Left ventricular geometry and function are related to electrocardiographic characteristics and diagnoses

We investigated the relationships between echocardiographic indices of left ventricular geometry and function and major electrocardiographic (ECG) abnormalities in 540 elderly (69–74 years old) male participants of a health survey conducted in Uppsala county, Sweden. Comparing men with major ECG abnormalities that were present or absent in various hierarchic mutually exclusive categories, left ventricular mass indexed to body surface area (LVMI) was significantly increased with major Q-waves (P = 0·0002), ST or T-wave abnormalities (P = 0·005), left bundle-branch block (P = 0·005) and also with atrioventricular block type 1 (P = 0·008) and frequent premature beats (P = 0·02). The left atrial diameter was also significantly increased with most ECG abnormalities. The increased LVMI was in left bundle-branch block mainly due to an increased left ventricular diameter, whereas left ventricular wall thickness was increased with frequent premature beats, atrioventricular block type 1 and ST or T-wave abnormalities. The prevalence of Q-waves was highest in eccentric left ventricular hypertrophy, whereas the prevalence of ST or T-wave abnormalities and atrioventricular block type 1 was highest in concentric left ventricular hypertrophy. Both left ventricular systolic (ejection fraction) and diastolic function (E/A ratio) were inversely related to Sokolow–Lyon QRS amplitude (r = ?0·25, P < 0·02 and r = ?0·22, P < 0·03 respectively). In conclusion, LVMI was increased in subjects with ECG signs of coronary artery disease as well as in subjects with several other ECG diagnoses. Furthermore, both left ventricular systolic and diastolic dysfunction were related to increased QRS amplitudes. Thus, the finding of ECG abnormalities in elderly men should raise the suspicion of structural and/or functional left ventricular abnormality.     

Interrelationships between indices of longitudinal movement of the common carotid artery wall and the conventional measures of subclinical arteriosclerosis

Our objective was to study the interrelationships between longitudinal movement of the wall of the common carotid artery and the conventional measures of arteriosclerosis in a large and well-characterized study population. Successful longitudinal movement analyses were performed on 292 subjects. The peak-to-peak and retrograde amplitudes of the longitudinal movement were directly correlated with carotid artery distensibility (r = 0·21, P<0·001 and r = 0·23, P<0·001, respectively) and inversely correlated with pulse wave velocity (r = −0·14, P<0·05 and r = −0·17, P<0·01, respectively). All longitudinal motion parameters were independent of brachial flow-mediated dilatation and intima-media thickness. Our findings indicate that arterial stiffening modulates longitudinal movement and, therefore, measurement of longitudinal movement can be of value in the assessment of vascular health.     

Assessment of left ventricular diastolic function from mitral annulus motion,a comparison with pulsed Doppler measurements in patients with heart failure

Summary. Mitral and pulmonary venous flow velocity recordings are often used for the assessment of left ventricular diastolic function. These curves are, however, also influenced by other factors. To investigate whether mitral annulus motion carries additional information in this context, mitral annulus motion was compared to Doppler registrations of mitral and pulmonary flow velocities in 38 patients with heart failure (NYHA II—III) after myocardial infarction. Patients with an increased atrial contribution to mitral annulus motion (> 57%, n= 12) had a higher mitral late-to-early flow velocity ratio (A/E) and pulmonary systolic to diastolic filling ratio (<0–01). Patients with atrial displacement above average for the group (? 5.1 mm, n= 19) had a higher mitral AVE ratio and pulmonary systolic to diastolic filling ratio than patients with a lower than average atrial component (P < 0.05). There was a significant correlation between a/T ratio and A/E ratio (r= 0.61, P < 0.001) and between pulmonary flow and transmitral flow (= 0.76, P < 0.001). We conclude that an increased atrial displacement of the mitral annulus is a frequent finding in patients with signs of left ventricular relaxation abnormality. There is a significant correlation between a/T ratio and A/E ratio but the information contained in the two indices are not identical.     

