Reduced systolic performance by tissue Doppler in patients with preserved and abnormal ejection fraction: New insights in chronic heart failure

doi:10.1016/j.ijcard.2005.04.026

International Journal of Cardiology

Volume 108, Issue 2, 4 April 2006, Pages 181-188

https://doi.org/10.1016/j.ijcard.2005.04.026 Get rights and content

Abstract

Background

Tissue Doppler imaging (TDI) is useful in the evaluation of systolic and diastolic function. It allows assessment of ventricular dynamics in its longitudinal axis. We sought to investigate the difference in systolic and diastolic longitudinal function in patients with chronic heart failure (CHF) with normal and reduced ejection fraction.

Methods and Results

One hundred ten outpatients with CHF and 68 controls were included. Ejection fraction (EF) was obtained and longitudinal systolic (S) and diastolic (E′ and A′) wall velocities were recorded from basal septum. Group A (controls) were normal and CHF patients were classified by EF in Group B1: > 45% and B2: ≤ 45%. In A, B1 and B2 the mean S peak was 7.74; 5.45 and 4.89 cm/s (p < 0.001); the mean E′ peak was 8.56; 5.72 and 6.1 cm/s (p < 0.001); and the mean A′ peak was 10.2; 7.3 and 5.3 cm/s (p < 0.001). Also, isovolumic contraction and relaxation time were different among control and CHF groups, (both p < 0.001). The most useful parameters for identifying diastolic CHF were IVRT and S peak, with area under ROC curves of 0.93 and 0.89. The cut-off of 115 ms for IVRT and 5.8 cm/s for S peak showed a sensitivity of 94 and 97%, with a specificity of 82 and 73%, respectively.

Conclusion

These findings suggest that impairment of left ventricular systolic function is present even in those with diastolic heart failure, and that abnormalities may have an important role to identifying the condition.

Section snippets

Materials and methods

This prospective study was approved by the Institutional Committee on Human Research and patients gave informed consent to participate. The study population included 110 patients who fulfilled the inclusion criteria for CHF and 68 normal subjects, who were evaluated between January and March 2001.

Patients were included if they had a diagnosis of CHF and remained stable, without hospital admission and under appropriated treatment, for more than 30 days. CHF was defined in the presence of one of

Results

There were 68 healthy individuals (Group A), and 110 CHF patients (Group B). The last group was subdivided in patients with EF > 45% (group B1): 37 patients (33.6%), and EF < 45% (group B2): 73 patients (66.4%).

Table 1 shows the demographics all groups. There was no significant difference in age between group A and B, 62 ± 9.5 and 64 ± 11.1 years (p = ns). In group B, heart failure secondary to coronary artery disease was found in 62%, NYHA functional class III or IV was reported in 56% and 36% of the

Discussion

This study provides evidence that reduced global systolic left ventricular performance, measured by TDI in the longitudinal axis, can be uniformly detected in patients with CHF, independent of ejection fraction. As expected, diastolic abnormalities were detected in all patients with CHF. In addition, systolic longitudinal axis dysfunction had a pivotal role in diagnosing heart failure in the presence of preserved ejection fraction.

Systolic AV displacement assesses global left ventricular

Diagnostic usefulness of TDI to identifying heart failure in the presence of preserved ejection fraction

The diagnosis of heart failure frequently presents a clinical challenge in particular inpatients with preserved ejection fraction. The physical exam has been the method more broadly used in the daily practice. However, there is continued controversy surrounding the diagnostic criteria for diastolic heart failure. Recently, data available from different studies have provided evidence to standardize such diagnoses.

The present study confirms the contribution of TDI for that purpose. Area under ROC

Limitations

TDI was obtained only in the septal aspect of the mitral annulus. In patients with coronary artery disease and segmental wall motion abnormalities, velocities can vary among the different regions of the mitral annulus. The abnormalities found in this study may reflect regional wall motion abnormalities. However, another study has already shown that assessment of diastolic function using the septal annular motion is slightly better than the lateral annulus [25].

