Longitudinal Functional Reserve Research Articles

Decreased biventricular mechanics and functional reserve in nonobstructive hypertrophic cardiomyopathy patients: implications for exercise capacity.

The present study investigated the changes of biventricular mechanics at rest and during exercise and examined the association between exercise capacity and biventricular mechanics and functional reserve in nonobstructive hypertrophic cardiomyopathy (NHCM) patients. A total of 50 NHCM patients and 25 controls were consecutively recruited for this study. Using echocardiography and two-dimensional speckle-tracking imaging, an experienced echocardiographer determined the following indices: RV free wall longitudinal strain (RVFWLS), LV global longitudinal strain (LVGLS), strain rate (SR), and functional reserve of strain values. We also investigated the relationships between biventricular mechanics and exercise capacity using metabolic equivalents (METs). NHCM patients had lower RVFWLS, LVGLS, systolic SR, early diastolic SR, and systolic and diastolic reserve during exercise compared to controls. An association of biventricular mechanics (LVGLS, RVFWLS) with exercise capacity at rest and during exercise was established. Multivariable logistic regression revealed that RVFWLS and LVE/e' during exercise (RVFWLS-exe, E/e'-exe) were independent predictors of exercise intolerance. Receiver operating characteristic curve analysis indicated that LVE/e'-exe had a higher area under the curve for predicting exercise intolerance in NHCM patients. In hierarchical analysis, RVFWLS-exe provided an incremental predictive value of exercise intolerance over LVGLS during exercise (LVGLS-exe) and LVE/e'-exe. LVE/e'-exe also changed incrementally compared to LVGLS-exe and RVFWLS-exe. NHCM patients have decreased biventricular mechanics at rest and during exercise and impaired biventricular functional reserve, and biventricular mechanics are associated with functional capacity. We propose that simultaneous evaluation of biventricular function should provide incremental predictive value for exercise intolerance.

Corrigendum: Effects on Subclinical Heart Failure in Type 2 Diabetic Subjects on Liraglutide Treatment vs. Glimepiride Both in Combination with Metformin: A Randomized Open Parallel-Group Study.

[This corrects the article on p. 325 in vol. 8, PMID: 29184539.].

Effects on Subclinical Heart Failure in Type 2 Diabetic Subjects on Liraglutide Treatment vs. Glimepiride Both in Combination with Metformin: A Randomized Open Parallel-Group Study.

We aimed to investigate the effect of liraglutide treatment on heart function in type 2 diabetes (T2D) patients with subclinical heart failure. Randomized open parallel-group trial. 62 T2D patients (45 male) with subclinical heart failure were randomized to either once daily liraglutide 1.8 mg, or glimepiride 4 mg, both add on to metformin 1 g twice a day. Mitral annular systolic (s') and early diastolic (e') velocities were measured at rest and during bicycle ergometer exercise, using tissue Doppler echocardiography. The primary endpoint was 18-week treatment changes in longitudinal functional reserve index (LFRIdiastolic/systolic). Clinical characteristics between groups (liraglutide = 33 vs. glimepiride = 29) were well matched. At baseline left ventricle ejection fraction (53.7 vs. 53.6%) and global longitudinal strain (-15.3 vs. -16.5%) did not differ between groups. There were no significant differences in mitral flow velocities between groups. For the primary endpoint, there was no treatment change [95% confidence interval] for: LFRIdiastolic (-0.18 vs. -0.53 [-0.28, 2.59; p = 0.19]), or LFRIsystolic (-0.10 vs. -0.18 [-1.0, 1.7; p = 0.54]); for the secondary endpoints, there was a significant treatment change in respect of body weight (-3.7 vs. -0.2 kg [-5.5, -1.4; p = 0.001]), waist circumference (-3.1 vs. -0.8 cm [-4.2, -0.4; p = 0.019]), and heart rate (HR) (6.3 vs. -2.3 bpm [-3.0, 14.2; p = 0.003]), with no such treatment change in hemoglobin A1c levels (-11.0 vs. -9.2 mmol/mol [-7.0, 2.6; p = 0.37]), between groups. 18-week treatment of liraglutide compared with glimepiride did not improve LFRIdiastolic/systolic, but however increased HR. There was a significant treatment change in body weight reduction in favor for liraglutide treatment.

