Response to the Letter to the Editor by Hammoudi et al

Abstract

We appreciate the caution by Hammoudi et al. regarding routine clinical application of E/e’ as a noninvasive measure of LV filling pressure in subjects with normal ejection fraction. It is true that several studies have shown that correlation between PCWP and E/e’ in healthy individuals at rest and with exercise is poor. The lack of correlation is due to the fact that e’ increases with higher preload and also with exercise in normal subjects so that E/e’ remains normal as shown by Ha et al. and Bruengger et al. with exercise as well as at rest.1Ha J.W. Lulic F. Bailey K.R. Pellikka P.A. Seward J.B. Tajik A.J. et al.Effects of treadmill exercise on mitral inflow and annular velocities in healthy adults.Am J Cardiol. 2003; 91: 114-115Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 2Studer Bruengger A. Kaufmann B. Buser M. Hoffmann M. Bader F. Bernheim A. Diastolic Stress Echocardiography in the Young: a Study in Non-athletic and Endurance-trained Healthy Subjects.J Am Soc Echocardiogr. 2014; 27: 1053-1059Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The elevation of filling pressure with fluid infusion in normal subjects is transient since augmented relaxation would normalize filling pressure relatively quickly with no clinical consequence. However, in patients with reduced myocardial relaxation, E/e’ has been shown to track left atrial or pulmonary capillary wedge pressure well, including a good correlation between the simultaneous intra-left atrial pressure and E/e’.3Ritzema J.L. Richards A.M. Crozier I.G. Frampton C.F. Melton I.C. Doughty R.N. et al.Serial Doppler echocardiography and tissue Doppler imaging in the detection of elevated directly measured left atrial pressure in ambulant subjects with chronic heart failure.JACC Cardiovasc Imaging. 2011; 4: 927-934Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar We have to admit that there are several technical challenges and clinical conditions which may make the interpretation of E/e’ difficult as a non-invasive measure of left ventricular filling pressure, but in most cases we should be able to assess whether a patient has increased filling pressure with exercise. E/e’ measurement has been part of our stress echocardiography protocol since 2008 and this practice has helped our evaluation of patients with exertional dyspnea, which is the most common referral reason for an exercise echocardiography. As mentioned in our editorial,4Oh J.K. Kane G.C. Diastolic Stress Test. Time has come for its integration into clinical practice.J Am Soc Echocardiogr. 2014; 27: 1060-1063Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar the diagnostic yield from exercise echocardiography for patients with dyspnea has doubled after diastolic evaluation was added routinely to our exercise echocardiography protocol at Mayo Clinic. E/e’ was also found to correlate well with exercise capacity, and when added to clinical substrates for developing heart failure, half of the subjects were reclassified to stage B heart failure from stage A.5Kosmala W. Jellis C.L. Marwick T.H. Exercise limitation associated with asymptomatic left ventricular impairment: Analogy with stage B heart failure.J Am Coll Cardiol. 2015; 65: 257-266Crossref PubMed Scopus (45) Google Scholar One of the most powerful features of echocardiography is to be able to assess intracardiac hemodynamics noninvasively, and E/e’ is a simple hemodynamic measure that can help many of our patients whose exertional dyspnea needs a comprehensive diagnostic evaluation. If E/e’ is not diagnostic or difficult to be interpreted, unexplained exertional dyspnea requires cardiac catheterization to measure intracardiac hemodynamics at rest and with exercise. Exercise E/e′ for the Assessment of Left Ventricular Filling Pressures: With Caution in Clinical Practice?Journal of the American Society of EchocardiographyVol. 28Issue 3PreviewWe read with interest the article by Studer Bruengger et al.1 and the related scientific editorial.2 The study confirmed previous reports of normal exercise E/e′ ratios, considered an index of left ventricular filling pressure (LVFP), in healthy subjects.1 The article encourages the use of diastolic stress echocardiography in clinical practice, especially to investigate patients with exercise dyspnea.2 Full-Text PDF Diastolic Stress Echocardiography in the Young: A Study in Nonathletic and Endurance-Trained Healthy SubjectsJournal of the American Society of EchocardiographyVol. 27Issue 10PreviewThe response of diastolic Doppler indices to exercise is not well defined for young subjects. The aims of this study were to evaluate this in nonathletic and endurance-trained probands and to correlate echocardiographic data with maximal oxygen consumption. Full-Text PDF Authors’ ReplyJournal of the American Society of EchocardiographyVol. 28Issue 3PreviewWe thank Hammoudi et al. for their stimulating comments on our article “Diastolic Stress Echocardiography in the Young: A Study in Nonathletic and Endurance-Trained Healthy Subjects”1 and the related editorial.2 Full-Text PDF