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PubMed2005

Left ventricular function in patients with chronic kidney disease evaluated by colour tissue Doppler velocity imaging.

BACKGROUND: Cardiovascular disease is the leading cause of death in chronic kidney disease (CKD) patients. Tissue Doppler velocity imaging (TVI) is a new objective method that accurately quantifies myocardial tissue velocities, deformation, time intervals and left ventricular (LV) filling pressure. In this study, TVI was compared with conventional echocardiography for the assessment of left ventricular (LV) function in pre-dialysis patients with different stages of CKD. The results obtained by TVI were used to analyse possible relationships between LV function and clinical factors such as hyperparathyroidism and hypertension that could influence LV function. METHODS: Conventional echocardiography and TVI images were recorded in 40 patients (36 men and 4 women, mean age 60+/-14 years, range 28-80 years) and in 27 healthy controls (21 men and 6 women, mean age 58+/-17 years, range 28-82 years). Twenty-two patients had mild/moderate CKD (CCr>29 ml/min; Group 1) and 18 patients had severe CKD (CCr<or=29 ml/min; Group 2). Using TVI, the myocardial tissue velocities (v; cm/s) for isovolumetric contraction (IVCv), peak systole (PSv), early (E') and late (A') diastolic filling velocities as well as strain rate (SR), mitral annulus displacement, isovolumetric relaxation time (IVRT) and LV filling pressure were estimated using TVI. The average of six LV wall measurements was used to evaluate LV global function. RESULTS: Using TVI, we were able to identify significantly more patients with diastolic dysfunction than using conventional echocardiography (33 vs 26, P<0.05). There was no difference in the prevalence of diastolic dysfunction between Group 1 and 2. However, using TVI, Group 2 CKD patients had lower E' velocities (6.2+/-1.9 vs 8.0+/-2.9 cm/s, P<0.05) and higher IVRT (137.4+/-13 vs 88.2+/-26 ms, P<0.001) in comparison with controls, indicating more accentuated diastolic dysfunction. Systolic blood pressure (SBP) was associated with E' velocities (rho=-0.68, P<0.005) and E'/A' was strongly associated with SBP (rho=-0.60; P<0.01) and PTH (rho=-0.64, P<0.005) in Group 2. Using conventional echocardiography, there was no difference in the prevalence of systolic and diastolic dysfunction between patients with and without LVH. However, using TVI, patients with LVH had significantly lower IVCv (2.8+/-1.3 vs 3.8+/-1.5 and 3.8+/-1.5 cm/s, P<0.05) and PSv (5.5+/-1.0 vs 6.3+/-1.2 and 6.4+/-1.3 cm/s, P<0.05) compared with patients without LVH and controls, and they also had lower E' velocities (7.1+/-2.7 vs 8.0+/-2.9 cm/s, P<0.05) compared with controls, indicating disturbances in systolic and diastolic left ventricular function. CONCLUSIONS: TVI provided additional information on left ventricular function in CKD patients. In patients with advanced renal failure, TVI revealed more accentuated diastolic dysfunction associated with increased systolic blood pressure (SBP) and increased levels of PTH. TVI also demonstrated disturbances in contractility and contraction in patients with LVH, which could not be detected by conventional echocardiography.

Adult↗
PubMed2002

Nipradilol can prevent left ventricular systolic and diastolic dysfunction after myocardial infarction in rats.

The purpose of this study was to examine the effects of nipradilol on the cardiac function and mRNA expression in Wistar rats with a myocardial infarction (MI) that was created by ligation of the anterior descending coronary. Ten mg x kg(-1) x day(-1) of nipradilol were administrated to the rats in random order, and hemodynamic and Doppler-echocardiographic findings and myocardial mRNA expression were analyzed at 4 weeks after MI. Although left ventricular end-diastolic pressure (LVEDP) and central venous pressure (CVP) were increased in the MI rats, nipradilol significantly reduced the degree of the increase in both parameters. MI also significantly increased the weight of the left and right ventricles, and increased the left ventricular end-diastolic dimension (LVDd), effects that were attenuated by nipradilol. The MI rats showed decreased fractional shortening as systolic dysfunction and decreased E wave deceleration rate as diastolic dysfunction, and nipradilol significantly prevented these. Nipradilol significantly suppressed the increase in the non-infarcted myocardial mRNA expression of atrial natriuretic peptide, brain natriuretic peptide and collagen I and III. In conclusions, nipradilol prevents the cardiac remodeling that is accompanied by systolic and diastolic dysfunction, and inhibits abnormal myocardial gene expression after MI.

