Late Diastolic Velocity Ratio Research Articles

Effect of Glucagon-like Peptide-1 Receptor Agonists on Prognosis of Heart Failure and Cardiac Function: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Whether an antidiabetic drug, glucagon-like peptide-1 receptor agonist (GLP-1RA), could improve the prognosis of heart failure and cardiac function remains controversial. We conducted a systematic review and meta-analysis of randomized controlled trials to explore the influence of GLP-1RAs on heart failure in patients regardless of diabetes diagnosis. Literature in English from the PubMed, EMBASE, and Cochrane Library databases was searched from inception to July 2022. The study aim was to identify published, randomized, placebo-controlled trials testing GLP-1RAs in patients with or without diabetes. Outcomes were heart failure hospitalization, cardiac function, and structure measures. Twenty-two randomized controlled trials involving 61,412 patients are included in the meta-analysis. Overall, compared with the placebo group, GLP-1RA treatment could not significantly decrease heart failure hospitalization in patients with a history of heart failure (hazard ratio [HR], 1.07; 95% CI, 0.91 to 1.25; P=0.422). Six-minute walking test distances (WMD, 19.08 m; 95% CI, 4.81 to 33.36; P=0.01), E-wave (SMD, -0.40; 95% CI, -0.60 to -0.20; P < 0.001), early diastolic to late diastolic velocities ratio (WMD, -0.10; 95% CI, -0.18 to -0.02; P=0.01), mitral inflow E velocity to tissue Doppler e' ratio (WMD, -0.97; 95% CI, -1.54 to -0.41; P < 0.001), and E-wave deceleration time (WMD, -9.96 milliseconds; 95% CI, -18.52 to -1.41; P=0.02) increased significantly after administration of GLP-1RAs. However, GLP-1RAs do not significantly influence N-terminal pro-B-type natriuretic peptide levels (WMD, -20.02 pg/mL; 95% CI, -53.12 to 13.08; P=0.24), Minnesota Living with Heart Failure Questionnaire quality of life scores (WMD, -1.08; 95% CI, -3.99 to 1.84; P=0.47), or left ventricular ejection fractions (WMD, -0.37%; 95% CI, -1.19 to 0.46; P=0.38). GLP-1RAs did not reduce heart failure readmissions in patients with a history of heart failure and elevated N-terminal pro-B-type natriuretic peptide levels. Thus, the prognosis of heart failure was not improved, although GLP-1RAs did significantly improve left ventricular diastolic function in patients. PROSPERO identifier: CRD42021226231.

Correlation Between Transmitral Early and Late Diastolic Velocities Ratio and Ratio of Medial Mitral Annular Early and Late Tissue Doppler Velocities

Echocardiography is now the most commonly used noninvasive tool for the assessment of cardiac anatomy and function. In addition to commonly established roles such as confirming the diagnosis, etiologic work-up, complication screening, and disease monitoring, echocardiography plays an important clinical role in prognostic assessment.

Study of the Prevalence of Echocardiographic Abnormalities and their Relation to Disease Progression in Chronic Kidney Disease

Context: Study of the prevalence of echocardiographic abnormalities and there relation to disease progression in chronic kidney disease (CKD). Aims: Study correlation of echocardiographic changes and CKD progression. Settings and Design: A prospective, cross-sectional, observational, analytical study, where we performed complete echocardiographic evaluation of patients with CKD stage II–V. We compared various echocardiographic parameters to predict the progression of CKD. Subjects and Methods: Ninety CKD patients stage II–V presenting to our hospital from November 2016 to December 2017 were included in the study. A complete echocardiographic evaluation was done. Left ventricular hypertrophy (LVH), systolic and diastolic dysfunction using Doppler indices at mitral inflow, left atrial volume, speckle tracking, and global longitudinal strain (GLS) were studied. Results: Patients were age and sex matched in all the groups with a male preponderance. Forty-one patients (45.56%) were diabetic and 74 (82.22%) were hypertensive. The prevalence of hypertension increased from 66.67% to 89.29% as CKD stage progressed from stage II to stage V. There were significant echocardiographic abnormalities seen in CKD patients. The severity increased with worsening of the stages of CKD. LVH and early diastolic mitral inflow to annular velocity ratio progression was statistically significant when stage V was compared to stage II. Left atrial volume, mitral early diastolic to late diastolic velocity ratio, maximum tricuspid regurgitation (TRmax) velocity, and diastolic dysfunction prevalence were significantly raised in stage IV and stage V compared to stage II. Only GLS showed statistical significance between stage II to stage III, stage IV and stage V and thus predicting progression of CKD. Conclusions: LVH, dilated left atrium, abnormal GLS, TRmax, diastolic dysfunction, and related tissue Doppler imaging parameters correlate with worsening renal function. GLS was the only parameter showing significant difference between stage II and stage III. This can be used as a novel modality for detection of subclinical cardiac dysfunction in CKD.