Moderated Posters: A little bit of everythingP1190What causes mitral annulus dilatation-A three dimensional studyP1191Impact of interventional edge-to-edge repair with the MitraClip system on mitral valve geometry: Long-term results from a prospective single centre studyP1192Real live applications of three-dimensional echocardiographic quantification of the left atrial volumes using an automated adaptive analytics algorithmP1193Quantitative ultrasound evaluation of the changes on tissue characteristics of

Moderated Posters: A little bit of everythingP1190What causes mitral annulus dilatation-A three dimensional studyP1191Impact of interventional edge-to-edge repair with the MitraClip system on mitral valve geometry: Long-term results from a prospective single centre studyP1192Real live applications of three-dimensional echocardiographic quantification of the left atrial volumes using an automated adaptive analytics algorithmP1193Quantitative ultrasound evaluation of the changes on tissue characteristics of

The relationship between ventricular-vascular uncoupling during exercise and impaired left ventricular longitudinal functional reserve in hypertensive patients

Uncoupling between heart and vessel may be accompanied by left ventricular (LV) dysfunction during exercise. We investigated the association between ventricular-vascular uncoupling during exercise and impaired LV longitudinal functional reserve in hypertensive subjects. Supine bicycle exercise echocardiography (25-watt, 3-minute increments) was performed in 216 hypertensive patients (106 male; mean age, 58 ± 9 years). Arterial elastance (Ea), end-systolic ventricular elastance (Ees), and ventricular-vascular interaction (VVI) index (Ea/Ees) were calculated at rest and at each stage of exercise. The patients were divided into three groups according to the tertile value of VVI ratio. The VVI ratio was defined as the ratio of VVI index at 50 W exercise over VVI index at rest; normal VVI response (n = 72); borderline VVI response (n = 72); and abnormal VVI response (n = 72). There were no significant differences in conventional echo parameters, mitral inflow velocities, mitral annular early diastolic (E’) velocity, and mitral annular systolic velocity (S’) at rest among the three groups. However, E’ velocities and S’ velocities at 25 W and 50 W were significantly lower in patients with abnormal VVI response compared with those in the other groups (P = .010 at 25 W, P = .008 at 50 W in E’ velocity; P = .022 at 25 W, P = .043 at 50 W in S’ velocity). Longitudinal diastolic functional reserve index from rest to 50 W was significantly lower in patients with abnormal VVI response compared with the other groups. Ventricular-vascular uncoupling during exercise was related to impaired LV longitudinal functional reserve in hypertensive patients.

Extent of Late Gadolinium Enhancement on Cardiovascular Magnetic Resonance Imaging and Its Relation to Left Ventricular Longitudinal Functional Reserve During Exercise in Patients With Hypertrophic Cardiomyopathy

The aim of this study was to investigate whether the extent of late gadolinium enhancement (LGE) on cardiovascular magnetic resonance imaging reflecting myocardial fibrosis correlates with left ventricular (LV) longitudinal function during exercise in hypertrophic cardiomyopathy (HCM). Mitral annular velocities (E' and S') were measured on echocardiography at rest and during graded bicycle exercise (25 W, 3-min increments) in 46 HCM patients (mean age, 53 years; 32 men). LV longitudinal diastolic and systolic functional reserve indices were calculated as ΔE'×E'base and ΔS'×S'base, where ΔE' and ΔS' are the changes in E' and S' from baseline to 50 W of exercise, respectively. The patients were divided into 2 groups according to the extent of LGE (as "percentage of LV mass containing LGE": %LV with LGE; range, 0-37%; median, 6%): group 1 (n=23), %LV with LGE <6%, and group 2, %LV with LGE ≥6%. Baseline echocardiographic parameters were similar between the 2 groups, but changes in E' and S' during exercise were smaller in group 2 (ΔE': 2.8±1.8 cm/s vs.1.5±1.0 cm/s, P=0.007; ΔS': 2.2±1.2 cm/s vs. 0.9±0.8 cm/s, P<0.0001). LV functional reserve indices were also significantly lower in group 2 (ΔE'×E'(base): 12.8±7.7 vs. 5.5±3.4, P=0.001; ΔS'×S'(base): 12.6±7.4 vs. 4.7±4.5, P<0.0001). LV longitudinal function during exercise is influenced by the extent of LGE in HCM. Myocardial fibrosis may represent a pathologic substrate that determines LV functional reserve in patients with HCM.

