Tissue Doppler echocardiography for the diagnosis of new-onset heart failure with normal ejection fraction: influence of serum protein concentration on clinical interpretation in elderly patients.

INTRODUCTION: According to Starling's law, low serum colloid osmotic pressure related to hypoproteinaemia is likely to modulate the pulmonary capillary hydrostatic pressure threshold of pulmonary oedema formation. We therefore examined the clinical relevance of bedside tissue Doppler echocardiography in the emergency diagnosis of new-onset heart failure with normal ejection fraction (HFnlEF) according to serum protein concentration. METHODS: A total of 105 consecutive elderly patients presenting with acute severe dyspnoea were prospectively enrolled. B-type natriuretic peptide (BNP) concentration and spectral tissue Doppler-derived septal E/E' ratio were obtained at presentation. Serum protein concentration was measured immediately after clinical stabilization, with a value of less than 6g/dL defining hypoproteinaemia. RESULTS: The diagnostic performance of E/E' was excellent in normoproteinaemic patients (n=71; area under the receiver-operating characteristic [ROC] curve 0.97; p<0.001) and reasonable in hypoproteinaemic patients (n=34; area under ROC curve 0.83; p<0.001). By multivariable logistic regression analysis, E/E' provided independent and incremental diagnostic information over the Boston score and BNP concentration in patients with a normal serum protein concentration (p<0.01). Critical elevation of pulmonary capillary pressure, defined as E/E'>15, was present in 93% of patients with HFnlEF and normoproteinaemia versus 55% of patients with HFnlEF and hypoproteinaemia (p=0.0017). CONCLUSION: Septal E/E'>15 is clinically relevant for the emergency diagnosis of new-onset HFnlEF among elderly patients with normal serum protein concentration. Lower abnormal values less than 15 should be considered predictive of this condition in the setting of hypoproteinaemia.

Comparison of B-type natriuretic peptide with left atrial enlargement by echocardiography for the diagnosis of new-onset congestive heart failure with a preserved left ventricular systolic function in the setting of longstanding hypertension.

The present study attempted to determine the accuracy of B-type natriuretic peptide (BNP) compared with left atrial enlargement at echocardiography in the emergency diagnosis of new-onset heart failure with preserved systolic function (HFPSF) related to longstanding hypertension. The study comprised 57 patients in sinus rhythm hospitalized for acute dyspnea, 30 with hypertensive HFPSF and 27 with noncardiac cause. By stepwise logistic regression analysis, BNP provided independent and incremental diagnostic information over the score of Boston criteria. There was a trend toward superiority of this biomarker compared to the left atrial area index for the diagnosis of HFPSF. A BNP concentration >142 pg/ml was 93% sensitive and 85% specific for the diagnosis of HFPSF in this clinical setting (area under the ROC curve of 0.91 [0.8-0.97], p<0.001).

Accuracy of the isovolumic relaxation time in the emergency diagnosis of new-onset congestive heart failure with preserved left ventricular systolic function in the setting of B-type natriuretic peptide levels in the mid-range.

Despite the fact that B-type natriuretic peptide (BNP) is a useful diagnostic complement to clinical and radiographic data in the emergency diagnosis of acute congestive heart failure, levels of BNP in the mid-range (100-500 pg/ml) are acknowledged to be inconclusive for the diagnosis. We assessed the diagnostic value of the pulsed Doppler-derived isovolumic relaxation time (IVRT) by bedside Doppler echocardiography in the emergency diagnosis of new-onset congestive heart failure with preserved systolic function in 43 patients presenting with acute severe dyspnea and inconclusive BNP levels. A short IVRT <50 ms was a good predictor of acute congestive heart failure in this clinical setting, with a positive predictive value of 94%.

Usefulness of bedside tissue Doppler echocardiography and B-type natriuretic peptide (BNP) in differentiating congestive heart failure from noncardiac cause of acute dyspnea in elderly patients with a normal left ventricular ejection fraction and permanent, nonvalvular atrial fibrillation: insights from a prospective, monocenter study.

BACKGROUND: The incremental role of bedside tissue Doppler echocardiography and B-type natriuretic peptide (BNP) over the clinical judgment has been recently reported in the emergency diagnosis of congestive heart failure with a normal left ventricular ejection fraction (HFNEF). However, how well does this diagnostic strategy be applicable in the setting of atrial fibrillation is unknown. OBJECTIVE: To investigate the usefulness of bedside tissue Doppler echocardiography and BNP in the emergency diagnosis of HFNEF in elderly patients with permanent, nonvalvular atrial fibrillation. METHODS: Forty-one consecutive elderly patients with an ejection fraction > or =50% (mean age 84 years; 22 with HFNEF and 19 with noncardiac cause), hospitalized for acute dyspnea at rest, were prospectively enrolled; bedside septal E/Ea and BNP were obtained at admission. RESULTS: By multivariable logistic regression analysis including the clinical judgment of heart failure, E/Ea and BNP, E/Ea (P = 0.014) and BNP (P = 0.018) provided independent diagnostic information. Optimal cutoffs were 13 for E/Ea (area under the ROC curve of 0.846, P < 0.0001; sensitivity 81.8%, specificity 89.5%) and 253 pg/ml for BNP (area under the ROC curve of 0.928, P < 0.0001; sensitivity 86.4%, specificity 89.5%). The concordance between the clinical judgment and BNP concentration at the cutoff of 253 pg/ml correctly classified 24 of 25 patients; E/Ea at the cutoff of 13 correctly classified 14 of the 16 patients with discrepancy. CONCLUSION: Bedside tissue Doppler echocardiography and BNP provide useful additional diagnostic information over the clinical judgment for the emergency diagnosis of HFNEF in elderly patients with permanent, nonvalvular atrial fibrillation.