Adrenergic beta-Antagonists↗
PubMed2002

The role of dobutamine stress echocardiography in idiopathic dilated cardiomyopathy.

In patients with chronic heart failure, myocardial contractile responsiveness to dobutamine is diminished as a result of beta-receptor desensitization due to chronic adrenergic activation. Changes in beta-receptor effector mechanisms are more marked in idiopathic dilated cardiomyopathy (IDCM) than in ischemic dilated cardiomyopathy. As the magnitude of the dobutamine effect is proportional to the severity of left ventricular systolic dysfunction, the heterogeneous cardiotonic effects of dobutamine in IDCM may represent different evolutive stages of a progressive disease process. On the basis of this pathophysiologic background, some studies were undertaken to investigate the prognostic and functional implications of dobutamine stress echocardiography (DSE) in IDCM. Prognostic studies consistently suggest that myocardial response to dobutamine is related to the clinical outcome. However, the limited number of patients and events in the individual studies are important limitations. Moreover, the impact of beta-blockers on the potential ability of DSE to predict the prognosis needs to be assessed. A few studies also suggest that changes in left ventricular systolic function parameters following dobutamine infusion are related to exercise tolerance, as assessed by peak exercise oxygen consumption and functional recovery of the failing myocardium. The data suggest that DSE is a promising method, which may improve the risk stratification process in patients with IDCM and provide further insights into the pathophysiologic mechanisms underlying progressive systolic pump dysfunction and exercise intolerance. Further studies are however needed to define the role of DSE in IDCM.

Cardiomyopathy, Dilated↗
PubMed2005

Quantitative assessment of systolic and diastolic ventricular function with tissue Doppler imaging after Fontan type of operation.

BACKGROUND: There is evidence that "inappropriate hypertrophy" of the single left ventricle, which occurs as a result of acute preload reduction, leads to adverse consequences on ventricular function. However, a systematic study of the capability of tissue Doppler imaging (TDI) to assess systolic and diastolic ventricular functions after the Fontan procedure is still missing. METHODS: Twenty-four postoperative patients aged 12-33 years were prospectively evaluated with two-dimensional echocardiography equipped with TDI capabilities. Nineteen age-matched normal subjects were selected as controls. Good-quality echoes for the measurement of ejection fractions were available in 21 patients. Ten patients (group 1) had systolic dysfunction (ejection fraction < 50%), and 11 patients (group 2) had normal systolic function. Peak systolic and diastolic wall velocities were acquired from the two-chamber view in the myocardia and mitral annulus. RESULTS: Compared with controls, the Fontan patients had a significantly reduced peak systolic velocity at wall and annulus sites. A linear correlation existed between ejection fraction and systolic myocardial velocity from the annular sites. Group 1 patients had lower wall velocities and lower annulus velocities both in systole and diastole. Group 2 patients had preserved systolic velocities but decreased regional and annular early diastolic velocities, suggesting impaired filling. Multiple correlation analysis showed a relation between peak early diastolic mitral velocity and ventricular ejection fraction, mean mitral annular motion at systole, mass/volume ratio, and the number of years post Fontan revision. CONCLUSIONS: Myocardial velocities recorded after the Fontan operation give insight into systolic and diastolic ventricular functions. The peak systolic mitral annular velocity correlated well with the ventricular ejection fraction. The peak early diastolic velocity and the ratio between the early and late diastolic mitral annular velocity are reduced and reflect diastolic dysfunction even in the presence of normal systolic ejection fraction.

Adolescent↗
PubMed2005

Can pro-brain natriuretic peptide be used as a noninvasive predictor of elevated left ventricular diastolic pressures in patients with normal systolic function?

