Reduced End-Systolic Pressure-Volume Ratio Response to Exercise

Abstract

Background-Limitations in the predictive value of negative exercise echocardiography in type 2 diabetes mellitus has been linked to a reduced end-systolic pressure-volume response (ESPVR). We sought whether abnormal ESPVR reflected subclinical diabetic heart disease by examining the association between the ESPVR and markers of myocardial dysfunction and to establish if the change (⌬) or peak systolic blood pressure/end-systolic left ventricular volume ratio (SP/ESV) is a better marker of contractile reserve in type 2 diabetes mellitus. Methods and Results-Resting and exercise echocardiography was performed in 167 apparently healthy patients with type 2 diabetes mellitus (97 men; age, 55Ϯ10 years) without ischemia, other cardiac disease, or noncardiac complications of diabetes. Standard echocardiographic and color tissue Doppler measures (early diastolic tissue velocity, strain, and strain rate) were acquired at baseline and peak stress in apical long-axis views. Calibrated integrated backscatter was calculated from a resting parasternal long-axis view. ⌬SP/ESV was calculated as [(peak stress SP/ESV)Ϫ(rest SP/ESV)]. The 83 subjects who demonstrated a ⌬SP/ESV Յ12 mm Hg/mL/m 2 after exercise were older and had lower peak heart rate, resting diastolic and stress systolic tissue velocity, stress ejection fraction, and exercise capacity than the remainder. There was no significant association between ⌬SP/ESV and metabolic derangement or echocardiographic measures of deformation or backscatter. Change in Sm and stress ejection fraction were independent correlates of ⌬SP/ESV. Conclusions-⌬SP/ESV ratio is associated with established features of subclinical diabetic heart disease as well as determinants of contractile reserve (peak hemodynamic response and stress systolic function). Peak ESPVR is poorly associated with markers of myocardial dysfunction. (Circ Cardiovasc Imaging. 2010;3:443-449.)

Cardiac energetics, oxygenation, and perfusion during increased workload in patients with type 2 diabetes mellitus

“…However, previous studies have shown exaggerated diastolic and systolic dysfunction in response to stress in patients with diabetes. 46,47 Subjecting our participants to a third stress protocol (in addition to leg exercise during the acquisition of 31 P-MRS and adenosine stress for the assessment of MPRI and oxygenation SIΔ) was deemed too high a burden on study subjects as this would lead to significantly longer adenosine infusion times, higher risk of adverse event rates, and high drop-out rates. For the same reasons, we have not carried out invasive coronary angiography for the assessment of endothelium-dependent coronary vasodilatation and vascular smooth muscle cell responsiveness.…”

Myocardial contractility in the stress echo lab: from pathophysiological toy to clinical tool

“…In asymptomatic patients with aortic stenosis the ΔESPVR could be calculated during stress, but the trans aortic systolic pressure drop should be added to the brachial systolic pressure to correctly calculate the ESPVR both at rest and at peak stress. Different normal vs abnormal ΔESPVR cut-off-values have been observed for different stressors such as exercise [6,15,18,23,25,27,28], subclinical heart disease in diabetes [19,28], to donor hearts not eligible for heart transplant [17,26,29]. A systematic review of the literature with meta-analysis was needed to identify all published papers examining the use of ΔESPVR (PVR) for the prediction of cardiac death and/or heart failure hospitalization in patients with resting LV dysfunction.…”

“…In an another paper by Jellis et al [28], in subclinical diabetic heart disease the ΔESPVR is relatively poorly associated with standard echocardiographic measures of myocardial dysfunction such as calibrated integrated backscatter, strain, and strain rate. The disparity between the ΔESPVR and echocardiographic parameters of myocardial dysfunction is likely because individual markers of LV dysfunction identify different pathological processes occurring concurrently within the spectrum of diabetic heart disease.…”

“…However, there is a close relationship between these two variables, and any sampling error is duplicated between rest and stress values, thereby not affecting the overall ratio [28]. Calcium channel blockers and β-blockers were not withdrawn before testing in 227 (57%) of patients, and there may still have been blunting of the systolic blood pressure.…”