Elevated Left Ventricular Filling Pressure Research Articles

Utilizing echocardiographic findings and machine learning to predict elevated left ventricular filling pressures in patients with preserved ejection fraction

Abstract Background Estimation of left ventricular filling pressures (LVFP) is important for accurate diagnosis and prognosis of heart failure (HF). The current ASE/EACVI algorithm for identifying elevated LVFP shows modest performance in the setting of preserved ejection fraction (EF) (1). Left atrial reservoir strain (LASr) has been proposed as a novel and additional diagnostic marker to identify elevated LVFP in HF with preserved EF (HFpEF) (1). While machine learning has shown good diagnostic performance utilising conventional echocardiographic findings (2), the incremental value of LASr has not been adequately explored using ML models. Purpose This study aimed to evaluate the performance of a machine learning (ML) model that integrates clinical and echocardiographic data including LASr to identify elevated LVFP in the setting of suspected HF with preserved EF. Methods Patients with dyspnoea, EF ≥50% and sinus rhythm undergoing right heart catheterisation (RHC) and near-simultaneous echocardiography were selected from the KARUM database. Patients with atrial fibrillation, pacemakers, significant valvular disease or infiltrative cardiomyopathy were excluded. Elevated LVFP was defined as invasive pulmonary artery wedge pressure (PAWP) ≥15 mmHg. The dataset was split into 75% for model development (training set) and 25% for unbiased testing of model performance (test set). Missing numerical and categorical variables were imputed based on the training data using Bayesian Ridge regression and K-Nearest Neighbours, respectively. Recursive Feature Elimination (RFE) was used to reduce the number of variables. A comprehensive grid search with repeated 10-fold cross-validation was employed to optimise hyperparameters for an XGBoost (Xtreme Gradient Boosting) ML model. The model with the highest mean area under the receiver operating characteristic curve (AUC) across cross-validation folds was reported and selected as the final model, with its performance reported on the independent test set. Finally, we applied SHapley Additive exPlanations (SHAP) to evaluate and rank the individual variable importance. Results Of 210 patients, 157 were allotted for model development (training set) and 53 for reporting model performance (test set). Ten significant variables were identified through RFE. The best-performing XGBoost model achieved a mean AUC of 86.6 % across the cross-validation folds and maintained good diagnostic performance in the test set with an AUC of 89.4% (95% CI: 79.1-99.7%) (Fig 1). Applying SHAP ranked the variables and found LASr the most important variable (Fig 2). Conclusion An ML model based on clinical and echocardiographic data, including LASr, demonstrated good diagnostic performance in identifying elevated LVFP in the setting of suspected HF with preserved EF. ROC Curve for XGBoost Model SHAP summary plot

Explainable machine learning for estimation of elevated left ventricular filling pressure: development and validation using multicenter data

Abstract Background Guideline-recommended algorithms (GL-algorithm) (1) often results in indeterminate left ventricular filling pressure (LVFP) (2). Despite high accuracy, machine learning (ML) methods lack interpretability, limiting their clinical use. Objective To develop an explainable ML model for LVFP estimation, which provides patient-level interpretation. Methods We retrospectively enrolled patients who underwent echocardiography and right heart catheterization at three hospitals within a median of 3 days. Two extreme gradient boosting (XGBoost) models were trained using data from two hospitals to estimate elevated pulmonary artery wedge pressure (PAWP >18 mmHg) as a surrogate for elevated LVFP. Model 1 used variables from GL-algorithm, while model 2 used variables selected by Shapley additive explanations (SHAP) values. Model performances were compared using external test data from the other hospital. Results In a cohort of 956 patients (mean age 68±14 years; 43.2% female; 44.6% with left ventricular ejection fraction ≤50%), 296 (31.0%) had elevated PAWP. The GL-algorithm classified 42.5% as indeterminate LVFP, with 34.1% of these having elevated PAWP. The algorithm's area under the receiver-operating-characteristics curve (AUROC) was 0.72 (95% CI 0.60–0.83) for elevated LVFP. ML models classified all patients, with Model 1 achieving an AUROC of 0.81 (95% CI 0.75–0.87, p=0.020 vs. GL-algorithm) and Model 2 achieving an AUROC of 0.84 (95% CI 0.79–0.89, p=0.016). Notably, the ML models performed equally well regardless of GL-algorithm classification. SHAP force plots enabled patient-level interpretation. The model is available online. Conclusions Explainable ML outperformed the GL-algorithm in estimating LVFP, providing patient-level interpretability and potentially more user-friendly tools for clinicians.

