Associations among plasma adiponectin, hypertension, left ventricular diastolic function and left ventricular mass index

OBJECTIVE: The purpose of this study was to characterize the relationships among plasma adiponectin, essential hypertension, left ventricular diastolic function and left ventricular hypertrophy. METHODS AND RESULTS: Plasma adiponectin concentration was assessed by radioimmunoassay, and body mass index (BMI) was measured in 275 patients (138 women and 137 men). Various echocardiographic parameters such as deceleration time (DT) and isovolumetric relaxation time (IVRT) were measured by using echocardiograms. The authors calculated left ventricular mass index (LVMI) and E/A ratio. Pulse wave velocity (PWV) was calculated by dividing the distance between the left subclavian artery ostium and the tip of the femoral sheath with the time interval between two pulse waves. The plasma adiponectin concentration of the hypertensive group was significantly lower than that of the non-hypertensive group (9.9 +/- 9.8 microg/ml vs. 12.9 +/- 9.5 microg/ml, p = 0.019). PWV in the hypertensive group was 12.0 +/- 3.9 m/s compared with 9.3 +/- 2.8 m/s in the normotensive group (p < 0.001). LVMI in the hypertensive group was 135.1 +/- 35.4 g/m2 compared with 100.5 +/- 18.7 g/m2 in the normotensive group (p < 0.001). E/A ratio (0.8 +/- 0.3 vs. 1.1 +/- 0.4, p = 0.041) was lower in the hypertensive group. DT (200.0 +/- 61.2 ms vs. 177.3 +/- 40.8 ms, p = 0.048) and IVRT (106.9 +/- 25.4 vs. 91.3 +/- 27.6 ms, p = 0.243) were higher in the hypertensive group. Plasma adiponectin showed an inverse correlation with LVMI (r = -0.525; p < 0.001) and PWV (r = -0.557; p < 0.001), IVRT (r = -0.485; p = 0.008), and showed a positive correlation with E/A ratio (r = 0.359; p < 0.001). Multiple regression analyses showed that PWV and plasma adiponectin were able to explain the 73.3% of LVMI variability (r = 0.856; p < 0.001). CONCLUSION: The results suggest that a decrease in plasma adiponectin concentration is associated with the progression of left ventricular hypertrophy with diastolic dysfunction.     

Assessment of the relationship between functional capacity and right ventricular ultrasound tissue characterization by integrated backscatter in patients with isolated mitral stenosis

AIM: The aim of the present study was to investigate right ventricular (RV) myocardial textural properties in asymptomatic and symptomatic mitral stenosis (MS) patients with normal RV systolic function using integrated backscatter (IBS). METHODS: The study included 40 patients with MS of moderate or severe degree. Patients were classified into 2 groups according to NYHA class (asymptomatic group, NYHA class I, symptomatic group, NYHA class II-III). RV pulsed-wave tissue Doppler imaging (TDI) and IBS analyses were performed in all patients. Isovolumic contraction time (IVCT), systolic wave velocity (S), isovolumic relaxation time (IVRT), early diastolic wave velocity (E), and late diastolic wave velocity (A) were measured by TDI. IBS amplitude (IB) and cyclic variation (CV) of the RV lateral wall in the parasternal long-axis view were measured by IBS. CV was calculated by subtracting systolic IB from diastolic IB. RESULTS: IVRT (54.2 +/- 11.9 ms versus 86.2 +/- 16.2 ms, P < 0.001) and A wave amplitude (10.2 +/- 2.1 cm/s versus 13.6 +/- 1.8 cm/s, P < 0.05) were higher whereas E wave amplitude (11.7 +/- 1.6 cm/s and 10.3 +/- 1.5 cm/s, P < 0.05) and E/A ratio (1.3 +/- 0.3 versus 0.7 +/- 0.1, P < 0.001) were lower in group 2. Symptomatic patients had a lower CV value of RV (9.5 +/- 3.4 dB versus 6.7 +/- 1.9 dB, P = 0.004). There was a positive correlation between CV and E/A (r = 0.964, P < 0.001) CONCLUSION: Symptomatic isolated MS patients had RV echo texture changes and diastolic dysfunction in comparison to asymptomatic ones with similar mitral valve areas in the presence of normal RV systolic function. In isolated MS, both pulsed-wave TDI and IBS may aid in the detection of RV diastolic pathology.     

