondiabetic patients with treated hypertension. Since a slight increase in plasma glucose levels is associated with abnormalities in diastolic function independent of LV hypertrophy, an early stage of impaired glucose metabolism in hypertensive patients may specifically deteriorate cardiac diastolic function.     

Factors of Importance to Doppler Indexes of Left Ventricular Filling in 50-Year-Old Hypertensive Persons

Altered left ventricular (LV) diastolic filling has been shown in subjects with hypertension. Age is a major determinant of Doppler indexes of LV diastolic filling; therefore, a group of subjects of uniform age should preferably be chosen, if other determinants of diastolic LV filling are to be studied. A limited body of data is available regarding Doppler indexes of LV filling in hypertensive persons of a similar age. We therefore evaluated 26 hypertensive subjects (13 women and 13 men) 50 years old by Doppler echocardiography. The peak velocity of early diastolic filling (E wave), the peak velocity of atrial filling (A wave), the early-to-atrial peak velocity (E/A) ratio, and the deceleration time of early velocity were measured. The peak E wave velocity was 0.76 ± 0.11 versus 0.62 ± 0.13 m/s (P < 0.005), and the E/A ratio was 1.11 ± 0.24 versus 0.93 ± 0.23 (P < 0.05) in hypertensive women and men, respectively. The peak A wave velocity was increased and the E/A ratio was decreased in both hypertensive women and men compared with healthy 50-year-old subjects. In multivariate analyses, LV diameter, body mass index, and gender correlated with the E/A ratio in hypertensive persons. It is concluded that there is a significant difference in Doppler LV filling indexes between 50-year-old hypertensive women and men. LV diameter, gender, and body mass index are independent determinants of LV diastolic inflow in similarly aged hypertensive persons.     

Left ventricular hypertrophy differences in male professional runners and in young patients suffering from mild hypertension

AIMS: This study was executed to evaluate left ventricular (LV) geometry, diastolic and systolic function assessed by B- and M-mode and pulsed Doppler echocardiography in a group of professional sprinter runners (group I), in young patients suffering from mild hypertension (group II) and in control young adults (group III). Twenty-one male sprinter runners were checked during a period of training and compared with 19 young patients suffering from mild hypertension and 15 healthy controls matched for gender and body size. FINDINGS: LV septum thickness, LV posterior wall thickness, LV ejection fraction, LV shortening fraction, midwall fractional shortening and stroke volume were significantly higher in runners compared to hypertensive patients and controls (p < 0.001). A significant increase of diastolic function parameters of the early peak flow velocity, E, and the early/late diastolic wave ratio, E/A, and in the isovolumic relaxation time or in the E velocity deceleration time wave was observed in hypertensive patients when compared to runners and controls (p < 0.05). The study of the pulmonary venous flow revealed a significant increase in the early systolic flow velocity, S, in hypertensive patients compared to runners (p < 0.05); the late diastolic flow velocity, D, appeared to be similar in all groups, while atrial backward flow velocity, Ar, was higher in group I and II respect to control (p < 0.001). CONCLUSIONS: Our data indicate that LV concentric hypertrophy in sportsmen is associated with improvement of systolic and diastolic performance, whereas diastolic dysfunction can occurs even in the early stages of hypertension in young patients, in whom an alteration in the LV filling appears even in absence of systolic dysfunction and evident concentric myocardial hypertrophy.     

Combining tissue Doppler echocardiography and B-type natriuretic peptide in the evaluation of left ventricular filling pressures: review of the literature and clinical recommendations

Tissue Doppler imaging is an echocardiographic technique that directly measures myocardial velocities. Diastolic tissue Doppler velocities reflect myocardial relaxation, and in combination with conventional Doppler measurements, ratios (transmitral early diastolic velocity/mitral annular early diastolic velocity [E/Ea]) have been developed to noninvasively estimate left ventricular (LV) filling pressure. Consequently, mitral E/Ea can help to establish the presence of clinical congestive heart failure in patients with dyspnea. However, E/Ea has a significant 'gray zone', and is not well validated in nonsinus rhythm and mitral valve disease. B-type natriuretic peptide (BNP) is a protein released by the ventricles in the presence of myocytic stretch, and has been correlated to LV filling pressure and, independently, to other cardiac morphological abnormalities. In addition, BNP is significantly affected by age, sex, renal function and obesity. Given its correlation with multiple cardiac variables, BNP has high sensitivity, but low specificity, for the detection of elevated LV filling pressures. Taking into account the respective strengths and limitations of BNP and mitral E/Ea, algorithms combining them can be used to more accurately estimate LV filling pressures in patients presenting with dyspnea.     