Utility of Simultaneous Left Atrial Strain–Volume Relationship During Passive Leg Lift to Identify Elevated Left Ventricular Filling Pressure—A Proof-of-Concept Study

Background: The assessment of left ventricular (LV) filling pressure in heart failure (HF) poses a diagnostic challenge, as HF patients may have normal LV filling pressures at rest but often display elevated LV filling pressures during exercise. Rapid preload increase during passive leg lift (PLL) may unmask HF in such challenging scenarios. We explored the dynamic interplay between simultaneous left atrial (LA) function and volume using LA strain/volume loops during rest and PLL and compared its diagnostic performance with conventional echocardiographic surrogates to detect elevated LV filling pressure. Methods: We retrospectively reviewed 35 patients with clinical HF who underwent simultaneous echocardiography and right heart catheterization before and immediately after PLL. Patients with atrial fibrillation (n = 4) were excluded. Twenty age-matched, healthy controls were added as controls. LA reservoir strain (LASr) was analyzed using speckle-tracking echocardiography. LA strain–volume loops were generated, including the best-fit linear regression line employing simultaneous LASr and LA volume. Results: LA strain–volume slope was lower for HF patients when compared with controls (0.71 vs. 1.22%/mL, p < 0.001). During PLL, the LA strain–volume slope displayed a moderately strong negative correlation with invasive pulmonary arterial wedge pressure (PAWP) (r = −0.71, p < 0.001). At a 0.74%/mL cut-off, the LA strain–volume slope displayed 88% sensitivity and 86% specificity to identify elevated PAWP (AUC 0.89 [0.76–1.00]). In comparison, LASr demonstrated strong but numerically lower diagnostic performance (AUC 0.82 [0.67–0.98]), and mitral E/e’ showed poor performance (AUC 0.57 [0.32–0.82]). Conclusions: In this proof-of-concept study, LA strain–volume characteristics provide incremental diagnostic value over conventional echocardiographic measures in the identification of elevated LV filling pressure.

Left Ventricular Diastolic Dysfunction with Elevated Filling Pressures Is Associated with Embolic Stroke of Undetermined Source and Atrial Fibrillation.

Background/Objectives: Left ventricular diastolic dysfunction (LVDD) and elevated left ventricular filling pressure (LVFP) are strong predictors of clinical outcomes across various populations. However, their diagnostic utility in embolic stroke of undetermined source (ESUS) remains unclear. We hypothesized that LVDD with elevated LVFP (based on echocardiography) was more likely to be prevalent in ESUS compared to non-cardioembolic stroke (NCE) and to be associated with atrial fibrillation (AF) on follow-up monitoring. Methods: This is a single-center retrospective study that included adult patients with a diagnosis of acute ischemic stroke between January 2016 and June 2017. LV function was assessed by inpatient transthoracic echocardiogram (TTE), and stroke etiology was adjudicated by the neurologist per the consensus criteria. Patients with cardioembolic stroke and those with indeterminate diastolic function on TTE were excluded. Baseline patient characteristics and clinical variables were compared among patients with and without LVDD and elevated LVFP. Multivariable regression models were used to assess the associations between diastolic dysfunction, ESUS, and AF detection in ESUS patients. Results: We identified 509 patients with ESUS and NCE stroke who had reported diastolic function. The mean age was 64.19 years, 45.19% were female, and 146 had LVDD with available LVFP data. LVDD was not associated with ESUS (adjusted OR: 1.43, 95% CI: 0.90-2.27, p = 0.130) or atrial fibrillation (AF) detection on cardiac monitoring (adjusted OR: 1.88, 95% CI: 0.75-4.72, p = 0.179). However, LVDD with elevated LVFP was borderline associated with ESUS (adjusted OR: 2.17, 95% CI: 0.99-4.77, p = 0.054) and significantly associated with AF detection (adjusted OR: 3.59, 95% CI: 1.07-12.06, p = 0.038). Conclusions: Our data suggest that LVDD with elevated LVFP is borderline associated with ESUS and significantly associated with AF detection on follow-up cardiac monitoring. Therefore, the presence of LVDD with an increased probability of elevated LVFP may help identify a subset of stroke patients more likely to have ESUS, potentially due to atrial cardiopathy with underlying occult AF. Further studies are needed to confirm our findings and to evaluate the safety and efficacy of anticoagulation in patients with ESUS and LVDD with elevated LVFP.

Increased preload and echocardiographic assessment of diastolic function.