OBJECTIVES: This study was sought to investigate whether plasma N-terminal pro-brain natriuretic peptide (proBNP) can help identify patients with an elevated left ventricular end-diastolic pressure (LVEDP) or filling pressures in patients with a normal systolic function. BACKGROUND: The proBNP is a good predictor of an elevated LVEDP in patients with a systolic dysfunction. However, whether proBNP can predict an elevated LVEDP in patients with a normal systolic function remains to be determined. METHODS: The LV pressures were measured by fluid-filled catheters in 216 patients (125 men, mean age 60 +/- 10 years) with a normal systolic function (ejection fraction 66% +/- 8%, range 50%-81%) who were undergoing diagnostic cardiac catheterization. The proBNP was sampled at the time of cardiac catheterization and was measured using a quantitative electrochemiluminescence immunoassay. RESULTS: The log-transformed proBNP levels correlated significantly with the LVEDP (r = 0.33, P = .001) and LV pre-A-wave pressure (pre-A pressure) (r = 0.31, P = .001). An elevated proBNP, defined as >315 pg/mL, predicted an LVEDP > or = 15 mm Hg with a sensitivity of 16% and a specificity of 95% as well as a pre-A pressure > or = 15 mm Hg with a sensitivity of 36% and a specificity of 95%. However, among the 93 patients with an LVEDP > or = 15 mm Hg, 77 (83%) patients had a normal proBNP concentration (< 315 pg/mL). CONCLUSION: The proBNP level showed weak correlations with the LVEDP and LV pre-A pressure in patients with a normal systolic function. Although high proBNP levels can predict an elevated LV diastolic pressure with high specificity, the sensitivity was quite low. Because the majority of patients with an elevated LVEDP had a normal proBNP, the proBNP level may not be suitable as a screening test for assessing LV filling pressures in the presence of normal systolic function.

Adult↗
PubMed2006

Isolated left ventricular diastolic dysfunction: implications for exercise left ventricular performance in patients without congestive heart failure.

OBJECTIVE: Clinical relevance of left ventricular (LV) diastolic dysfunction in the absence of congestive heart failure (CHF) and LV systolic dysfunction is not fully established. METHODS: Asymptomatic outpatients, sedentary, with cardiovascular risk factors but no history of cardiovascular events, underwent echocardiographic evaluation of LV structure and function by standard Doppler, color M-mode, and Doppler tissue methods, and exercise testing with simultaneous noninvasive assessment of LV stroke index and cardiac index. LV ejection fraction less than 50% and significant valvular disease or stress test suggestive of coronary disease were additional exclusion criteria. RESULTS: In 70 patients selected (40 +/- 10 years old, 63% men, 34% hypertensive, 34% diabetic, 4% diabetic and hypertensive, 11% with LV hypertrophy), LV diastolic dysfunction was detected in 26%, which was associated with hypertension, higher LV mass index, lower systolic function, lower peak exercise heart rate, and chronotropic reserve (all P < .05), and with lower peak exercise stroke index and cardiac index (both covariates adjusted P < .05), but not with lower peak exercise metabolic equivalents (P > .5). Abnormal LV relaxation was independently correlated with lower peak exercise cardiac index and stroke index (both P < .05). Peak exercise systolic and cardiac indices were comparable between patients with CHF risk factors (74%) versus those without. CONCLUSIONS: Isolated LV diastolic dysfunction was independently associated with lower peak exercise LV systolic performance in patients without CHF. Its diagnosis may provide a target for aggressive CHF risk management.

Adult↗
PubMed2004

Cellular and molecular mechanisms of systolic and diastolic dysfunction in an avian model of dilated cardiomyopathy.

We investigated the cellular and molecular mechanisms of systolic and diastolic dysfunction in a furazolidone (Fz)-induced model of dilated cardiomyopathy (DCM) in turkey poults. Serial echocardiograms disclosed marked systolic dysfunction in the Fz-treated poults, and ventricular weight and left ventricular (LV)/body weight ratio were significantly increased. Isolated heart experiments were performed to determine LV pressure-volume (P-V) relationships. In addition, LV sarcomere lengths (SLs) were measured after hearts had been fixed, and wall stress (sigma)-SL relationships were determined. When compared to control hearts, LV chamber volume in DCM hearts was approximately 3-fold increased, the active or developed LV P-V relationship was markedly depressed, the passive or diastolic P-V relationship was steeper, and SLs were significantly shorter. However, the developed sigma-SL relationships of DCM and control hearts were not different indicating that intrinsic myocardial capacity to generate active force is unaffected in this model of DCM. In contrast, passive sigma, and passive tension in trabecular muscle preparations increased much more steeply with SL in DCM than normal hearts. Trabecular muscle experiments disclosed that the increase in passive myocardial stiffness was primarily collagen based. Titin, the giant sarcomeric molecule, which is an important determinant of passive myocyte properties in normal myocardium, did not contribute significantly to increased passive myocardial stiffness in DCM. We conclude that increased collagen-based passive myocardial stiffness is the major cause of the steeper passive or diastolic P-V relationship in DCM. Further, altered passive myocardial properties and ventricular geometry in DCM play a critical role to reduce ventricular systolic function by limiting SL extension during diastole, thereby limiting the use of the myocardial length-tension relationship.