Impact of left ventricular longitudinal diastolic functional reserve on clinical outcome in patients with type 2 diabetes mellitus

BackgroundLeft ventricular longitudinal diastolic functional reserve (DFR), as assessed by the change in early diastolic mitral annular velocity (E′) during exercise, is abnormal in patients with type 2 diabetes mellitus...

Metabolic Syndrome and Myocardial Contractile Reserve

REFER TO THE PAGE 176-182 Metabolic syndrome (MetS) is a clustering of cardiovascular risk factors including hyperglycemia, dyslipidemia, and hypertension, which have been shown to increase cardiovascular (CV) morbidity and mortality.1),2) In addition, it is well known that the association between the presence of MetS and adverse CV outcomes is independent of diabetes mellitus (DM) and arterial hypertension.3),4) Since the MetS is a strong predictor of future CV events, the changes of left ventricular (LV) structure and function in patients with MetS are considered one of mechanisms explaining the link between the MetS and CV morbidity and mortality. The previous studies have already reported the LV geometry and function by demonstrating increased LV mass and subclinical LV systolic and/or diastolic dysfunctionis impaired in the MetS patients.5-7) However, the most studies were conducted in the resting state, not during exercise. Considering that most patients with type 2 DM and/or hypertension have symptoms during exercise, the study by Ha et al.8) suggests that the patients with MetS might also have decreased LV functional reserve during dynamic exercise. A total of 112 hypertensive patients complaining of exertional dyspnea were included and divided into two groups according to the existence of MetS. Exercise stress echocardiography using supine bicycle was performed and a variety of Doppler parameters were measured at baseline, at each stage of exercise, and during recovery. There was a significant difference in E/E' parameter, that is an index of LV filling pressure, in MetS patients at resting state. The increased E/E' value was maintained during dynamic exercise test, which is similar to the result of a prior study.9) A unique result to this study is that LV longitudinal functional reserve, defined as the change in tissue Doppler imaging (TDI), S' (longitudinal tissue velocity) from baseline to peak exercise was significantly lower in MetS patients even though there was no significant difference in baseline TDI S' velocity between the two. After adjusting for known CV risk factors, an independent relationship between the presence of MetS and LV systolic functional reserve was observed. The recent use of TDI, strain, and strain rate at resting state allows detecting earlier subclinical dysfunction and providing essential mechanisms in understanding the development of heart failure. In addition, TDI parameters such as S', E', A', and E/E' have been known to have independent prognostic values in various cardiac diseases,10) even in low risk population.11) However, there is a study showing that resting LV TDI parameter did not add any incremental prognostic impact over the clinical data in patients with type 2 DM.12) Thus, even though exercise capacity is already recognized as a significant predictor of CV diseases, the LV TDI measurements acquired by stress echocardiography seem to be more reliable and stronger in detecting the presence of subclinical CV disease13) and predicting clinical outcome,12) compared with resting TDI values. Nevertheless, measuring Doppler parameters including TDI during exercise stress echocardiography for the evaluation of longitudinal diastolic functional reserve is still challenging, especially at peak stress, because the mitral velocities summate as the heart rate increases. In this study, no differences in longitudinal diastolic functional reserve may be due to these limitations in addition to a small sample size. Although the exact mechanism related to abnormal contractile reserve in patients with MetS is still unknown, it seems that multiple factors including sympathetic nervous system, renin-angiotensin-aldosterone system, myocardial metabolism, and coronary flow reserve contribute to subclinical dysfunction of longitudinal myocardial contraction during exercise. In summary, MetS is associated with LV systolic and diastolic dysfunction at resting state and decreased LV longitudinal contractile reserve during exercise despite of similar values at baseline examination. Although larger studies to confirm the results of this study are needed, the assessment of longitudinal functional reserve in MetS patients, using exercise stress echocardiography, is helpful for earlier identification of subclinical dysfunction and more aggressive treatment strategies to prevent a progression to overt heart failure.

