Doppler Indices Of Diastolic Function Research Articles

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

BackgroundTissue 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. MethodsWe 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. ResultsDuring 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). ConclusionsIn 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.

Improvement of impaired diastolic left ventricular function after diet-induced weight reduction in severe obesity.

Background/objectivesObesity is independently associated with left ventricular (LV) diastolic dysfunction and altered cardiac morphology. Morbidity and mortality in patients with diastolic dysfunction are similar to values observed in patients with systolic heart failure. We hypothesized that dysfunctional cardiac responses in people with obesity are reversible after weight loss. Thus, we studied the effect of dietary weight reduction on LV diastolic function as well as on cardiac structure using transthoracic echocardiography and tissue Doppler imaging (TDI).Subjects/methodsThirty-two subjects with obesity underwent a 12-week low-calorie fasting phase of a formula diet. Echocardiographic tissue Doppler indices of diastolic function and measurements of cardiac size were obtained prior to and after the fasting phase.ResultsA 12-week diet significantly reduced body mass index from 40.3 ± 6.6 kg/m2 to 33.2 ± 6.1 kg/m2 (p < 0.01). Weight loss was associated with a significant reduction in blood pressure and heart rate. Echocardiography revealed diastolic dysfunction in subjects with obesity, which was improved by dieting. After weight loss, trans-mitral Doppler echocardiography showed a significant reduction in A-wave velocity, from 65.8 ± 19.2 cm/s to 57.0 ± 16.8 cm/s, and an increase in E/A ratio from 1.2 ± 0.4 to 1.4 ± 0.5 (p < 0.01). TDI displayed a significantly lower a′-wave velocity (10.3 ± 2.3 cm/s and 8.9 ± 1.7 cm/s; p < 0.01). Left atrial and LV dimensions were normal and remained unchanged after weight loss.ConclusionObesity is associated with diastolic dysfunction. A 12-week low-calorie diet with successful weight loss can reduce blood pressure and heart rate and partially normalize diastolic dysfunction.

Study of left ventricular diastolic dysfunction in recently diagnosed hypertensives in Central Nepal

CORRECTION: The conclusion on the PDF of this article was replaced on 17th April 2016. The corrected PDF is now available by clicking on the link below.Background &amp; Objectives: Ectopic Left ventricular diastolic dysfunction is now well established as a cause of left sided heart failure and as a powerful predictor of cardiovascular events. It is attributed mostly to systemic hypertension. The objective of the study was to determine the prevalence of left ventricular diastolic dysfunction in recently diagnosed hypertensives in Nepalese population using echocardiography. Materials &amp; Methods: Two-dimensional echocardiography was performed on 120 newly diagnosed patients of systemic hypertension. Transmitral Doppler indexes of diastolic function, Valsalva maneuver applied to the same mitral inflow pattern, pulsed tissue Doppler of the mitral annulus, deceleration time, isovolumic relaxation time and pulmonary venous flow pattern.Results: The age of the patients in our study ranged from 20 to 84 years with mean age of 50years±14.13 years (standard deviation) and male:female ratio being 1.35:1. Hypertensive patients were highest in age group 45-64 years followed by 25-44 years in both the genders. Majority of the patients had stage 1 hypertension (44.16%) followed by stage 2 HTN in 34.17% and pre-hypertension in 21.67%. The majority of the patients in our study had Grade 1 LVDD (66.67%), 10.83% patients had Grade II LVDD, only 2.50% had non-restrictive Grade III LVDD and none had LVDD-IV. Stage II hypertensives had more LVDD(I+II+III): 39/41-95.12% than stage I hypertensives(39/53-73.58%) and pre-hypertensives (8/26-30.77%). The association between stages of systemic HTN and LVDD was found to be highly statistically significant (p=0.002). Conclusion: Our study showed that left ventricular diastolic dysfunction is a common entity in Nepalese population with systemic hypertension.JCMS Nepal. 2016;12(1):14-18.