Assessment of left and right ventricular diastolic function in patients with systemic sclerosis

BACKGROUND: Systemic sclerosis (SSc) is a connective tissue disease characterised by vascular changes and immunologically induced fibrosis of the skin and internal organs. Systemic sclerosis may be associated with both right (RV) and left ventricular (LV) diastolic dysfunction. AIM: To analyse RV and LV myocardial diastolic function in patients with SSc and its relation to exercise capacity. METHODS: We prospectively studied 51 consecutive patients (47 females, 4 males, age 53.3+/-15.2 years) with SSc (mean disease duration 9+/-12.4 years) and a group of 31 age-matched healthy subjects (28 females, 3 males, age 52.68+/-12.1 years). In addition to conventional investigation, transthoracic echocardiography (TTE) for assessment of RV and LV myocardial diastolic function and 6-minute walking test (6MWT) were performed. RESULTS: Abnormal LV filling, as expressed by an inverted mitral E/A ratio (Mit E/A <1), was detected in 28 (55%) SSc patients and in 8 (25%) controls (p <0.001). The mean value of Mit E/A in the SSc group was lower than in controls (1.0+/-0.3 vs. 1.2+/-0.3, p=0.04). There were no differences in pulmonary venous flow between SSc patients and controls. The mean value of Tei index for the LV was higher in SSc than in controls (0.44+/-0.08 vs. 0.38+/-0.05, p <0.001). Abnormal RV filling, as expressed by an inverted tricuspid E/A ratio (TR E/A <1), was detected in 16 (31%) SSc patients and in 5 (16%) controls (p <0.001). Patients with SSc were found to have an inverted Tr E/A ratio (Tr E/A <1), indicating abnormal RV filling. The mean value of Tr E/A in SSc was lower than in controls (1.0+/-0.2 vs. 1.2+/-0.3, p=0.04). The mean value of Tei index for the RV was higher in SSc patients than in controls (0.35+/-0.07 vs. 0.29+/-0.03, p <0.001). In multiple regression analysis Tr E/A ratio was independently correlated with Mit E/A ratio (r=0.65, p=0.01). The mean 6MWT distance was shorter in the SSc group than in controls (528+/-100.6 vs. 617.7+/-80 m, p <0.001) and the mean saturation of capillary blood after the 6-MWT was lower in SSc patients (92.7+/-4.9 vs. 97.2+/-1.2%, p <0.001). Mean desaturation after test and D sat was significantly more pronounced in the SSc group than in controls (3.4+/-3.1 vs. 0.7+/-0.9, p <0.001). The Tr E/A ratio and Mit E/A ratio correlated positively with 6MWT distance (r=0,49, p=0.01 and r=0.48, p=0.02). CONCLUSIONS: Impaired RV and LV relaxation is observed in a significant percentage of SSc patients and is associated with decreased exercise capacity.     

Right ventricular diastolic function in systemic hypertension

Right (RV) and left ventricular (LV) diastolic function was evaluated in 50 patients with mild, uncomplicated essential hypertension using pulsed-wave Doppler echocardiography. Patients with pulmonary, valvular or coronary artery disease were excluded and antihypertensive drugs were discontinued for the 2 weeks preceding the study. Ten normotensive patients without heart disease acted as control subjects. In the hypertensive patients, RV peak velocity of atrial filling was higher (42 +/- 10 vs 31 +/- 7 cm/s, p less than 0.01) and deceleration half-time was prolonged (96 +/- 20 vs 83 +/- 10 ms, difference not significant); ratio of early/atrial filling velocity (1.1 +/- 0.3 vs 1.7 +/- 0.4, p less than 0.001) and peak filling rate corrected to stroke volume (3.6 +/- 0.7 vs 5.3 +/- 0.9 SV/s, p less than 0.001) were lower. LV filling parameters showed similar changes. RV filling parameters did not correlate with age, LV mass or septal thickness but correlated weakly with LV radius/thickness ratio. There was good correlation between RV and the following corresponding LV filling parameters: peak filling rate, r = 0.68, p less than 0.001; ratio of early/atrial filling, r = 0.88, p less than 0.0001; and deceleration half-time, r = 0.62, p less than 0.001. Data indicate that RV diastolic function is abnormal in essential hypertension and these abnormalities are closely related to those of LV diastolic function.     

Serum N-terminal brain natriuretic peptide as a prognostic parameter in patients with pulmonary hypertension

STUDY OBJECTIVES: Baseline prognostic assessment in patients with pulmonary hypertension (PH) may help in the selection of treatment. High plasma levels of natriuretic peptide type B have been reported in patients with right ventricular (RV) dysfunction and suggest poor prognosis in patients with idiopathic pulmonary arterial hypertension (IPAH). We prospectively assessed the correlation of N-terminal brain natriuretic peptide (NT-proBNP) with echocardiographic and hemodynamic indexes of RV function as well as with baseline functional status and long-term survival of PH patients.Patients and design: Fifty-five consecutive patients with a mean (+/- SD) age of 41 +/- 15 years and severe PH (including 36 patients with IPAH) were followed up for up to 36 months. Serum samples for NT-proBNP were secured, and 6-min walk test (6 MWT), RV catheterization, and echocardiography were all performed on the same day, before the introduction of targeted treatment. RESULTS: The median baseline serum NT-proBNP concentration was 1,674 pg/mL (range, 51 to 10,951 pg/mL). NT-proBNP concentration correlated with 6MWT distance (r = 0.6; p < 0.001), cardiac index, pulmonary vascular resistance, and right atrial pressure (RAP), but not with pulmonary arterial pressure. NT-proBNP levels were also related to the ratio of the diastolic area of the RV and the LV, and to pericardial effusion during echocardiography. Receiver operating characteristic analysis identified > or = 1,400 pg/mL as the best NT-proBNP threshold predicting fatal outcome for the entire study group as well as for IPAH patients (sensitivity, 88% and 100%, respectively; specificity, 53% and 56%, respectively). In multivariate analysis, NT-proBNP, troponin T, and RAP were identified as independent factors for poor prognosis for the entire study group, while only NT-proBNP and RAP were identified as markers for poor prognosis in the IPAH subgroup. CONCLUSIONS: NT-proBNP level is related to the right heart morphology and dysfunction in PH patients. A serum NT-proBNP level of > or = 1,400 pg/mL was found to be useful in identifying patients with poor long-term prognosis both in the whole studied group and in the IPAH subgroup.     