Left ventricular stiffness in paediatric patients with end-stage kidney disease.

We tested the hypothesis that myocardial stiffness is altered in paediatric patients with end-stage kidney disease (ESKD) and explored its association with clinical parameters of chronic kidney disease (CKD). Thirty-five patients with ESKD (16 males) aged 17.5 ± 3years old, 18/35 of whom were receiving dialysis and 17 post kidney transplant, were studied. Left ventricular (LV) myocardial stiffness was determined by measurement of diastolic wall strain (DWS) and stiffness index (SI), while LV diastolic function was interrogated by pulsed-wave and tissue Doppler echocardiography. Compared with available literature data, both dialysis and transplanted patients had significantly lower DWS and greater SI, reduced transmitral early (E) to late diastolic velocity ratio and septal and lateral mitral annular early (e') diastolic velocities, and greater septal and lateral E/e' ratios (all p < 0.05). Multivariate analysis revealed that z score of diastolic blood pressure (β = 0.43, p = 0.004) and the duration of renal replacement therapy (β = 0.55, p < 0.001) were significant determinants of LV SI. Subgroup analysis in post-transplant patients showed z score of diastolic blood pressure (β = 0.54, p = 0.025) remained as a significant determinant of LV SI. Increased LV myocardial stiffness is evident in paediatric dialysis and transplanted patients with ESKD, and is associated with blood pressure and duration of renal replacement therapy.

IGFBP7 (Insulin-Like Growth Factor-Binding Protein-7) and Neprilysin Inhibition in Patients With Heart Failure.

Increased activity of IGFBP7 (insulin-like growth factor-binding protein-7) is associated with cellular senescence, tissue aging, and obesity. IGFBP7 may be related to heart failure with preserved ejection fraction, a disease of elderly obese people. In a subset of patients with heart failure with preserved ejection fraction (N=228) randomized to receive sacubitril/valsartan versus valsartan, IGFBP7 concentrations were measured at baseline, 12 weeks, and 36 weeks. Patient characteristics and echocardiographic measures including left atrial (LA) size and volume, ratio of early mitral inflow velocity/annular diastolic velocity, and ratio of early diastole/peak late diastolic velocity were assessed as a function of IGFBP7 concentration. Effect of sacubitril/valsartan on IGFBP7 concentrations was analyzed. With increasing baseline IGFBP7 quartiles, LA size and LA volume index (LAVi) were higher (both P<0.001); modest association between IGFBP7 and higher early mitral inflow velocity/annular diastolic velocity ( P=0.03) and early diastole/peak late diastolic velocity ratio ( P=0.04) was also seen. IGFBP7 concentrations were higher in those with LAVi ≥34 mL/m2 compared with lower LAVi at all time points (all P<0.01). IGFBP7 independently predicted LAVi at baseline even in the presence of NT-proBNP (N-terminal pro-B-type natriuretic peptide) concentrations; highest LAVi was seen in those with elevation in both biomarkers. Treatment with sacubitril/valsartan resulted in lower IGFBP7 concentrations over 36 weeks compared with valsartan (adjusted treatment effect, -7%; P<0.001). Among patients with heart failure with preserved ejection fraction, concentrations of the cellular senescence biomarker IGFBP7 were associated with abnormalities in diastolic filling and LA dilation. Treatment with sacubitril/valsartan resulted in lower IGFBP7 concentrations compared with valsartan. URL: https://www.clinicaltrials.gov . Unique identifier: NCT00887588.

Echocardiogram changes following parathyroidectomy for primary hyperparathyroidism: A systematic review and meta-analysis.