彩色多普勒超声检测高血压肾动脉血流指标的临床意义

目的探讨高血压患者肾动脉血流指标变化的临床意义。方法应用彩色多普勒超声检测40例正常人和75例高血压患者的双侧肾脏段动脉（SRA）及叶间动脉（IRA）的血流频谱,对两组测定指标进行比较分析。结果高血压组患者SRA、IRA的收缩期最大血流速度（Vmax）、舒张末期最小血流速度（Vmin）与对照组比较差异均无统计学意义（P〉0．05）。高血压组患者左肾、右肾的搏动指数和阻力指数与对照组比较差异均有统计学意义（P〈0．05）。结论彩色多普勒超声检测肾动脉血流指标能为临床高血压的早期诊断和评价预后提供重要依据之一。     

Correlates of diastolic filling abnormalities in hypertension: a Doppler echocardiographic study

Hypertension and aging are both associated with changes of left ventricular (LV) diastolic filling and increased LV mass. To determine whether diastolic filling abnormalities are present in hypertension independent of aging and significant hypertrophy, we studied 19 hypertensive patients following a period of 4 weeks when they were not receiving therapy and 18 normotensive subjects matched for sex, age, and LV mass. All subjects had normal systolic function and ejection fraction as assessed by radionuclide angiography. We measured peak velocity of early filling (E), late filling (A), and their ratio (E/A) by Doppler echocardiography. Filling indices were abnormal in hypertensive patients, but none of the filling indices were significantly correlated with LV mass. E was inversely related to age (r = -0.62; p less than 0.01) and diastolic blood pressure (r = 0.45; p less than 0.05) in normotensive individuals, but these correlations were not significant in hypertensive patients. E was not significantly correlated to LV mass or wall thickness. In contrast, A was influenced by septal wall thickness and blood pressure in both groups. E/A correlated inversely with age in both normal individuals (r = -0.74) and hypertensive patients (r = -0.51). These findings indicate that diastolic filling abnormalities in hypertension are not solely caused by either LV hypertrophy or by aging and therefore must be in part related to the hemodynamic load or altered myocardial or chamber properties.     

The prevalence of impaired left ventricular diastolic filling is related to the extent of coronary atherosclerosis in patients with stable coronary artery disease

AIMS: The relation between abnormal left ventricular (LV) diastolic filling and the extent of coronary atherosclerosis per se has not been described. We aimed to investigate the prevalence of impaired LV diastolic filling in patients with stable coronary artery disease (CAD) and its relationship to the number and location of coronary lesions visualized at coronary angiography. METHODS AND RESULTS: In 170 consecutive patients with stable CAD and an abnormal coronary angiogram we assessed LV diastolic filling by Doppler evaluation of the transmitral early to atrial peak flow velocity (E/A) and the systolic to diastolic ratio of the pulmonary venous peak inflow to the left atrium (S/D). Abnormal diastolic filling was defined as E/A < or =0.75, or E/A >1.0 combined with S/D < or =1.0, and was present in 41% of the patients. In patients with one-, two- and three-vessel disease the prevalence of impaired diastolic filling was 27, 30 and 49%, respectively (P = 0.026). In multiple logistic regression analysis diastolic filling was independently correlated with the number of stenotic coronary vessel areas. CONCLUSION: In patients with stable angiographically verified CAD, the prevalence of impaired diastolic filling was 41%. The prevalence increased with an increasing number of stenotic coronary artery areas independent of other variables tested, including prior myocardial infarction, LV systolic function and mitral regurgitation.     