Evidence of left ventricular dysfunction in asymptomatic elderly patients with non-insulin-dependent diabetes mellitus

Diabetic cardiomyopathy is a distinct entity in diabetic patients with congestive heart failure, who have no angiographic evidence of significant coronary artery stenosis. The aim of this study was to evaluate left ventricular (LV) function in 24 elderly patients (mean age 67 +/- 2 years) with type 2 diabetes, who were asymptomatic and had no history of hypertension, or coronary or valvular heart disease. LV systolic indices (ejection fraction [EF] and fractional shortening [FS]), diastolic indices (E wave, A wave, E/A ratio, isovolumic relaxation time [IVRT] and deceleration time [DT]) and the myocardial performance index (MPI) were evaluated with echocardiography. Compared to controls (24 age- and gender-matched normal subjects), the E wave was reduced (0.60 +/- 0.10 m/sec vs 0.72 +/- 0.08 m/sec, p < 0.05), the A wave was increased (0.77 +/- 0.07 m/sec vs 0.68 +/- 0.06 m/sec, p < 0.05), the E/A ratio was decreased (0.78 +/- 0.20 vs 1.06 +/- 0.18, p < 0.001) and both IVRT and DT were prolonged (0.115 +/- 0.01 sec vs 0.09 +/- 0.01 sec, p < 0.001 and 0.240 +/- 0.04 sec vs 0.180 +/- 0.03 sec, p < 0.001, respectively). The MPI was significantly increased (0.640 +/- 0.170 vs 0.368 +/- 0.098, p < 0.001). LV diastolic function and the MPI are markedly impaired in asymptomatic elderly patients with type 2 diabetes.     

Early changes in left ventricular function in chronic asymptomatic alcoholics: relation to the duration of heavy drinking

OBJECTIVES: This study sought to assess preclinical cardiac abnormalities in chronic alcoholic patients and possible differences among alcoholics related to the duration of heavy drinking. BACKGROUND: Chronic excessive alcohol intake has been reported as a possible cause of dilated cardiomyopathy. However, before the appearance of severe cardiac dysfunction, subtle signs of cardiac abnormalities may be identified. METHODS: We studied 30 healthy subjects (age 44 +/- 8 years) and 89 asymptomatic alcoholics (age 45 +/- 8 years, p = NS) divided into three groups, with short (S, 5-9 years, n = 31), intermediate (I, 10-15 years, n = 31) and long (L, 16-28 years, n = 27) duration of alcoholism. Transmitral early (E) and late (A) Doppler flow velocities, E/A ratio, deceleration time of E (DT) and isovolumic relaxation time (IVRT) were obtained. Left ventricular (LV) wall thickness and volumes were also determined by echocardiography, and LV mass and ejection fraction (EF) were calculated. RESULTS: The alcoholics had prolonged IVRT (92 +/- 11 vs. 83 +/- 7 ms, p < 0.001), longer DT (180 +/- 20 vs. 170 +/- 10 ms, p < 0.01), smaller E/A (1.25 +/- 0.34 vs. 1.40 +/- 0.32, p < 0.05), larger LV volumes (73 +/- 8 vs. 65 +/- 7 ml/m2, p < 0.001 for end-diastolic volume index; 25 +/- 4 vs. 21 +/- 2 ml/m2, p < 0.001 for end-systolic volume index), higher LV mass index (92 +/- 14 vs. 78 +/- 8 g/m2, p < 0.001) and thicker posterior wall (9 +/- 1 vs. 8 +/- 1 mm, p < 0.001). Ejection fraction did not differ between the two groups (66 +/- 4 vs. 67 +/- 2%). Deceleration time of the early transmitral flow velocity was longer in groups L (187 +/- 18 ms) and I (185 +/- 16 ms) compared with group S (168 +/- 17 ms, p < 0.001 for L and I vs. S), whereas A was higher in group L compared with S (43 +/- 10 vs. 51 +/- 10 cm/s, p < 0.005). Multiple regression analysis identified duration of heavy drinking as the most important variable affecting DT and A. CONCLUSIONS: Left ventricular dilation with preserved EF and impaired LV relaxation characterized LV function in chronic asymptomatic alcoholic patients. It appeared that the progression of abnormalities in LV diastolic filling related to the duration of alcoholism.     