Animals↗
PubMed2002

Ultrasonic tissue characterization and Doppler tissue imaging in the analysis of left ventricular function in essential arterial hypertension: a preliminary study.

It is not known if diastolic abnormalities are independent of systolic dysfunction in arterial hypertension. We studied three groups of 10 male subjects of comparable mean age (31.6 +/- 3.5 years), weight, and height: Athletes (A) (cyclists), essential hypertensive patients (H), and controls (C). Ultrasonic myocardial integrated backscatter signals (IBS) of the septum and the posterior wall were analyzed, while the systo-diastolic variation of the backscatter was considered as a cyclic variation index (CVI(ibs)). Myocardial velocities across the left ventricular major axis were sampled at septum and lateral wall levels by pulsed-wave Doppler tissue imaging (DTI). CVI(ibs) at the septum and the posterior wall were significantly lower in the hypertensive group in comparison with athletes and controls, who were comparable. Early diastolic myocardial velocity (E(m)) of the lateral wall and of the septum were significantly lower in hypertensives, while the late diastolic myocardial velocity (A(m)) was significantly higher in hypertensives in comparison with athletes. The E(m)/A(m) at the septum level was significantly lower in hypertensives in comparison with athletes and controls. Significant correlations were found between CVI and DTI parameters: CVI(ibs) and E(m)/A(m) septum (r = 0.50, P < 0.002). Furthermore, significant correlations were found between mean arterial pressure (MAP) and E(m)/A(m) septum (r = - 0.65, P < 0.001). Ultrasonic tissue characterization with the intrinsic contractility study and the evaluation of the regional diastolic function should, therefore, represent a new integrated diagnostic modality for the evaluation of left ventricular hypertrophied intramyocardial function. This study demonstrated that diastolic abnormalities of left ventricular function, in arterial hypertension, are related and progress with systolic intrinsic dysfunction.

Adult↗
PubMed2006

Rationale and design of a randomized controlled trial to assess the safety and efficacy of cardiac resynchronization therapy in patients with asymptomatic left ventricular dysfunction with previous symptoms or mild heart failure--the REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction (REVERSE) study.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves symptoms, reduces heart failure (HF)-related hospitalizations, and reverses left ventricular remodeling in some patients with moderate to severe HF and ventricular dyssynchrony defined by a prolonged QRS duration. The effects of CRT on HF outcomes in patients with asymptomatic left ventricular dysfunction (ALVD) or mild HF remain to be determined. METHODS: The REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction (REVERSE) study is a prospective, multicenter, randomized, double-blind, parallel, controlled clinical trial designed to establish whether CRT combined with optimal medical treatment can attenuate HF disease progression compared with optimal medical treatment alone in patients with ALVD +/- New York Heart Association class I American College of Cardiology/American Heart Association stage C or New York Heart Association class II HF, QRS duration > or =120 milliseconds, left ventricular ejection fraction < or =0.40, and left ventricular end-diastolic diameter > or =55 mm. The primary end point is the HF clinical composite response and left ventricular end-systolic volume index is the first-order secondary end point. Approximately 500 patients from 100 centers in the United States, Canada, and Europe will be randomized to CRT versus no CRT. The follow-up is 5 years in total with the primary and first secondary end points reported at 12 months. Enrollment began in September 2004 and is expected to be completed in 2006. CONCLUSION: REVERSE will assess the safety and efficacy of CRT in patients with ALVD or mild HF and electrocardiographic evidence of ventricular dyssynchrony.

Cardiac Output, Low↗
PubMed2002

[Reversible thyrotoxic cardiomyopathy--report of three cases].

Three patients with thyrotoxicosis, atrial tachyarrhythmia and congestive heart failure despite successful treatment of hyperthyroidism revealed atrial fibrillation/flagellation and left ventricular systolic dysfunction. Congestive heart failure resolved and left ventricular systolic function normalized only after successful cardioversion to sinus rhythm. In some patients treated for hyperthyroidism, achievement of euthyroid state is not by itself sufficient to reverse left ventricular failure. Improvement after successful reversion of atrial tachyarrhythmia suggest its essential role in pathogenesis of thyrotoxic cardiomyopathy.

