Prognostic significance of exercise‐induced diastolic dysfunction: A systematic review

Abstract

Background: Recent guidelines recommend diastolic stress testing among patients with unexplained dyspnea. Previous studies have reported exercise related change in diastolic parameters as a prognostic marker for worse outcomes. However, the role of exercise-induced diastolic dysfunction (DD) in predicting adverse outcomes has not been fully established. Method: We conducted a meta-analysis to explore the prognostic significance of exercise-induced DD. PUBMED/EMBASE/SCOPUS databases were searched for studies reporting adverse outcomes in patients undergoing exercise echocardiography based on diastolic response during exercise. Exercise-induced DD was defined as an increase in E/e′ or E/A ratio with stress. Outcomes of interest were cardiovascular mortality or hospitalizations. Results: A total of 8 studies were identified, including 4,462 patients who underwent exercise stress echocardiography. The follow-up ranged from 13 months to 5 years. The major indication for stress testing was exertional dyspnea. All studies reported cardiac mortality and hospitalization in the composite outcome. Meta-analysis conducted using random-effects model showed that exercise-induced DD was associated with a higher likelihood of cardiovascular mortality or hospitalization (HR = 1.32, P < .05). Significant heterogeneity was noted among the studies. Conclusions: Exercise-induced DD is associated with worse cardiovascular outcomes. Changes in echocardiographic parameters such as e′ with exercise might be useful for risk stratification and identification of high-risk patients.

Diastolic stress echocardiography and biomarkers in patients with preserved left ventricle ejection fraction and heart failure symptoms

“…In our study, DSE revealed DD in 21% of patients with HF symptoms and suspected DD or borderline diastolic abnormalities on rest TTE. There is considerable heterogeneity among other studies in the rates of abnormal LV diastolic function on exercise echocardiography related to study groups and various echocardiographic parameters used as markers of diastolic function [15,16]. Therefore, the rates of positive diastolic stress tests varied from a few percent [17] to nearly half of the study group [18].…”

“…Finally, DSE was found to predict clinical outcomes. The meta-analysis by Sud et al found that exercise-induced DD was associated with a higher likelihood of cardiovascular mortality or hospitalization [15].…”

Prognostic significance of incorporating exercise tissue doppler mitral annular early diastolic velocity in exercise diastolic dysfunction assessment

“…Routine supplementation of exercise echocardiography with post‐exercise diastolic measures can improve the prognostic utility of the test. Several studies and one meta‐analysis have demonstrated that exercise‐induced diastolic dysfunction is associated with a higher likelihood of adverse cardiovascular outcomes 2 . The American Society of Echocardiography (ASE) guidelines recommend diastolic stress testing for echocardiographic assessment of exercise hemodynamics in patients with unexplained dyspnea, but studies have suggested the prognostic utility of diastolic measures in a broader group of patients referred for stress echocardiography 3 .…”

“…Several studies and one meta-analysis have demonstrated that exercise-induced diastolic dysfunction is associated with a higher likelihood of adverse cardiovascular outcomes. 2 The American Society of Echocardiography (ASE) guidelines recommend diastolic stress testing for echocardiographic assessment of exercise hemodynamics in patients with unexplained dyspnea, but studies have suggested the prognostic utility of diastolic measures in a broader group of patients referred for stress echocardiography. 3 The diastolic variables recommended by ASE guidelines include resting septal e' velocity, post-exercise E/e' ratio, and post-exercise tricuspid regurgitant jet velocity, measures that can be routinely obtained during treadmill exercise echocardiography testing in all patients regardless of indication.…”

Peripheral Venous Pressure: An Important but Neglected Contributor to Echocardiographic Estimation of Pulmonary Artery Pressure With Exercise

“…5 For this reason, exercise echocardiography has been used to estimate left ventricular filling pressure, pulmonary artery pressure, and the right ventricular–arterial coupling responses to exercise. 6 However, although exercise hemodynamic results are prognostically meaningful, 7,8 there are broad limits of agreement between invasive and noninvasive assessment of filling pressure 9 and pulmonary artery systolic pressure (PASP) 10 with exercise.…”