Gender difference in diastolic function in hypertension (the HyperGEN study)

Although several studies indicate that there are gender differences in left ventricular (LV) systolic function, it remains unclear whether similar differences exist with regard to diastolic function. Accordingly, Doppler echocardiograms were analyzed in 515 male and 839 female, mostly treated (95%) hypertensive participants enrolled in the Hypertension Genetic Epidemiology Network (HyperGEN) study with no evidence of abnormal wall motion or significant valvular heart disease. There was no difference in age between genders, but after adjusting for age and race, men had lower body mass indexes (29.8 +/- 5.2 vs 32.3 +/- 7.6 kg/m(2)) and heart rates (67 +/- 12 vs 69 +/- 11 beats/min) and higher systolic and diastolic blood pressures (BP) than women (134 +/- 20 vs 130 +/- 21 and 80 +/- 11 vs 72 +/- 11 mm Hg, all p <0.001). LV mass/height(2.7) was slightly greater in women than in men (43 +/- 10 vs 42 +/- 9 g/m(2.7), p <0.05). After adjusting for age, race, systolic BP, body mass index, heart rate, and LV hypertrophy, both mitral E-wave (70 +/- 18 vs 77 +/- 19) and A-wave (74 +/- 15 vs 79 +/- 17, both p <0.001) velocities were lower in men than in women, but the mitral E/A ratio and atrial filling fraction were nearly identical in both genders. Deceleration time (221 +/- 55 vs 214 +/- 46 cm/s, p = 0.018) and isovolumic relaxation time (IVRT) were longer in men than in women (85 +/- 18 vs 81 +/- 17 cm/s, p <0.001). Prolonged IVRT was present in more men than women (14% vs 7%, p <0.05). In analyses of covariance, adjusting for age, race, systolic BP, body mass index, heart rate, and medications, male gender remained related to prolonged deceleration time and IVRT. Thus, in this population-based sample of hypertensive adults, men had evidence of slower early diastolic LV filling than women. This gender difference in diastolic function may provide insight into gender differences in congestive heart failure and other specific cardiovascular diseases.     

Doppler-echo evaluation of left ventricular diastolic filling in patient with mixed connective tissue disease

Left ventricular diastolic function was assessed in 17 patients (2 males and 15 females; mean age 44 +/- 9 years) with mixed connective tissue disease (MCTD) and 18 sex- and age-matched healthy control subjects (2 males and 16 females; mean age 44 +/- 8 years) by means of M-mode and pulsed Doppler echocardiography. None had clinical evidence of overt myocardial disease or abnormal left ventricular systolic function. Compared with the control group, patients with MCTD had a significantly longer isovolumic relaxation time (IVRT) (59 +/- 7 versus 70 +/- 12 ms; p less than 0.01), a lower peak early diastolic flow velocity (E) (0.79 +/- 0.10 versus 0.70 +/- 0.07 m/s; p less than 0.005), a higher peak late diastolic flow velocity due to atrial contraction (A) (0.47 +/- 0.08 versus 0.54 +/- 0.08 m/s; p less than 0.05) and a reduced E/A ratio (1.72 +/- 0.37 versus 1.33 +/- 0.26; p less than 0.005). Although there was no significant correlation of left ventricular diastolic filling indexes with age, heart rate, left ventricular end-diastolic and end-systolic dimensions, interventricular septal and left ventricular posterior wall thickness, and fractional shortening, the duration of illness was significantly related to IVRT (r = 0.62; p less than 0.01), peak A (r = 0.79; p less than 0.001) and velocity half-time (r = 0.54; p less than 0.05). The results suggest the presence of an abnormal left ventricular diastolic filling pattern in patients with MCTD and may represent myocardial involvement in this disease.     

Doppler echocardiographic evaluation of right ventricular diastolic function in patients with mitral regurgitation

BACKGROUND AND AIM OF THE STUDY: The effect of left ventricular (LV) pressure overload on right ventricular (RV) diastolic function has been extensively studied. In contrast, no data are available concerning the influence of LV volume overload on RV diastolic function. Accordingly, RV diastolic function was studied in patients with mitral regurgitation (MR) using Doppler echocardiography. METHODS: RV diastolic indices were calculated, using pulsed Doppler echocardiography, in 30 patients (mean age 56.87 +/- 8.58 years) with severe MR, and in 30 healthy control subjects (mean age 56.67 +/- 8.52 years). RESULTS: Compared with controls, MR patients had a significantly lower RV E/A ratio (0.85 +/- 0.12 versus 1.21 +/- 0.16, p <0.001), a significantly prolonged RV isovolumic relaxation time (70 +/- 20 versus 30 +/- 10 ms, p <0.001), a significantly prolonged deceleration time of the transtricuspid E wave (210 +/- 20 versus 140 +/- 10 ms, p <0.001), and a significantly greater right atrial filling fraction (38.58 +/- 4.59 versus 32.58 +/- 3.14%, p <0.001). There was no statistically significant correlation between RV diastolic indices and LV mass index and interventricular septum thickness. CONCLUSION: RV diastolic function in patients with MR is impaired, reflecting prolonged relaxation and redistribution of RV filling into late diastole. Ventricular interdependence constitutes the most likely mechanism of this action.     