The aim of the study is to systematically review the evidence on post parathyroidectomy (PTX) changes as measured by echocardiogram (ECHO) in patients with primary hyperparathyroidism (PHPT).PHPT may increase risk of cardiovascular morbidity/mortality. Conclusions of studies assessing ECHO changes, pre versus post PTX, are inconsistent.A systematic literature search was conducted to locate published and unpublished studies. Randomized control trials, nonrandomized control trials, and observational studies were included. Variables were reported as means and standard deviations. An inverse variance statistical method, with random-effects analysis model, was applied to continuous data. The effect measure was standardized mean difference, confidence interval of 95%. Primary outcome measure was left ventricular ejection fraction (LVEF). Secondary outcome measures were left ventricular mass index (LVMI), peak early over peak late diastolic velocity ratio (E/A ratio), isovolumetric relaxation time (IVRT), intraventricular septal thickness (IVST), and posterior wall thickness (PWT).Fourteen studies were included. Follow-up time ranged 3 to 67 months. No significant differences (P > .05) in primary outcome measure LVEF (SMD = −0.03, CI = −0.24, 0.19), or secondary outcome measures E/A Ratio (SMD = −0.05, CI = −0.24, 0.14), IVST (SMD = 0, CI = 0.31, 0.32), PWT (SMD = 0.01, CI = −0.38, 0.39), LVMI (SMD = −0.18, CI = −0.74, 0.38), and IVRT (SMD = −0.84, CI = −1.83, 0.14) were observed.There was no significant difference in LVEF pre to post PTX. Due to heterogeneity of current literature, we were unable to determine if other outcome measures of cardiac function are affected after PTX in patients with PHPT. We recommend a randomized control trial be conducted to make concrete conclusions.

Cardiovascular effects of dietary salt intake in aged healthy cats: a 2-year prospective randomized, blinded, and controlled study.

High salt dry expanded diets are commercially available for cats to increase water intake and urine volume, as part of the prevention or treatment of naturally occurring urinary stone formation (calcium oxalates and struvites). However, chronic high salt intake may have potential cardiovascular adverse effects in both humans, especially in aging individuals, and several animal models. The objective of this prospective, randomized, blinded, and controlled study was to assess the long-term cardiovascular effects of high salt intake in healthy aged cats. Twenty healthy neutered cats (10.1±2.4 years) were randomly allocated into 2 matched groups. One group was fed a high salt diet (3.1 g/Mcal sodium, 5.5 g/Mcal chloride) and the other group a control diet of same composition except for salt content (1.0 g/Mcal sodium, 2.2 g/Mcal chloride). Clinical examination, systolic and diastolic arterial blood pressure measurements, standard transthoracic echocardiography and conventional Doppler examinations were repeatedly performed on non-sedated cats by trained observers before and over 24 months after diet implementation. Radial and longitudinal velocities of the left ventricular free wall and the interventricular septum were also assessed in systole and diastole using 2-dimensional color tissue Doppler imaging. Statistics were performed using a general linear model. No significant effect of dietary salt intake was observed on systolic and diastolic arterial blood pressure values. Out of the 33 tested imaging variables, the only one affected by dietary salt intake was the radial early on late diastolic velocity ratio assessed in the endocardium of the left ventricular free wall, statistically lower in the high salt diet group at 12 months only (P = 0.044). In conclusion, in this study involving healthy aged cats, chronic high dietary salt intake was not associated with an increased risk of systemic arterial hypertension and myocardial dysfunction, as observed in some elderly people, salt-sensitive patients and animal models.

Impact of Left Ventricular Diastolic Function on Left Atrial Mechanics in Systolic Heart Failure

The relation between left atrial (LA) mechanics and left ventricular (LV) diastolic function and adverse cardiovascular events are not well established in chronic systolic heart failure (HF). In 108 patients, we performed comprehensive echocardiography with an assessment of LA global longitudinal strain (LAε) by Velocity Vector Imaging. We also performed complete diastolic examinations including mitral inflow, pulmonary vein flow, and tissue Doppler. Death, cardiac transplantation, and HF hospitalization were tracked for 5 years. In our study cohort (age 57 ± 15 years, LV ejection fraction 25 ± 6%), mean global LA negative (εnegative), positive (εpositive), and total ε (εtotal) were -6.8 ± 4.4%, 7.7 ± 5.7%, and 14.5 ± 8.2%, respectively. All LAε indexes correlated with individual indexes of LV diastolic dysfunction, including mitral flow early (E) to late diastolic velocity ratio (p <0.05 for all), mitral deceleration time (p <0.01 for all), E to early diastolic velocity of the septal mitral annulus (e') ratio (p <0.05 for all), pulmonary vein flow systolic to diastolic velocity ratio (p <0.001 for all), and maximal LA volume index (p <0.01 for all). All LAε indexes increased across diastolic stage (p <0.001 for all). In multivariate logistic regression analysis, LAεnegative and LAεtotal were associated with the presence of LV diastolic dysfunction grade III even after adjustment for E/e' septal and LA volume index. In Cox proportional hazards analysis, lower magnitude LAεnegative predicted long-term adverse clinical events. In conclusion, more impaired LA mechanics are associated with more severe diastolic dysfunction and predict long-term adverse events in patients with chronic systolic HF.