Left ventricular diastolic function in physiologic and pathologic hypertrophy

BACKGROUND: Patients with hypertensive heart disease and left ventricular hypertrophy demonstrate an impaired left ventricular diastolic filling pattern. The aim of this study was to find out whether physiologic left ventricular hypertrophy induced by endurance training causes disturbances in left ventricular systolic and diastolic filling. METHODS: We examined 49 athletes with left ventricular (LV) hypertrophy due to endurance training, 49 patients with LV hypertrophy due to arterial hypertension, and 26 untrained healthy control subjects by conventional echocardiography. Parameters of LV diastolic filling using pulse wave and color flow Doppler were also assessed. RESULTS: All three study groups showed normal fractional shortening and mid-wall fractional shortening. Conventional echocardiography revealed a higher LV muscle mass index in the two study groups compared with the controls (athletes, 99 +/- 10 g; hypertensive patients, 95 +/- 11 g: controls: 52 +/- 7 g; P < .01 for athletes and hypertensive patients). In patients with arterial hypertension, a diastolic dysfunction consisting of a delayed relaxation pattern with a decrease in maximal early velocity of diastolic filling (0.44 +/- 0.1 m/sec) and a compensatory increase of the maximal late velocity of diastolic filling (0.53 +/- 0.1 m/sec) was demonstrated. In athletes with physiologic LV hypertrophy, a normal LV diastolic filling pattern was documented. CONCLUSIONS: Doppler echocardiographic parameters of LV diastolic function can be of diagnostic importance for discrimination between pathologic and physiologic LV hypertrophy.     

Influence of low high-density lipoprotein cholesterol on left ventricular hypertrophy and diastolic function in essential hypertension

BackgroundLeft ventricular (LV) hypertrophy and LV diastolic dysfunction, which are common cardiac changes in hypertensive patients, are modified by several nonhemodynamic (eg, genetic, neurohumoral, and metabolic) factors. However, the influence of serum lipids on these LV changes has not been sufficiently studied. Although low high-density lipoprotein (HDL) cholesterol is well known to be a major risk factor for coronary heart disease, it is unclear whether HDL cholesterol plays a role in hypertensive heart disease.MethodsIn 274 patients with treated essential hypertension, two-dimensional and Doppler echocardiography were performed, and LV mass, ratio of peak velocity of atrial filling to early diastolic filling (A to E ratio [A/E]), and deceleration time of the E-wave were evaluated. The relationship of dyslipidemia, especially low HDL cholesterol, to LV hypertrophy and diastolic function was investigated in these patients.ResultsIn a univariate regression analysis, HDL cholesterol was inversely associated with LV mass, A/E, and deceleration time. The association of HDL cholesterol with LV diastolic function was observed in both men and women. Its association with LV mass was gender-dependent, being significant only in women. Triglycerides were weakly correlated with LV mass and A/E, but total and low-density lipoprotein cholesterol had no correlations with these indices. In a multiple regression analysis, only low HDL cholesterol among several lipid levels was an independent predictor of both LV mass and LV diastolic dysfunction.ConclusionsOur findings suggest that low HDL cholesterol may unfavorably modify LV structure and diastolic function in patients with treated essential hypertension.     

Worsening of left ventricular diastolic dysfunction during exercise causes decreased exercise tolerance in hypertension

BACKGROUND: Exercise tolerance is reduced in hypertension. Hypertension affects left ventricular (LV) diastolic filling by causing abnormal relaxation and decreasing compliance. HYPOTHESIS: This study was designed to determine whether worsening of LV diastolic dysfunction during exercise causes decreased exercise tolerance in hypertension. METHODS: Left ventricular diastolic filling parameters were examined at mitral valve by Doppler echocardiography at rest and at peak exercise in hypertensive patients and were compared with those of age- and gender-matched normotensive individuals. Treadmill exercise stress test was performed according to the Bruce protocol and the exercise time was recorded. RESULTS: Exercise time was significantly shorter in the hypertensive group than that in the normotensive group (320 +/- 29 vs. 446 +/- 38 s, p 0.03). The hypertensive group demonstrated abnormal relaxation pattern of diastolic mitral inflow at rest, which became pseudonormal at peak exercise (E/A velocity ratio, rest 0.86 +/- 0.06 vs. exercise 1.19 +/- 0.09, p < 0.001). The diastolic mitral inflow pattern remained normal at peak exercise in the normotensive group. The deceleration time and the pressure half time of early mitral inflow at peak exercise were significantly shorter in the hypertensive group than those in the normotensive group (deceleration time, 182 +/- 20 vs. 238 +/- 22 ms, p 0.02: pressure half time, 54 +/- 5 vs. 70 +/- 12 ms, p 0.01). CONCLUSIONS: This study demonstrates that reduced exercise tolerance in hypertension is associated with worsening of diastolic dysfunction during exercise consistent with an increase in left atrial pressure.     