Usefulness of At Rest and Exercise Hemodynamics to Detect Subclinical Myocardial Disease in Type 2 Diabetes Mellitus

Patients with type 2 diabetes mellitus (T2DM) might have subclinical myocardial dysfunction identified at rest or unmasked during exercise. We examined the correlates of the myocardial exercise response in patients with T2DM. Myocardial dysfunction was sought during at rest and exercise echocardiography in 167 healthy patients with T2DM (97 men, 55 ± 10 years). Myocardial ischemia was excluded using stress echocardiography. Standard echocardiography and color tissue Doppler imaging measures (early diastolic tissue velocity [Em], strain, and strain rate) were acquired at baseline and peak stress. The calibrated integrated backscatter was calculated from the at rest parasternal long-axis view. The longitudinal diastolic functional reserve index after exercise was defined as ΔEm [1 - (1/Em(base))]. The clinical, anthropometric, and metabolic data were collected at rest and stress. Subclinical myocardial dysfunction at baseline (n = 24) was independently associated with weight (odds ratio [OR] 1.02, p = 0.04) and hemoglobin A1c (OR 1.36, p = 0.03). This group displayed an impaired exercise response that was independently associated with a reduced exercise capacity (OR 0.84, p = 0.034) and longitudinal diastolic functional reserve index (OR 0.69, p = 0.001). Inducible myocardial dysfunction (stress Em <-9.9 cm/s) was identified after exercise in 70 of the remaining 143 subjects. This finding was associated with calibrated integrated backscatter (OR 1.08, p = 0.04) and lower peak heart rate (OR 0.97, p = 0.002) but not metabolic control. The intensity of the metabolic derangement in patients with T2DM was associated with subclinical at rest myocardial dysfunction, but not with the myocardial exercise response. In conclusion, the association of an abnormal stress response with nonmetabolic factors, including backscatter and blunted peak heart rate, suggests potential roles for myocardial fibrosis and cardiac autonomic neuropathy in patients with nonischemic diabetic heart disease.

Importance of dynamic dyssynchrony in the occurrence of hypertensive heart failure with normal ejection fraction

The impact of haemodynamic stress on left ventricular (LV) dyssynchrony in heart failure with normal ejection fraction (HFNEF) remains unknown. We sought to evaluate the relationship and predictive value of dynamic changes of LV dyssynchrony on hypertensive HFNEF. A total of 131 subjects including 47 hypertensive HFNEF patients, 34 hypertensive patients with left ventricular hypertrophy (LVH) without HFNEF, and 50 normal controls were studied by dobutamine stress echocardiography with tissue Doppler imaging. Systolic and diastolic dyssynchrony were assessed using the LV six-basal-six-mid-segment model and cut-off values were derived from normal controls. The mean basal segments longitudinal systolic (mean Sm) and early diastolic (mean Em) velocities were measured. In normal controls, systolic and diastolic dyssynchrony did not develop during stress. The prevalence of resting systolic (36.2% vs. 38.2%, P = 0.85) and diastolic (34.0% vs. 29.4%, P = 0.66) dyssynchrony was similar in HFNEF and LVH groups. During stress, the prevalence of systolic and diastolic dyssynchrony increased dramatically to 85.1% and 87.2%, respectively, in HFNEF group, but only 52.9% and 58.8% in LVH group (P < 0.005). In HFNEF group, stress-induced increase in mean Sm was significantly blunted (2.8 ± 2.0 vs. 4.2 ± 2.4 cm/s, P = 0.004), and the increase was abolished for mean Em (-0.3 ± 2.5 vs. 2.4 ± 3.4 cm/s, P < 0.001). On multivariate analysis, stress-induced changes in mean Em (OR = 0.69, P = 0.004) and mean Sm (OR = 0.56, P = 0.004), and diastolic (OR = 4.6, P = 0.005) and systolic dyssynchrony during stress (OR = 4.3, P = 0.038) were independent determinants for occurrence of HFNEF. Dynamic dyssynchrony during stress and impaired myocardial longitudinal function reserve are characteristics of HFNEF.