Left ventricular diastolic function and endothelial function in patients with erectile dysfunction

The aim of this study was to assess left ventricular diastolic function and forearm endothelial function in patients with erectile dysfunction (ED) without overt cardiovascular disease. Forearm endothelial function and diastolic Doppler parameters, including tissue Doppler imaging, were studied in 32 men with ED and 27 age-matched, healthy, male control subjects. Left ventricular diastolic function in patients with ED and the relation between endothelium-dependent vasodilation and the Doppler parameters of left ventricular diastolic function, including tissue Doppler imaging, were assessed. Endothelium-dependent vasodilation (4.1+/-3.3% vs 9.7+/-4.2%, p<0.001) as well as the mitral inflow E velocity (0.66+/-0.17 vs 0.80+/-0.16 m/s, p=0.01), the E/A ratio (the ratio of mitral inflow E velocity to mitral inflow A velocity; 0.91+/-0.3% vs 1.22+/-0.26%, p<0.001), and the E/Em ratio (the ratio of mitral A-wave velocity to early diastolic velocity in the annulus derived by tissue Doppler imaging; 7.4+/-2.7% vs 6.6+/-1.6%, p=0.03) were smaller in the ED group than in the control group. Deceleration time (228.6+/-61.6 vs 192.9+/-44.6 ms, p=0.03) and isovolumetric relaxation time (112.8+/-18 vs 94+/-15.9 ms, p<0.001) were also prolonged in the ED group compared with the control group. The mitral E-wave velocity (r=0.40, p=0.022), the E/A ratio (r=0.40, p=0.027), and the E/Em ratio (r=-0.52, p= 0.003) were related to endothelium-dependent vasodilation by nivariate analysis. Only the E/Em ratio was correlated with endothelium-dependent vasodilation by multivariate analysis. In conclusion, this study indicates that endothelial function and left ventricular diastolic function are impaired in patients with ED without overt cardiovascular disease.     

NT-proBNP levels and diastolic dysfunction in beta-thalassaemia major patients

BACKGROUND: The early diagnosis and treatment of heart failure in beta-thalassaemic patients is related to survival. Iron alone or in combination with other factors causes diastolic dysfunction, which usually precedes systolic dysfunction. NT-proBNP is a sensitive biomarker of ventricular dysfunction. AIM: To evaluate NT-proBNP in non heart failure beta-thalassaemic patients. METHODS: Fifty-two beta-thalassaemia major patients (mean age: 27.2+/-12.5 years) with normal LV systolic function, underwent NT-proBNP measurement and a thorough Doppler-echocardiographic and pulsed tissue-Doppler study, 4 days following blood transfusion. Fifty-two age matched healthy controls were also studied. RESULTS: NT-proBNP and E/E' ratio were increased in thalassaemic patients compared with controls [(469+/-171 vs 262+/-51 pmol/l, p<0.001) and (10.8+/-4.0 vs 6.6+/-1.1, p<0.001)] and were well correlated (r: 0.54, p<0.01). Although NT-proBNP levels were increased in patients with higher E/E' ratios (E/E' <8: 354+/-119, 8-15: 516+/-177, >15: 565+/-114 pmol/l, ANOVA p: 0.002) this increase only became statistically significant in the 3rd decade of life, while E/E' ratio increased in the 4th decade. CONCLUSION: NT-proBNP increases in beta-thalassaemia major patients and is related to age and LV diastolic dysfunction. NT-proBNP appears to be an early biomarker of LV diastolic dysfunction, compared with the conventional Echo-Doppler indexes.     

Evaluation of the relationship between functional capacity and right ventricular diastolic function in patients with isolated mitral stenosis and sinus rhythm: a tissue Doppler study

