Abstract
Background The ratio of early mitral inflow velocity to the global diastolic strain rate (E/E'sr) and global longitudinal systolic strain (GLS) of the left ventricle (LV) are emerging indices of diastolic and systolic functions, respectively, for the LV. Their prognostic significance in the prediction of mortality and cardiovascular (CV) outcomes remains underexplored in hemodialysis (HD) patients. Methods This prospective study included 190 maintenance HD patients. The E/E'sr ratio and GLS were assessed using two-dimensional speckle tracking echocardiography. The clinical outcomes included overall mortality, CV mortality, and major adverse cardiovascular events (MACE). The associations between the E/E'sr ratio, GLS, and clinical outcomes were evaluated using multivariate Cox regression analysis. The incremental values of the E/E'sr ratio and GLS in outcome prediction were assessed by χ2 changes in Cox models. Results Over a median follow-up period of 3.7 years, there were 35 overall deaths, 16 CV deaths, and 45 MACE. Impaired diastolic function with a higher E/E'sr ratio was associated with overall mortality (HR, 1.484; 95% CI, 1.201−1.834; p < 0.001), CV mortality (HR, 1.584; 95% CI, 1.058–2.371; p = 0.025), and MACE (HR, 1.205; 95% CI, 1.040−1.397; p = 0.013) in multivariate adjusted Cox analysis. Worsening GLS was associated with overall mortality (HR, 1.276; 95% CI, 1.101−1.480; p = 0.001), CV mortality (HR, 1.513; 95% CI, 1.088−2.104; p = 0.014), and MACE (HR, 1.214; 95% CI, 1.103−1.337; p < 0.001). The E/E'sr ratio and GLS had better outcome prediction than the E to early diastolic mitral annular velocity (E/E') ratio and left ventricular ejection fraction (LVEF). Moreover, adding the E/E'sr ratio and GLS to Cox models containing relevant clinical and conventional echocardiographic parameters improved the prediction of overall mortality (p < 0.001), CV mortality (p < 0.001), and MACE (p < 0.001). Conclusion The E/E'sr ratio and GLS, as emerging indices of LV diastolic and systolic functions, significantly predict mortality and CV outcomes and outperform conventional echocardiographic parameters in outcome prediction in HD patients.
Highlights
Cardiovascular (CV) disease is the leading cause of mortality in patients undergoing hemodialysis (HD) [1]
Patients belonging to the 3rd tertile of the early diastolic mitral annular velocity (E/E)’sr ratio had higher prevalence of diabetes mellitus (DM) and coronary artery disease, higher cardiothoracic ratio, higher Aortic Arch Calcification (AoAC), lower serum creatinine, higher prevalence of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) and β-blocker use, higher left atrial volume index (LAVI), higher LV mass index (LVMI), lower left ventricular ejection fraction (LVEF), higher E/E’ ratio, higher E/A ratio, lower E’ wave, lower early global diastolic strain rate (E’sr), and less negative global longitudinal systolic strain (GLS) compared to patients in the 1st tertile of the E/E’sr ratio (Table 1)
A high E/E’sr ratio was significantly associated with overall mortality in the unadjusted model (HR, 1.191; 95% confidence interval (CI), 1.090−1.301; p < 0 001), in the age- and sex-adjusted model (HR, 1.185; 95% CI, 1.074−1.308; p = 0 001), and in the multivariable model adjusted for age, sex, dialysis vintage, DM, coronary artery disease, cerebrovascular disease, BMI, systolic blood pressure, Ankle-Brachial Index (ABI) < 0 95, Brachial-Ankle Pulse Wave Velocity (baPWV), cardiothoracic radio, AoAC, albumin, triglycerides, total cholesterol, hemoglobin, creatinine, calcium-phosphorous product, and high-sensitivity C-reactive protein (hs-CRP)
Summary
Cardiovascular (CV) disease is the leading cause of mortality in patients undergoing hemodialysis (HD) [1]. The ratio of early mitral inflow velocity to the global diastolic strain rate (E/E’sr) and global longitudinal systolic strain (GLS) of the left ventricle (LV) are emerging indices of diastolic and systolic functions, respectively, for the LV Their prognostic significance in the prediction of mortality and cardiovascular (CV) outcomes remains underexplored in hemodialysis (HD) patients. Impaired diastolic function with a higher E/E’sr ratio was associated with overall mortality (HR, 1.484; 95% CI, 1.201−1.834; p < 0 001), CV mortality (HR, 1.584; 95% CI, 1.058–2.371; p = 0 025), and MACE (HR, 1.205; 95% CI, 1.040−1.397; p = 0 013) in multivariate adjusted Cox analysis. Adding the E/E’sr ratio and GLS to Cox models containing relevant clinical and conventional echocardiographic parameters improved the prediction of overall mortality (p < 0 001), CV mortality (p < 0 001), and MACE (p < 0 001). The E/E’sr ratio and GLS, as emerging indices of LV diastolic and systolic functions, significantly predict mortality and CV outcomes and outperform conventional echocardiographic parameters in outcome prediction in HD patients
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