Adult↗
PubMed2005

Frequency of diastolic dysfunction in patients with sickle cell anaemia: a tissue Doppler imaging study.

OBJECTIVE: Although cardiac dilatation and systolic dysfunction have been well documented as a late manifestation, there are conflicting reports regarding the diastolic dysfunction, by using traditional echocardiographic methods in patients with sickle cell anaemia (SCA). The aim of this study was to investigate left ventricular diastolic function in SCA patients without congestive heart failure by using pulsed wave tissue Doppler imaging (TDI). METHODS: Thirty-one patients (18 men and 13 women, mean age: 26.4 +/- 8.5 years) with homozygous SCA without congestive heart failure and 31 healthy control subjects (19 men and 12 women, mean age: 26.5 +/- 7.6 years) were enrolled in the study. All patients and the controls underwent echocardiographic examination. Left ventricular diastolic function was evaluated by using both traditional pulsed wave Doppler (PWD) and TDI. RESULTS: The cardiac chamber dimensions, wall thicknesses, E and A transmitral peak diastolic velocities, systolic (Sm), early (Em) and late (Am) diastolic myocardial velocities were significantly increased in the patients compared to the controls. Diastolic dysfunction was found in 7 (22.6%) and 3 (9.7%) patients by PWD and TDI, respectively. Of the 7 patients with diastolic abnormalities, 4 patients with a restrictive pattern by PWD were found to be normal by TDI. CONCLUSION: Our results show that left ventricular diastolic dysfunction is not a frequent finding in patients with SCA without congestive heart failure and TDI is a more reliable and easy method to evaluate diastolic function. Patients with a restrictive pattern found by PWD should be reevaluated by using TDI.

Adolescent↗
PubMed2003

[Hemodynamic consequences of atrial fibrillation].

Beside supraventricular extra beats, atrial fibrillation is the most common cardiac arrhythmia. Atrial fibrillation according to Douglas P. Zipes definition is an arrhythmia characterised by complete asynchronous atrial depolarisation, without following hemodynamic effective contraction. Atrial electric activity can be detected during electrocardiography as irregular oscillation of the isoelectric line of low and variable amplitude 350-600/min waves. Atrial fibrillation previously considered as a benign arrhythmia is associated with severe clinical complications as hemodynamic disturbances and closely connected with it cerebral embolization. In the present study we focused on left ventricle function during atrial fibrillation. We evaluate a deterious effect of high, irregular heart rate which stimulates left ventricle systolic dysfunction, so called "tachycardiomyopathy". Deterioration of left ventricle systolic function usually coexists with diastolic impairment, which is difficult to treat even if sinus rhythm is restored. We also analysed the pathophysiologic mechanism of left ventricle impairment during atrial fibrillation at cellular level. In second part of this paper we discussed dependence between size and function of left atrium and its appendage and atrial fibrillation induction. One must take into account of vicious circle mechanism induction during atrial fibrillation, which promotes arrhythmia stabilization, as well as after sinus rhythm restoration--may provoke recurrence of arrhythmia. Intracellular changes followed by electrophysiological alteration are regarded as causes of the mentioned mechanism. Accordingly to the newest studies, gene expression plays a role in arrhythmia induction and stabilization. This means that the problem is very complicated and also gives hope to effective treatment of atrial fibrillation including gene modification.

Atrial Fibrillation↗
PubMed2000

[Diastolic dysfunction and left ventricular hypertrophy in familial amyloidotic polyneuropathy: a cause-effect relationship?].

