Imaging and Diagnostic Testing
A comparison of echocardiographic measures of
diastolic function for predicting all-cause mortality
in a predominantly male population
Patricia K. Nguyen, MD, FACC,a,bIngela Schnittger, MD, FACC,aand Paul A. Heidenreich, MD, FACCa,bPalo Alto, CA
Background Prior studies demonstrating the prognostic value of echocardiographic measures of diastolic function have
been limited by sample size, have included only select clinical populations, and have not incorporated newer measures of
diastolic function nor determined their independent prognostic value. The objective of this study is to determine the independent
prognostic value of established and new echocardiographic parameters of diastolic function.
Methods We included 3,604 consecutive patients referred to 1 of 3 echocardiography laboratories over a 2-year
period. We obtained measurements of mitral inflow velocities, pulmonary vein filling pattern, mitral annulus motion (e′), and
propagation velocity (Vp). The primary end point was 1-year all-cause mortality.
Results The mean age of the patients was 68 years, and 95% were male. There were 277 deaths during a mean follow-up
of 248 ± 221 days. For patients with reduced left ventricular ejection fraction (LVEF), all measured parameters except for e′
were associated with mortality (P b .05) on univariate analysis. For patients with preserved LVEF, the E-wave velocity was
significantly associated with mortality (P b .05) on univariate analysis. The deceleration time/E-wave velocity ratio, Vp, and
pulmonary vein filling pattern were borderline significant (P b .10). With multivariate analysis, only Vpwas associated with
survival for both reduced (P = .02) and preserved LVEF groups (P = .01).
Conclusion In a large, clinically diverse population, most measures of diastolic function were predictive of all-cause
mortality without adjustment for patient characteristics. On multivariate analysis, only Vpwas independently associated with
total mortality. This association with mortality may be related to factors other than diastolic function and warrants further
investigation. (Am Heart J 2011;161:530-7.)
Diastolic dysfunction refers to an abnormality of left
ventricular compliance, filling, and/or relaxation1and
can be estimated by echocardiography. Many of these
echocardiographic measures have been associated with
increased morbidity and mortality.2Most studies,2
however, were performed in small or clinically select
populations, specifically patients who had a history of
recent myocardial infarction,3,4heart failure,4-6and/or
cardiomyopathy.5,7,8Most studies2did not incorporate
new Doppler techniques, nor did they evaluate the
prognostic value of each technique independent of
demographic, clinical, and echocardiographic para-
meters including diastolic measures.9
The purpose of this study was to compare the
independent prognostic value of established and new
markers of diastolic dysfunction in a broad population of
patients with reduced and preserved left ventricular
ejection faction (LVEF).
We identified 3,716 consecutive patients who underwent
echocardiography at 1 of 3 centers in the Veteran Affairs Palo
Alto Health Care System over a 2-year period. We included
only patients who had measurements of mitral inflow pattern
and annular velocity. We excluded patients who were
younger than 40 years (n = 50), had any mitral stenosis
(n = 23), had severe mitral regurgitation (n = 35), had severe
aortic regurgitation (n = 1), or were missing ejection fraction
(EF) data (n = 3). The remaining 3,604 patients were
subdivided into those with reduced (b50%) or with preserved
We used the Veterans Affairs and the Social Security Death
Index data to determine the primary end point of all-cause
University, Palo Alto, CA, andbCardiology Section, Veterans Affairs Palo Alto Health Care
Systems, Palo Alto, CA.
There are no conflicts of interest.
Jeroen J. Bax, MD, PhD served as guest editor for this article.
Submitted May 27, 2010; accepted December 4, 2010.
Reprint requests: Patricia K. Nguyen, 3801 Miranda Ave, Palo Alto, CA 94304.
0002-8703/$ - see front matter
© 2011, Mosby, Inc. All rights reserved.
aDepartment of Medicine, Division of Cardiovascular Medicine, Stanford
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American Heart Journal
Volume 161, Number 3