Abnormal left ventricular function occurs on exercise in well-treated hypertensive subjects with normal resting echocardiography

ObjectivesThis study tests the hypothesis that patients with treated hypertension with well-controlled blood pressure, without ventricular hypertrophy and normal resting echocardiography, may have abnormalities of ventricular function that are apparent...

High Resolution Speckle Tracking Dobutamine Stress Echocardiography Reveals Heterogeneous Responses in Different Myocardial Layers: Implication for Viability Assessments

Speckle-tracking echocardiography (STE) can be used to quantify wall strain in 3 dimensions and thus has the potential to improve the identification of hypokinetic but viable myocardium on dobutamine stress echocardiography (DSE). However, if different myocardial layers respond heterogeneously, STE-DSE will have to be standardized according to strain dimension and the positioning of the region of interest. Therefore, the aim of this study was to create a high-resolution model for ejection time (ET) strain and tissue flow in 4 myocardial layers at rest, during hypoperfusion, and during dobutamine challenge to assess the ability of STE-DSE to detect deformation and functional improvement in various layers of the myocardium. In 10 open chest pigs, the left anterior descending coronary artery was constricted to a constant stenosis, resulting in 35% initial flow reduction. Fluorescent microspheres were used to measure tissue flow. High-resolution echocardiography was performed epicardially to calculate ET strain in 4 myocardial layers in the radial, longitudinal, and circumferential directions using speckle-tracking software. Images were obtained at rest, during left anterior descending coronary artery constriction (hypoperfusion), and during a subsequent dobutamine stress period. Dobutamine stress at constant coronary stenosis increased flow in all layers. ET strain increased predominantly in the midmyocardial layers in the longitudinal and circumferential directions, whereas subendocardial strain did not improve in either direction. Dobutamine stress influences ET strain differently in the various axes and layers of the myocardium and only partially in correspondence to tissue flow. Longitudinal and circumferential functional reserve opens the potential for the specific detection of midsubendocardial viable tissue by high-resolution STE.

The Pathophysiology of Heart Failure With Normal Ejection Fraction: Exercise Echocardiography Reveals Complex Abnormalities of Both Systolic and Diastolic Ventricular Function Involving Torsion, Untwist, and Longitudinal Motion

The purpose of this study was to test the hypothesis that in heart failure with normal ejection fraction (HFNEF) exercise limitation is due to combined systolic and diastolic abnormalities, particularly involving ventricular twist and deformation (strain) leading to reduced ventricular suction, delayed untwisting, and impaired early diastolic filling. A substantial proportion of patients with heart failure have a normal left ventricular ejection fraction. Currently the pathophysiology is considered to be due to abnormal myocardial stiffness and relaxation. Patients with a diagnosis of HFNEF and proven cardiac limitation by cardiopulmonary exercise testing were studied by standard, tissue Doppler, and speckle tracking echocardiography at rest and on submaximal exercise. Fifty-six patients (39 women; mean age 72 +/- 7 years) with a clinical diagnosis of HFNEF and 27 age-matched healthy control subjects (19 women; mean age 70 +/- 7 years) had rest and exercise images of sufficient quality for analysis. At rest, systolic longitudinal and radial strain, systolic mitral annular velocities, and apical rotation were lower in patients, and all failed to rise normally on exercise. Systolic longitudinal functional reserve was also significantly lower in patients (p < 0.001). In diastole, patients had reduced and delayed untwisting, reduced left ventricular suction at rest and on exercise, and higher end-diastolic pressures. Mitral annular systolic and diastolic velocities, systolic left ventricular rotation, and early diastolic untwist on exercise correlated with peak VO(2)max. In HFNEF there are widespread abnormalities of both systolic and diastolic function that become more apparent on exercise. HFNEF is not an isolated disorder of diastole.