Clinical implications

This study showed that both contraction and relaxation abnormalities are present in individuals with heart failure, independent of levels of ejection fraction. Moreover, contractility indices were important tools to identify heart failure in the presence of preserved systolic function. Thus, these findings suggest that differentiation between systolic and diastolic heart failure based on ejection fraction assessment should be reevaluated.

Conclusion

Annular septal velocity is a useful, simple, non-invasive, and reproducible method to detect impairment of left ventricular function in patients with CHF. TDI velocities were reduced in CHF compared with normal subjects, and there were only slight differences between CHF with preserved and reduced EF. These findings suggest that impairment of left ventricular systolic function is present even in those with diastolic heart failure, and those abnormalities may have an important role to

Acknowledgements

AcknowledgmentsThe investigators are grateful to Cayré Raúl MD, Zaracho María Technician and Medina Gustavo Technician.

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Other studies have reported that a reduced S′ measured manually by PW tissue Doppler predicts systolic dysfunction (EF <50%) with a sensitivity from 80% to 94% and a specificity from 89% to 93% (Elnoamany and Abdelhameed 2006; Vinereanu et al. 2002). In a sample consisting only of patients with diastolic dysfunction (EF >45%) and healthy controls, Garcia et al. (2006) found that S′ measured manually by PW tissue Doppler detected the abnormal cases with a sensitivity of 97% and a specificity of 73%. By comparing only patients with diastolic dysfunction and those without any cardiovascular disease, we obtained a similar result (data not shown), but this approach is misleading because patients with systolic function will be part of a real-world population.
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Global longitudinal strain (GLS), assessed by speckle tracking echocardiography, is a sensitive marker of myocardial systolic function and an independent predictor of cardiovascular outcomes. The aim of this study was to investigate the effect of hypotensive treatment on GLS and evaluate the relation between change in GLS and left ventricular (LV) diastolic function. In a group of 125 hypertensive subjects, without any symptoms of heart failure, the detailed echocardiographic assessment of LV systolic and diastolic function was performed before and after 12 months of hypotensive treatment.The mean GLS improved from −18.1 ± 2.6% to −19.3 ± 2.3% (P = .004). Positive change was also observed within parameters of LV diastolic function (E/A: 1.05 ± 0.32 vs. 1.15 ± 0.34; P = .008; e': 9.54 ± 2.60 cm/s vs. 10.59 ± 2.39 cm/s; P = .003; E/e': 7.35 ± 1.85 vs. 6.69 ± 1.61; P = .044). The greatest benefit from hypotensive treatment was noticed within the patients with the lowest baseline absolute values of GLS. The significant correlations between change in GLS and e' (r = −0.51; P < .001) as well as GLS and E/e' ratio (0.23; P = .022) were also observed. Mild systolic and diastolic LV alterations are interdependent and partially reversible. The effects of hypotensive therapy are differentiated in particular individuals, and those with more impaired LV function seem to benefit most.
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The low prevalence of those subjects (17.6%) and washout period of minimum 7 days limited the potential influence of pharmacotherapy on our results. Our findings regarding the relevant relationship between GLSS and LVDD were previously presented and discussed.23–25 Since several years, it has been well known that GLSS may be impaired in hypertensives with LVDD.4
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Through integrated use of echo-Doppler and tissue Doppler imaging (TDI), it is possible to obtain a comprehensive evaluation of both left ventricular (LV) diastolic and longitudinal functions. In this study, we sought to assess the prevalence of LV diastolic dysfunction (LVDD) and its relation with indices of long-axis function in asymptomatic patients with arterial hypertension.
