Article

Classification of Left Ventricular Diastolic Function Using American Society of Echocardiography Guidelines: Agreement among Echocardiographers

Cardiovascular Medicine Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
Echocardiography (Impact Factor: 1.25). 04/2013; 30(9). DOI: 10.1111/echo.12185
Source: PubMed

ABSTRACT

Guidelines for assessing diastolic function by echocardiography are continually being updated. Our ability to use available guidelines effectively has not been completely investigated. Six trained echocardiographers were asked to interpret 105 echocardiograms using current American Society of Echocardiography (ASE) algorithms for interpretation of diastolic grade and estimation of left atrial (LA) pressure. Diastolic grade was categorized as normal, mild, moderate, or severe dysfunction. The presence or absence of elevated LA pressure was determined using a second ASE algorithm. As a reference comparison for level of agreement, left ventricular ejection fraction was visually determined. By the ASE algorithm, 29 subjects (28%) met all measurement criteria in their assigned grade and 57 subjects (55%) met all or all but one criterion of their assigned grade. Of the 45 subjects (43%) for whom the guidelines disagreed by more than 1 criterion, the readers debated between normal and moderate dysfunction in 22% or mild and moderate diastolic dysfunction in 31%. Percent inter-reader agreement and kappa values were 76% (0.7) for determining diastolic grade, 84% (0.67) for determining elevated LA pressure, and 84% (0.67) for estimation of ejection fraction, the reference standard. For all subjects, if multiple echocardiographic criteria failed to fit into the proposed guidelines, agreement fell to 66% (0.58) for determining diastolic grade and 74% (0.48) for determining LA pressure. There is reasonable agreement estimating diastolic grade and LA pressure using current guidelines. Further refinements in the definition of mild and moderate dysfunction may improve agreement.

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    ABSTRACT: Introduction: Heart failure can be caused by systolic or diastolic dysfunction. Diagnosing diastolic dysfunction remains challenging, although several criteria have been identified. Ventricular wall stress is crucially involved. It is hypothesized whether increased end-diastolic and end-systolic ventricular wall stress as assessed by the wall stress index is associated with cardiac dysfunction and thus provide novel diagnostic criteria. Methods: 1050 consecutive patients with suspected non-ischemic heart failure covering a broad spectrum from normal to severely impaired cardiac function were observed. Cardiac magnetic resonance imaging was performed to assess left ventricular (LV) volumes, myocardial mass, peak ejection (PER) and filling rate (PFR). Results: A reduced PFR was found in 348 patients (33.1%), which resulted from 275 of 422 patients (65.2%) with reduced and from 73 of 628 patients (11.6%) with preserved LVEF (p<0.0001). Increased LV volume and mass was correlated with reduced PER and PFR (p<0.0001). Increased end-diastolic wall stress was the strongest predictor of a reduced PER (OR 4.5 [2.6 to 7.8], p<0.0001) and increased end-systolic wall stress predicted a reduced PFR (OR 1.2 [1.1 to 1.3], p<0.0001). Increased end-systolic wall stress was correlated with increased pulmonary pressure (p<0.0001). Normal end-systolic wall stress <18kPa had a favorable predictive value for the absence of an impaired filling and increased pulmonary capillary pressure. Conclusion: Increased end-diastolic wall stress precedes a reduced ventricular ejection rate and increased end-systolic wall stress determines an impaired diastolic filling. It is thus suggested to add assessment of ventricular wall stress as diagnostic criterion of heart failure.
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    ABSTRACT: BACKGROUND: A hallmark characteristic of heart failure (HF) is reduced physical activity (PA) patterns and functional capacity. The relationship between key cardiopulmonary exercise testing (CPX) variables and PA patterns has not been investigated. PURPOSE: To evaluate PA patterns in patients with ischemic HF and its relationship to peak oxygen consumption (VO2), the minute ventilation/dioxide carbon production (VE/VCO2) slope and the oxygen uptake efficiency slope (OUES). METHODS: A cross sectional study was carried out in 16 patients with ischemic HF (age 57 ± 9 years). Subjects wore an accelerometer for six days to measure total steps/day as well as percent time at light, moderate and vigorous PA. A symptom-limited CPX was performed on a treadmill. Oxygen consumption (ml.Kg-1.min-1), VCO2 (L/min) and VE (L/min) were collected throughout the CPX. The VE/VCO2 slope and OUES were obtained by least squares linear regression. One way analysis of variance was used to assess differences between PA patterns at different intensities. Pearson’s correlation was used to assess the relationship between PA and CPX variables. A p-value < 0.05 was considered statistically significant. RESULTS: Subjects performed an average of 9029 steps/day, with the majority of PA performed at light intensity compared to moderate and vigorous intensities ( p < 0.05). PA patterns demonstrated a significant correlation with key CPX variables. Total steps correlated with peak VO2 (r = 0.64 p < 0.05), the VE/VCO2 slope (r = - 0.72; p < 0.05) and the OUES (0.63; p <0.05). The percent time at light intensity PA correlated with the VE/VCO2 slope (r = 0.58; p < 0.05) and the OUES (- 0.51; p <0.05). The percent time at vigorous intensity PA correlated with peak VO2 (r = 0.55; p < 0.05) and the VE/VCO2 slope (r = - 0.52; p < 0.05). CONCLUSION: PA assessed by accelerometer is significantly associated with key CPX variables in patients with HF. These findings suggest PA monitoring may provide insight into functional patterns and identify patients with a higher likelihood for a poor CPX response.
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