Atrioventricular plane displacement correlates closely to circulatory dimensions but not to ejection fraction in normal young subjects

Aims Mitral atrioventricular plane displacement (AVPD) provides information about left ventricular systolic function. M‐mode of systolic annulus amplitude or tissue Doppler imaging of systolic annulus velocity are the current methods of evaluating AVPD. A correlation to ejection fraction (EF) has been demonstrated in patients with coronary artery disease and left ventricular dysfunction. Our aim was (i) to investigate the mitral AVPD of normal subjects with different physical work capacities and (ii) to further evaluate AVPD as an index of left ventricular systolic function. Methods and results Twenty‐eight healthy men mean age 28 years (20–39) were included: endurance trained (ET) (n=10), strength trained (ST) (n=9) and untrained (UT) (n=9). The systolic AVPD was recorded at four sites, septal, lateral, anterior and posterior, using M‐mode. Left ventricular volumes were calculated according to Simpson’s rule. Systolic AVPD was higher in endurance trained, 16·9 ± 1·5 mm, as compared with both strength trained, 13 ± 1·6 (P<0·001) and untrained, 14 ± 1·6 (P<0·001). Left ventricular systolic AVPD correlated strongly with end‐diastolic volume (r=0·82), stroke volume (r=0·80) and maximal oxygen consumption per body weight (r=0·72). The correlation between AVPD and EF was poor (r=0·22). Conclusion In the subjects studied, with a range of normal cardiac dimensions, AVPD correlated to stroke volume, end‐diastolic volume and maximal oxygen consumption per body weight, but not to EF. On theoretical grounds, it also seems reasonable that a dimension like AVPD is related to other cardiac dimensions and volumes, rather than to a fraction, like EF. AVPD is one parameter that is useful for evaluation of left ventricular systolic function but is not interchangeable with other measurements such as EF.     

Validation of a newly developed B-mode image-processing technique versus wall-tracking ultrasound for the study of wall mechanics in small-calibre arteries

Purpose: To validate a newly developed image‐processing technique for the assessment of arterial wall compliance and distensibility from non‐invasive B‐mode ultrasound compared with the invasive wall‐tracking technique. Materials and methods: Arterial wall compliance and distensibility coefficient were measured invasively by wall‐tracking with an ultrasonic transducer implanted on the vessel wall, and non‐invasively by automatic processing of B‐mode ultrasound images, with a dedicated workstation and software (IO^ 3·1, IO^DP, Paris). Measurements were performed in the normal aorta of five animals, and upstream, at the stent level, and downstream from the stent in eight other animals (immediately after stenting in six, and 3 months later in four), for a total of 35 paired measurements. Results: There was no significant difference between the two techniques for compliance but there was a significant difference in diameter (P<0·005) and distensibility (P<0·05) as external ultrasound measured the inner diameter, while wall‐tracking measured the outer diameter. Agreement between the two methods as assessed by the Bland–Altman approach was acceptable for aortic diameter, compliance and distensibility. Conclusion: Automatic processing of B‐mode ultrasound images is a reliable non‐invasive technique to assess the compliance of small‐calibre arteries.     

Right ventricular long-axis function in relation to left ventricular systolic function

A decrease in left ventricular (LV) systolic function is accompanied by a decrease in maximal relaxation velocity in LV long‐axis direction, but is it also accompanied by a decrease in right ventricular (RV) long‐axis function? To study this 35 consecutive patients were examined by echocardiography. Ejection fraction (LVEF) and mitral annulus motion (MAM) were used as indices of LV systolic function and tricuspid annulus motion (TAM), that is the systolic shortening in RV long‐axis direction, was used as an index of RV systolic long‐axis function. In the same way the maximal relaxation velocity in LV long‐axis direction, that is the maximal diastolic velocity of MAM (MDV MAM), has been suggested as an index of LV diastolic function the maximal diastolic velocity of TAM (MDV TAM) can be supposed to be an index of RV diastolic function measuring the maximal relaxation velocity in the RV long‐axis direction. A significant positive correlation was found between MDV TAM and MAM (r = 0·64, P<0001) and LVEF (r = 0·54, P = 0·001) and between TAM and the two studied indices of LV systolic function, with the highest correlation to MAM (r = 0·68, P<0·001) and the lowest to LVEF (r = 0·57, P<0·001). Thus, a decrease in LV systolic function is accompanied by a decrease in both systolic and diastolic RV long‐axis function, findings that probably are due to the close anatomical connection between the ventricles and to changes that occur in afterload of the RV secondary to LV systolic dysfunction.     