AIM: The right ventricular (RV) systolic function is an important determinant of clinical symptoms and exercise capacity in patients with mitral stenosis. No sufficient data are available concerning the effect of RV diastolic function on symptoms of patients with mitral stenosis. In the presence of normal RV systolic function, RV diastolic functions of asymptomatic patients with mitral stenosis of moderate or severe degree were compared to symptomatic ones by pulsed-wave tissue Doppler echocardiography in this study. MATERIALS AND METHODS: The study included 40 patients with mitral stenosis. Patients were classified into two groups according to New York Heart Association (NYHA) class (asymptomatic group NYHA class I, symptomatic group NYHA class II-III). RV diastolic functions were evaluated via pulsed-wave tissue Doppler in terms of isovolumic contraction time (IVCT), systolic wave velocity (S), isovolumic relaxation time (IVRT), early diastolic wave velocity (E'), and late diastolic wave velocity (A'). RESULTS: Statistical difference was not determined in systolic parameters (S, IVCT) between the two groups. However, IVRT (54.21 +/- 11.93 msec vs 86.19 +/- 16.23 msec, P < 0.0001) and A' wave amplitude (10.16 +/- 2.14 cm/sec vs 13.55 +/- 3.35 cm/sec, P < 0.0001) were higher whereas E' wave amplitude (11.68 +/- 1.60 cm/sec and 10.25 +/- 2.73 cm/sec, P = 0.009) and E'/A' ratio (1.18 +/- 0.23 vs 0.76 +/- 0.17, P < 0.0001) were lower in group 2. CONCLUSION: In isolated mitral stenosis, pulsed-wave tissue Doppler may be used for the detection of RV diastolic pathology. Diastolic functions of RV may deteriorate in the presence of normal systolic functions in symptomatic patients with isolated mitral stenosis.     

Amount of left ventricular hypertrophy determines the plasma N-terminal pro-brain natriuretic peptide level in patients with hypertrophic cardiomyopathy and normal left ventricular ejection fraction

BACKGROUND: N-terminal pro-brain natriuretic peptide (NT-proBNP) is increased in patients with hypertrophic cardiomyopathy (HCM); however, the determinants of NT-proBNP level have not been clarified in HCM. HYPOTHESIS: This study was performed to determine the relationship between NT-proBNP levels and various echocardiographic variables of patients with HCM and normal left ventricular ejection fraction (LVEF). METHODS: We assessed plasma NT-proBNP levels and echocardiographic variables of 36 patients (19 men, 58 +/- 14 years) with HCM and an LVEF of > or = 55%. Echocardiographic variables measured were LV wall thickness, end-diastolic LV internal dimension (LVIDd) and volume (LVEDV), LV mass, and LV mass index (LV mass/body surface area, LVMI). Left ventricular outflow tract pressure gradient, transmitral E and A velocities, deceleration time (DT) of the transmitral E wave, and septal annular E' velocity were measured by Doppler technique. The relationship between echocardiographic variables and plasma NT-proBNP level was analyzed. RESULTS: The plasma NT-proBNP level was 775.2 +/- 994.2 pg/ml (range 33.1-4729.0 pg/ml). It showed positive correlations with LV end-diastolic septal thickness (r = 0.39, p = 0.010) and LVMI (r = 0.27, p = 0.050), while it revealed negative correlations with LVIDd (r = -0.44, p = 0.004), LVEDV (r = -0.44, p = 0.004) and DT(r = -0.31,p = 0.034). The NT-proBNP level was higher in the patients with than in those without LV diastolic dysfunction (p = 0.033) and was independently related to LVIDd (p = 0.001), LVMI (p = 0.006) and DT (p = 0.031) by multivariate analysis. CONCLUSION: In patients with HCM and normal LVEF, the amount of LV hypertrophy and LV diastolic dysfunction may exert a significant role in determining plasma NT-proBNP level.     

氨基末端B型脑钠肽前体与非梗阻性肥厚型心肌病患者左心室舒张功能的相关性研究

目的探讨血浆氨基末端B型脑钠肽前体(NT-proBNP)水平与非梗阻性肥厚型心肌病(HNCM)患者左心室舒张功能的关系。方法选择46例HNCM患者,20名健康体检者作为对照组,电化学发光法检测两组血浆NT-proBNP水平,超声心动图、组织多普勒显像(TDI)检测室间隔厚度、射血分数和反映左心室舒张功能的参数。结果HNCM组患者平均NT-proBNP血浆水平明显高于对照组(P<0.001);NT-proBNP血浆水平与以下左心室舒张功能参数均呈正相关:二尖瓣室间隔侧舒张早期最大运动速度e(r=0.74,P<0.001)、e与二尖瓣室间隔侧舒张晚期最大运动速度a比值e/a(r=0.69,P<0.001)、心房收缩开始至左室流出道内心室收缩期前流速开始的间期A-Ar(r=0.63,P=0.029)、Tei指数(r=0.63,P<0.001)、肺静脉频谱收缩期肺静脉血流速度S与舒张期肺静脉血流速度D的比值S/D(r=0.62,P<0.001)、等容舒张时间(IVRT)(r=0.56,P<0.001)、二尖瓣血流频谱舒张早期充盈峰值速度E(r=0.54,P<0.001)、a(r=0.53,P<0.001)、二尖瓣血流频谱舒张晚期充盈峰值流速A(r=0.36,P=0.02)、E/A(r=0.47,P<0.001)。多因素Logistic回归分析显示,e/a、S/D是NT-proBNP血浆水平的独立影响因素。结论NT-proBNP血浆水平与超声心动图左心室舒张功能参数间存在明显的正相关性,可以作为评价HNCM患者左心室舒张功能不全的客观指标。     

Dobutamine stress-induced ischemic right ventricular dysfunction and its relation to cardiac output in patients with three-vessel coronary artery disease with angina-like symptoms

