Article

Prediction of Heart Failure and Adverse Cardiovascular Events in Outpatients with Coronary Artery Disease Using Mitral E/A Ratio in Conjunction with E-Wave Deceleration Time: The Heart and Soul Study

Department of Medicine, University of California, San Francisco, San Francisco, California.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography (Impact Factor: 3.99). 07/2011; 24(10):1134-40. DOI: 10.1016/j.echo.2011.06.003
Source: PubMed

ABSTRACT Deceleration time (DT) of early mitral inflow (E) is a marker of diastolic left ventricular (LV) chamber stiffness that is routinely measured during the quantitation of LV diastolic function with Doppler echocardiography. Shortened DT after myocardial infarction predicts worse cardiovascular outcome. Recent studies have shown that indexing DT to peak E-wave velocity (pE) augments its prognostic power in a population with a high prevalence of coronary risk factors and in patients with hypertension during antihypertensive treatment. However, in ambulatory subjects with stable coronary artery disease (CAD), it is not known whether DT predicts cardiovascular events and whether DT/pE improves its prognostic power.
The ability of DT and DT/pE to predict heart failure (HF) hospitalizations and other major adverse cardiovascular events (MACEs) was studied prospectively in 926 ambulatory patients with stable CAD enrolled in the Heart and Soul Study. Unadjusted and multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for HF and other MACEs.
During a mean of 6.3 ± 2.0 years, there were 124 hospitalizations for HF and 198 other MACEs. Relative to participants with mitral E/A ratios in the normal range (0.75 < E/A < 1.5; n = 604), those with E/A ratios ≥ 1.5 (n = 107) had an increased risk for HF (HR, 2.54; 95% CI, 1.52-4.25, P < .001) but not for other MACEs (HR, 1.00; 95% CI, 0.60-1.68; P = 1.00), while those with E/A ratios ≤ 0.75 (n = 215) were not at increased risk for either outcome. Among patients with normal E/A ratios, lower DT/pE predicted HF (HR, 0.47; 95% CI, 0.23-0.97, P = .04 per point increase in ln{msec/[cm/sec]}), while DT alone did not. However, in this group with normal E/A ratios, neither DT/pE nor DT alone was predictive of other MACEs. In patients with E/A ratios ≤ 0.75 (n = 215) and those with E/A ratios ≥ 1.5 (n = 107), neither DT nor DT/pE predicted either end point.
In ambulatory patients with stable CAD, restrictive filling (E/A ratio ≥ 1.5) is a powerful predictor of HF. Among those with normal mitral E/A ratios (0.75-1.5), only DT/pE predicts HF, while neither DT nor DT/pE predicts other MACEs. This suggests that mitral E/A ratio has significant prognostic value in patients with CAD, and in those with normal mitral E/A ratios, the normalization of DT to pE augments its prognostic power.

0 Followers
 · 
75 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: African Americans with hypertension are at high risk for adverse outcomes from cardiovascular and renal disease. Patients with stage 3 or greater chronic kidney disease have a high prevalence of left ventricular (LV) hypertrophy and diastolic dysfunction. Our goal was to study prospectively the relationships of LV mass and diastolic function with subsequent cardiovascular and renal outcomes in the African American Study of Kidney Disease and Hypertension cohort study. Of 691 patients enrolled in the cohort, 578 had interpretable echocardiograms and complete relevant clinical data. Exposures were LV hypertrophy and diastolic parameters. Outcomes were cardiovascular events requiring hospitalization or causing death; a renal composite outcome of doubling of serum creatinine or end-stage renal disease (censoring death); and heart failure. We found strong independent relationships between LV hypertrophy and subsequent cardiovascular (hazard ratio, 1.16; 95% confidence interval, 1.05-1.27) events, but not renal outcomes. After adjustment for LV mass and clinical variables, lower systolic tissue Doppler velocities and diastolic parameters reflecting a less compliant LV (shorter deceleration time and abnormal E/A ratio) were significantly (P<0.05) associated with future heart failure events. This is the first study to show a strong relationship among LV hypertrophy, diastolic parameters, and adverse cardiac outcomes in African Americans with hypertension and chronic kidney disease. These echocardiographic risk factors may help identify high-risk patients with chronic kidney disease for aggressive therapeutic intervention.
    Hypertension 07/2013; 62(3). DOI:10.1161/HYPERTENSIONAHA.111.00904 · 7.63 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The left ventricular end-diastolic pressure-volume relationship (LV-EDPVR) is a measure of LV distensibility, conveying the size the LV will assume at a given LV end-diastolic pressure (LV-EDP). Measurement of LV-EDPVR requires invasive testing with specialized equipment. Echocardiography can be used to measure LV end-diastolic volume (EDV) and to grossly estimate LV-EDP noninvasively. We therefore hypothesized that categorization of patients based on these parameters to create an estimate of the end-diastolic pressure-volume loop position (EDPVE) could predict congestive heart failure (CHF) prognosis. Echocardiograms from 968 CHF clinic patients were reviewed. LV-EDP was considered to be elevated if mitral filling pattern was pseudo-normal or restrictive. EDPVE was categorized into 3 groups. EDPVE was considered to have evidence of rightward shift if the LV was severely dilated (>97 mL/m(2)). EDPVE was considered to have evidence of leftward shift if the LV was normal size (<76 mL/m(2)) and there was Doppler evidence of increased LV-EDP. Patients who did not meet criteria for leftward or rightward shift were classified as "intermediate." Using the intermediate group for comparison, those with evidence of leftward shift in EDPVE had increased mortality (hazard ratio [HR] 1.77; 95% confidence interval [CI]: 1.23-2.54). Rightward shift only correlated with increased mortality in those older than age 70 years. Leftward shift remained an independent predictor of mortality even after adjusting for LV ejection fraction, atrial fibrillation, mitral regurgitation, and Doppler indices of diastolic dysfunction. EDPVE is a strong predictor of CHF survival which is independent of LV ejection fraction and traditional Doppler indices of LV diastolic function.
    Journal of cardiac failure 04/2013; 19(4):251-9. DOI:10.1016/j.cardfail.2013.02.003 · 3.07 Impact Factor