Effects of transient regional ischemia on left ventricular diastolic function

Simultaneous left ventricular echograms and high-gain pressure recordings were made during 30 s of regional myocardial ischemia induced by snare occlusions of the proximal left anterior descending (LAD) or left circumflex (LCx) coronary arteries in open-chest dogs. Left ventricular diastolic diameter (d) and pressure (p) were measured during slow filling. A normalized (for diameter D) distensibility estimate (DE = Δd/Δp/D) was calculated, as were slow filling slopes (SFSs) of the septum and posterior wall. After occlusion, significant (p < 0.05) decreases of DE and anterior and posterior left-ventricular-wall mid-diastolic normalized slow-filling slopes (ASFS/D and PSFS/D) were observed. Correlations were noted between percentage decreases of DE and ASFS/D (r = 0.69, p < 0.0001) and PSFS/D (r = 0.62, p < 0.0001). No significant differences between decreases of DE and SFS were noted between ischemic and non-ischemic regions. Transient regional myocardial ischemia was associated with a generalized alteration in left ventricular filling patterns in mid-diastole.     

The relationship between tissue Doppler imaging and seric NTproBNP levels in sinus rhythm patients: a prospective study

N-terminal pro-brain natriuretic peptide (NTproBNP) correlates with left ventricular (LV) filling pressure. The ratio between early diastolic transmitral velocity and early mitral annular diastolic velocity (E/Ea) reflects LV filling pressure in a variety of cardiac diseases. However this relationship was not validated in some categories of patients. Our aim was to evaluate the correlation between tissue Doppler velocities of the mitral annulus and NTproBNP levels in sinus rhythm patients. Methods Echocardiography was performed in 111 consecutive patients simultaneously with NTproBNP measurement. E/Ea and E/(Ea × Sa) were calculated (Sa is the maximal systolic velocity of mitral annulus); the average of the velocities of septal and lateral mitral annulus was used. Results Simple regression analysis demonstrated a significant linear correlation between E/(Ea × Sa) and NTproBNP (r = 0.71, P < 0.0001), superior to E/Ea correlation (r = 0.58, P < 0.0001). Significant but weaker correlations were found between NTproBNP and Sa, pulmonary artery systolic pressure, Ea, mitral E/A (early/late diastolic transmitral velocity), E wave, mitral E deceleration time and LV ejection fraction (LVEF). The optimal E/(Ea × Sa) cut-off for prediction of NTproBNP levels > 900 pg/ml was 1.5 (sensitivity = 81%, specificity = 70%). Among analyzed parameters, E/(Ea × Sa) was best correlated with NTproBNP levels in patients with LVEF ≥ 50% (r = 0.80, P < 0.0001), with depressed LVEF (<50%) (r = 0.66, P < 0.0001), with regional wall motion abnormalities (r = 0.75, P < 0.0001), and with E/Ea 8 to 15 (r = 0.58, P < 0.0001). Conclusions E/(Ea × Sa) strongly correlates with NTproBNP, regardless of LVEF, and can be a simple and accurate echocardiographic index in patients in sinus rhythm, particularly in those with regional wall motion abnormalities or intermediate E/Ea.     

Brachial artery hyperaemic blood flow velocity in relation to established indices of vascular function and global atherosclerosis: the Prospective Investigation of the Vasculature in Uppsala Seniors study

Background: Systolic to diastolic blood flow velocity (SDFV) ratio in the brachial artery recently proved to be related to cardiovascular risk and carotid atherosclerosis. We hypothesized that the SDFV ratio was related to established markers of vascular function and global atherosclerosis. Methods: Established markers of endothelial function in forearm resistance vessels, flow‐mediated vasodilation and arterial stiffness were assessed in the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study including 1016 individuals aged 70. Whole‐body magnetic resonance angiography was performed in a random 306 of the participants. Atherosclerotic lesions were summarized in a total atherosclerotic score (TAS). Before and during hyperaemia of the brachial artery, systolic and diastolic blood flow velocities were measured by Doppler. Results: The SDFV ratio was positively related to endothelium‐independent vasodilatation, while inverse relations were found to flow‐mediated dilation, common carotid artery distensibility and the stroke volume to pulse pressure ratio. Endothelium‐dependent vasodilatation and total peripheral resistance index were not significantly related to the SDFV ratio. The SDFV ratio (P = 0·015) and the blood flow increase (BFI) during hyperaemia (P = 0·020) were both significantly related to TAS after gender adjustment. When adjusted for the Framingham risk score, both the SDFV ratio (P = 0·057) and BFI (P = 0·078) lost somewhat in significance. Conclusion: The SDFV ratio was related to established markers of both vasodilation and arterial compliance, and to global atherosclerosis. Future larger studies have to evaluate whether the SDFV ratio is related to global atherosclerosis independently of traditional risk factors.     