Tissue Doppler indices of diastolic function in critically ill patients and association with mortality - a systematic review.

Systolic impairment is well reported in critically ill patients but diastolic function has been relatively understudied. The objective of this review was to assess tissue Doppler indices of diastolic function in critically ill patients along with any association with mortality. A systematic review of articles in English using Medline, EMBASE, CINAHL and the Cochrane database of systematic reviews. Search terms included diastolic function, diastolic dysfunction, diastolic abnormal*, diastolic heart failure, diastolic filling, ventricular relaxation, pulmonary artery occlusion pressure, left ventricular filling pressure, cardiac dysfunction, intensive care, critical care, critically ill, critical illness, sepsis and septic shock. Only studies of critically ill adult patients (excluding post-cardiac surgical patients) whose diastolic function was assessed using tissue Doppler imaging were included. Study quality was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). Nineteen studies were included, with a total of 1365 patients. All trials were observational. There was a large heterogeneity in patient populations and the methodology of tissue Doppler assessment of diastology resulting in a descriptive analysis. Patient groups included severe sepsis or septic shock (5 studies), septic shock (5 studies), systemic inflammatory response syndrome and shock (1 study), septic shock and acute lung injury (1 study), cancer and septic shock (2 studies), general ICU patients (1 study), combined medical and surgical ICU (2 studies) and sub-arachnoid haemorrhage patients (2 studies). Seventeen studies scored 5/6 on the NOS with the remaining two scoring 4/6. Fourteen studies reported on numbers of patients diagnosed with diastolic dysfunction (500/999, mean 50%, range 20-92%). Three studies found that diastolic dysfunction was an independent predictor of mortality. Current data shows a large range in the incidence of diastolic dysfunction in this patient population and a variable link with mortality. Future research should focus on the definition of normal values for diastolic function in critically ill patients along with the effects of ICU therapies and consensus criteria for its assessment in this patient population.

Abstract 19158: Myocardial Function Abnormalities in Obesity: Assessment via Standard Doppler Indices, Myocardial Speckle-tracking and Kinematic Modeling of Early Diastolic Filling

Background: Obesity is an established risk factor for heart failure. We aimed to comprehensively characterize early subclinical obesity-related abnormalities in diastolic and systolic function in a large general population sample. Methods: We studied 1,603 middle-aged adults enrolled in the Asklepios study. We assessed standard Doppler indices of diastolic function, speckle-tracking echocardiography-derived myocardial systolic deformation and parameters describing the elastic recoil-driven early diastolic suction attribute of the left ventricle (LV), obtained via kinematic modeling of early mitral inflow. All models were adjusted for, age, gender and LV size. Results: Speckle tracking echocardiography revealed decreased longitudinal peak systolic strain in obesity (-17.3; 95%CI=-17. 7 to -16.8; P=0.001), with preserved circumferential strain (P=0.35). Obesity was also independently associated with lower stored elastic strain energy (9013 vs. 10695 m 2 /s 2 ; P&lt;0.0001) available at mitral valve opening, resulting in a lower peak force driving early diastolic filling (1824 vs. 2013 m/s2; P&lt;0.001). Despite exhibiting a lower early diastolic mitral annular tissue velocity (8.32 vs. 9.6 cm/s; P&lt;0.001), obese subjects demonstrated a significantly greater early diastolic mitral inflow propagation velocity (81.5 vs. 73.8 cm/s; P&lt;0.001) and a lower damping constant c (15.1 vs. 16.7 /s; P&lt;0.01), which represents the dampening effects of slow LV relaxation and increased tissue viscoelasticity preventing rapid LV filling). Conclusions: Our results suggest that the main abnormality underlying abnormal early diastolic LV filling in obesity is a reduced stored elastic strain / potential energy during systolic contraction, leading to decreased mechanical recoil during early diastole. This may be related to loss of longitudinal (but not circumferential) systolic function. Our findings have implications for our understanding the underlying mechanisms of obesity-related LV dysfunction.