We investigated markers of ischemic dysfunction and their relation to overall right ventricular (RV) performance during dobutamine stress echocardiography in patients who had coronary artery disease. Thirty-three patients (58 +/- 10 years old) who had 3-vessel coronary artery disease were compared with 17 age-matched controls (58 +/- 11 years old). RV long-axis amplitude (M mode), systolic and diastolic myocardial tissue Doppler velocities, and filling and ejection velocities were measured, and cardiac output (CO) was calculated at rest and during peak stress. There was no difference in RV size (inlet dimension <3.5 cm), RV systolic long-axis amplitude, systolic and diastolic velocities, peak early/late diastolic velocity ratio, and RV CO between patients and controls at rest. During stress, RV systolic long-axis amplitude increased in controls (from 24 +/- 6 to 30 +/- 5 mm) and CO increased significantly (from 4.9 +/- 1.2 to 12.5 +/- 2.1 L/min, p <0.001 for the 2 items). In contrast, RV amplitude did not change with stress in patients (from 24 +/- 5 to 22 +/- 6 mm, p = NS), and the stress-increment in CO was augmented (from 4.2 +/- 1.2 to 8.3 +/- 2.0 L/min, p <0.001 vs control stress increment). Failure to increase RV systolic amplitude >2 mm was 79% sensitive and 88% specific for detecting ischemic RV dysfunction, and there was a close correlation between stress-induced change in RV systolic amplitude and change in CO in patients (r = 0.56, p <0.001). Early diastolic velocity increased in controls (from 10.8 +/- 3.2 to 13.1 +/- 3.6 cm/s, p <0.01) but did not change in patients (from 11.5 +/- 3.7 to 11.3 +/- 4.8 cm/s, p = NS). RV shortening after ejection did not appear in any control subject but did develop in 8 of 33 patients, thus contributing to the decrease in RV peak early/late diastolic velocity ratio in patients (from 1.1 +/- 0.3 to 0.76 +/- 0.4, p <0.001) compared with that in controls (1.3 +/- 0.3 to 1.0 +/- 0.2, p <0.001). In conclusion, markers of RV dysfunction are not related to left ventricular wall motion score index or long-axis changes with stress.     

N-terminal proBNP levels in patients with Chagas disease: a marker of systolic and diastolic dysfunction of the left ventricle.

AIMS: NT-proBNP levels are known to be elevated in systolic and diastolic dysfunction. Doppler indices of diastolic dysfunction (DD) have been shown to have prognostic value in patients with Chagas' cardiomyopathy (CC). However, the additional value of NT-proBNP levels in further stratifying these patients according to DD has not been established. This study analyzed the correlation of N-terminal proBNP (NT-proBNP) levels with systolic and diastolic function in patients with CC. METHODS AND RESULTS: NT-proBNP levels were measured in 59 patients with dilated cardiomyopathy due to Chagas disease without other systemic illness that were studied by Doppler echocardiography, including left atrial volume (LAV) calculation and tissue Doppler evaluation of LV longitudinal function. Univariate analysis showed a strong correlation of NT-proBNP values with LVEF (r=-0.733, p<0.001) and a weak correlation with most Doppler echocardiographic parameters of diastolic function. On a multivariate analysis, LVEF and LAV volume emerged as correlating with elevated levels of the NT-proBNP. Patients with restrictive filling pattern (n=10), when compared to other patterns of DD, (n=49), showed a lower LVEF (25.4+/-6.4% vs. 39.8+/-9.4, p<0.001), a larger LAV (50.1+/-17.2 vs. 37.7+/-15.6 ml/m(2), p=0.004) and higher NT-proBNP levels (median+/-IQR: 3488+/-3056 vs. 492+/-700 pg/dl, p<0.001). A marked elevated concentration of NT-proBNP (> or =800 pg/ml) had a sensitivity of 90.0%, specificity of 70.5%, positive predictive value of 40.9% and negative predictive value of 96.9% for detecting a restrictive filling pattern. CONCLUSION: In patients with CC, NT-proBNP augmentation is a marker of LV dysfunction, with higher levels correlating with the more severe forms of both systolic and diastolic dysfunction.     

Assessment of left ventricular function by Doppler tissue imaging in patients with atrial fibrillation following acute myocardial infarction