Effect of termination of the left anterior descending coronary artery (wrapped or non-wrapped property) on tissue Doppler echocardiography findings in patients with anterior myocardial infarction: an observational study

We aimed to evaluate effect of termination property of left anterior descending (LAD) on tissue Doppler echocardiography (TDE) parameters in patients experiencing their first anterior myocardial infarction (AMI) who had undergone successful primary percutaneous coronary intervention (PCI). A prospective, cross-sectional observational study was performed. Eighty-four patients were enrolled in the study. Echocardiography was performed during the first three days of AMI. Conventional TDE measurements were obtained from right ventricular (RV) and four left ventricular (LV) walls: for the systolic function - mitral annular TDE systolic velocity - Sm, for diastolic function - mitral annular TDE early and late diastolic velocities - Em, Am, transmitral early and late diastolic velocities ratio - E/A, and combined systolic and diastolic function - myocardial performance index (MPI). Coronary arteries were evaluated and patients were divided into two groups (non-wrapped LAD and wrapped LAD) according to the termination properties. Student-t, Mann-Whitney U and Chi-square tests, bivariate Pearson and Spearman correlation analyses were used for statistical analysis. Baseline characteristics and conventional echocardiographic parameters of the patients were similar. There was a statistically significant difference for the anterior wall Sm parameter, whereas there was no substantial difference for Em, Am and MPI values. The anterior wall Sm was more affected in patients with non wrapped LAD than in patients with wrapped LAD (6.70 ± 1.66 and 7.44 ± 1.66 cm/s; p=0.036,).The anterior Sm parameter was uniquely correlated with LAD termination status when compared with other independent parameters (r=0.236, p=0.036). We showed that termination of LAD is important for the anterior wall systolic functions in the early stage of AMI treated successfully.

RIGHT VENTRICULAR FUNCTIONAL ALTERATIONS IN HYPERTENSION-RELATED LEFT VENTRICULAR HYPERTROPHY: PP.8.340

Objective: The aim of this study was to determine the effect of hypertension-related left ventricular hypertrophy on right ventricular function indices. Design and Method: Our population consisted of 55 subjects (aged = 51 ± 6 years, 44 men) with newly diagnosed, untreated, stage I-II essential hypertension and 34 age- and sex-adjusted control subjects. Standard transthoracic echocardiographic measurements as well as pulsed-wave tissue Doppler from tricuspid annulus were obtained. Results: Age and heart rate were similar between the two groups. Hypertensive subjects had significantly increased left ventricular (LV) diastolic septal and posterior wall thickness, left atrial diameter, LV mass, LV mass index and relative wall thickness. Right ventricular TAPSE and RVOTfs (%) were similar between the two groups (2.45 ± 0.3 vs 2.25 ± 0.23 and 47 ± 5 vs 46 ± 5, respectively, p = NS for all). Conventional echo Doppler study revealed similar RV peak E, A velocities as well as their ratio between the two groups. At the level of lateral tricuspid annulus, all of the diastolic measurements were altered in hypertensives [early diastolic velocity (cm/sec) 13 ± 4 vs 18 ± 4, p < 0.01, late diastolic velocity (cm/sec) 20 ± 3 vs 14 ± 4, p < 0.01, early to late diastolic velocity ratio 20 ± 4 vs 14 ± 3, p < 0.01]. Systolic velocity did not differentiate between the two groups (16 ± 3 vs 17 ± 3, p = NS). Conclusions: Right ventricular functional alterations can be identified by TDI imaging in patients with hypertension-related left ventricular hypertrophy. TDI imaging unmasks sublte changes in the diastolic function of the right ventricle.

Comparison of Echocardiographic Measures of Left Ventricular Diastolic Function in Early Hypertension

