Clinical Value of Types of Exercise-Induced Diastolic Abnormalities in Patients with Myocardial Disease

Abstract

It has recently been demonstrated that the handgrip-apexcardiographic test (HAT) represents a low-level (40% of maximal voluntary contraction) isometric stress test of short duration (2 min) by which one can assess early occurring silent left ventricular diastolic abnormalities in coronary patients. The aim of this study is to determine the pattern of these exerciseinduced diastolic abnormalities and to assess its potential diagnostic as well as prognostic significance in patients with various myocardial disease states. HAT was performed in 242 healthy subjects and 155 patients; 15 patients with previous infarction without symptoms (group 1), 40 patients with prior infarction and angina pectoris (group 2), 74 patients with typical angina pectoris without infarction (group 3), and 26 patients with congestive heart failure (group 4). As index of compliance served the relative A wave to the total height (A/H) of apexcardiogram, and as indices of relaxation the total apexcardiographic relaxation time (TART) and TART corrected for the duration of diastole (TARTI). The following three types of handgrip-induced changes of these diastolic indices were observed: (1) the compliance (C)-type, which was present when A/H increased during and/or after handgrip >21 % (= largest individual value in controls); (2) the relaxation (Retype being present when TART during handgrip >TART at rest >143 ms or/and TARTI <0.14 (= lowest individual value in controls), and (3) the mixed (RC)-type which is defined by the presence of both the criteria of R- and C-types. These 3 types showed a different distribution in the four groups of patients. The C-type was predominant in groups 2 and 4 (73 and 58%, respectively), whereas in group 3 all three types showed a similar distribution (C-type: 31%, R-type: 27% and RC-type: 34%). In contrast, in group 1 the C-type was absent and the R- as well as RC-types were rare (13 and 7%, respectively). During a clinical follow-up period of 20 ± 2 months, patients with C-type of dysfunction had a less favorable outcome (7% deaths, 6% new infarctions and 4% acute lung edema). According to our present data derived from HAT in patients with myocardial disease, it can be concluded that: (1) three different types of diastolic abnormalities are present during isometric stress; (2) there is a different distribution of these patterns depending on the presence of previous infarction, angina pectoris or heart failure, and (3) the C-type is probably associated with the worst long-term prognosis. Thus, this study introduces the 3-type concept of exercise-induced diastolic abnormalities and demonstrates their potential diagnostic and prognostic significance in clinical practice.

Invasive and Noninvasive Assessment of Exercise-induced Ischemic Diastolic Response Using Pressure Transducers

“…As shown in Table 2 , a positive presso test is defined by the presence of one of the following 3 “diastolic types” at rest or/and with handgrip [ 33 ]: the “relaxation or R-type”, the “compliance or C-type” and the “mixed or RC-type”. Patients with a C-type presso test result showed the worst, those with R-type the most favorable and those with RC-type an intermediate outcome [ 33 ]. Therefore, the transmission from R- to RC- and C-type is defined as a “deterioration of type”.…”

Patterns of Diastolic Abnormalities during Isometric Stress in Patients with Systemic Hypertension

“…40, 41], Addi tionally, since apexcardiographic diastolic variables have been found to correlate with internally pressure-derived indices during handgrip [42], the apexcardiogram appears to represent a more suitable method for detecting both exercise-induced early (relaxation) and late (compliance) diastolic alterations. This discrimination between relax ation and compliance changes has been found to be of prognostic value in a long follow-up study in patients with myocardial disease [48].…”

“…27. These values represent the largest or lowest individual values observed in a large cohort o f normals [43,47], Moreover, a 'compliance' (C) type of diastolic variables response to handgrip was defined by the presence of an isolated abnormal ele vation of the A/H during and/or after handgrip, a 'relaxation1 (R) type of diastolic response by an isolated abnormal prolongation of TART and/or a decrease in TARTI during handgrip, whereas a 'mixed' (RC) type was defined by the presence of both the C and R types of handgrip-induced diastolic abnormalities [48], In addition to this '3 type' concept, a fourth 'DATI type' was defined in the present study as an isolated abnormal DATI decrease during hand grip. On the other hand, an 'ischemic' pattern of exercise-induced diastolic dysfunction was defined by either an absolute or relative prolongation of resting normal relaxation time or by a pathologic A/ H (>21%) and an increase of more than double the resting normal A/H (max AHI >2).…”

“…Most importantly, three different types of exercise-in duced diastolic changes in apexcardiographic indices have been found to show a different distribution in a vari ety of myocardial diseases and to be of prognostic signifi cance, whereas the C type was associated with the worst and the R type with the most favorable outcome [48].…”

“…This higher sensitivity of apexcardiographic variables can be explained by the fact that these noninvasivc diastolic indices have been found by numerous authors to correlate significantly with pressure changes within the left ventricle in diastole both at rest [31][32][33][34][35][36][37][38][39][40][41] and during isometric stress [42]. Since little is known about diastolic function abnormalities during ex ercise in untreated patients with systemic hypertension, the present study was designed to determine the preva lence and patterns of diastolic abnormalities at rest as well as during isometric handgrip stress using the recently introduced handgrip-apexcardiographic test (HAT) [43][44][45][46][47][48][49][50] in patients with systemic hypertension not receiving therapy by measuring apexcardiographic diastolic indices which reflect left ventricular pressure changes in early and late diastole. …”