Cardiac performance during exercise in patients with Fabry's disease

Background Fatigability and dyspnoea on effort are present in many patients with Fabry's disease. We assessed the determinants of cardiac performance during exercise in patients with Fabry's disease and preserved left ventricular ejection fraction at rest. Materials and methods Sixteen patients with Fabry's disease and 16 control subjects underwent radionuclide angiography at rest and during exercise, tissue Doppler echocardiography and magnetic resonance imaging at rest. Results The exercise‐induced change in stroke volume was +25 ± 14% in controls and +5·8 ± 19% in patients with Fabry's disease (P < 0·001). In 10 patients (group 1), the stroke volume increased (+19 ± 10%), and in 6 patients (group 2) it decreased (–16 ± 9%) with exercise. Patients of group 2 were older, had worse renal function, higher left ventricular mass and impaired diastolic function compared to group 1. The abnormal stroke volume response to exercise in group 2 was associated with a decrease in end‐diastolic volume (P < 0·001) and a lack of reduction of end‐systolic volume (P < 0·01) compared with both controls and group 1. The ratio of peak early‐diastolic velocity from mitral filling to peak early‐diastolic mitral annulus velocity was the only independent predictor of exercise‐induced change in stroke volume (B –0·44; SE 0·119; β–0·70; P < 0·005). Conclusions The majority of patients with Fabry's disease were able to augment stroke volume during exercise by increasing end‐diastolic volume, whereas patients with more advanced cardiac involvement may experience the inability to increase cardiac output by the Frank Starling mechanism.     

Arterial stiffness in relation to subclinical atherosclerosis

Background Increased arterial stiffness or arteriosclerosis, represents a physiological part of ageing. Atherosclerosis is a process that does not affect the arterial bed uniformly but has a variable local distribution and is frequently superimposed on stiffened vessels. We therefore addressed the question of whether any correlation exists between the general characteristics of arterial stiffness or wave reflection and subclinical atherosclerosis as assessed by carotid intima‐media thickness (IMT) in a sample of healthy subjects. Methods A total of 116 healthy subjects (mean age 55 years, 43 female) were evaluated. Arterial stiffness and wave reflection was assessed with the use of digital volume pulse analysis (DVP) and pulse wave analysis (PWA). Subclinical atherosclerosis was assessed by measurement of IMT. Results Stiffness Index (SI_DVP), the measure of general arterial stiffness correlated significantly with IMT (r = 0·37, P < 0·01). IMT correlated significantly with age (r = 0·5, P < 0·0001), waist to hip ratio (WHR) (r = 0·39, P < 0·0001) and mean blood pressure (BPmean) (r = 0·4, P < 0·0001). IMT did not correlate with measures of wave reflection. SI_DVP correlated significantly with age (r = 0·32, P < 0·005), WHR (r = 0·36, P < 0·0001), BPmean (r = 0·36, P < 0·0001) and measurements of wave reflection. However analysis of a model which included variables that significantly influenced SI_DVP and IMT, such as age, WHR and mean BP showed that arterial stiffness is not independently associated with subclinical atherosclerosis. Conclusions The indices of subclinical atherosclerosis, arterial stiffness and wave reflection, indicate different aspects of vascular status in otherwise healthy subjects     

Atherosclerosis measured by whole body magnetic resonance angiography and carotid artery ultrasound is related to arterial compliance,but not to endothelium‐dependent vasodilation – the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study