Differentiation of left ventricular diastolic dysfunction, identification of pseudonormal/restrictive mitral inflow pattern and determination of left ventricular filling pressure by Tei index obtained from tissue Doppler echocardiography

BACKGROUND: Tei index obtained from tissue Doppler echocardiography (TDE-Tei index) has an inherent advantage of recording its systolic and diastolic components simultaneously on the same cardiac cycle. The aims of this study are to evaluate whether TDE-Tei index also exerts a correlation with left ventricular (LV) systolic and diastolic function and filling pressure and to see whether it can effectively identify the pseudonormal/restrictive mitral filling pattern. METHODS: Echocardiographic examination was performed in 243 consecutive patients. These patients were classified into three groups as normal, abnormal relaxation, and pseudonormal/restrictive groups according to the transmitral E/A-wave velocity (E/A), early diastolic velocity of lateral mitral annulus (Ea) and E/Ea. RESULTS: Standard Doppler indices of LV filling such as E, A, E/A, and E-wave deceleration time had a bimodal distribution, but Ea decreased and E/Ea and TDE-Tei index increased progressively with worsening of LV diastolic function. The sensitivity and specificity of TDE-Tei index>0.51 in the discrimination of pseudonormal/restrictive filling pattern were 85% and 96%, respectively. After stepwise multiple linear regression analysis, TDE-Tei index had a significant negative correlation with Ea (beta=-0.296, P<0.001) and ejection fraction (beta=-0.293, P<0.001) and positive correlation with E/Ea (beta=0.235, P=0.001). CONCLUSIONS: TDE-Tei index increased with worsening of LV diastolic function and can effectively identify the pseudonormal/restrictive mitral inflow pattern. It also correlated with the echocardiographic parameters of LV systolic and diastolic function and filling pressure. It suggests that TDE-Tei index is a simple and feasible marker in assessing global LV function.     

Tissue Doppler imaging provides incremental prognostic value in patients with systemic hypertension and left ventricular hypertrophy

OBJECTIVES: We sought to determine the prognostic value of left ventricular (LV) mitral annular velocities measured by tissue Doppler imaging (TDI) in hypertensive patients with echocardiographic evidence of LV hypertrophy. BACKGROUND: Echo LV hypertrophy and LV geometry provide additional predictive value of all-cause mortality beyond traditional cardiovascular risk factors. Limited data exist regarding the predictive value of TDI velocities for cardiovascular risk stratification in treated hypertensive patients. METHODS: Two-dimensional and Doppler echocardiograms were obtained in 252 consecutive subjects, including 174 subjects with systemic hypertension and 78 age-matched normal subjects. The end point was cardiac death in subsequent median follow-up of 19 months. RESULTS: Nineteen patients (7.54%) died of cardiac causes. The TDI mitral annulus systolic velocity and the early diastolic mitral annular velocity (Em) were significantly lower in the non-survivors (all P < 0.001). The pseudonormal (PN) or restrictive filling pattern (RFP) was associated with cardiac mortality. The other parameters associated with cardiac mortality were LV ejection fraction, LV mass index, inter-ventricular septal wall thickness in diastole and the ratio of early mitral inflow to early myocardial velocity. In multivariate analysis, Em, inter-ventricular septal wall thickness in diastole and either PN or RFP were the strongest predictors. The addition of Em < 3.5 cm/s significantly improved the outcome of a model that contained clinical risk factors, inter-ventricular septal wall thickness in diastole > 1.4 cm and either PN or RFP (P = 0.043). CONCLUSIONS: Early diastolic mitral annulus velocity measured by TDI provides prognostic information, incremental to clinical data and standard echocardiographic variables, for risk stratification of hypertensive patients under treatment.     