Endurance sport and "cardiac injury": a prospective study of recreational ironman athletes.

Background: Participation in triathlon competitions has increased in recent years. Many studies have described left or right ventricular injury in endurance athletes. The goal of this study was to examine the right and left ventricular cardiac structures and function and dynamic cardio-pulmonary performance in a large cohort of middle- and long-distance triathletes. Methods: 87 triathletes (54 male and 33 female) were examined using spiroergometry and echocardiography. The inclusion criterion was participation in at least one middle- or long distance triathlon. Results: Male triathletes showed a maximum oxygen absorption of 58.1 ± 8.6 mL/min/kg (female triathletes 52.8 ± 5.7 mL/min/kg), maximum ergometer performance of 347.8 ± 49.9 W (female triathletes 264.5 ± 26.1 W). Left ventricular ejection fraction (EF) was normal (male triathletes EF: 61.9% ± 3%, female triathletes EF: 63.0% ± 2.7%) and systolic right ventricular area change fraction (RV AFC%) showed normal values (males RV AFC%: 33.5% ± 2.2%, females 32.2% ± 2.8%). Doppler indices of diastolic function were normal in both groups. With respect to the echocardiographic readings the left ventricular mass for males and females were 217.7 ± 41.6 g and 145.9 ± 31.3 g, respectively. The relative wall thickness for males was 0.50 ± 0.07, whereas it was 0.47 ± 0.09 for females. The probability of left ventricular mass >220 g increased with higher blood pressure during exercise (OR: 1.027, CI 1.002–1.052, p = 0.034) or with higher training volume (OR: 1.23, CI 1.04–1.47, p = 0.019). Conclusions: Right or left ventricular dysfunction could not be found, although the maximal participation in triathlon competitions was 29 years. A left ventricular mass >220 g is more likely to occur with higher arterial pressure during exercise and with a higher training volume.

Influence of age and gender on Doppler index of diastolic function in Chinese hypertensive patients.

This paper explores age- and gender-specific changes in Doppler echocardiographic index-E' of left ventricular diastolic function. The study involved 366 hypertensive patients (197 men and 169 women) who were aged from 20 to 90 years (mean 58.60 ± 15.68 years), without a diagnosis of any other disease. Early diastolic mitral inflow velocity (E), late diastolic mitral annular velocity (A), and E/A ratio were measured with pulse wave Doppler. Early diastolic mitral annular velocity (E') and E/E' ratios were measured with tissue Doppler imaging of lateral mitral annulus. Diastolic indices were highly correlated with age. Among those aged 20-29, E' was significantly higher in female than in male. In patients aged 30-39, 40-49, 50-59, 60-69 and 70-79 years, E' was similar in both genders. Among those aged 80-89 years, E' was significantly lower in female than in male. Overall (n = 366) predictors of the lowest quartile of E' (E' < 8.00 cm/s) were age (P < 0.0001; χ(2) = 67.35; OR 1.28; 95% CI 1.26-1.30) and female gender (P < 0.05; χ(2) = 5.76; OR 1.56; 95% CI 1.19-1.94). Age-related changes in diastolic indices correlated with gender among hypertensive patients. Diastolic function deteriorated more significantly among elderly women compared with elderly men. The study may explain the increased incidence of diastolic heart failure in elderly women with hypertension.