Background: Arterial compliance and endothelium‐dependent vasodilation are two characteristics of the vessel wall. In the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study, we studied the relationships between arterial compliance and endothelium‐dependent vasodilation versus atherosclerosis as measured with two imaging modalities. Methods: In the population‐based PIVUS study (1016 subjects aged 70), arterial compliance was determined by ultrasound in the carotid artery and the stroke volume to pulse pressure ratio by echocardiography, while endothelium‐dependent vasodilation was assessed by the invasive forearm technique with acetylcholine and brachial artery ultrasound. Intima‐media thickness was evaluated by ultrasound in the carotid artery (n = 954). Stenosis in the carotid, aorta, renal, upper and lower leg arteries were determined by magnetic resonance angiography in a random subsample of 306 subjects. Results: After adjustments for gender, Framingham risk score, obesity, myocardial infarction and stroke, distensibility in the carotid artery and the stroke volume to pulse pressure ratio were both significantly related to a weighted index of stenosis in the five arterial territories evaluated by magnetic resonance angiography (p<0·02 for both). Distensibility in the carotid artery (P = 0·021), but not the stroke volume to pulse pressure ratio (P = 0·08), was also significantly related to intima‐media thickness. Conclusion: In the elderly population, atherosclerosis is mainly related to arterial compliance, but not to endothelium‐dependent vasodilation in peripheral conduit or resistance vessels.     

Right ventricular diastolic abnormalities in rheumatoid arthritis and its relationship with left ventricular and pulmonary involvement. A tissue Doppler echocardiographic study

Objectives To investigate right ventricular diastolic function in rheumatoid arthritis (RA) and its relationship with left ventricular and pulmonary involvement.Methods Thirty-five RA patients and 30 healthy subjects were submitted to conventional Doppler (CE) and tissue Doppler echocardiography (TDE) to assess left and right systolic and diastolic function and to estimate maximal arterial systolic pulmonary pressure (PAP). To detect pulmonary involvement, pulmonary function tests and high-resolution computed tomography (HRCT) scans were performed in all RA patients.Results An abnormal RV filling, as expressed byan inverted tricuspid (Tr.) E/A ratio, was detected in 12 (34%) of the 35 RA patients and in 2 (7%) of the 30 controls (P<0.004). If compared to CE findings, prevalence of RV diastolic abnormalities were found higher in patients with RA by TDE (RV annulus Em/Am ratio <1 (in 31 (89%) of 35 patients) (P = 0.002). Twenty-two (63%) of 35 patients had abnormal HRCT findings. Pulmonary involvement with pulmonary hypertension (PHT) (36±5 mmHg) was detected in 10 (29%) of 35 RA. In this group, increase of RV annulus and basal Am wave, decrease of Tr. E/A ratio and RV annulus Em/Am ratio were statistically significant compared to RA (12 (34%) of 35) patients with pulmonary involvement who had normal PAP (19±5 mmHg), (P = 0.014, P = 0.006, P = 0.015, P = 0.049, respectively).Conclusions This study points out an impaired RV filling in a significant part of RA patients without overt heart failure. Impairment of RV diastolic function may be a predictor of subclinic myocardial and pulmonary involvement in patients with RA.     

Cardiac power output and its response to exercise in athletes and non‐athletes

Cardiac power output (CPO) is an integrative measure of overall cardiac function as it accounts for both, flow‐ and pressure‐generating capacities of the heart. The purpose of the present study was twofold: (i) to assess cardiac power output and its response to exercise in athletes and non‐athletes and (ii) to determine the relationship between cardiac power output and reserve and selected measures of cardiac function and structure. Twenty male athletes and 32 age‐ and gender‐matched healthy sedentary controls participated in this study. CPO was calculated as the product of cardiac output and mean arterial pressure, expressed in watts. Measures of hemodynamic status, cardiac structure and pumping capability were assessed by echocardiography. CPO was assessed at rest and after peak bicycle exercise. At rest, the two groups had similar values of cardiac power output (1·08 ± 0·2 W versus 1·1 ± 0·24 W, P>0·05), but the athletes demonstrated lower systolic blood pressure (109·5 ± 6·2 mmHg versus 117·2 ± 8·2 mmHg, P<0·05) and thicker posterior wall of the left ventricle (9·8 ± 1 mm versus 9 ± 1·1 mm, P<0·05). Peak CPO was higher in athletes (5·87 ± 0·75 W versus 5·4 ± 0·69 W, P<0·05) as was cardiac reserve (4·92 ± 0·66 W versus 4·26 ± 0·61 W, P<0·05), respectively. Peak exercise CPO and reserve were only moderately correlated with end‐diastolic volume (r = 0·54; r = 0·46, P<0·05) and end‐diastolic left ventricular internal diameter (r = 0·48; r = 0·42, P<0·05), respectively. Athletes demonstrated greater maximal cardiac pumping capability and reserve than non‐athletes. The study provides new evidence that resting measures of cardiac structure and function need to be considered with caution in interpretation of maximal cardiac performance.     