Echocardiographic diastolic parameters are used to diagnose and monitor increased left ventricular filling pressure (LVFP) and we hypothesized that increased loading conditions cause increased E/e'. Our aim was to assess the effect of preload augmentation on diastolic parameters among both healthy subjects and subjects with known cardiac disease. We included 129 subjects merged from two cohorts; one dialysis cohort (n=47) and one infusion cohort (n=82). Echocardiography was performed immediately before and after hemodialysis (HD) or saline infusion, under low and high loading conditions. Elevated LVFP was defined as septal E/e'≥15 and/or lateral E/e'≥13 at high-loading conditions. The population was divided according to elevated LVFP (n=31) and normal LVFP (n=98). The load difference for the population was 972±460mL, with no differences in load difference between elevated and normal LVFP (p NS). The subjects with elevated LVFP were older (63±11 vs. 46±16 years, p<.001), and had lower LV ejection fraction (50±14vs. 59±8.1%, p<.01). After augmented preload, EDV increased in the normal LVFP group (p<.01) but remained unchanged in the elevated LVFP group (p NS). Both E and e' increased among the subjects with normal LVFP, whereas E/e' remained unchanged (∆E/e' +.1 [-.5-1.2]), p NS). Among the subjects with elevated, LVFP we observed increased E but not e', resulting in significantly increased E/e' (∆ average E/e' +2.4 [0-4.0], p<.01). Augmented preload does not seem to affect E/e' among subjects with normal LVFP, whereas E/e' seems to increase significantly among subjects with elevated LVFP.

The LATE score: A novel framework for echocardiographic evaluation of left ventricular filling pressure

BackgroundThe LATE score (LATE: Left Atrial reservoir strain (LASr), Tricuspid regurgitation maximum velocity (TR Vmax), and E/e’ average) is a novel framework for echocardiographic assessment of left ventricular filling pressure (LVFP). LATE = 0 indicates normal LVFP. LATE = 1 indicates resting LVFP is borderline elevated, and the patient may be at risk of pathological elevation of LVFP during exertion. LATE ≥2 indicates LVFP is severely elevated. MethodsThe LATE score was derived from reported thresholds of LASr and conventional echocardiographic parameters for predicting LVFP. The LATE score was prospectively evaluated in a cross-sectional study of 63 patients undergoing transthoracic echocardiography immediately prior to cardiac catheterization with invasive assessment of LVFP. Accuracy of the LATE score was compared to 2016 ASE diastology algorithms. ResultsMean patient age was 62.9 ± 13.6 years with 22% female. LATE = 0 in 29 patients, of which 24 (83%) had normal LVFP (mean LVFP 9 mmHg, SD ±3 mmHg). LATE = 1 in 23 patients, of which 11 (48%) had elevated LVFP (mean LVFP 12 mmHg, SD ± 4 mmHg). LATE was ≥2 in 11 patients, all of which had elevated LVFP (100%) (mean LVFP 16 mmHg, SD ±3 mmHg). The LATE score showed greater agreement with invasive assessment than the 2016 algorithms (LATE kappa = 0.73, 2016 kappa = 0.37). ConclusionsThe LATE score is a simple and effective tool for evaluation of LVFP that is more accurate than the 2016 algorithms. The LATE score provides insight beyond binary classification of normal versus elevated LVFP.

Diagnosing diastolic dysfunction and heart failure with preserved ejection fraction in patients with atrial fibrillation: a clinical challenge.

Left ventricular (LV) diastolic dysfunction, atrial fibrillation (AF), and heart failure with preserved ejection fraction (HFpEF) share common risk factors and are closely related to one another and to adverse cardiovascular events. Exertional dyspnoea in patients with AF should trigger a comprehensive LV diastolic function evaluation since AF frequently precedes incident HFpEF. An echocardiographic assessment of LV diastolic function in patients with AF is challenging, mainly because of variability in cycle length, the absence of atrial contraction, and the frequent occurrence of left atrial enlargement regardless of LV filling pressures (LVFPs). The algorithm of the 2016 recommendations for the evaluation of LV diastolic function cannot be directly applied in this setting. This review discusses the modalities available for diastolic function assessment and HFpEF diagnosis in patients with AF. Based on currently available data, a reasonable clinical target of diastolic function evaluation in AF would be to reach a binary conclusion: LVFP elevated or not. Recently, a two-step algorithm that combined several echocardiographic parameters plus the inclusion of body mass index has been proposed to differentiate normal from elevated LVFP in patients with AF. The echocardiographic evaluation must be complemented by a thorough clinical evaluation along with natriuretic peptides and cardiac catheterization in selected cases. If a diagnosis of HFpEF cannot be ascertained, a close follow-up for timely identification of diastolic dysfunction markers, along with monitoring and correction of modifiable risk factors, is recommended.

Non-invasive assessment of left ventricular filling pressure in aortic stenosis.