Effect of bariatric surgery on left ventricular geometry and function in severe obesity

Weight loss improves cardiac abnormalities associated with severe obesity. We evaluated the impact of weight loss following laparoscopic gastric bypass (LGBP) on left ventricular (LV) geometry and function in obese patients. Twenty-six patients with severe obesity (41 ± 8 years, 50% women) underwent Doppler echocardiograms before and after LGBP, to measure LV geometry, excess of LV mass relative to hemodynamic load and systolic and diastolic function. Pre-operatively, 85% of patients exhibited LVH, and 62% hypertension and metabolic syndrome, reflecting high cardiometabolic risk. After 8 ± 4 months of follow-up, the average weight loss was 19 ± 8%. Weight loss was significantly associated with improved metabolic parameters and reduced heart rate (-9 bpm), systolic (-11 mmHg) and diastolic (-6 mmHg) blood pressure (all p < 0.02). After surgery, there was significant reduction in relative wall thickness (0.43 ± 0.07 versus 0.39 ± 0.06), LV mass index (63 ± 14 g/m(2.7) versus 49 ± 10 g/m(2.7)) and excess of LV mass in relation to hemodynamic load (all p < 0.004). LVH remained in 54% of patients, hypertension in 23% and metabolic syndrome in 27%. Ejection fraction and Doppler indices of diastolic function did not change significantly, even after adjusting for changes in heart rate. All favorable changes in LV geometry and function were also confirmed in the subgroup with <9 month follow-up (median), whereas no further improvement could be detected in patients with longer follow-up. In patient with severe obesity, LV geometry and systolic function improved rapidly after LGBP, without evidence of further improvement during prolonged follow-up.

Abstract 1059: Left Atrial Volume and E/E′ Ratio are Most Predictive of Exercise Capacity in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is characterized by LVH and myocardial disarray which result in ischemia, diastolic dysfunction and arrhythmias. While many experience functional limitation, the precise mechanisms are still unknown. We aim to determine the relation between echocardiogram findings and exercise capacity. We studied 48 patients (48 ± 15 years; 15 females) referred for symptom-limited cardiopulmonary testing and stress echocardiography for clinical reasons: 23 had a proximal HCM pattern (group I), 7 had a classic reverse curvature pattern (group II), 4 had an apical pattern (group III) and 14 had a concentric pattern (group IV). At baseline, patients in group I were significantly older than in other groups (54 ± 13 (I) vs. 41 ± 12 (II), 38 ± 12(III) and 44 ± 17 years (IV); p=0.04). No other significant difference in clinical characteristics was noted between groups. The maximal septum thickness was higher in groups I and II than in III and IV (19 (16 – 23), 22 (17–33), 17, and 16 (13–18) mm, respectively; p=0.05). Groups I and II were more likely to have resting gradient of &gt;10 mm Hg (68% and 18%, respectively vs. 14% in IV; p=0.01) and to present rest systolic anterior movement (74% and 15% vs. 11% in IV; p &lt;0.001). A higher prevalence of abnormal transmitral inflow E to lateral E′ ratio (E/E′) was also noted in Group I (80%, p=0.05): high ratios are known to be associated with high pulmonary wedge pressure in non-HCM populations. At peak exercise, group I achieved a lower peak VO 2 (21.8 ±2.1 vs. 27.1±6.6 in II 36.6 ±5.1 in III and 29.4 ±2.7 ml/kg/min in IV; p=0.03). No significant differences in Valsalva and exercise gradients and delta rest-to-peak gradients were noted between patterns. In age-adjusted multivariate analysis, only negative correlations between E/E′ (R2=0.45; p=0.03) and indexed LA volume (R2=0.39; p=0.009) and peak VO 2 were significant. In contrast, no correlation was found between maximal exercise capacity and LV dimensions, conventional Doppler indices of diastolic function, lateral E′ or gradients. Lateral E/E′ and indexed LA volume are negatively correlated with functional capacity even after age-adjustment. Although patients with proximal HCM achieved the lowest peak VO 2 , gradient and morphology were not related to exercise capacity.