Both leg blood flow and the femoral blood flow pattern are related to left ventricular mass in elderly men

Left ventricular mass (LVM) was significantly related to both the leg blood flow (r = –0·31, P<0·05) and a Doppler-derived index of femoral arterial stiffness (r = 0·35, P<0·05) in a sample of elderly men. Together with blood pressure, these two characteristics of peripheral blood flow explained 42% of the variation in LVM.     

Age-dependency of left ventricular filling dynamics and relaxation as assessed by pulsed Doppler echocardiography

Summary. Left ventricular diastolic function was assessed from transmitral flow velocity curves as measured by Doppler echocardiography in healthy individuals aged 21–69 years, each decade comprising 12 subjects. By ageing, progressive changes in the various filling parameters were observed. When comparing the youngest and oldest age groups, the ratio between peak velocities in early and late diastole decreased from 2.0±0.3 to 1.2±0.3 (P<0.001). The filling fraction of first third of diastole decreased from 54 ± 5% to 45 ± 4% (P<0.001). Isovolumic relaxation time increased from 61 ± 11 ms to 77 ± 12 ms (P<0.01). Correlation coefficients of velocity ratio, filling fraction and isovolumic relaxation time vs. age were r= -0.71 (P<0.001), r= -0.56 (P<0.001) and r= 0.44 (P<0.001), respectively. When isovolumic relaxation time and age were used together in multivariate regression analysis, only age was an independent predictor of velocity ratio and filling fraction. Stroke volume, peak velocity in left ventricular outflow tract, heart rate and systolic blood pressure were similar in all age groups. Thus, velocity ratio and filling fraction indicated a relative filling shift towards late diastole by ageing and were more sensitive than s?ystolic parameters in reflecting age-related changes in cardiac function. The changes could be explained neither by delayed relaxation nor by change in systolic parameters. When using Doppler echocardiography for evaluation of left ventricular filling, agematching of reference groups is necessary.     

Adenosine infusion to patients with ischaemic heart disease may provoke left ventricular dysfunction detected by echocardiography

Summary. Infusion of the endogenous vasodilator adenosine to patients with ischaemic heart disease (IHD) frequently provokes myocardial ischaemia, possibly caused by a coronary steal. The aim of this study was to detect the occurrence and incidence of disturbances in left ventricular (LV) wall motion and Doppler indices of altered LV function during infusion of adenosine. Thirty-seven patients (six female) aged 37–74 years with IHD, verified by coronary angiography, were given up to 200 μg kg^-1 min^-1 (mean 155 ± 5) adenosine i.v. for 18 ± 1 min. LV wall motion was monitored by two-dimensional echocardiography (2D-echo). Doppler spectral signal was obtained from the mitral blood flow. All but six of the patients experienced angina pectoris of habitual character in connection with the adenosine infusion. Heart rate increased by 22 ± 1 beats min^-1, systolic blood pressure was unchanged, but diastolic blood pressure decreased slightly. 2D-echo revealed severe regional LV wall motion disturbances already in the basal state in 17 patients. During infusion of adenosine, these abnormalities were aggravated and disturbances also occurred in another 15 patients. Thus, adenosine increased the sensitivity for IHD in this selected material from 49 to 89%. In all, the mean index of wall motion abnormalities increased from 5·1 ± 1·1 to 10·1 ± 1·4 (P< 0·001). The diastolic LV filling characteristics, as evaluated by the Doppler A/E ratios, were of limited value for determination of IHD grade. It is concluded that infusion of adenosine to patients with IHD frequently elicits myocardial ischaemia with disturbances in LV function, and offers an alternative to exercise for stress echocardiography.     