The assessment of left ventricular (LV) filling pressure (FP) is important for the management of aortic stenosis (AS) patients. Although, it is often restricted for predict LV FP in AS because of mitral annular calcification and a certain left ventricular hypertrophy. Thus, we tested the predictive ability of the algorithm for elevated LV FP in AS patients and also applied a recently-proposed echocardiographic scoring system of LV FP, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score. We enrolled consecutive 116 patients with at least moderate AS in sinus rhythm who underwent right heart catheterization and echocardiography within 7 days. Mean pulmonary artery wedge pressure (PAWP) was measured as invasive parameter of LV FP. LV diastolic dysfunction (DD) was graded according to the ASE/EACVI guidelines. The VMT score was defined as follows: time sequence of opening of mitral and tricuspid valves was scored to 0-2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). When the inferior vena cava was dilated, one point was added and VMT score was finally calculated as 0-3. Of the 116 patients, 29 patients showed elevated PAWP. Ninety patients (93%) and 67 patients (63%) showed increased values for left atrium volume index (LAVI) and E/e', respectively when the cut-off values recommended by the guidelines were applied and thus the algorism predicted elevated PAWP with a low specificity and positive predictive value (PPV). VMT≥2 predicted elevated PAWP with a sensitivity of 59%, specificity of 90%, PPV of 59%, and negative predictive value of 89%. An alternative algorithm that applied tricuspid regurgitation velocity and VMT scores was tested, and its predictive ability was markedly improved. VMT score was applicable for AS patients. Alternative use of VMT score improved diagnostic accuracy of guideline-recommended algorism.

Evaluating left atrial strain and left ventricular diastolic strain rate as markers for diastolic dysfunction in patients with mitral annular calcification

BackgroundMitral annular calcification (MAC) poses many challenges to the evaluation of diastolic function using standard echocardiography. Left atrial (LA) strain and left ventricular early diastolic strain rate (DSr) measured by speckle-tracking echocardiography (STE) are emerging techniques in the noninvasive evaluation of diastolic function. We aim to evaluate the utility of LA strain and early DSr in predicting elevated left ventricular filling pressures (LVFP) in patients with MAC and compare their effectiveness to ratio of mitral inflow velocity in early and late diastole (E/A).MethodsWe included adult patients with MAC who presented between January 1 and December 31, 2014 and received a transthoracic echocardiogram (TTE) and cardiac catheterization with measurement of LVFP within a 24-h period. We used Spearman’s rank correlation coefficient to assess associations of LA reservoir strain and average early DSr with LVFP. Receiver operating characteristic (ROC) curves were computed to assess the effectiveness of LA strain and DSr in discriminating elevated LVFP as a dichotomized variable and to compare their effectiveness with E/A ratio categorized according to grade of diastolic dysfunction.ResultsFifty-five patients were included. LA reservoir strain demonstrated poor correlation with LVFP (Spearman’s rho = 0.03, p = 0.81) and poor discriminatory ability for detecting elevated LVFP (AUC = 0.54, 95% CI 0.38–0.69). Categorical E/A ratio alone also demonstrated poor discriminatory ability (AUC = 0.53, 95% CI 0.39–0.67), and addition of LA reservoir strain did not significantly improve effectiveness (AUC = 0.58, 95% CI 0.42–0.74, p = 0.56). Average early DSr also demonstrated poor correlation with LVFP (Spearman’s rho = −0.19, p = 0.16) and poor discriminatory ability for detecting elevated LVFP (AUC = 0.59, 95% CI 0.44–0.75). Addition of average early DSr to categorical E/A ratio failed to improve effectiveness (AUC = 0.62, 95% CI 0.46–0.77 vs. AUC = 0.54, 95% CI 0.39–0.69, p = 0.38).ConclusionsIn our sample, LA reservoir strain and DSr do not accurately predict diastolic filling pressure. Further research is required before LA strain and early DSr can be routinely used in clinical practice to assess filling pressure in patients with MAC.

What underlies sex differences in heart failure onset within the first year after a first myocardial infarction?