Effect of Preload Augmentation on Pulsed Wave and Tissue Doppler Echocardiographic Indices of Diastolic Function After a Marathon

The mechanisms underlying alterations in left ventricular diastolic function after a marathon are unknown and may be a consequence of a reduced preload. We sought to assess the effect of preload augmentation through passive leg elevation (PLE) on echocardiographic indices of diastolic function after a marathon. Fourteen trained participants (13 male) were echocardiographically assessed before and after a marathon in the supine position and during PLE. Diastolic function was measured via conventional Doppler, color M-mode, and tissue Doppler echocardiography. Early and late transmitral filling velocities (E and A, respectively), flow propagation velocity of early filling, and basal early and late left ventricular wall velocities (E' and A', respectively) were obtained. The E/A ratio, flow propagation velocity of early filling, and the E'/A' ratio decreased by 31%, 24%, and 32%, respectively (P < .05), after marathon running. Postrace PLE returned E to baseline and increased E/A compared with postrace supine (P < .05). However, E/A remained depressed compared with baseline as a result of the persistent elevation in A. Postrace PLE caused Vp to return to baseline; mean E' also increased (9%, P < .05), but did not return to resting levels. Mean A' was unaffected by postrace PLE, therefore, E'/A' was unchanged postrace despite PLE. Postexercise alterations in Doppler indices of diastolic function can be partially explained by a reduction in preload. However, data from tissue Doppler echocardiography indicate that there is an intrinsic impairment in myocardial relaxation after marathon running.

No evidence for left ventricular diastolic dysfunction in asymptomatic normotensive type 2 diabetic patients: a case-control study with new echocardiographic techniques

Objective We sought to determine whether abnormalities of left ventricular structure and function could be detected in asymptomatic type 2 diabetic patients free of cardiovascular complications. Research design and methods We compared 48 subjects with type 2 diabetes (34 men, 50 ± 6 years) without hypertension, coronary artery disease and microangiopathic complications with 30 age-matched healthy controls. Left ventricular diastolic function was assessed by conventional Doppler echocardiography and new echocardiographic techniques (tissue Doppler imaging, color M-mode propagation velocity). A pseudonormal (PN) pattern of left ventricular filling was screened by several methods including Valsalva maneuver. Results Systolic function was normal in all patients. There was no significant difference in conventional and new echocardiographic Doppler indices of diastolic function between patients and control subjects. A PN diastolic function frequently suggested by the Valsalva maneuver (20 patients) was excluded using the new parameters. Conclusions Diastolic dysfunction is not as frequent as previously described in selected patients with type 2 diabetes free of microangiopathic complications. New Doppler echocardiographic methods provide, in contrast with the Valsalva maneuver, a reliable estimate of diastolic function and should be incorporated in the non-invasive screening for diabetic cardiomyopathy.

Understanding Diastolic Heart Failure With Preserved Ejection Fraction

Congestive heart failure (HF) is a frequent reason for hospital admission. Fifty percent of HF hospitalizations have normal ejection fraction (EF), 1 referred to as diastolic HF (DHF). In contrast, patients with systolic HF (SHF) have reduced EF. The DHF phenotype describes patients with signs and symptoms of HF, normal EF, normal left ventricular (LV) volume, hypertension with increased relative wall thickness, LV diastolic dysfunction, and predominantly elderly women. 1,2 Etiology of DHF Longstanding hypertension may result in significant myocardial hypertrophy, appearance of a smaller ventricular chamber, increased ventricular stiffness, and delayed relaxation. Increased ventricular stiffness requires increased pressure to maintain normal filling in the presence of normal or reduced chamber volume.3 Although DHF has not been studied as extensively as SHF, limited data obtained from patients hospitalized for DHF suggest that demographic characteristics, comorbidities, and pathology differ from those with SHF. Despite these differences, DHF is similar to SHF with regard to volume overload, reduced exercise capacity, impaired quality of life, and long-term mortality.1

Abnormalities of Doppler Measures of Diastolic Function in the Healthy Elderly Are Not Related to Alterations of Left Atrial Pressure