Left ventricular (LV) diastolic dysfunction identifies patients at risk of developing heart failure and may be common in patients with hypertension. The prevalence of LV diastolic dysfunction in patients with newly diagnosed hypertension was compared using criteria provided by the Canadian Consensus, European Study Group, and American Medical Association guidelines. One hundred twenty patients with newly diagnosed untreated hypertension (mean age 46.9 +/- 2.1 years; 62 men, 58 women) with increased blood pressure (clinic >140/90 mm Hg, daytime ambulatory >135/85 mm Hg) underwent comprehensive 2-dimensional echocardiography. Transmitral inflow velocities were measured using pulse-wave Doppler with and without Valsalva's maneuver, and a comprehensive assessment of tissue Doppler velocities was performed. The prevalence of LV diastolic dysfunction varied according to criteria used. There was a high prevalence of LV diastolic dysfunction (59%; n = 71) using Canadian Consensus guidelines; 27% of patients (n = 32) had a pseudonormal pattern unmasked using Valsalva's maneuver and 32% (n = 39) had impaired relaxation at rest. Significantly fewer patients (10%; n = 12) had this diagnosis using European or American Medical Association guidelines (23%; n = 27). Using tissue Doppler imaging (early-late diastolic velocity ratio <1), the prevalence of LV diastolic dysfunction was 59% (n = 71), identical to findings using the Canadian Consensus guidelines. In conclusion, current national consensus guidelines defining LV diastolic dysfunction varied widely and underdiagnosed LV diastolic dysfunction in patients with newly diagnosed hypertension. Tissue Doppler imaging assessment is a rapidly and widely available tool that is as sensitive as the most stringent national guidelines and should be systematically incorporated into a more comprehensive assessment of LV diastolic dysfunction in this population.

Effects of beta blockers on left ventricular diastolic function: the importance of optimal heart rate reduction

Left ventricular (LV) diastolic dysfunction is an important cause of heart failure in hypertensive heart disease.The aim of this study is to establish the effects of beta blockers on LV diastolic function and long axis motion in patients with arterial hypertension.Methods — Sixty patients (aged 55 ± 8 y) with mild-to-moderate arterial hypertension were treated with beta blockers for 12 weeks. Clinical and echocardiographic assessment was done prior to and after the treatment. Doppler transmitral flow velocity recording was used to evaluate left ventricular diastolic function. Left ventricular long axis function was analysed using digitized M-mode tracings of mitral annulus motion.Results — Therapy with beta blockers resulted in an increase in the transmitral early to late diastolic velocity ratio (from 0.90 ± 0.22 m/s to 1.00 ± 0.26 m/s, P < 0.05), and systolic amplitude of mitral annulus motion (from 7.9 ± 1.5 mm to 8.4 ± 1.6 mm, P < 0.05). The changes in left ventricular diastolic function and mitral annulus motion parameters were related to changes in heart rate. When the heart rate was reduced to 57-68 bpm, left ventricular diastolic and long axis functions improved.Conclusion — Beta blockers can improve left ventricular diastolic and long axis function when a significant heart rate reduction is achieved in patients with mild-to-moderate arterial hypertension.

Effect of Obesity on Left Ventricular Structure and Myocardial Systolic Function: Assesment by Tissue Doppler Imaging and Strain/Strain Rate Imaging

Obesity is associated with heart failure, cardiovascular morbidity, and mortality. A direct effect of weight on left ventricle (LV) structure and myocardial function is not well-established. The aim of our study is to determine the effect of obesity on LV morphology and systolic function by using LV standard Doppler echocardiographic indices, myocardial Doppler imaging and strain/strain rate imaging indices. We studied 33 obese and 34 age, sex-adjusted control subjects who had no other pathological conditions. Standard transthoracic Doppler echocardiographical measurements, reconstructed spectral pulsed wave tissue Doppler velocities, strain and strain rate imaging of six different myocardial regions were obtained. Peak systolic velocity (SR), peak systolic strain (I), peak systolic strain rate (SR) for each region and as a global systolic longitidunal LV function mean of peak systolic strain of six myocardial regions (glsca) were compared. Age, body surface area, blood pressure, and heart rate were comparable between the two groups. Obese subjects had significantly increased LV end-diastolic volume, septal wall thickness, left atrial diameter, and decreased transmitral early to late diastolic velocity ratio. In obese subjects, reconstructed spectral pulsed-wave tissue Doppler analysis showed significantly decreased basal lateral peak systolic (Sm) velocity (6.68 +/- 1.89 vs. 8.08 +/- 2.50, P < 0.05), mid lateral Sm (5.01 +/- 2.17 vs. 6.78 +/- 3.22, P < 0.05). Differences in regional strain rate (mid septal SR, 1.45 +/- 0.23 vs. 1.63 +/- 0.18, P < 0.05), regional strain (basal septum I, 19.13 +/- 3.83 vs. 22.09 +/- 4.60, P < 0.05; mid-septum I, 18.03 +/- 2.91 vs. 20.25 +/- 4.77, P < 0.05; radial I, 27.50 +/- 7.32 vs. 35.53 +/- 9.48, P < 0.05), and global strain (glsca, 19.38 +/- 1.34 vs. 21.24 +/- 2.82, P < 0.05) were identified between obese and the referent subjects. Obesity is associated with morphologic alterations in left ventricle and left atrium and subclinical changes in left ventricle systolic function which can be detected by strain and strain rate imaging even without overt heart disease.

