Doppler echocardiographic analysis of left ventricular filling in treated hypertensive patients

Early detection and prevention of cardiac dysfunction is an important goal in the management of hypertensive patients. In this study, Doppler echocardiography was used to evaluate the pattern of left ventricular diastolic filling in 38 subjects: 18 treated hypertensive patients (blood pressure 141 +/- 17/83 +/- 10 mm Hg, mean +/- SD) without other coronary risk factors and 20 risk-free normotensive subjects of similar age (47 +/- 10 and 49 +/- 13 years, respectively). Peak velocity of late left ventricular filling due to the atrial contraction was greater in hypertensive compared with normotensive subjects (69 +/- 14 versus 52 +/- 13 cm/s; p less than 0.001). Peak velocity of late filling was significantly greater in hypertensive versus normotensive subjects in those aged 50 years or younger and those older than age 50 (65 +/- 12 versus 50 +/- 11; p less than 0.01 and 75 +/- 15 versus 56 +/- 15 cm/s; p less than 0.05, respectively). In hypertensive subjects, peak velocity of late filling did not correlate with routine indexes of hypertensive heart disease (including posterior wall thickness and left ventricular mass), systolic and diastolic blood pressure or duration of hypertension. These results indicate that increased velocity of late left ventricular filling may be independent of left ventricular hypertrophy and persist despite effective blood pressure control.     

Subclinical cardiotoxicity by doxorubicin: a pulsed Doppler echocardiographic study

In order to detect subclinical levels of Doxorubicin (D) cardiotoxicity, 21 patients aged 42 +/- 8 years with malignancies and treated with D as a part of a multiple regimen, were evaluated. The mean cumulative dose of D was 242 +/- 112 mg.m-2 (150 to 520 mg.m-2). Patients with systemic hypertension, valvular diseases, suspected coronary artery disease, ejection fraction less than 55% as assessed by radionuclide angiography, and aged more than 50 years were excluded from the study. A Doppler echocardiographic examination was performed before and after the course of D therapy with a mean interval of 142 days. The following variables were assessed: fractional shortening (FS), ejection fraction (EF), stroke volume (SV), isovolumic relaxation time (IVRT), maximal early diastolic flow velocity (Emax), maximal late diastolic flow velocity (Amax), and mitral deceleration time (Mdt). Indices derived from 19 aged-matched normal subjects were compared to those of the patients before the course of therapy. Doppler echocardiographic measurements did not differ significantly between the control group and patients before the course of therapy. While there were no significant changes in FS, EF, and SV in the study group before and after therapy, indices of diastolic filling showed striking differences: IVRT changed from 72 +/- 11 to 87 +/- 19 ms (P less than 0.001), Emax from 81 +/- 12 to 65 +/- 17 cm.s-1 (P less than 0.001), Mdt from 174 +/- 25 to 183 +/- 34 ms (P less than 0.05), Amax from 44 +/- 17 to 52 +/- 16 cm.s-1 (P less than 0.01). These data demonstrate impaired diastolic filling after doxorubicin therapy at conventional dosages.     

Pulsed Doppler echocardiographic study of left ventricular filling in dilated cardiomyopathy

Patients with dilated cardiomyopathy (DC) have been reported to have abnormal left ventricular (LV) diastolic properties. To evaluate LV diastolic filling characteristics in patients with DC, pulsed Doppler echocardiography was used to study mitral flow velocity in 21 patients with DC and mitral regurgitation (MR), 12 patients with DC but no MR and 19 age-matched normal subjects. Diagnosis of MR was based on the Doppler echocardiographic finding of holosystolic turbulent flow in the left atrium. Peak mitral flow velocity in early diastole (PFVE) and during atrial systole (PFVA), PFVA/PFVE and deceleration half-time of early diastolic flow were measured from Doppler mitral flow velocity recordings. In 21 patients with DC and MR, PFVE (61 +/- 13 cm/s), PFVA (37 +/- 19 cm/s) and PFVA/PFVE (0.6 +/- 0.4) were not significantly different from PFVE (53 +/- 10 cm/s), PFVA (47 +/- 12 cm/s) and PFVA/PFVE (1.0 +/- 0.4) in normal subjects (p greater than 0.05). Deceleration half-time in DC patients with MR (62 +/- 32 ms) was shorter than normal (87 +/- 25 ms) (p less than 0.05). In contrast, PFVE (31 +/- 11 cm/s) was lower and PFVA/PFVE (1.7 +/- 0.8) was higher in the 12 DC patients without MR than in normal subjects and DC patients with MR (p less than 0.005). PFVA (46 +/- 8 cm/s) and deceleration half-time (88 +/- 33 ms) in patients without MR were not significantly different from normal mean values. Thus, abnormalities of peak diastolic mitral flow velocity were detected in DC patients without MR but not in DC patients with MR, suggesting that MR masks LV filling abnormalities in patients with DC.     