Normal healthy aging results in changes in Doppler indexes of diastolic function. One widely accepted explanation for these alterations that is based on animal data is an age-associated impairment of myocardial relaxation resulting from abnormal myocyte calcium handling. However, an alternative theory based on altered left atrial compliance with aging has been proposed in which early left atrial pressure could be low in the aged heart but rise rapidly during atrial diastole, resulting in a higher late atrial pressure and thus a normal mean pressure. We sought to explore this issue directly by performing a detailed analysis of the pulmonary capillary wedge pressure waveform obtained by right-heart catheterization during 5 different loading conditions. Twelve healthy elderly sedentary subjects (mean age, 69.8+/-3 years) were recruited for the seniors group. An additional 12 young sedentary subjects (mean age, 35+/-8 years) made up the young group. All subjects were rigorously screened for comorbidities. All subjects underwent transthoracic echocardiography to determine Doppler variables of early and late transmitral filling (E and A velocities) and isovolumetric relaxation time. Each subject also underwent pulmonary artery catheterization with measurement of pulmonary capillary wedge pressure waveform during 5 different loading conditions: baseline, lower-body negative pressures of -15 and -30 mm Hg, and rapid saline infusions of 10 to 15 and 20 to 30 mL/kg. Pressure was measured at 6 points of the waveform: point 1, peak of the atrial contraction (a wave); point 2, the left atrial pressure during the start of ventricular systole; point 3, peak of atrial filling (v wave); point 4, earliest left atrial pressure during ventricular filling; and the line between points 5 and 6, pressure during diastasis. Aging resulted in a decrease in the E/A ratio (P<0.001) and a prolongation of the isovolumetric relaxation time (P<0.001) as assessed by echocardiography, but there was no effect of age on pulmonary capillary wedge pressure at any point throughout the cardiac cycle (P=0.290). Specifically, at no measured point at any level of cardiac filling volume was the pulmonary capillary wedge pressure of the seniors lower than that of the young subjects. We conclude that the age-related echocardiographic change of decreasing E/A ratio is not the result of a lowering of early diastolic left atrial pressure.

The effect of isolated ultrafiltration on Doppler-derived indices of left ventricular diastolic function

Haemodialysis (HD) is associated with acute changes simultaneously in fluid status (ultrafiltration) and in many biochemical parameters (dialysis). Reports on the effects of these changes on left ventricular (LV) diastolic function are scant. This study evaluated the effect of isolated ultrafiltration (UF) and subsequent HD with minimal fluid removal on Doppler-derived indices of LV diastolic function in patients who were asymptomatic and stable on HD. In 11 HD cases, the 5 h treatment session was divided into a 2.5 h period of fluid removal without dialysis (UF phase) and 2.5 h of dialysis with minimal fluid removal (HD phase). We examined the following parameters of LV diastolic function echocardiographically: early rapid filling (Emax), atrial peak filling (Amax), Emax/Amax ratio, isovolumic relaxation time (IVRT) and deceleration time of the E-wave (DT). During the UF phase, Emax decreased from 0.82 +/- 0.2 to 0.62 +/- 0.2 m/s (P = 0.003), Amax decreased from 0.72 +/- 0.2 to 0.63 +/- 0.2 m/s (P = 0.042) and the ratio Emax/Amax did not change (P = NS). During the HD phase, Emax increased from 0.62 +/- 0.2 to 0.72 +/- 0.2 m/s (P = 0.018), Amax increased from 0.63 +/- 0.2 to 0.70 +/- 0.3 m/s (P = NS) and the Emax/Amax ratio remained unchanged (P = NS). IVRT was prolonged in 10 out of 11 patients at the start of the UF phase and it was further prolonged from 142 +/- 40 to 171 +/- 55 ms (P = 0.03) during the UF phase. IVRT did not alter during the HD phase (P = NS). During the UF phase, DT increased from 175 +/- 83 to 244 +/- 119 and it decreased from 244+/-119 to 209 +/- 98 in the HD phase, but both changes were statistically insignificant. No statistically significant correlations were observed between the changes in the Doppler indices of diastolic function and changes in biochemical parameters during the HD phase. UF affects the parameters Emax, Amax and IVRT used to evaluate LV diastolic function. The changes in Emax and Amax during the HD phase are due to fluid refilling from tissues into the blood space, HD as such having no effect on Doppler indices. However, isolated UF or HD does not affect the Emax/Amax ratio. Emax and IVRT seem to be the most volume-sensitive parameters.