AIMS: We studied tissue Doppler parameters in patients with atrial fibrillation following acute myocardial infarction, and their relation to P wave durations and P dispersion. METHODS: Echocardiographic examination was performed in 84 consecutive patients with first anterior acute myocardial infarction. In addition to other conventional echocardiographic parameters, the peak systolic (Sm), early diastolic (Em) and late diastolic (Am) velocities were obtained at the lateral corner of the mitral annulus by pulsed wave tissue Doppler. The Em/Am ratio and the ratio of early diastolic mitral inflow velocity to Em (E/Em), which is a marker of diastolic filling pressure, were calculated. Electrocardiogram was recorded from all patients on admission; P wave measurements were also performed. RESULTS: Atrial fibrillation occurred in 20 (23.8%) of 84 patients. The patients with atrial fibrillation had significant reduction of Em (5.6+/-1.5 vs. 8.7+/-2.7 cm/s, p < 0.001), Em/Am (0.61+/-0.27 vs. 0.84+/-0.23, p = 0.001) and Sm (7.1+/-1.0 vs. 8.3+/-1.9 cm/s, p < 0.001) values compared with those without. The E/Em ratio (14.45+/-4.62 vs. 7.47+/-2.79, p < 0.001), P maximum (102+/-11 vs. 95+/-11 ms, p = 0.02) and P dispersion (35+/-7 vs. 26+/-7 ms, p < 0.001) were significantly higher in patients with atrial fibrillation than in those without. In all patients, P dispersion showed significant correlation with Em (r = -0.33, p = 0.002), Sm (r = -0.40, p < 0.001) and E/Em (r = 0.32, p = 0.003). When E/Em > or = 10 was used as cutpoint, atrial fibrillation could be predicted with a sensitivity of 90%, and a specificity of 84%. CONCLUSIONS: The patients with atrial fibrillation following acute myocardial infarction have reduced systolic and diastolic mitral annular velocities and increased E/Em ratio, P maximum and P dispersion values compared to those without. P dispersion is correlated with systolic and diastolic left ventricular function after acute myocardial infarction. The E/Em ratio appears to be a useful parameter for assessing the risk of atrial fibrillation occurrence after anterior acute myocardial infarction.     

The determinants of right ventricular function in patients with atrial septal defect

OBJECTIVE: The purpose of this study was to ascertain the determinants of right ventricular (RV) systolic and diastolic functions in patients with atrial septal defect. METHODS: Thirty-three patients with atrial septal defect having left to right shunt were enrolled in this study. RV function parameters were assessed echocardiographically. RV systolic function was assessed using tricuspid tissue Doppler S velocity (St). With regard to RV diastolic function parameters, E/A ratio, deceleration time (DT), E/Et ratio (Et = tissue Doppler E velocity), RV isovolumetric relaxation time (RVIVRT) were assessed. RV myocardial performance index (MPI) was calculated as an index of both systolic and diastolic function. Pulmonary artery stiffness (PAS) was also calculated. After echocardiography, right and left heart catheterization was performed. Mean pulmonary artery pressure (MPAP), mean right atrial pressure (MRAP), systemic flow (Qs), pulmonary flow (Qp), systemic vascular resistance (SVR), and pulmonary vascular resistance (PVR) were obtained using the data of invasive measurements. RESULTS: In multivariate analysis, MPAP was found to be the parameter closest related to RVIVRT (r = 0.73, p < 0.001) and E/Et (r = 0.66, p < 0.001), while PAS was found to be the parameter closest related to MPI (r = 0.53, p = 0.002). In addition, St velocity was found the only parameter related to PVR (r = -0.39) in univariate analysis. There was no relationship between QP/QS and any of the RV function parameters. CONCLUSION: The pulmonary vascular bed appears to be the predictor of the RV functions in patients with atrial left to right shunts, and the amount of the shunt seems to have no direct adverse influence on the RV functions.     

Usefulness of right ventricular tissue Doppler imaging to predict outcome in left ventricular heart failure independent of left ventricular diastolic function

It is unknown whether right ventricular (RV) tissue Doppler (TD) predicts outcome in patients with left ventricular (LV) heart failure (HF) independently of contemporary echocardiographic Doppler variables of LV diastolic function. Comprehensive echocardiographic Doppler examination was performed before discharge in 107 patients hospitalized with LV HF. The primary end point was cardiac death or rehospitalization for HF. Follow-up was complete for 100 of 107 patients a mean of 527 days after hospital discharge. There were no significant differences in baseline clinical variables (mean age 58+/-12 years, 46% women, 77% hypertensive, 48% diabetic, 41% current smokers, and 23% known coronary artery disease) in prediction of the primary end point. Compared with patients without an event, patients with an event had a larger left atrial volume index (42+/-16 vs 33+/-13 ml/m2, p=0.001), lower LV ejection fraction (35+/-19% vs 46+/-22%, p=0.01), higher mitral peak early diastolic flow velocity/TD early diastolic velocity (19+/-7 vs 14+/-7, p=0.001), lower RV fractional area change (39+/-11% vs 43+/-10%, p=0.04), and lower RV TD systolic velocity (8+/-2 vs 10+/-3 cm/s, p=0.005). On Cox proportional hazards multivariate analysis, left atrial volume index (p=0.01), mitral peak early diastolic flow velocity/TD early diastolic velocity (p=0.03), and RV TD systolic velocity (p=0.04) were independent predictors of outcome. Even when contemporary echocardiographic Doppler measures of LV diastolic function are considered, RV TD systolic velocity is an independent predictor of cardiac death or rehospitalization for HF in patients hospitalized with HF and appears to be superior to conventional 2-dimensional parameters of RV function.