Doppler echocardiographic evaluation of right and left ventricular filling in hypertension]

Left (LV) and right ventricular (RV) filling was evaluated by pulsed doppler echocardiography in 56 hypertensive (HTN) untreated patients and in 30 normotensive (N) subjects, matched for age, body surface and heart rate. HTN were classified in two groups: HTN1: with normal LV mass index (LV mi) (< 135 g.m-2 for men, < or = 115 g.m.-2 for women); HTN2: with increased LV mi (> or = 135 g.m-2 for men, > or = 115 g.m-2 for women). All subjects had normal systolic function by echo. We derived: LV wall thickness (h), antero-posterior radius (r), h/r ratio, LV mi, ratio of early to late filling (E/A) in both ventricle. RESULTS. h and h/r were significantly in HTN1 (p < 0.01 vs N) and particularly in HTN2 (p < 0.001 vs N and HTA1). E/ALV and E/ARV were significantly decreased (p < 0.001) in both HTA compared to N. There was no significant difference between HTN1 and HTN2 concerning E/ALV and E/ARV. Relations of E/ALV and E/ARV with age, systolic blood pressure (SBP), LV mi, h, h/r: [table: see text] E/ALV is correlated to E/ARV (r = 0.37; p < 0.01) only in HTA. CONCLUSIONS. 1) In HTN in comparison with N: h, h/r are higher in the presence but also in the absence of increased LV mi. 2) In N and HTN: E/ALV and E/ARV are better correlated to h (and also to h/r in N) than to LV mi. Though the respective values of E/ALV and E/ARV are identical, they are correlated significantly only in HTN. 3) In the absence of the direct measures of the RV pressures and volumes, the interpretation of the results concerning the RV filling in uncertain. Only in HTN, they could be explained at least in part by the diastolic interplay between the two ventricles.     

Doppler assessment of right ventricular filling dynamics in systemic hypertension: comparison with left ventricular filling.

To assess right ventricular filling dynamics in systemic hypertension, pulsed Doppler echocardiographic studies were obtained at the tricuspid and mitral anuli in 43 untreated hypertensive patients, aged 23 to 66 years, and in 42 age-matched normotensive control subjects. In hypertensive patients, the ratio of late to early peak filling velocity and atrial filling fraction were higher, while normalized peak filling rate, one third and one half filling fractions were lower, compared with control values. Right ventricular filling dynamics correlated poorly with age in hypertensive patients, and were unrelated to left ventricular mass or left ventricular wall thickness. Weak correlations were only found between right ventricular wall thickness and right ventricular peak late inflow velocity, first half and first third filling fractions. However, right ventricular filling dynamics were closely related to left ventricular filling dynamics in both hypertensive patients (r = 0.49 to 0.82) and normal individuals (r = 0.55 to 0.86). Thus right ventricular filling dynamics are altered in hypertension, independently of left ventricular mass or blood pressure, are weakly related to right ventricular thickness, but remain closely correlated to left ventricular filling dynamics.     

