Tissue Doppler indices of diastolic function as prognosticator in patients without heart failure in primary care

Abstract

Background: Tissue Doppler imaging (TDI) indices of left ventricular (LV) diastolic function provide incremental prognostic information on mortality and morbidity in the general population and in several clinical scenarios. Their independent, additional role in outpatients with normal LV ejection fraction (LVEF) and without heart failure (HF) is undefined. Methods: We reviewed clinical and echocardiographic records of 2628 consecutive outpatients 52.8% male, median age 71 years) with LVEF > 50% without concurrent or prior HF, from the Cardiovascular Center of Trieste. We analyzed septal early mitral annular velocity (e') and its combination with mitral peak early filling velocity (E/e') in relation to the composite end-point of death and cardiovascular hospitalizations. Results: During follow-up of 26 months (interquartile range: 12-41), 392 (15%) patients experienced the endpoint (88 deaths). Increasing E/e' showed an overall association with the clinical end-point (log rank p < 0.02), but with no prognostic difference between the middle and upper tertile. Decreasing e' also showed an association with the end-point, with a more balanced stepwise risk increase for increasing tertiles (log rank p < 0.01 for all contrasts). At multivariable analysis, E/e' (either in tertiles or dichotomized according to the threshold of 15) was no longer associated with clinical outcome, whereas e' independently predicted the combined endpoint [hazard ratio 0.73 (0.53-0.94), p = 0.04]. The prognostic value of e' was incremental to that of other clinical and echocardiographic variables (p = 0.04). Conclusions: In outpatients with normal LVEF and without HF, e' and E/e' are both associated with clinical end-points, though only e' is an independent and incremental predictor of outcome. These findings suggest a potential role for e' as a prognosticator, and spread a cautionary word about the utilization of septal E/e' alone as a surrogate for a comprehensive assessment of diastolic function in this context.

The role of systolic–diastolic coupling in distinguishing impaired diastolic recoil in healthy aging and heart failure with preserved ejection fraction

“…Given the rising incidence of HFpEF in the elderly population, a need exists for novel, noninvasive diagnostic markers. Prior studies have shown that e′ and E/e′ ratio are not predictive of heart failure in the elderly population, and even within HFpEF, degrees of diastolic dysfunction can vary significantly 3,4 . Diastolic function changes as one ages with slowing of relaxation, decreased diastolic recoil and increase stiffness 5,9,13,22 .…”

“…1,2 e′ declines with normal healthy aging and may be considered abnormal by diastolic dysfunction criteria in over two-thirds of elderly patients. [3][4][5] Better identification of heart failure with preserved ejection fraction (HFpEF) is of particular interest because noninvasive diagnosis is limited, and prevalence is high among seniors. 6 Echocardiographic markers of diastolic dysfunction include sequelae of increased left atrial pressure (E/e′, right ventricular systolic pressure, left atrial (LA) size), which may not be elevated in euvolemic or early stage HFpEF patients.…”

“…Assessment of early diastolic ventricular lengthening is important in identifying patients with suspected abnormal left ventricular (LV) relaxation and is traditionally measured by early diastolic velocities at the mitral annulus (e′) or with speckle tracking (strain rate) 1,2 . e′ declines with normal healthy aging and may be considered abnormal by diastolic dysfunction criteria in over two‐thirds of elderly patients 3–5 . Better identification of heart failure with preserved ejection fraction (HFpEF) is of particular interest because noninvasive diagnosis is limited, and prevalence is high among seniors 6 .…”

Discrepancies in Assessing Diastolic Function in Pre-Clinical Heart Failure Using Different Algorithms—A Primary Care Study

“…Moreover, in a recent cohort of HFrEF, guideline-based diastolic-grading algorithm independently predicted mortality but was undefinable in 30% of subjects implicating a better prognostic performance of elevated E/e′ ratio [ 35 ]. However, in patients with normal LVEF, the relationship of E/e’ with LVFP is modest, and hence, using E/e’ for estimating LVFP in routine clinical practice is of limited benefit [ 36 , 37 ]. We used only un-enhanced TR velocities; thus, we cannot rule out some underestimation of the prevalence of increased estimated pulmonary pressures.…”

Modeling of Right Ventricular Longitudinal Strain detection in Images using Statistical Analysis of Cardiac function in Severe Infantile Pneumonia by Milrinone

“…The most popular indices are the left ventricular shortening rate and ejection fraction [10]. With the quick advancement of tissue Doppler technology, strain/strain rate imaging, quantitative tissue velocity imaging, and tissue tracking imaging technologies may now precisely and dependably assess patients' cardiac function [11]. The myocardial function can be locally analyzed and assessed using two-dimensional speckle tracking imaging.…”