Abnormal Left Ventricular Longitudinal Functional Reserve Assessed by Exercise Pulsed Wave Tissue Doppler Imaging in Patients with Subclinical Hypothyroidism

Response of systolic and diastolic velocities of mitral annulus to exercise in patients with subclinical hypothyroidism (SCH) has not been explored previously. We sought to investigate whether SCH is associated with abnormal left ventricular (LV) longitudinal function reserve to exercise. Mitral annular systolic (S') and early diastolic (E') velocities were measured at rest and during supine bicycle exercise using tissue Doppler echocardiography (TDE) in 23 patients with newly diagnosed SCH and 25 controls. LV diastolic and systolic longitudinal function reserve indices were calculated. There were no significant differences in mitral inflow velocities at rest between groups except for LV end-diastolic dimension and LV end-systolic dimension, which were higher in the control group. E' and S' at rest were also similar between the groups. However, S' (9.8 +/- 1.5 vs. 11.3 +/- 1.5 cm/sec at 25 W, P = 0.001; and 11.3 +/- 1.8 vs. 13.1 +/- 1.8 cm/sec at 50 W, P = 0.001) and E' (13.8 +/- 1.4 vs. 15.7 +/- 1.6 cm/sec at 25 W, P < 0.001; and 15.6 +/- 1.6 vs. 18.2 +/- 1.5 cm/sec at 50 W, P < 0.001) during exercise were significantly lower in patients with SCH. Longitudinal systolic and diastolic function reserve indices were significantly lower in patients with SCH (systolic index, 1.4 +/- 0.9 vs. 2.5 +/- 0.9 cm/sec at 25 W, P = 0.001; and 2.7 +/- 1.3 vs. 4.1 +/- 1.2 cm/sec at 50 W, P = 0.001; diastolic index, 2.3 +/- 1.3 vs. 3.6 +/- 1.5 cm/sec at 25 W, P = 0.003; and 3.9 +/- 1.6 vs. 5.9 +/- 1.3 cm/sec at 50 W, P < 0.001). Assessment of LV longitudinal functional reserve with exercise using TDE appears to be helpful in identifying early myocardial dysfunction in SCH.

Importance of Left Ventricular Longitudinal Function and Functional Reserve in Patients With Degenerative Mitral Regurgitation: Assessment by Two-Dimensional Speckle Tracking

The aim of this study was to determine whether two-dimensional speckle tracking of longitudinal myocardial deformation can detect limited contractile reserve during exercise in patients with asymptomatic degenerative mitral regurgitation (MR). Seventy-one patients with degenerative MR and normal left ventricular (LV) ejection fractions underwent quantitative exercise echocardiography. Compared with 23 normal subjects matched for age and sex, LV volumes were greater in patients with MR. At rest, global longitudinal strain (GLS) was lower in patients, indicating subclinical LV dysfunction. During exercise, the extent and the magnitude of changes in GLS were larger in controls than in patients with MR. On multivariate regression analysis, left atrial volume at rest and changes in GLS at peak exercise were independently associated with changes in LV ejection fraction. In asymptomatic patients with degenerative MR, subnormal LV function can be reliably identified by two-dimensional strain imaging. Limited exercise LV longitudinal contractile recruitment during exercise predicts postoperative LV dysfunction.