Characteristics of left ventricular diastolic function in patients with hypertension]

Left ventricular (LV) diastolic filling was examined by Doppler echocardiography in 239 patients with essential hypertension and 100 normal subjects. The Doppler study showed an inverse correlation between age and early diastolic peak velocity (PVE, r-0.201, P less than 0.05) [and a positive correlation between age and late diastolic peak velocity (PVA, r = 0.202, P less than 0.05) in normal subjects. Isovolumic relaxation time and late diastolic filling time were prolonged, PVA, A/E and Ai elevated, PVE, E/A and Ei/Ai as well as total filling time decreased in patients with hypertension as compared with the values found in the normal subjects (P less than 0.05 to 0.01). The results showed definite impairement of LV diastolic function in hypertensive patients. PVA correlated positively with systolic blood pressure (r = 0.68, P less than 0.01) and modestly with left atrial dimension in the hypertensives. No significant differences were found in FS and EF between the two study populations, indicating that LV filling abnormalities may occur early in patients with hypertension, even at a time when systolic performance has not yet been affected.     

Impaired left ventricular diastolic function during isometric exercise in asymptomatic patients with hyperlipidaemia

BACKGROUND: Left ventricular (LV) diastolic dysfunction is an early sign, and may be more sensitive indicator, of ischaemic heart disease (IHD) than systolic dysfunction. METHODS: LV diastolic function was assessed during isometric exercise (IME) in 37 consecutive normotensive hyperlipidaemics (LIP), without cardiac history or symptoms. Each patient underwent a stress ECG test and 2-D echo and Doppler cardiography. During the latter, transmitral flow at rest and at peak standardised IME using handgrip was studied. From the tracings, the E/A (peak velocity of the early/atrial components), the contribution of atrial systole to LV filling (ACF), the deceleration time (DT) of the E wave and the isovolumic relaxation time (IVRT) were calculated. Results were compared to 37 age-matched normal healthy volunteers (NOR). RESULTS: Resting E/A was not different between NOR and the LIP. A significant reduction in E/A with IME was observed in LIP but not in NOR. Impaired LV filling (shown by E/A<1) was demonstrated in five patients (13%) at rest and in 20 patients (54%) at peak IME. All NOR had E/A>1 suggesting normal LV filling. Fifteen of the 30 patients with negative stress ECG test demonstrated LV diastolic dysfunction. ACF was higher in LIP than NOR and increased significantly (P<0.005) by 23% during IME. DT and IVRT in LIP were not different from NOR. In neither NOR nor LIP, were the LV diastolic functional parameters related to gender, smoking habit or levels of total cholesterol, LDL- or HDL-cholesterol or triglycerides. CONCLUSION: The prevalence of LV diastolic dysfunction in asymptomatic patients with hyperlipidaemia despite a negative stress ECG test may be evidence of early underlying pre-clinical myocardial ischaemia.     

Feasibility of tissue magnetic resonance imaging: a pilot study in comparison with tissue Doppler imaging and invasive measurement

OBJECTIVES: This research was intended to determine the feasibility of tissue magnetic resonance (MR) imaging in comparison with tissue Doppler imaging and its potential implications for the estimation of filling pressure, in comparison with invasive measurement. BACKGROUND: Evaluation of diastolic function using MR imaging is commonly confined to the study of transmitral flow. However, transmitral flow is unreliable for the estimation of left ventricular (LV) filling pressures in hypertrophy and normal systolic function. Normalizing early mitral velocity (E) for the influence of myocardial relaxation by combining E with early diastolic mitral septal tissue velocity (Ea) provides better Doppler estimates of filling pressures. METHODS: Eighteen patients with hypertensive heart disease (LV mass index: 114 +/- 21 g/m(2)), absence of valvular regurgitation, and with normal or mildly reduced systolic function (LV ejection fraction: 57.6 +/- 6.5%) referred for cardiac catheterization, underwent consecutive measurement of mitral flow and septal tissue velocities with phase-contrast MR and Doppler. These data were compared with mean pulmonary capillary wedge pressure (PCWP). RESULTS: There was a strong relation between MR (11.6 +/- 4.3) and Doppler-assessed (12.1 +/- 3.5) E/Ea (95% confidence interval of -1.5 to 0.5) (r = 0.89, p < 0.0001). In addition, E/Ea related strongly to invasively measured PCWP (MR: r = 0.80, p < 0.0001 and Doppler: r = 0.85, p < 0.0001). CONCLUSIONS: Tissue MR imaging is a feasible method to assess Ea. Combining E and Ea allowed similar estimation of filling pressure by MR and Doppler, in good agreement with invasive measurement. The potential confounding effect of valvular regurgitation needs further study.     