Doppler echocardiographic evaluation of left ventricular diastolic filling in isolated valvular aortic stenosis

Doppler echocardiography was used to study left ventricular (LV) diastolic filling in 49 adults with isolated aortic stenosis (AS), selected from 155 consecutive patients with AS by excluding coexisting mitral disease (n = 41) and/or significant aortic regurgitation (n = 80). There were no differences between patients with AS and age-matched normal subjects for early diastolic filling (E) velocity (68 +/- 17 vs 67 +/- 13 cm/s), late diastolic filling (A) velocity (79 +/- 25 vs 67 +/- 21 cm/s), E/A ratio (1.00 +/- 0.78 vs 1.06 +/- 0.32) or early diastolic deceleration slope (264 +/- 151 vs 319 +/- 137 cm/s2, differences not significant for all). There was no correlation between any LV filling parameter and AS severity, but late diastolic filling velocity was higher in patients with AS who had LV hypertrophy (n = 33) vs those who did not (n = 16) (86 +/- 23 vs 65 +/- 26 cm/s, p less than 0.01). In the patients with AS and systolic dysfunction (LV ejection fraction less than 50%) (n = 6), early diastolic filling velocity was higher (88 +/- 20 vs 65 +/- 15 cm/s, p less than 0.01), late diastolic filling velocity lower (53 +/- 23 vs 83 +/- 23 cm/s, p less than 0.01), E/A ratio higher (2.20 +/- 1.80 vs 0.84 +/- 0.28, p less than 0.01), deceleration slope steeper (439 +/- 230 vs 240 +/- 121 cm/s2, p = 0.02) and LV end-diastolic pressure higher (23 +/- 9 vs 10 +/- 6 mm Hg, p less than 0.01) than in patients with AS and normal systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler echocardiographic assessment of left ventricular filling dynamics in patients with coronary heart disease and normal systolic function

The purpose of this study was to assess altered left ventriculardiastolic filling by noninvasive means in patients with coronaryartery disease and normal systolic pump function. Mitral inflowvelocity was measured by pulsed Doppler, and left ventricularvolumes were obtained from cross-sectional echocardiographyat rest and during upright bicycle exercise. Peak and integratedearly and late diastolic filling velocities were calculatedfrom Doppler-derived time-velocity curves. Studies were performedin normal subjects (group I, n = 8) and in patients with angiographicallyproven coronary artery disease (Group II, n = 18). The ejectionfraction was not significantly different in group II as comparedto group I (group 1, 60 ± 7%; group II, 55 ± 11%).During exercise, ejection fraction increased significantly ingroup I by 7·6%, but did not increase in group II. Inall cases, diastolic filling showed a biphasic pattern. At rest,the major part of diastolic filling occurred during early diastole:the ratio of early filling velocity integral (E) to the latefilling velocity integral (L) was significantly greater in groupI than in group II (group I, 1·74 ± 37; groupII, 1·19 ±·3, P<0·001). Duringexercise, early diastolic filling was unchanged in normal subjectsbut decreased in patients, with a significant decrease in E/Lindex of 34% (P < 0·001). Thus, pulsed Doppler echocardiography provides a useful methodfor assessing noninvasively exercise-induced changes in leftventricular diastolic filling dynamics in patients with coronaryartery disease.     

Early detection of anthracycline induced cardiotoxicity in asymptomatic patients with normal left ventricular systolic function: autonomic versus echocardiographic variables

OBJECTIVE: To investigate left ventricular dysfunction in patients who had been treated with anthracycline based chemotherapy. METHODS: Autonomic function was compared with left ventricular diastolic function in 20 asymptomatic women with normal systolic function (left ventricular ejection fraction (LVEF) > 0.50) treated for breast cancer with high dose anthracycline based chemotherapy, and 20 age matched healthy controls. Left ventricular diastolic function was assessed echocardiographically by measuring the early peak flow velocity to atrial peak flow velocity ratio, isovolumic relaxation time, and deceleration time. Heart rate variability analysis was assessed for time domain and frequency domain parameters. RESULTS: The mean (SD) age of the patients was 45 (7) years and the mean LVEF was 0.59 (0.06). The time interval after the end of chemotherapy was 29 (27) months. One or more diastolic variables were abnormal in 50% of the patients. Heart rate variability was abnormal in 85% of patients. Mean values of both time domain and frequency domain parameters were decreased (p < 0.05), in particular the parasympathetic indices. CONCLUSIONS: Autonomic impairment occurs in a large proportion of asymptomatic patients with normal systolic left ventricular function after high dose anthracycline based chemotherapy. In particular, heart rate variability analysis may be a sensitive tool to identify the first signs of cardiotoxicity in these patients.     