Women are more likely to develop heart failure (HF) after myocardial infarction. However, diagnosis and reperfusion are often delayed. To compare the prevalence of HF after primary percutaneous coronary intervention (PPCI)-treated ST segment myocardial infarction (STEMI) between sexes and to study its associations with comorbidities, infarct size, and left ventricular (LV) systolic and diastolic dysfunctions (DD). The patients with PPCI-treated anterior STEMI, from the CIRCUS study cohort, were followed up for 1 year and HF events were recorded. Evaluation of ejection fraction (LVEF) and DD were performed at baseline and at 1 year. The elevated LV filling pressure (LVFP) included Grades 2 and 3 DD. Of the 791 patients from the CIRCUS study, 135 were women. At 1 year, the proportion of patients who developed HF was 21% among men and 34% among women (p = 0.001). In the subset of 407 patients with available diastolic parameters, the rate of HF was also higher in women. HF during the initial hospitalization was comparable between the sexes. However, women had a higher incidence of rehospitalization for HF within the first year after STEMI (14.1% vs. 4.1%, p = 0.005). Women were older with a higher prevalence of hypertension. The infarct size and LVEF were similar between the sexes. Elevated LVFP was observed more frequently in women than in men during the initial hospitalization and at 1 year (26% vs. 12%, p = 0.04, and 22% vs. 12%, p = 0.006, respectively). Interestingly, only initial elevated LVFP (HR 5.9, 95% CI: 2.4-14.5, p < 0.001), age, and hypertension were independently associated with rehospitalization for HF. After PPCI-treated anterior STEMI, despite comparable infarct size and LVEF, women presented a higher proportion of rehospitalization for HF than men. That was likely due to a greater DD associated with older age and hypertension.

High sodium intake and fluid overhydration predict cardiac structural and functional impairments in chronic kidney disease.

High sodium intake and fluid overhydration are common factors of and strongly associated with adverse outcomes in chronic kidney disease (CKD) patients. Yet, their effects on cardiac dysfunction remain unclear. The study aimed to explore the impact of salt and volume overload on cardiac alterations in non-dialysis CKD. In all, 409 patients with CKD stages 1-4 (G1-G4) were enrolled. Daily salt intake (DSI) was estimated by 24-h urinary sodium excretion. Volume status was evaluated by the ratio of extracellular water (ECW) to total body water (TBW) measured by body composition monitor. Recruited patients were categorized into four groups according to DSI (6 g/day) and median ECW/TBW (0.439). Echocardiographic and body composition parameters and clinical indicators were compared. Associations between echocardiographic findings and basic characteristics were performed by Spearman's correlations. Univariate and multivariate binary logistic regression analysis were used to determine the associations between DSI and ECW/TBW in the study groups and the incidence of left ventricular hypertrophy (LVH) and elevated left ventricular filling pressure (ELVFP). In addition, the subgroup effects of DSI and ECW/TBW on cardiac abnormalities were estimated using Cox regression. Of the enrolled patients with CKD, the median urinary protein was 0.94 (0.28-3.14) g/d and estimated glomerular filtration rate (eGFR) was 92.05 (IQR: 64.52-110.99) mL/min/1.73 m2. The distributions of CKD stages G1-G4 in the four groups was significantly different (p = 0.020). Furthermore, compared to group 1 (low DSI and low ECW/TBW), group 4 (high DSI and high ECW/TBW) showed a 2.396-fold (95%CI: 1.171-4.902; p = 0.017) excess risk of LVH and/or ELVFP incidence after adjusting for important CKD and cardiovascular disease risk factors. Moreover, combined with eGFR, DSI and ECW/TBW could identify patients with higher cardiac dysfunction risk estimates with an AUC of 0.704 (sensitivity: 75.2%, specificity: 61.0%). The specificity increased to 85.7% in those with nephrotic proteinuria (AUC = 0.713). The magnitude of these associations was consistent across subgroups analyses. The combination of high DSI (>6 g/d) and high ECW/TBW (>0.439) independently predicted a greater risk of LVH or ELVFP incidence in non-dialysis CKD patients. Moreover, the inclusion of eGFR and proteinuria improved the risk stratification ability of DSI and ECW/TBW in cardiac impairments in CKD.

Prognostic Significance of Elevated Left Ventricular Filling Pressures with Exercise: Insights from a Cohort of 14,338 Patients

Exercise echocardiography can assess for cardiovascular causes of dyspnea other than coronary artery disease. However, the prevalence and prognostic significance of elevated left ventricular (LV) filling pressures with exercise is understudied. We evaluated 14,338 patients referred for maximal symptom-limited treadmill echocardiography. In addition to assessment of LV regional wall motion abnormalities (RWMAs), we measured patients' early diastolic mitral inflow (E), septal mitral annulus relaxation (e'), and peak tricuspid regurgitation velocity before and immediately after exercise. Over a mean follow-up of 3.3±3.4years, patients with E/e' ≥15 with exercise (n=1,323; 9.2%) had lower exercise capacity (7.3±2.1 vs 9.1±2.4 metabolic equivalents, P<.0001) and were more likely to have resting or inducible RWMAs (38% vs 18%, P<.0001). Approximately 6% (n=837) had elevated LV filling pressures without RWMAs. Patients with a poststress E/e' ≥15 had a 2.71-fold increased mortality rate (2.28-3.21, P<.0001) compared with those with poststress E/e' ≤ 8. Those with an E/e' of 9 to 14, while at lower risk than the E/e' ≥15 cohort (hazard ratio [HR]= 0.58 [0.48-0.69]; P<.0001), had higher risk than if E/e' ≤8 (HR= 1.56 [1.37-1.78], P<.0001). On multivariable analysis, adjusting for age, sex, exercise capacity, LV ejection fraction, and presence of pulmonary hypertension with stress, patients with E/e' ≥15 had a 1.39-fold (95% CI, 1.18-1.65, P<.0001) increased risk of all-cause mortality compared with patients without elevated LV filling pressures. Compared with patients with E/e' ≤ 15 after exercise, patients with E/e' ≤15 at rest but elevated after exercise had a higher risk of cardiovascular death (HR= 8.99 [4.7-17.3], P<.0001). Patients with elevated LV filling pressures are at increased risk of death, irrespective of myocardial ischemia or LV systolic dysfunction. These findings support the routine incorporation of LV filling pressure assessment, both before and immediately following stress, into the evaluation of patients referred for exercise echocardiography.