Limited atrial compensation to reduced early diastolic filling in hypertensive patients with advanced left ventricular hypertrophy: A Doppler echocardiographic study

Summary To assess atrial contribution to left ventricular (LV) filling in hypertension, we studied, using pulsed Doppler echocardiography, 22 hypertensive patients without apparent LV hypertrophy (LVH), 12 hypertensive patients with LVH, and 24 age-matched normal subjects. From mitral flow velocity waveform, we determined peak velocity of early diastolic filling flow (peak E), peak velocity of late diastolic filling flow (peak A), and the peak A/peak E ratio (peak A/peak E). Peak E decreased in hypertensives without apparent LVH and showed a further decrease in hypertensives with LVH compared with normal subjects (57±8 [mean ± SD];P<0.001, 46±7;P<0.0001, vs 65±10 cm/s). On the other hand, peak A/peak E increased in hypertensives without apparent LVH, and greatly increased in hypertensives with LVH (1.06±0.14;P<0.001, 1.40±0.29;P<0.0001, vs 0.79±0.21). However, increased peak A was not significantly different between the hypertensive groups (60±8 vs 64±8; NS, both;P<0.001 vs 50±10 cm/s for normal subjects). In hypertensives, we found no significant correlation between peak A and the wall thickness index (WTI, determined as mean LV wall thickness normalized by LV diastolic dimension), whereas peak E was significantly correlated with WTI (r=–0.65;P<0.001). Our findings indicate that atrial contraction can not fully compensate the decrease in early diastolic filling caused by advanced LVH. We conclude that atrial compensation for reduced early diastolic filling is limited in hypertensive patients with advanced left ventricular hypertrophy.     

Dobutamine stress echocardiography Doppler estimation of cardiac diastolic function: a simultaneous catheterization correlation study

Background: Doppler echocardiography using the ratio of early diastolic transmitral velocity to early diastolic mitral annular tissue velocity (E/E′) is routinely used to evaluate left ventricular (LV) filling pressures at rest. We tested the hypothesis that measurement of E/E′ in patients undergoing dobutamine stress echocardiography (DSE) will detect changes in LV filling pressures. Methods: In this prospective study, 16 patients with normal LV ejection fraction and normal coronary arteries by angiography underwent a standard DSE protocol with simultaneous LV filling pressure monitoring with a fluid filled pigtail catheter. Doppler echocardiographic assessment of LV diastolic function was performed using E/E′ at rest and during DSE. Results: The average age of the study participants was 57 ± 8 years. Average heart rate was 61 ± 11 bpm at baseline and 141 ± 12 bpm at peak stress. LV mean diastolic pressure decreased from 12.3 ± 2.6 mmHg at baseline to 9.0 ± 2.3 mmHg at peak stress (P = 0.0001). Baseline E/E′ at the septum and lateral annulus were 8.7 ± 2.2 and 7.5 ± 1.9 and during peak stress were 8.3 ± 3.1 and 7.9 ± 3.5, respectively. There was no significant change in E/E′ at either the septum or the lateral annulus (P = 0.55, P = 0.66). There was no significant correlation between LV mean diastolic pressure and E/E′ with dobutamine stress. Conclusions: In patients with normal LV ejection fraction and no significant coronary artery disease undergoing DSE, the ratio of early diastolic transmitral velocity to early diastolic tissue velocity (E/E′) at peak stress with dobutamine does not predict changes in LV filling pressures. (Echocardiography 2011;28:442‐447)     

Longitudinal changes and prognostic implications of left ventricular diastolic function in first acute myocardial infarction