Doppler assessment of right ventricular filling in a normal population. Comparison with left ventricular filling dynamics

To examine whether alterations in right ventricular filling dynamics occur with increasing age and to compare right and left ventricular filling in normal subjects, pulsed Doppler echocardiographic studies were performed at the tricuspid and mitral anuli in 50 normal volunteers (23 males and 27 females) with an age range of 5-66 years. An age-related decrease in peak early filling velocity, increase in peak late velocity, and augmentation in the late/early ratio of peak velocities at the tricuspid anulus were observed (r = -0.68, 0.63, and 0.84, respectively). Significant correlations were also found between age and first third, first half, and atrial filling fractions (r = -0.60, -0.72, and 0.69, respectively). Weaker relations were observed between heart rate and Doppler-derived diastolic parameters (r = 0.18-0.54). Right ventricular filling indexes related significantly to those of the left ventricle (r = 0.58-0.88), the best being for the late/early ratio of peak velocities. With inspiration, an increase in early and late right ventricular filling occurred, whereas a reduction in filling occurred in the left ventricle. Thus, careful consideration for age, heart rate, and respiration is necessary in examining the effect of disease states or therapeutics on the filling dynamics of either the right or left ventricle.     

Pulsed Doppler echocardiographic determination of the time course of left ventricular filling: validation with cineangiography

Several noninvasive techniques are used to evaluate left ventricular diastolic function, but none has optimally characterized the time course of left ventricular filling. We have developed a method to characterize left ventricular filling, by integrating Doppler measurements of flow velocity across the mitral valve. The purpose of the present study was to compare this new method with contrast left ventriculographic assessment of left ventricular filling. Pulsed Doppler studies were obtained within 24 hours of left ventriculography in 15 patients: three normal subjects, seven with coronary disease, two with mitral stenosis, and three with dilated cardiomyopathy. Patients with myocardial infarction, regional wall movement abnormalities, or aortic regurgitation were excluded. Doppler-derived relative left ventricular filling was compared to filling from right anterior oblique left ventriculograms. Doppler and angiographic filling curves were qualitatively different in normal subjects and in patients with mitral stenosis and cardiomyopathy. For individual patients, however, the Doppler and angiographic filling curves were qualitatively similar, with a strong correlation between Doppler and angiographic estimates of percent filling (r = 0.95; p less than 0.001). These preliminary observations suggest that Doppler echocardiography may provide a reliable assessment of the time course of left ventricular diastolic filling. Further studies are warranted and should include more patients with diverse cardiac abnormalities.     

Effects of beta-adrenergic blockade on left ventricular relaxation and filling dynamics in coronary artery disease: a pulsed Doppler echocardiographic study

Left ventricular (LV) filling as assessed by Doppler transmitralflow velocity measurements was studied in 20 male patients withcoronary artery disease (CAD) and in 18 normal individuals.Stroke volume, blood pressure and heart rate in the two groupswere not significantly different. Compared to normals, the ratiobetween early and atrial-induced peak velocities was significantlylower in the patients (1.2±0.3 vs.1.40±0.3, P=0.01), as was the fraction of transmitral filling during thefirst of diastole (45 ±7% vs.50 ± 4%, P >0.001). Isovolumic relaxation time (IVR) was 96 ± 13ms in patients vs. 74±12 ms in normals (P>0-001) The CAD patients were treated with atenolol for 13–24days. The velocity ratio increased by 30% (P>0001) due toa 12% increase in early (P = 0.004) and an 11% decrease in atrial-inducedpeak velocities (P = 0.01). Filling fraction and decelerationrate of early inflow both increased by 22% (P > 0001). IVRdecreased by 8% (P = 0.01). After atenolol treatment, heartrate and blood pressure decreased by 23% and 10% (P>0001),respectively, whereas stroke volume increased by 14% (P>0001). Thus, CAD was associated with Doppler indices of retarded LVfilling and myocardial relaxation. After atenolol treatment,significant increases in velocity ratio and filling fractionindicated a shift of filling from late towards early diastole,suggesting improved diastolic function. However, different factorsrelated to betaadrenergic blockade may have contributed to theobserved changes.     