Abstract 4204: Impact of Left Ventricular Diastolic Functional Reserve on Clinical Outcome in Patients with Diabetes Mellitus

Left ventricular (LV) longitudinal diastolic functional reserve, assessed by the change of early diastolic mitral annular velocity (E′) during exercise, is abnormal in patients with diabetes without overt heart disease. However, its impact on clinical outcome has not been explored previously. We hypothesized that LV diastolic reserve could further stratify diastolic dysfunction, and have a prognostic significance in patients with diabetes. Of 1,170 patients who were referred for diastolic stress echocardiography, 227 consecutive patients (mean age 58 years, male 103, mean ejection fraction [EF] 68 %) with diabetes were identified. LV diastolic function reserve index (DFRI) was calculated as E′ base x ΔE′; where ΔE′ is the change of E′ from baseline to exercise. The primary end-point was a composite of all-cause death and re-hospitalization for heart failure. The median follow-up duration was 34 months, and the primary end-point was occurred in 14 (6.1%) of 227 patients. Among the predictors that showed a significance in the univariate Cox analysis, including age, coronary artery disease history, renal insufficiency, LV mass index, LAVI, and EF, LV DFRI was the most independent predictor of adverse outcomes. When patients were classified by the median value of DFRI at 50W of exercise, patients with DFRI &lt; 13.5 showed poorer clinical outcomes compared to those with DFRI ≥ 13.5 (p=0.001). The assessment of LV diastolic functional reserve using exercise Doppler echocardiography is helpful in further stratifying diastolic dysfunction, and provides incremental prognostic information in patients with diabetes without overt heart disease.

Incremental Value of Left Ventricular Diastolic Function Reserve Index for Predicting Exercise Capacity in Patients with Hypertrophic Cardiomyopathy

The changes of left ventricular diastolic function during exercise are heterogeneous in patients with hypertrophic cardiomyopathy (HCM). We sought to investigate whether exertional changes of mitral annular velocities and plasma N-terminal-pro-B-type natriuretic peptide (BNP) concentration are associated with exercise capacity in patients with HCM. After a comprehensive echocardiographic study, 32 patients with HCM performed symptom-limited graded supine bicycle exercise. Echocardiographic Doppler parameters were measured at each stage of exercise. Blood samples were collected at rest and immediately after exercise to determine the concentration of pro-BNP. Resting pro-BNP (r = -0.620, P < .001), E'(base) (r = 0.414, P = .018), and DeltaE'(50W) (change of E' from base to 50 W of exercise) (r = 0.367, P = .039) were significantly correlated with exercise duration. Left ventricular longitudinal diastolic function reserve index, defined as DeltaE' x E'(base), significantly correlated with exercise duration (at 50 W, r = 0.540, P = .001) independent of age, sex, body mass index, and resting pro-BNP level. When combining DeltaE' x E'(50W) (<5.85 cm(2)/s(2)) and resting pro-BNP (>740 mg/dL), the predictive accuracy for exercise capacity could be improved (for <500 seconds, global chi(2) = 5.84 in pro-BNP vs 8.10 in pro-BNP + DeltaE' x E'(50W), P = .023). The assessment of left ventricular longitudinal diastolic function reserve can provide incremental information to pro-BNP for the prediction of exercise capacity in patients with HCM.

Increased Plasma Aldosterone-to-Renin Ratio Is Associated with Impaired Left Ventricular Longitudinal Functional Reserve in Patients with Uncomplicated Hypertension

Relative aldosterone excess is associated with endothelial dysfunction and higher incidence of end organ damage. We sought to investigate whether plasma aldosterone-to-renin ratio (ARR) is associated with left ventricular (LV) longitudinal function reserve to exercise in patients with controlled hypertension. In the patients with controlled and uncomplicated hypertension without overt LV hypertrophy, plasma aldosterone concentrations (ng/dL) and renin activities (ng/mL/h) were measured. Then 28 consecutive patients with higher ARR (group II, ARR > or = 30, 55 +/- 10 years) and 56 age- and sex-matched patients with lower ARR (group I, ARR < 30) underwent supine bicycle exercise echocardiography. Despite similar 24-hour blood pressure, LV mass index was significantly higher in group II (91.1 +/- 16.4 vs 101.7 +/- 18.2 g/m(2), P = .008). Early diastolic and systolic mitral annular velocity (E' and S', cm/s) at 50-W exercise was significantly lower in group II compared with group I (9.91 +/- 1.66 vs 8.67 +/- 1.65 cm/s, P = .002; 9.52 +/- 1.71 vs 8.46 +/- 1.79, P = .010, respectively) despite similar resting values. Longitudinal diastolic functional reserve at 25-W and 50-W exercise, defined as DeltaE' (change from resting E', cm/s) of group II was significantly lower than that of group I (2.60 +/- 1.42 vs 1.85 +/- 1.44 cm/s, P = .016; 3.40 +/- 1.48 vs 2.36 +/- 1.43 cm/s, P = .003, respectively). In conclusion, in patients with hypertension without overt LV hypertrophy, increased ARR is associated with increased LV mass, and impaired LV longitudinal functional reserve during exercise.