Diagnostic accuracy of mitral E/e' and time between E and e' in predicting elevated left ventricular filling pressure in patients with nonvalvular atrial fibrillation undergoing coronary angiography

Abstract Background Assessment of left ventricular (LV) diastolic function using Doppler echocardiography is very challenging in atrial fibrillation (AF) because of the absence of mitral A wave and beat-to-beat variability. While mitral E/e’ retains its value in predicting elevated LV filling pressure (LVFP) in patients with AF, cut-off points remain variable. Moreover, the diagnostic accuracy of this parameter and the time between E and e’ (T E-e’) in predicting elevated LVFP in AF is unknown. Therefore, this study aims to determine the sensitivity (Sn), specificity (Sp), and positive and negative predictive values (PPV, NPV) of mitral E/e’ and T E-e’ in predicting elevated LVFP among adult patients with nonvalvular AF undergoing coronary angiography in the Philippines from October 2022 to January 2023. Purpose Knowledge about the diagnostic accuracy of mitral E/e’ and T E-e’ in predicting elevated LVFP in adult Filipino patients with nonvalvular AF can lead to better management of left ventricular diastolic dysfunction (LVDD) in the Philippines. This study can also serve as a baseline for further studies to develop international recommendations for classifying LVDD in patients with nonvalvular AF. Methods A total of 44 adult patients with nonvalvular AF who underwent invasive measurement of LVEDP during coronary angiography then Doppler assessment of LVFP within 24 hours were included in this cross-sectional study. The primary outcome was determination of diagnostic accuracy of mitral E/e’ and T E-e’ in predicting elevated LVFP in the study population. Independent Samples T-test and Fisher’s Exact test were used to determine the difference of mean and frequency between patients with and without elevated LVFP. Area under the receiver operating characteristic curve (AUROC), Sn, Sp, NPV and PPV were used to determine the diagnostic accuracy of mitral E/e’ and T E-e’ to predict elevated LVFP. All statistical tests were two-tailed tests. Shapiro-Wilk test was used to test the normality of the continuous variables. STATA v13.1 was used for data analysis at 95% confidence interval. Results Overall, lateral E/e’ ≥ 9.8 has the highest diagnostic accuracy (82%) in predicting elevated LVFP in patients with nonvalvular AF with Sn of 83%, Sp of 80%, PPV of 89% and NPV of 70%. Average E/e’ ≥ 10.7 is also specific at 80%. Average E/e’ ≥ 10.7 and lateral TE-e’ ≥ 4.3 have the largest AUROC of 0.79 (95% CI 0.6550 to 0.9358) and 0.67 (95% CI 0.4888 to 0.8445), respectively. Of the T E-e’, lateral ≥ 4.3 ms has the highest diagnostic accuracy (70%) in predicting the same outcome but with poor AUROC (0.67; 95% CI 0.49 to 0.84). Conclusion Mitral E/e’ is accurate in predicting elevated LVFP in adult Filipino patients with nonvalvular AF. Lateral E/e’ ≥ 9.8 and average E/e’ ≥ 10.7 can be used as cut-offs to predict elevated LVFP in this population. T E-e’ has no additional diagnostic value to mitral E/e’ in predicting elevated LVFP in this study.