Doppler echocardiographic evaluation of left ventricular function

Invasive measurements of maximum acceleration of aortic blood flow are sensitive indicators of left ventricular function. Doppler echocardiography provides noninvasive measurements of aortic blood flow acceleration. Our studies establish the accuracy of Doppler-derived indices of aortic blood flow velocity for evaluation of left ventricular function. Doppler-derived peak velocity and mean acceleration showed excellent correlation with invasively measured peak left ventricular dP/dt and maximum aortic blood flow (dQ/dt) under varying heart rate, preload, afterload, and inotropic states. Similar correlations were observed between Doppler-derived peak velocity and mean acceleration and invasively measured left ventricular dP/dt and dQ/dt under conditions of varying degrees of myocardial ischemia. Thus, Doppler echocardiography provides an accurate noninvasive method to evaluate left ventricular performance.     

Progressive impairment of left ventricular diastolic filling with advancing age: a Doppler echocardiographic study.

OBJECTIVE: To identify the sequence and significance of left ventricular filling abnormalities associated with progressive aging in humans. DESIGN: Cross-sectional study comparing three age groups. SETTING: Department of Geriatrics at University of Naples. PARTICIPANTS: Seventy-five healthy subjects in three age groups: 25 subjects from 25 to 45 years (Group I), 25 subjects from 46 to 65 years (Group II), and 25 subjects from 66 to 85 years (Group III). INTERVENTION: None. MAIN OUTCOME MEASURES: All underwent pulsed-doppler echocardiography under color guide to measure the following parameters: peak velocity flow for early (E wave) and late (A wave) mitral flow; A/E wave ratio; deceleration time of mitral flow (MDt); isovolumic relaxation time (IRT); ratio of velocity time integrals of the A wave to the velocity time integrals of the entire mitral spectrum (VTIA/VTIM). RESULTS: Peak velocity of the E wave was slightly lower in Group II and III compared to Group I; in contrast, peak velocity of the A wave was greater (P less than 0.005) in aged individuals. Also A/E wave ratio, MDt, and IRT were significantly greater with advancing age (P less than 0.01; P less than 0.05 and P less than 0.001, respectively). Finally, VTIA/VTIM tended to be greater in the oldest group, but not significantly so. CONCLUSIONS: Left ventricular relaxation is progressively impaired in late middle age and old age, presumably an early marker of cardiac aging. Increased left atrial pressure is compromised only in the oldest group, presumably representing a compensation for impaired left ventricular relaxation.     

Wave-intensity analysis: a new approach to left ventricular filling dynamics

Summary In order to explore a new approach to the analysis of diastolic dysfunction, we adapted wave-intensity analysis (WIA), a time-domain analysis that provides information regarding both upstream and downstream events, to left ventricular (LV) filling. WIA considers the pressure and flow waves as summations of successive wavelets, characterised by the direction they travel and by the sign of the pressure gradient associated with them. Wave intensity is the product, dPdU, calculated from the incremental differences in LV pressure (dP) and mitral velocity (dU) and, during the diastolic filling interval, yields up to five dPdU peaks.Peak 1 is caused by backward-travelling expansion waves that accelerate the blood while LV pressure falls, and may be related to “diastolic suction”.Peak 2 is caused by forward-travelling compression waves which occur if acceleration continues after LV pressure begins to increase.Peak 3 is caused by backward compression waves and is associated with rising LV pressure and deceleration.Peak 4 is caused by forward compression waves and is associated with the increasing LV pressure and acceleration caused by atrial contraction.Peak 5 is caused by backward compression waves and is associated with increasing pressure and deceleration. These preliminary observations suggest that WIA can be useful in describing the mechanics of LV filling and, after much further work has been accomplished, it might prove useful in the detection and characterization of diastolic dysfunction. The results of this investigation were presented, in part, at the Annual Scientific Sessions of the American Heart Association in Dallas, November 16, 1994     

Doppler echocardiographic assessments of left ventricular diastolic filling in patients with amyloid heart disease.