Lack of relationship between doppler indices of diastolic function and left ventricular pressure transients in patients with definite diastolic heart failure

Objectives The purpose of this study was to compare invasive with noninvasive indices of diastolic function in a well-defined group of patients with diastolic dysfunction and a history of diastolic heart failure. Background Patients with heart failure and a normal left ventricular (LV) ejection fraction comprise a very large portion of the heart failure population and most are thought to have diastolic heart failure. While clinical and Doppler criteria for diastolic dysfunction and diastolic heart failure have been developed, there remains some controversy about the need for invasive cardiac catheterization and/or echo-Doppler evaluation of LV diastolic function. To date, there is no consensus as to the utility of these 2 methods in the diagnosis of diastolic heart failure. Methods Forty-seven patients (mean age 58 ± 11 years) with a history of congestive heart failure and preserved ejection fraction (≥50%) by echocardiography underwent a combined hemodynamic/echo-Doppler study. Patients with coronary disease were excluded. Invasive parameters of LV diastolic function (tau, LV diastolic pressures) and Doppler parameters (peak E, peak A, E/A ratio, isovolumic relaxation time, and E deceleration time) were measured using standard techniques. Results There was a close correlation between invasively-determined parameters (tau vs end diastolic pressure: r = 0.62, P < .001). The relationships between standard Doppler parameters and LV diastolic pressures were uniformly poor. However, the relationship between Doppler isovolumic relaxation time and tau improved considerably when patients were subgrouped by hemodynamic load. Conclusions Standard echo-Doppler indices of diastolic function correlate poorly with LV diastolic pressure transients. The diagnosis of diastolic heart failure cannot be made on the basis of a single echo-Doppler parameter but, rather, all parameters must be examined in concert and used in combination with clinical observations.

Rapid-onset endothelial dysfunction with adriamycin: evidence for a dysfunctional nitric oxide synthase.

Adriamycin (ADR) is a commonly used chemotherapeutic agent that is believed to exert its effects through the generation of oxygen free radicals. We hypothesized that administration of a single dose of ADR results in endothelial nitric oxide synthase (eNOS)-dependent generation of superoxide (O2*-) and acute endothelial dysfunction. A single dose of ADR (10 mg/kg i.v.) administered to rabbits resulted in rapid attenuation of agonist-dependent responses to acetylcholine and calcium ionophore (A23187). In vitro exposure of ring segments to ADR for < 30 min resulted in O2*- generation measured by electron spin resonance (ESR) with the spin trap segments 5-tert-butoxycarbonyl-5-methyl-1-pyrroline N-oxide (BMPO) that was abolished by endothelial denudation and incubation with diphenyliodonium (DPI) (10 microM) but not L-NMMA (10 microM). Brachial artery flow-mediated dilation (FMD) in patients undergoing chemotherapy with ADR was markedly attenuated after a single dose of ADR (6.5 +/- 1.0 to 2.5 +/- 1.1% (p = 0.0004, time to end of infusion 27 +/- 8 min) while endothelial-independent dilatation with nitroglycerin was unchanged (16.3 +/- 3.1 and 14.33 +/- 2.1% respectively, p = 0.36). Serum nitrite and nitrate concentrations fell from 50 +/- 6 micromol/l pre-ADR to 33 +/- 6 micromol/l post-ADR infusion (p = 0.0005) while serum concentrations of CD141 thrombomodulin and von Willebrand factor (vWF) activity remained unchanged after ADR infusion (36 +/- 13 to 52 +/- 22% ng/ml versus 3.25 +/- 0.98 to 3.01 +/- 0.91%, respectively, p = NS for pre versus post for both). Doppler indices of diastolic function (IVRT, DT and E/A ratios) were not altered in response to ADR. In conclusion, ADR administration results in rapid depletion of systemic NO* levels and attenuation of agonist-dependent responses in rabbits and flow-mediated dilation in the brachial artery of humans. ESR measurements in rabbit ring suggest an endothelial origin for radical production via flavin-containing oxido-reductases such as eNOS or NADPH cytochrome P450 reductase. These findings may have implications for cardiovascular complications noted with ADR.