The Impact of Hypertension and Hypertension‐Related Left Ventricle Hypertrophy on Right Ventricle Function

The aim of our study is to determine the effect of hypertension and hypertension-related left ventricle hypertrophy on right ventricle (RV) morphology and function by using RV standard Doppler echocardiographic indices, myocardial Doppler imaging, and strain/strain rate imaging indices. We studied 35 patients with arterial hypertension and 30 age- and sex-adjusted control subjects who had no other pathological conditions. Standard transthoracic Doppler echocardiographical measurements, pulsed-wave tissue Doppler from tricuspid anulus (Peak systolic-st, peak early diastolic-et, peak late diastolic velocity-at), reconstructed spectral pulsed-wave tissue Doppler velocities (peak systolic-S, peak early-E, peak late diastolic velocity-A), and strain/strain rate imaging of RV free wall mid region (peak systolic strain-in, peak systolic strain rate-SR) were obtained. Age, body surface area, blood pressure, and heart rate were comparable between two groups. Hypertensive subjects had significantly increased LV end-diastolic septal and posterior wall thickness, left atrial diameter, LV mass, LV mass index, and relative wall thickness during diastole. At the level of right ventricular lateral tricuspid annulus without systolic changes, the majority of diastolic measurements were altered in hypertensives (early diastolic velocity et; 13 +/- 2 vs. 18 +/- 4 m/sec, P < 0.0001, late diastolic velocity at; 20 +/- 4 vs. 14 +/- 3 m/sec, P < 0.0001, early to late diastolic velocity ratio; 0.69 +/- 0.14 vs. 1.32 +/- 0.38, P < 0.0001). The velocity data from two-dimensional color myocardial imaging at the level of RV free wall mid region again showed altered diastolic measurements in hypertensives (E; 8.01 +/- 2.6 vs. 10.4 +/- 3.14 m/sec, P < 0.001, A; 11.5 +/- 2.6 vs. 9.12 +/- 3.7 m/sec, P < 0.0001, E/A ratio; 0.75 +/- 0.41 vs. 1.87 +/- 0.48, P < 0.00). The peak systolic strain of RV free wall mid region was significantly lower in hypertensive individuals than controls (25.666 +/- 5.64 vs. 30.03 +/- 6.78%, P < 0.05). No significant differences were found in other parameters of RV function between hypertensive and control subjects. The present study demonstrates that besides the manifest morphologic LV adaptations, significant RV functional alterations can be determined by TDI and strain/strain rate imaging in patients arterial hypertension. Both tissue velocities by TDI and strain imaging may be new tools to define and quantitate subtle change in systolic and diastolic function of right ventricular function in arterial hypertension that cannot be determined in standard echocardiographic parameters.

Subclinical left ventricular dysfunction in multiple sclerosis

To investigate the left (LV) and right ventricular (RV) function in multiple sclerosis (MS) using standard echocardiography and Doppler tissue imaging (DTI). A total of 41 patients with definite MS and 32 healthy controls were included in the study. LV end-systolic dimension was increased and LV ejection fraction was decreased in MS patients compared with controls (P < 0.05). LV end-diastolic dimension was increased in MS patients, however, did not reach significance. Among DTI parameters, mitral annular peak early diastolic velocity to peak late diastolic velocity ratio (Em/Am) was decreased in MS patients, but not reach statistical significance. No significant differences in tricuspid annular Em/Am ratio was found between MS patients and controls. A statistically significant increase of DTI derived LV myocardial performance index was found in MS patients as compared with controls. RV myocardial performance index showed a tendency to be increased in MS patients, however, did not reach significance. These findings suggest subclinical LV dysfunction and preserved RV function in patients with MS.