Right and left heart dysfunction predict mortality in pulmonary hypertension

In pulmonary hypertension (PH), the right heart dysfunction is a strong predictor of adverse clinical outcome, while the role of the left heart is not fully determined. The aim of this study was to identify predictors of mortality in precapillary PH including measures of both right and left heart function. We studied 34 patients (mean age 64 ± 13, range 31–82 years, 24 females) with precapillary PH, all of whom underwent detailed Doppler echocardiographic examination of the right and left heart function using conventional and speckle-tracking echocardiography. Patients were followed up for up to 8 years (mean 4·2 ± 1·9 years). At follow-up, 16 patients survived. Left ventricular (LV) filling time (P = 0·007), pulmonary artery acceleration time (P = 0·009), right atrial pressure (RAP) (P<0·001) and tricuspid regurgitation (TR) severity (P = 0·007) were worse in the deceased group. RV global longitudinal strain (GLS) (P = 0·001), RAP (P≤0·001), LV filling time (P<0·001) and TR severity (P<0·001) were the most accurate predictors, having the largest AUC (>0·65) and carried the highest risk for mortality (P<0·001 for all). The strongest predictors of mortality in precapillary PH indirectly reflect both left and right heart dysfunction including atrial structure and function disturbances. While an interaction pattern is observed, it needs to be confirmed in a larger cohort.     

Pulsed tissue Doppler evaluation of mitral annulus motion: a new window to assessment of diastolic function

Diastolic dysfunction is an important cause of cardiac heart failure. To date detailed assessment of diastolic left ventricular (LV) function has required invasive methods which are impractical in the clinical routine. The prevailing non-invasive method has been Doppler echocardiography with use of mitral inflow and pulmonary vein inflow parameters, measurements providing no direct assessment of either ventricular relaxation or compliance, and influenced by multiple haemodynamic factors. We sought to determine the tissue Doppler pattern from the mitral annulus motion in normals and in patients with expected LV-diastolic dysfunction. Using pulsed tissue Doppler we recorded peak velocities from the mitral annulus motion in 16 young normals, 10 older normals and in two groups of patients expected to have an LV-diastolic relaxation abnormality, i.e. 15 patients with systemic hypertension and 10 patients with significant aortic stenosis. The peak early diastolic (E) annulus velocity was significantly (P < 0·001) lower in older normals compared with young, and the late diastolic velocity (A) was higher (P < 0·01). Compared with the older normals, patients showed significantly lower E-velocities (P < 0·05 hypertensive patients), more pronounced in the patients with aortic stenosis (P < 0·001), but the A-velocities were not higher. In systole a decrease in peak velocity was noted with increasing age and in patients with aortic stenosis. In conclusion, pulsed tissue Doppler measurement of annulus motion seems to provide valuable and easily obtainable information about LV-diastolic function, and furthermore there is a striking change in velocity pattern with increasing age which necessitates age-matched reference values.     

Upright body position and weight loss improve respiratory mechanics and daytime oxygenation in obese patients with obstructive sleep apnoea

To determine whether upright body position and weight loss would improve daytime gas exchange in moderately obese patients with obstructive sleep apnoea (OSAS), 13 patients with mild or moderate OSAS were studied before and after weight loss. Pulmonary function tests, arterial blood gases and respiratory gas analysis were measured prior to and after a very low calorie diet (VLCD) period of six weeks. Arterial blood gases were measured in supine and standing positions and closing volume in supine and sitting positions before and after weight loss. In the upright position, there was a significant increase in PaO₂ (P<0·005) accompanied by a significant decrease in alveolar–arterial PO₂ difference (P<0·005) and closing volume (P<0·05). The median weight loss was 11 kg (range 5–18). The number of desaturation episodes (four percentage units or more per hour during sleep) (ODI₄) decreased (P<0·01) after weight loss. The change in PaO₂ with weight loss correlated with the decrease in ODI₄ (r=0·73, P<0·01). The increase in expiratory reserve volume (ERV) was closely related to the amount of weight lost (r=0·895, P<0·01). The results indicate that weight loss and upright body position improved daytime respiratory mechanics and gas exchange in obese patients with OSAS. The findings suggest that obesity plays an important role in the pathogenesis of daytime gas exchange disturbances in obese OSAS patients. The adoption of a more upright sleep posture might improve nocturnal oxygenation in obese patients with OSAS.