Impact of negative inotropic drugs on accuracy of diastolic stress echocardiography for evaluation of left ventricular filling pressure

Joe-Elie Salem,Jean Sebastien Hulot,Richard Isnard,Gerard Helft,Alexandre Ceccaldi,Christian Funck-Brentano,Nadjib Hammoudi,Florent Laveau,Claude Le Feuvre,Olivier Barthelemy,Amel Mameri

doi:10.1038/s41598-017-10301-5

Abstract

The ratio of early diastolic trans-mitral flow velocity to tissue-Doppler mitral annular early diastolic velocity (E/e′), and left ventricular end-diastolic pressure(LVEDP) have been shown to be correlated at rest, provided that patients are not on positive inotropic drugs. Data concerning the latter correlation during exercise stress are conflicting. Therefore, we investigated if use of negative inotropic drugs (NID), impacts the accuracy of E/e′ as a surrogate for LVEDP during low-level exercise. An exercise(50 watts) during cardiac invasive hemodynamic monitoring and an exercise echocardiography were performed prospectively within 24 hours in 54 patients (81%male, 62 ± 9years) with preserved LV Ejection-Fraction. Before exercise, the patients had scattered LVEDP (13.8 ± 5.8 mmHg) and septal E/e′ (8.7 ± 2.7). Half of them were on NID, mainly betablockers(n = 26). The correlation between septal-E/e′ and LVEDP was low for examinations performed at rest (r = 0.35,p = 0.01) with no significant impact of NID. For measurements performed at 50 Watts, NID had a significant impact on the association between septal-E/e′50 watts and LVEDP50 watts (β = −0.28,p = 0.03). Correlation between septal-E/e′50 watts and LVEDP50 watts persisted in patients on NID (r = 0.61,p = 0.001) while it disappeared in the group of patients with no NID (r = 0.15,p = 0.47). NID use is an important confounding factor to take into consideration when assessing exercise LVFP using stress E/e′ in patients with preserved LVEF.

Highlights

Cardiac catheterization has demonstrated its usefulness for the diagnosis of early stage of heart failure with preserved ejection fraction (HFpEF), which is characterized by exercise-induced abnormal left ventricular filling pressure (LVFP) despite normal resting values[1, 2]
Several studies have shown a good correlation between E/e′ and LVFP at rest, in patients with chronic heart failure, either with preserved or altered left ventricular ejection fraction (LVEF)[5,6,7,8]
In order to test this hypothesis, the aim of this study was to assess the impact of negative inotropic drugs (NID) use on accuracy of stress E/e′ as a surrogate for exercise LVFP using a direct invasive measurement as the reference method in patients at high risk of heart failure with preserved ejection fraction (HFpEF)

Summary

Introduction

Cardiac catheterization has demonstrated its usefulness for the diagnosis of early stage of heart failure with preserved ejection fraction (HFpEF), which is characterized by exercise-induced abnormal left ventricular filling pressure (LVFP) despite normal resting values[1, 2]. When dobutamine was used, LV relaxation was enhanced (Tau constant < 50 msec) and e′ lost its preload-independence[18] Confirming these non-clinical data, our group and others reported that positive inotropic agents severely impaired the correlation between E/e′ and invasive evaluation of LVFP in patients with decompensated end-stage systolic heart failure[21, 22] while this correlation was good in the same type of patients treated by beta-blockers[6]. In order to test this hypothesis, the aim of this study was to assess the impact of NID use on accuracy of stress E/e′ as a surrogate for exercise LVFP using a direct invasive measurement as the reference method in patients at high risk of heart failure with preserved ejection fraction (HFpEF)

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Conclusion