A perspective echo-Doppler study was performed in 1556 consecutive asymptomatic patients with grade 2-to-3 arterial hypertension aged 40–80 years enrolled in the SPHERE (multicenter proSPective study of ecHocardiography in hypERtEnsion) study. All patients had a LV ejection fraction (EF) ≥ 50% and no history of heart failure or coronary artery disease. Advanced LVDD was identified by an average mitral-to-peak early diastolic annular ratio (E/e′) ≥ 13. Less than advanced LVDD was identified by: 8 < E/e′ < 13 and left atrial volume index ≥ 34 ml/m². Overall LVDD was present in 286 patients (18%): advanced in 128, less than advanced in 158. LV long-axis function, as assessed by average peak systolic annular velocity (hazard ratio [HR]: 0.54, p < 0.0001), mitral E/A ratio (HR: 3.20, p = 0.0009), age (HR: 1.05, p = 0.0087), body mass index (HR: 1.06, p = 0.037), and relative wall thickness (HR: 1.05, p = 0.050) were independent predictors of advanced LVDD. LV long-axis function (HR: 0.78, p < 0.0001), E/A ratio (HR: 2.35, p = 0.0032), LV end-diastolic volume index (HR: 1.04, p = 0.0035), and age (HR: 1.03, p = 0.018) were independently associated with overall LVDD, with a borderline contribution of LV mass index (HR: 1.01, p = 0.062).
An abnormal LV long-axis function was a powerful determinant of any LVDD in asymptomatic patients with arterial hypertension.
Minor myocardial damage is a prevalent condition in patients with acute heart failure syndromes and preserved systolic function with long-term prognostic implications. A report from the CIAST-HF (Collaborative Italo-Argentinean study on cardiac troponin T in heart failure) study
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Event-free survival rates were comparable in patients with and without MMD when LVEF was 40% to ≥60%, suggesting little difference in prognosis between AHFS with normal or mildly abnormal LVEF and similar prognostic usefulness of cTnT.40 Tissue Doppler studies have reported reduced peak S′ wave velocities in patients with chronic HF and normal LVEF, demonstrating that impairments in cardiac contractility may coexist with preserved LVEF.41 These findings have led to the hypothesis that HF-PLVEF is just a different phenotypic expression of systolic HF, representing an evolutionary step toward deterioration of LVEF.42
Half of patients with acute heart failure syndromes (AHFS) have preserved left ventricular ejection fraction (PLVEF). In this setting, the role of minor myocardial damage (MMD), as identified by cardiac troponin T (cTnT), remains to be established.
To evaluate the prevalence and long-term prognostic significance of cTnT elevations in patients with AHFS and PLVEF.
This retrospective, multicenter, collaborative study included 500 patients hospitalized for AHFS with PLVEF (ejection fraction ≥40%) between October 2000 and December 2006. Blood samples were collected within 12 hours after admission and were assayed for cTnT. MMD was defined as a cTnT value of ≥0.020 ng/mL.
Mean age was 73 ± 12 years, 47% were female, 38% had an ischemic etiology, and New York Heart Association (NYHA) class was 2.2 ± 0.7. Mean cTnT value was 0.149 ± 0.484 ng/mL, and cTnT was directly correlated with serum creatinine (Spearman's Rho = 0.35, P < .001) and NYHA class (0.25, P < .001). MMD was diagnosed in 220 patients (44%). Patients with MMD showed lower left ventricular ejection fraction (P < .05), higher serum creatinine (P < .001), higher prevalence of ischemic etiology and diabetes mellitus, a worse NYHA class (P < .001), and higher natriuretic peptide levels (P < .001) as compared with patients without MMD. At 6-month follow-up, overall event-free survival was 55% and 75% in patients with and without MMD (P < .001), respectively. On multivariate Cox regression analysis, only NYHA class (HR = 1.50; P = .002) and MMD (HR = 1.81; P = .001) were identified as predictors of events.
Increased cTnT levels were detected in approximately 50% of patients with AHFS with preserved systolic function, and were found to correlate with clinical measures of disease severity. The presence of MMD was associated with a worse long-term outcome, lending support to cTnT-based risk stratification in the setting of AHFS.

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Reduced systolic performance by tissue Doppler in patients with preserved and abnormal ejection fraction: New insights in chronic heart failure

Abstract

Background

Methods and Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Diagnostic usefulness of TDI to identifying heart failure in the presence of preserved ejection fraction

Limitations

Clinical implications

Conclusion

Acknowledgements

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Med