UNLABELLED: TTR Met30 Familial Amyloidotic Polyneuropathy of the Portuguese type (FAP) is an incapacitating and lethal hereditary disorder that affects predominantly young adults of both genders. Portuguese type FAP patients have sensory, motor and autonomic polyneuropathy. The generalised systemic amyloid infiltration involves the heart, leading to the characteristic granular bright sparkling echocardiographic pattern. LV wall thickening occurs in the late phases of the disease. LV diastolic dysfunction has been reported in the absence of systolic dysfunction; an abnormal diastolic transmitral flow pattern assessed by pulsed wave Doppler (PW) was described. PW is very much dependent on load conditions. Tissue Doppler imaging (TDI) has been used as a more reliable method to assess long axis diastolic function. OBJECTIVE: 1--To identify the incremental value of TDI in the assessment of diastolic function in FAP. 2--To correlate diastolic pattern abnormalities and left ventricular mass index (LVMI) in FAP patients. METHODS: We performed a prospective evaluation of 24 consecutive FAP patients and selected 14 (sinus rhythm, age < 45 years). Diastolic function was assessed by PW and classified as normal (GI-E/A > 1) or abnormal (GII-E/A < 1). TDI was performed in 4 sites of the mitral annulus (septum, lateral, inferior, anterior). Velocities of the rapid filling wave (E') and atrial contraction wave (A') were measured and E'/A' calculated. In each site we considered the TDI as normal (E'/A' > 1) or abnormal (E'/A' < 1). The LVMI was calculated by Devereux's formula. RESULTS: Age, gender and heart rate were similar in both groups. TDI at the septal mitral annulus was normal in all of the GI patients (E'/A': 1.29 +/- 0.19) and suggestive of abnormal LV relaxation in all of the GII patients (E'/A': 0.82 +/- 0.11, p < 0.0001). TDI revealed abnormal diastolic pattern when a restricted number of sites of the mitral annulus were assessed, even in GI patients and before PW abnormalities occurred. Fractional shortening (FS) and LVMI were similar in GI and GII (FS-GI: 45.5 +/- 5.3, GII 43.5 +/- 8.1%, p: NS; LVMI--GI: 66 +/- 9.3, GII: 67 +/- 3.0 g/m2 p: NS). CONCLUSION: The assessment of mitral annulus motion has introduced new data in the study of diastolic function of FAP patients. An abnormal LV relaxation pattern occurred early in the evolution of the disease in patients with normal LVMI and systolic function.

Adult↗
PubMedDate not supplied

Clinical evaluation of left ventricular diastolic performance.

Diastole can be divided into four phases: isovolumic relaxation, early filling, diastasis, and atrial systole. The amount of LV filling that occurs during each of these phases depends on myocardial relaxation, the passive characteristics of the LV, the characteristics of the left atrium, pulmonary veins, and mitral valve, and the heart rate. When diastolic function is normal, the net effect of these factors results in an LV filling sufficient to produce an adequate cardiac output, while mean pulmonary venous pressure is maintained below 12 mm Hg. In the absence of systolic dysfunction, abnormal diastolic performance is usually due to abnormal relaxation and/or changes in the passive LV characteristics. Invasive studies can quantitate the rate of myocardial relaxation and the LV diastolic pressure-volume relation. More recently, RNA and Doppler echocardiography have been used to noninvasively evaluate diastolic performance by determining the pattern of LV diastolic filling. At rest, most LV filling occurs early in diastole. Conditions that produce diastolic dysfunction, such as LV hypertrophy and ischemia, are associated with reduced early diastolic filling and an augmented importance of atrial systole. It is important to recognize that such patterns can occur in patients who do not have clinically apparent diastolic dysfunction and in normals. Furthermore, a normal pattern can occur in patients who have severe diastolic dysfunction. A reduced early diastolic filling, in the absence of pulmonary congestion, indicates the loss of diastolic reserve, since the left atrium is being used as a booster pump. This pattern of diastolic filling in a patient who has symptoms of pulmonary congestion may suggest diastolic dysfunction, even if the systolic LV performance is normal. Since diastolic filling of the LV results from a complex interplay of factors, it is unlikely that a single, easily interpreted index of LV diastolic performance will ever be developed. However, the recent development of a noninvasive evaluation of the pattern of LV diastolic filling by RNA or Doppler echocardiography is an important advance. When interpreted with an understanding of the determinants of LV filling and the patient's clinical status, these noninvasive tests can contribute to the rational assessment of LV diastolic performance.

Animals↗
PubMed2005

Independent and incremental prognostic value of early mitral annulus velocity in patients with impaired left ventricular systolic function.

OBJECTIVES: This study sought to investigate the incremental prognostic value of non-invasive measures of early myocardial relaxation and left ventricular diastolic pressure (LVDP) in patients with impaired left ventricular (LV) systolic function. BACKGROUND: The early diastolic mitral annulus velocity (Em) reflects myocardial relaxation, and the combined ratio of the early transmitral flow velocity (E) to Em (E/Em) >15 correlates well with elevated mean LVDP. It is unknown if these new indexes will predict poorer survival in patients with LV systolic dysfunction. METHODS: Echocardiograms were prospectively obtained in 182 patients with impaired LV systolic function, defined as an LV ejection fraction <0.50. The end point was cardiac mortality. The majority of this patient sample (80%) has been reported on in a previous publication. RESULTS: After a median 48 months' follow-up, Em emerged as an independent predictor of survival (hazard ratio 0.61, 95% confidence interval 0.45 to 0.82). An Em <3 cm/s was associated with a significantly excess mortality (log-rank statistic 9.36, p = 0.002), and this measurement added incremental prognostic value to standard indexes of systolic or diastolic function, including a deceleration time <140 ms and an E/Em >15 (p = 0.038). CONCLUSIONS: Early diastolic mitral annulus velocity is a powerful predictor of cardiac mortality in patients with LV systolic impairment; Em <3 cm/s emerged as the best prognosticator in long-term follow-up, incremental to other clinical or echocardiographic variables, including the ratio E/Em.