Echocardiography as a Noninvasive Swan-Ganz Catheter

Diwan and co-investigators report in this issue of Circulation that the interval between onset of mitral E and annular early diastolic velocity (Ea) by tissue Doppler, TE−Ea, can be used to estimate left ventricular (LV) filling pressure in patients with mitral valve disease.1 Garcia and colleagues were the first to report that the onset of Ea occurred 7.5±3.5 ms after peak mitral inflow velocity in 7 patients with restrictive cardiomyopathy, whereas Ea started 22±19 ms earlier than did E in the normal group.2 Subsequently, TE−Ea has been shown to correlate with the time constant of LV relaxation (τ) demonstrated by Hasegawa and associates in their elegant animal experiment.3 With worsening of heart failure by rapid pacing, Ea progressively decreased in velocity and delayed in onset. Mitral E occurred coincidently with the termination of the early diastolic left arterial (LA) and LV pressure gradient at baseline and all stages of heart failure. In contrast, with increasing heart failure, Ea was progressively delayed after LA to LV pressure crossover, and TE−Ea was related to τ. Rivas-Gotz, Nagueh, and their associates also demonstrated that TE−Ea was prolonged after constriction of the circumflex coronary artery in dogs.4 In patients with heart failure, LV myocardial relaxation and compliance are decreased. See p 3281 Although LV filling is initiated and enhanced by augmentable myocardial relaxation in healthy individuals, it is driven by high filling pressure in patients with heart failure because myocardial relaxation remains reduced, not being sensitive to preload. Myocardial relaxation also affects the isovolumic relaxation time (IVRT). As relaxation becomes abnormal, LV pressure falls more slowly and the opening of the mitral valve is delayed, resulting in a longer IVRT. IVRT, however, becomes shorter as LA pressure increases; hence, IVRT∝τ/LA pressure. Because TE−Ea∝τ, …

Regression of left ventricular hypertrophy and improvement of diastolic function in hypertensive patients treated with telmisartan

Objectives: The study was designed to test whether or not the angiotensin II receptor blocker telmisartan brings about regression of left ventricular (LV) concentric hypertrophy and whether or not these changes are associated with improved diastolic filling. Methods: An echocardiographic follow-up study was performed in 85 hypertensive patients (systolic blood pressure [SBP] >140 mm Hg, diastolic blood pressure [DBP] >90 mm Hg) and mild-to-moderate LV hypertrophy (LV mass index related to body surface area [LVMI] 117–150 g/m 2 for men and 105–150 g/m 2 for women) treated with telmisartan monotherapy 40–80 mg once daily for 1 year. Blood pressure, LVMI, left atrial (LA) volumes, and diastolic function were determined at baseline and after 3, 6, 9, and 12 months of treatment. Blood pressure was also monitored at all visits. Diastolic function was assessed by examination of transmitral inflow and pulmonary vein flow patterns. Results: Telmisartan reduced blood pressure; after 12 months, the mean±S.D. SBP and DBP were reduced from 144±10 to 126±8 mm Hg ( p<0.001) and from 98±8 to 86±7 mm Hg ( p<0.001), respectively. The LVMI was decreased from 119±7 to 109±3 g/m 2 ( p<0.001) after 12 months' telmisartan treatment. All patients had diastolic dysfunction at baseline. After 12 months' telmisartan treatment, a normal pattern of transmitral inflow was present in 21% of patients. The regression of LV hypertrophy observed after 12 months was associated with increased peak early diastolic velocity/peak late diastolic velocity ratio from 0.60±0.18 to 0.83±0.20 ( p<0.001), shortened isovolumic relaxation time (IVRT) from 110±13 to 105±13 ms ( p<0.001), and decreased deceleration time from 229±30 to 215±28 ms ( p=0.002). Univariate analysis showed that shortened IVRT was related to a reduction in the LVMI and LA maximal and minimal volumes. In the multivariate analysis, the reduction in LVMI and the reduction in LA maximal and minimal volumes were independently associated with IVRT reduction. Conclusions: Telmisartan 40–80 mg is effective in LV hypertrophy regression in hypertensive patients. The reduction in LVMI due to telmisartan monotherapy was associated with a significant improvement of diastolic filling parameters and with a significant reduction of LA volumes.