Heart failure with normal ejection fraction: lack of relationship between doppler indices of diastolic function and LV pressure transients

Heart failure with normal ejection fraction: lack of relationship between doppler indices of diastolic function and LV pressure transients

Cardiovascular Effects of Short-Term Growth Hormone Hypersecretion

Many studies have shown that acromegaly has relevant effects on cardiovascular system, but few data are available regarding the effects of short-term acromegaly on heart morphology and function. These data would help to clarify the natural history of acromegalic disease and could provide new insight into the mechanisms of GH action on the human heart. Therefore, we studied by Doppler echocardiography a group of 10 young subjects strictly selected as having short-term (<5 yr) uncomplicated acromegaly. The results of this study have shown that shortterm acromegaly is characterized by significantly increased left ventricular mass (P<0.005), with normal relative wall thickness, associated with Doppler indices of diastolic function in the normal range. Furthermore, stroke index and cardiac index were significantly enhanced in the patient group (P<0.01 and P<0.001, respectively), whereas systemic vascular resistance was significantly reduced (P<0.001). In conclusion, our study shows that short-term acromegaly significantly affects the heart, but, at variance with long-term disease, it is characterized by increased left ventricular mass, with eccentric remodeling and normal diastolic function. Moreover, short-term acromegaly induces a high cardiac output state with reduction of systemic vascular resistance.

Doppler indices of diastolic function predict peak exercise oxygen consumption in heart failure

Doppler indices of diastolic function predict peak exercise oxygen consumption in heart failure

Cardiac Involvement in a Large Kindred With Myotonic Dystrophy

To evaluate and quantitate cardiac involvement in myotonic dystrophy and assess whether the size of the trinucleotide (cytosine-thymine-guanine [CTG]) repeat expansion is a significant predictor of cardiac abnormalities. Case-control study of a large kindred with myotonic dystrophy. Ninety-one bloodline members of the kindred underwent clinical and cardiac evaluation with electrocardiograms, echocardiography (with Doppler in the majority of cases), and genetic and neurologic evaluations. Affected individuals were age-matched to normal family members. Electrocardiographic conduction abnormalities, wall motion abnormalities, mitral valve prolapse, and global parameters of systolic and diastolic function were determined by an observer blinded to all clinical data and genetic analysis. Compared with age-matched normals, patients with myotonic dystrophy (n = 25) were more likely to have conduction abnormality (52% vs 9%), mitral valve prolapse (32% vs 9%), and wall motion abnormality (28% vs 0%) (all P < .05). Left ventricular ejection fraction and stroke volume were reduced compared with normals matched for age and heart rate (P < .05), whereas Doppler indexes of diastolic function were only marginally altered. Using multivariate analysis, the number of CTG repeats (range, 69 to 1367; normal, < or = 37) was the strongest predictor of abnormalities in wall motion and electrocardiographic conduction (odds ratio of 16.5 and 5.07 per 500 repeats, respectively). The relation of mitral valve prolapse to the size of the CTG repeat was of borderline significance. Patients with more extensive neurologic findings (n = 12) had a higher incidence of wall motion and/or electrocardiographic conduction abnormalities (83% vs 43%; P = .04). Cardiac involvement in myotonic dystrophy affects predominantly the conduction system and myocardial function. Alterations in myocardial relaxation and diastolic properties, in contrast to skeletal muscle myotonia, are minor. In this kindred, the number of CTG repeats was a significant predictor of cardiac dysfunction in myotonic dystrophy.