Aged↗
PubMed1997

Cardiac disease in chronic uremia: clinical outcome and risk factors.

Cardiac disease is common and is the major killer in end-stage renal disease (ESRD). Cardiac failure is a highly malignant condition in ESRD patients. Cardiac failure mediates most of the adverse prognostic impact of ischemic heart disease. Left ventricular (LV) abnormalities are already present at initiation of dialysis therapy in approximately 80% of patients. These abnormalities (ie, systolic dysfunction in approximately 15%, LV dilatation with preserved systolic function in 30%, concentric LV hypertrophy [LVH] in 40%) independently predict ischemic heart disease and cardiac failure, and are the largest baseline predictor of mortality after 2 years on dialysis therapy. The associations between classical risk factors (eg, hyperlipidemia, smoking, hypertension) and cardiac outcomes in ESRD are inconsistent. "Uremic" risk factors represent a nascent, but potentially important field. In our prospective 10-year study of 433 patients starting renal replacement therapy, we identified the following as major independent risk factors for cardiac disease: (1) hypertension (concentric LVH, LV dilatation, ischemic heart disease, cardiac failure, inverse relationship with mortality); (2) anemia (LV dilatation, cardiac failure, death); and (3) hypoalbuminemia (ischemic heart disease, cardiac failure, death). Transplantation dramatically improved LV abnormalities, suggesting that a uremic environment is cardiotoxic. Multiple risk factors act in concert to produce cardiac disease in ESRD; many of these are avoidable, suggesting that the enormous burden of disease can be reduced considerably.

Chronic Disease↗
PubMedDate not supplied

Ambulatory blood pressure monitoring: technique and application in the study of cardiac dysfunction and congestive heart failure.

Ambulatory blood pressure monitoring has become a widely used method of blood pressure and heart rate evaluation in the free-living subject. Recently, ambulatory monitoring has become covered by Medicare for the evaluation of "white-coat" hypertension. Although the technique provides only intermittent readings throughout the 24-hour period, average blood pressures obtained in this way correlate well with a variety of hypertensive disease processes and are also a better prognostic marker for future cardiovascular events than office blood pressure. Ambulatory blood pressure averages also correlate well with indices of diastolic dysfunction. In patients with congestive cardiac failure and systolic dysfunction, ambulatory monitoring suggests an impaired circadian blood pressure profile with high nocturnal blood pressure. Further research is needed on the relationship between ambulatory blood pressure and cardiac dysfunction, as well as the impact of observed circadian blood pressure changes on outcome. (c)2001 CHF, Inc.

Journal Article↗
PubMedDate not supplied

Treatment of acute pulmonary edema.

When possible, the management of acute cardiogenic pulmonary edema should be started before the patient reaches the hospital. Simple measures such as having the patient sit up with the legs dependent, administering oxygen by nasal prongs, giving sublingual nitroglycerin and small doses of morphine, and rotating tourniquets on the limbs may reduce the need for more intensive procedures. Digoxin and other inotropic agents, aminophylline, furosemide, and vasodilators are given as appropriate during hospitalization. A minority of patients need endotracheal intubation and pressure monitoring with a Swan-Ganz catheter. If the arterial PO2 cannot be maintained at 60 mm Hg or more during face mask ventilation, the PCO2 rises, and the arterial pH declines, the patient should be intubated. Pressure monitoring with a Swan-Ganz catheter is indicated if the patient does not immediately respond to treatment or in special situations such as cardiogenic shock with pulmonary edema. Pulmonary edema caused by diastolic dysfunction is managed differently than that caused by systolic dysfunction. The cause and precipitating factors of the acute pulmonary edema should be sought and treated as early as possible to prevent recurrences.

Acute Disease↗