142 Can BNP be a useful tool for predicting severe diastolic dysfunction in patients with chronic heart failure?

The assessment of severe diastolic disfunction (SDD) plays a major role for the prediction of outcome in patients (pts) with chronic heart failure (CHF). In these pts, Doppler echocardiography (DE) remains the first choice non- invasive technique, but other parameters could be alternatively utilized for a wider and cheaper screening of SDD in mildly symptomatic populations. Indeed, we sought to determine the accuracy of BNP, a cardiac neurohormone directly correlated to both left ventricular filling and pulmonary capillary wedge pressure, for predicting SDD. Methods: One-hundred sixty four consecutive pts (age: 70 ± 11; F 34%; betablocker therapy: 53%; ischemic 52%; NYHA functional class: I: 8%; II: 68%; III: 24%; mean ejection fraction: 41 + 12%) were considered. BNP plasma level was measured by means of the System (Biosite Diagnostic, Triage BNP Test). SDD was defined by peak mitral early diastolic velocity/peak late diastolic velocity ratio (E/A ratio > 1) and E deceleration time < 140 msec. Results: 54/164 PTS had DE criteria of SDD (33%); mean BNP was 502.30± 340.9 pg/ml in pts with SDD and 75.44 ± 122.8 in pts without SDD (p< 0.001). The receiving-operator (ROC) curves demonstrated BNP 3 138,5 pg/ml to be the best cut-off for determining SDD, with 70% overall accuracy (Sensitivity: 72%, Specificity: 70%), area under the curve: 0,764. A value of BNP < 46 pg/ml reliably discriminated PTS without SDD (Negative predictive value: 93%). Conclusions: BNP plasma levels could be helpful for the first - step assessment of SDD population referred with symptoms of CHF, improving the efficacy of diagnostic flow-chart in the individual patient.

Effect of Intravenous Calcitriol on Cardiac Systolic and Diastolic Function in Patients on Hemodialysis

The systolic and diastolic function of the heart of hemodialysis (HD) patients and the effect of intravenous vitamin D therapy on cardiac function was studied by Doppler and digitized M-mode echocardiography in 10 HD patients before and after 3–4.5 months of calcitriol therapy. Calcitriol was administered intravenously 1–3 times a week at a dose of 1–2 µg after the dialysis sessions. Ten age- and sex-matched healthy controls were also examined echocardiographically. Before calcitriol therapy cardiac wall thicknesses (interventricular septum, posterior wall) and left ventricle (LV) dimensions (end diastolic, end systolic) were greater, and LV diastolic (peak late diastolic velocity, peak early diastolic velocity/peak late diastolic velocity ratio, isovolumic relaxation time) and systolic (fractional shortening) function was impaired in HD patients as compared to controls. The LV posterior wall thickness was related to plasma parathyroid hormone (PTH; r = 0.70, p = 0.01) in the patients. Calcitriol therapy raised serum ionized Ca from 1.23±0.04 to 1.33 ± 0.04 mmol/l and reduced PTH from 41.1±10.7 to 34.2±11.7 pmol/l (29±11%). Calcitriol therapy did not cause any significant changes in cardiac function in the whole patient group. However, in a subgroup of 5 patients with severe but controllable hyperparathyroidism (PTH >3 times upper normal margin) the LV dimensions and systolic function improved (LV end systolic dimension from 39.0 ± 4.0 to 31.3 ± 2.9 mm, p = 0.03; LV end diastolic dimension from 57.7 ± 3.1 to 53.4 ± 3.0 mm, p = 0.06; fractional shortening from 33 ± 4 to 42 ± 3%, p = 0.03). The diastolic indices improved also, but not significantly. In conclusion, left ventricle hypertrophy and systolic and diastolic dysfunction was observed in HD patients. Intravenous calcitriol therapy improved cardiac function in patients with severe secondary hyperparathyroidism.

Filling patterns in left ventricular hypertrophy: A combined acoustic quantification and Doppler study

Objectives. The purpose of this study was to evaluate the potential of acoustic quantification compared with Doppler echocardiography for assessment of left ventricular diastolic dysfunction.Background. Diastolic dysfunction usually accompanies left ventricular hypertrophy. Although Doppler echocardiography is widely used, it has known limitations in the diagnosis of diastolic abnormalities. The ventricular area-change waveform obtained with acoustic quantification technology may provide an alternative to assess diastolic dysfunction.Methods. Potential acoustic quantification variables (peak rate of area change and mean slope of area change rate during rapid filling, amount of relative area change during rapid filling and atrial contraction) were obtained and compared with widely used Doppler indexes of ventricular filling (isovolumetric relaxation time, pressure half-time, peak early diastolic velocity/peak late diastolic velocity ratio, rapid filling, atrial contribution to filling) ia 16 healthy volunteers and 30 patients with left ventricular hypertrophy.Results. Criteria for abnormal relaxation were present in 68% of patients by acoustic quantification and in 64% of patients by Doppler echocardiography. However, abnormal relaxation was identified in 89% of patients by one or both methods. Acoustic quantification indicated abnormal relaxation in the presence of completely normalized Doppler patterns and in patients with mitral regurgitation or abnormal rhythm with unreliable Doppler patterns.Conclusions. Acoustic quantification potentially presents a new way to assess diastolic dysfunction. This technique may be regarded as complementary to Doppler echocardiography. The combined use of the methods may improve the diagnosis of left ventricular relaxation abnormalities.