Strategic noninvasive multimodal assessment of cardiac performance in patients with heart failure

Abstract Aims We sought to evaluate whether a noninvasive combination assay targeting left ventricular filling pressure (LVFP) would be useful for risk stratification of patients with heart failure (HF). Although abnormal LVFP is inevitably related to HF outcomes, its noninvasive application remains difficult in daily practice. Methods This prospective observational study enrolled consecutive hospitalized HF patients. According to the baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) and Doppler echocardiographic diastolic assessments, patients were classified into three groups: normal range of both LVFP and NT-proBNP (Group 1), normal range of LVFP but elevated NT-proBNP (Group 2), and elevated LVFP and NT-proBNP (Group 3). The primary endpoints were the composite adverse cardiovascular events. Results Event-free survival in Group 2 (n = 56, mean age of 65.4±12.4) was better than that in Group 3 (n = 45, mean age of 68.5±11.5) but worse than that in Group 1 (n = 123, mean age of 61.4±10.5) (log-rank p &amp;lt;0.001). Cardiopulmonary exercise test (CPET) findings were compatible with these findings. Left atrial strain showed better risk stratification than left atrial volume index. Serial addition of left atrial assessment and CPET in the model incrementally enhanced the predictive power of LVFP-based stratification for adverse events. Conclusions The strategic combination of NT-proBNP, echocardiographic LVFP and left atrial function, and CPET is helpful to predict adverse clinical outcomes in patients with HF. The larger the number of combined cardiac performance indicators, the better the noninvasive risk-stratification was.

Left atrial strain as a predictor of left ventricular filling pressures in coronary artery disease with preserved ejection fraction: a comprehensive study with left ventricular end-diastolic and pre-atrial contraction pressures.

Assessing left ventricular (LV) filling pressure (LVFP) is challenging in patients with coronary artery disease (CAD) and preserved LV ejection fraction (LVEF). We aimed to correlate left atrial strain (LAS) with two invasive complementary parameters of LVFP and compared its accuracy to other echocardiographic data to predict high LVFP.This cross-sectional, single-center study enrolled 81 outpatients with LVEF > 50% and significant CAD from a database. Near-simultaneous echocardiography and invasive measurements of both LV end-diastolic pressure (LVEDP) and LV pre-atrial contraction (pre-A) pressure were performed in each patient, based on the definition of LVEDP > 16 mmHg and LV pre-A > 12 mmHg as high LVFP.A moderate to strong correlation was observed between LAS reservoir (LASr), contractile strain, and LVEDP (r: 0.67 and 0.62, respectively; p < 0.001); the same was true for LV pre-A (r: 0.65 and 0.63, respectively; p < 0.001). LASr displayed good diagnostic performance to identify elevated LVFP, which was higher when compared to traditional parameters. Median value of LASr was higher for an isolated increase of LVEDP than for simultaneously high LV pre-A. The cutoff found to predict high LVFP was lower for LV pre-A than that one for LVEDP. In the current study, LASr did not provide an additional contribution to the 2016 diastolic function algorithm.LAS is a valuable tool for predicting LVFP in patients with CAD and preserved LVEF. The choice of LVEDP or LV pre-A as the representative marker of LVFP leads to different cutoffs to predict high pressures. The best strategy for adding this tool to a multiparametric algorithm requires further investigation.

Risk factors for raised left ventricular filling pressure by cardiovascular magnetic resonance: prognostic insights from UK Biobank

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute for Health and Care Research British Cardiovascular Society. Background Cardiovascular magnetic resonance imaging (CMR) can estimate left ventricular filling pressure (LVFP). The relationship between LVFP, determined by CMR measurements, and established risk factors for cardiovascular disease is unknown. This study quantifies these associations and investigates the prognostic value of CMR-derived LVFP compared to known risk factors for cardiovascular disease. Methods Using data from the UK Biobank prospective observational cohort study, CMR-derived LVFP was calculated using a model incorporating left atrial volume and left ventricular mass. Logistic regression was used to explore the relationships between raised LVFP (≥15mmHg) and typical cardiovascular risk factors. The non-linear relationship between LVFP and age was analysed using ordinary least squares regression and a restricted cubic spline of age with nine knots. Cox proportional hazards regression was used to analyse the relationships between typical cardiovascular risk factors and CMR-derived LVFP, and outcomes of incident heart failure and major adverse cardiovascular events. Results In this prospective population-based cohort study, 39,163 UK Biobank participants had CMR with adequate image quality. In a multivariable logistic regression model, male sex (OR 4.55, 95% CI 3.85–5.42, p&amp;lt;0.001), age (OR 1.89, 95% CI 1.72 - 2.09, per decade increment, p&amp;lt;0.001), BMI (OR 1.57, 95% CI 1.48–1.67, per SD increment, p&amp;lt;0.001), and hypertension (OR 1.46, 95% CI 1.26–1.68, p&amp;lt;0.001) were associated with increased odds of raised LVFP (Figure 1a). A non-linear regression model of the relationship between age and LVFP, adjusted for all covariables studied, showed little correlation between CMR-derived LVFP and age until 70 years, after which LVFP increased rapidly with age (Figure 2). In multivariable Cox regression models, elevated CMR-derived LVFP was associated with increased hazard of incident heart failure (HR 3.31, 95% CI 1.99–5.49, p&amp;lt;0.001) but not MACE (HR 1.33, 95% CI 0.86–2.07, p = 0.20) (Figure 1b). Conclusions Raised LVFP, as determined using CMR, is independently associated with male sex, age, BMI and hypertension. CMR-derived LVFP is independently associated with incident heart failure. These findings may have implications for clinical risk stratification, targeted population screening strategies and public health measures to reduce the risk of heart failure development.