Twenty-eight patients with amyloid heart disease, 9 with primary and 19 with familial amyloidosis, were examined by Doppler echocardiography to characterize transmitral flow velocity patterns and to assess restrictive ventricular hemodynamics. Six of the 28 patients had restrictive ventricular physiology, and the remaining 22 did not. Patients with a restrictive filling process had marked ventricular wall thickening with depressed fractional shortening. The transmitral flow velocity patterns in patients with restriction were characteristically manifested by the increased peak flow velocity and shortening of rapid diastolic filling, which was associated with a reduced flow velocity in atrial systole. In the 22 patients without restriction, the left ventricular filling patterns were subclassified as 1) filling patterns with the prolonged isovolumic relaxation time and reduced early diastolic filling, as well as enhanced atrial contribution to ventricular filling (16 patients with mild echocardiographic abnormalities), 2) normal filling patterns with normal echocardiograms (4 patients), and 3) normal filling patterns, with moderate ventricular wall thickening (2 patients). These findings suggested that restrictive ventricular hemodynamics can be characterized by the transmitral velocity pattern and that patterns of left ventricular diastolic filling are markedly varied depending on the magnitude of myocardial amyloid deposition in patients with amyloid heart disease.     

Doppler echocardiographic patterns of left ventricular filling in patients early after acute myocardial infarction.

Diastolic function is routinely assessed using Doppler-derived left ventricular (LV) filling patterns. Ratios between peak flow velocities during early filling and atrial contraction (E/A) of less than 1 are considered pathologic and diagnostic of impaired relaxation. Myocardial stiffness can normalize the E/A ratio, and thus, in some clinical settings, a normal E/A ratio may identify patients with high filling pressures. LV filling patterns were studied with Doppler echocardiography in 15 healthy subjects and 38 patients with recent acute myocardial infarction. The results were correlated with clinical and hemodynamic variables. E/A ratio less than 1 was found in 14 patients (37%) and in only 1 control subject; E/A ratio greater than 2 found in 5 patients (13%) and in only 1 control subject; 19 patients (50%) had an apparently normal E/A ratio. No correlation was found between LV filling pattern and ejection fraction or presence of diabetes or arterial hypertension. LV end-diastolic pressures were low to normal in patients with an E/A ratio less than 1 and were usually greater than 15 mm Hg in those with normal or abnormally increased (greater than 2) E/A ratios. Thus, an apparently normal E/A ratio in patients after myocardial infarction may identify those with more severe LV diastolic dysfunction and increased LV filling pressure.     

Assessment of left ventricular filling in patients with systemic hypertension. A Doppler echocardiographic study

To assess left ventricular (LV) diastolic function in patients with hypertension, a Doppler echocardiographic study of transmitral blood flow (TBF) was performed in 46 hypertensive patients (H), 18 without (H1) and 28 with (H2) left ventricular hypertrophy and in 25 age-matched normal subjects (N). All patients showed normal systolic function. The following indices of Doppler TBF were measured: peak flow velocity during early filling (Evel), atrial systole (Avel) and their ratio (E/Avel); area under early filling phase (Earea), area under atrial systole (Aarea), expressed as a percentage of total diastolic area and their ratio (E/Aarea); deceleration half-time (DHT) of early filling phase. When compared with N, H1 and H2 showed significant reductions in early filling indices and an increase in atrial contribution parameters. (Evel = 0.62 +/- 0.1(N), 0.52 +/- 0.1(H1) P less than 0.01, 0.44 +/- 0.1(H2) P less than 0.001; Earea = 56 +/- 5(N), 48 +/- 5(H1) P less than 0.001, 43 +/- 6(H2) P less than 0.001; Avel = 0.49 +/- 0.1(N), 0.59 +/- 0.1(H1) P less than 0.01, 0.69 +/- 0.14(H2) P less than 0.001; Aarea = 26 +/- 5(N), 41 +/- 4(H1) P less than 0.001, 47 +/- 7(H2) P less than 0.001). Also DHT was significantly prolonged, compared with N (80 +/- 12 msec), in H1 (90 +/- 12 msec, P less than 0.01) and H2 (105 +/- 20 msec, P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)