Abnormal left ventricular longitudinal functional reserve in patients with diabetes mellitus: implication for detecting subclinical myocardial dysfunction using exercise tissue Doppler echocardiography

Background:Sublinical myocardial dysfunction occurs in a significant number of patients with type 2 diabetes. Assessment of ventricular long-axis function by measuring mitral annular velocities using tissue Doppler echocardiography (TDE) is...

Abnormal Longitudinal Myocardial Functional Reserve Assessed by Exercise Tissue Doppler Echocardiography in Patients with Hypertrophic Cardiomyopathy

Previous studies have shown that mitral annular velocities are reduced in patients with hypertrophic cardiomyopathy (HCM). However, the response of systolic and diastolic velocities of the mitral annulus to exercise in patients with HCM has not been explored previously. Because pathologic left ventricular (LV) hypertrophy is associated with myocardial fibrosis, particularly in the subendocardium, we hypothesized that mitral annular systolic and diastolic velocities during exercise and at rest would be abnormal in patients with HCM. Mitral septal annular systolic (S') and early diastolic (E') velocities were measured at rest and during graded supine bicycle exercise (25 W, 3-minute increments) in 40 patients with HCM (29 male, mean age 56 years) and 41 age- and sex-matched control subjects. LV diastolic and systolic longitudinal function reserve index were calculated using a new formula. There were no significant differences in mitral inflow velocities (early mitral filling velocity [E], E/A, deceleration time of E velocity [DT]) at rest between the two groups except late mitral filling (A) velocity, which was higher in control group. Increase in E' with exercise was significantly smaller in patients with HCM compared with control subjects (1.7 +/- 1.3 vs 3.4 +/- 2.5 cm/s from base to 25 W, P = .0006; 2.2 +/- 1.9 vs 4.5 +/- 2.8 cm/s from base to 50 W, P = .0002). Although LV ejection fraction at rest was significantly higher in patients with HCM compared with that of control subjects (71 +/- 7 vs 66 +/- 7, P = .0019), S' at rest (6.0 +/- 1.2 vs 6.8 +/- 1.1 cm/s, P = .011) was significantly lower in patients with HCM. Although a significant increase in S' was detected with exercise in control subjects, increase in S' with exercise was blunted in patients with HCM (6.4 +/- 1.4 vs 8.5 +/- 2.5 cm/s at 25 W, P = .0004; 7.0 +/- 1.4 vs 9.5 +/- 2.4 cm/s at 50 W, P < .0001). Longitudinal systolic (0.37 +/- 0.85 vs 1.47 +/- 1.75 cm/s at 25 W, P = .0034; 0.79 +/- 1.08 vs 2.32 +/- 1.66 cm/s at 50 W, P = .0001) and diastolic (1.29 +/- 1.06 vs 2.84 +/- 2.12 cm/s at 25 W, P = .0002; 1.63 +/- 1.46 vs 3.77 +/- 2.31 cm/s at 50 W, P < .0001) function reserve index was significantly lower in patients with HCM compared with that of control subjects. Augmentation of LV longitudinal function during exercise is blunted in patients with HCM, suggesting longitudinal functional reserve and resting longitudinal function is abnormal in these patients.