Routine Non-Invasive Cardiac Imaging Indices Cannot Reliably Detect Elevated Left Ventricular Filling Pressure

Routine Non-Invasive Cardiac Imaging Indices Cannot Reliably Detect Elevated Left Ventricular Filling Pressure

Elevated Left Ventricular Filling Pressure as an Early Predictor of Progression of White-coat Hypertension to Sustained Hypertension

Background: White-coat hypertension is commonly observed in subjects presenting with elevated office blood pressure measurements. Although white-coat hypertension does not require medication long-term, studies have observed progression to sustained hypertension in about 30% of individuals. Left ventricular diastolic abnormalities have been described in some individuals with white-coat hypertension and early hypertension. Objective: The present study is a prospective study of follow-up of individuals with white-coat hypertension and the correlation of left ventricular diastolic parameters as determinants of the development of sustained hypertension. Materials and Methods: Individuals diagnosed to have white-coat hypertension based on elevated office blood pressure measurements and normal ambulatory blood pressure measurements were included in the study and were evaluated by echocardiography for left ventricular diastolic function and filling pressures (E/A ratio, E wave deceleration time, E/E’ ratio). They were followed up for 1-year to assess for the development of sustained hypertension and to correlate with the initial echocardiographic parameters. Results: A total number of 32 individuals with white coat hypertension were followed up for 1 year period. Moreover, 25 (78.12%) subjects remained to be normotensive and 7 (21.88%) subjects developed sustained hypertension. There was no significant correlation between E/A, and E wave deceleration time in all the subjects. E/E’ ratio had a positive correlation (R-value 0.77) in subjects who developed sustained hypertension over a 1-year follow-up. Conclusion: Echocardiographic evaluation of left ventricular filling pressure by E/E’ ratio can be considered as an early predictor for the development of sustained hypertension in white-coat hypertension in a long-term follow-up.

Bendopnea Is Due To Elevated Left Ventricular Filling Pressures Rather Than Elevated Pulmonary Artery Pressures

Bendopnea Is Due To Elevated Left Ventricular Filling Pressures Rather Than Elevated Pulmonary Artery Pressures

Left Ventricular Filling Pressure in Chronic Thromboembolic Pulmonary Hypertension

BackgroundChronic thromboembolic pulmonary hypertension (CTEPH) is characterized by obstruction of major pulmonary arteries with organized thrombi. Clinical risk factors for pulmonary hypertension due to left heart disease including metabolic syndrome, left-sided valvular heart disease, and ischemic heart disease are common in CTEPH patients. ObjectivesThe authors sought to investigate prevalence and prognostic implications of elevated left ventricular filling pressures (LVFP) in CTEPH. MethodsA total of 593 consecutive CTEPH patients undergoing a first diagnostic right and left heart catheterization were included in this study. Mean pulmonary arterial wedge pressure (mPAWP) and left ventricular end-diastolic pressure (LVEDP) were utilized for assessment of LVFP. Two cutoffs were applied to identify patients with elevated LVFP: 1) for the primary analysis mPAWP and/or LVEDP >15 mm Hg, as recommended by the current pulmonary hypertension guidelines; and 2) for the secondary analysis mPAWP and/or LVEDP >11 mm Hg, representing the upper limit of normal. Clinical and echocardiographic features, and long-term mortality were assessed. ResultsLVFP was >15 mm Hg in 63 (10.6%) and >11 mm Hg in 222 patients (37.4%). Univariable logistic regression analysis identified age, systemic hypertension, diabetes, atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume as significant predictors of elevated LVFP. Atrial fibrillation, calcific aortic valve stenosis, mitral regurgitation, and left atrial volume remained independent determinants of LVFP in adjusted analysis. At follow-up, higher LVFPs were measured in patients who had meanwhile undergone pulmonary endarterectomy (P = 0.002). LVFP >15 mm Hg (P = 0.021) and >11 mm Hg (P = 0.006) were both associated with worse long-term survival. ConclusionsElevated LVFP is common, appears to be due to comorbid left heart disease, and predicts prognosis in CTEPH.