BACKGROUND: Left ventricular (LV) diastolic dysfunction contributes to signs and symptoms of clinical heart failure and may be related to prognosis in heart diseases. LV diastolic dysfunction is reported to be present in acute myocardial infarction (MI); however, little is known about the time course of changes in LV diastolic function and its relation to prognosis after acute MI. METHODS AND RESULTS: Two-dimensional and Doppler echocardiographic examinations were performed in 58 consecutive patients with first acute MI. The patients were studied serially within 1 hour and at days 5, 90, and 360 after arrival to the coronary care unit. LV diastolic function was assessed by Doppler measurements of transmitral and pulmonary venous flow. On the basis of mitral inflow, patients with MI were stratified at baseline to 3 LV diastolic filling patterns: normal, impaired relaxation, or pseudonormal/restrictive. Patients with MI were observed for development of congestive heart failure (Killip class >I) during hospitalization and for death during 1-year follow-up, and these complications were related to LV diastolic function. LV diastolic dysfunction was present in the very early phase of acute MI, with signs of impaired relaxation or restrictive LV filling dynamics in 38% and 24% of the patients, respectively, whereas 38% had normal LV filling characteristics. Impaired relaxation of the LV was most pronounced and found in 60% after 1-year follow-up. In-hospital congestive heart failure (Killip class >I) was found in 50% of the patients with initial impaired LV relaxation and in 71% of the patients with initially pseudonormal or restrictive LV filling dynamics, whereas patients with normal LV filling were free of heart failure. Patients with initial impaired relaxation and restrictive LV filling dynamics demonstrated a significant LV dilation during 1-year follow-up. Patients with initial pseudonormal/restrictive LV filling pattern were more frequently readmitted to the hospital for heart failure and had significant higher New York Heart Association class score compared with patients with normal or impaired relaxation during follow-up. Cardiac death was (n = 6) only observed in patients with pseudonormal or restrictive LV filling pattern. In a multivariate stepwise regression analysis, mitral E deceleration time 相似文献   

Left ventricular diastolic function after anthracycline chemotherapy in childhood: relation with systolic function, symptoms, and pathophysiology.

OBJECTIVES--To examine left ventricular (LV) diastolic function in patients previously treated with anthracycline drugs for childhood malignancy. To consider clinical relevance, relations with systolic dysfunction, and the pathophysiology of anthracycline cardiotoxicity. DESIGN--Cross sectional echocardiographic study of LV function. SETTING--Supraregional centre for paediatric cardiology, principal centre for the treatment of childhood malignancy in southwest England. PATIENTS--226 of 236 patients surviving between 6.5 months and 17 (median 5.3) years from initial anthracycline treatment for childhood malignancy attended for clinical and echocardiographic examination. Cumulative anthracycline doses were between 50 and 750 (median 300) mg/m2. 22 patients had also received cardiac irradiation. METHODS--Detailed assessment of transmitral diastolic pulsed wave Doppler flow patterns along with LV dimensions and systolic function measured by M mode echocardiography. MAIN OUTCOME MEASURES--Peak early (E) and atrial (A) phase filling velocities and EA ratio, time and acceleration and deceleration to and from peak E velocity, velocity integrals and ratio, isovolumic relaxation time (IVRT), and heart rate were measured. Results were examined in relation to LV cavity and posterior wall dimensions and shortening fraction (SF), and compared with paired control data matched for body surface area. RESULTS--Eleven (5%) patients had abnormal effort tolerance. Fifty one (23%) had SF < 30% and SF was inversely correlated with cumulative dose and time from treatment. The relative risk of symptomatic cardiac failure was greatly increased by prior irradiation; > 60% of irradiated patients who received > 400 mg/m2 of anthracycline were symptomatic. Early diastolic filling was relatively normal or enhanced at low anthracycline doses or when SF was preserved, with a shorter IVRT and increased atrial phase filling. Early filling was reduced at higher doses or with reduced SF, with longer IVRT and a further increase in atrial phase filling. A more "restrictive" pattern of diastolic filling (with high E and low A velocities) was seen in some patients, particularly after cardiac irradiation. CONCLUSIONS--Significant abnormalities of diastolic function are associated with anthracycline induced cardiac damage. These are not linearly related to anthracycline dose but appear to reflect the underlying myocardial pathophysiology associated with anthracycline toxicity, which is not demonstrated by the standard M mode echocardiogram. Although the overall clinical significance of such diastolic dysfunction is uncertain, some individual abnormalities may have significant management and therapeutic implications.