Current clinical applications of spectral tissue Doppler echocardiography (E/E' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function.

Congestive heart failure with preserved left ventricular systolic function has emerged as a growing epidemic medical syndrome in developed countries, which is characterized by high morbidity and mortality rates. Rapid and accurate diagnosis of this condition is essential for optimizing the therapeutic management. The diagnosis of congestive heart failure is challenging in patients presenting without obvious left ventricular systolic dysfunction and additional diagnostic information is most commonly required in this setting. Comprehensive Doppler echocardiography is the single most useful diagnostic test recommended by the ESC and ACC/AHA guidelines for assessing left ventricular ejection fraction and cardiac abnormalities in patients with suspected congestive heart failure, and non-invasively determined basal or exercise-induced pulmonary capillary hypertension is likely to become a hallmark of congestive heart failure in symptomatic patients with preserved left ventricular systolic function. The present review will focus on the current clinical applications of spectral tissue Doppler echocardiography used as a reliable noninvasive surrogate for left ventricular diastolic pressures at rest as well as during exercise in the diagnosis of heart failure with preserved left ventricular systolic function. Chronic congestive heart failure, a disease of exercise, and acute heart failure syndromes are characterized by specific pathophysiologic and diagnostic issues, and these two clinical presentations will be discussed separately.

Accuracy of bedside tissue Doppler echocardiography for the prediction of in-hospital mortality in elderly patients with acute heart failure with preserved left ventricular systolic function. comparison with B-type natriuretic peptide measurement.

According to recent studies, tissue Doppler echocardiography used as a non-invasive surrogate for left ventricular diastolic pressures regardless of rhythm is likely to offer additional information beyond the clinical judgment and the B-type natriuretic peptide (BNP) assay in the emergency diagnosis of acute heart failure with preserved left ventricular systolic function (HFPSF). The present study attempted to determine the usefulness of bedside tissue Doppler echocardiography as compared with BNP, both obtained at presentation before unloading therapy, for the prediction of in-hospital outcome in 75 consecutive elderly patients with acute HFPSF, of whom 16 died during their in-hospital stay. Unlike BNP (p=0.002), the spectral tissue Doppler-derived E/Ea ratio was not able to provide prognostic information in such patients before tailored therapy (p=0.9).

Accuracy of tissue Doppler echocardiography in the diagnosis of new-onset congestive heart failure in patients with levels of B-type natriuretic peptide in the midrange and normal left ventricular ejection fraction.

BACKGROUND: Based on the hypothesis that it reflects left ventricular (LV) diastolic pressures, B-type natriuretic peptide (BNP) is largely utilized as first-line diagnostic complement in the emergency diagnosis of congestive heart failure (HF). The incremental diagnostic value of tissue Doppler echocardiography, a reliable noninvasive estimate of LV filling pressures, has been reported in patients with preserved LV ejection fraction and discrepancy between BNP levels and the clinical judgment, however, its clinical validity in such patients in the presence of BNP concentrations in the midrange, which may reflect intermediate, nondiagnostic levels of LV filling pressures, is unknown. METHODS: 34 patients without history of HF, presenting with acute dyspnea at rest, BNP levels of 100-400 pg/ml and normal LV ejection fraction were prospectively enrolled (17 with congestive HF and 17 with noncardiac cause). Tissue Doppler echocardiography was performed within 3 hours after admission. RESULTS: Unlike BNP (P = 0.78), Boston criteria (P = 0.0129), radiographic pulmonary edema (P = 0.0036) and average E/Ea ratio (P = 0.0032) were predictive of congestive HF by logistic regression analysis. In this clinical setting, radiographic pulmonary edema had a positive predictive value of 80% in the diagnosis of congestive HF. In patients without evidence of radiographic pulmonary edema, average E/Ea > 10 was a powerful predictor of congestive HF (area under the ROC curve of 0.886, P < 0.001, sensitivity 100% and specificity 78.6%). CONCLUSION: By better reflecting LV filling pressures, bedside tissue Doppler echocardiography accurately differentiates congestive HF from noncardiac cause in dyspneic patients with intermediate, nondiagnostic BNP levels and normal LV ejection fraction.

Diastolic asynchrony is more frequent than systolic asynchrony in dilated cardiomyopathy and is less improved by cardiac resynchronization therapy.

OBJECTIVES: To compare the incidence of diastolic and systolic asynchrony, assessed by tissue Doppler imaging (TDI), in patients with congestive heart failure (CHF) and severe left ventricular (LV) dysfunction, and to assess TDI changes induced by cardiac resynchronization therapy (CRT). BACKGROUND: Thirty percent of CRT candidates are nonresponders. Besides QRS width, the presence of echographic systolic asynchrony has been used to identify future responders. Little is known about diastolic asynchrony and its change after CRT. METHODS: Tissue Doppler imaging was performed in 116 CHF patients (LV ejection fraction 26 +/- 8%). Systolic and diastolic asynchrony was calculated using TDI recordings of right ventricular and LV walls. RESULTS: The CHF group consisted of 116 patients. Diastolic asynchrony was more frequent than systolic, concerning both intraventricular (58% vs. 47%; p = 0.0004) and interventricular (72 vs. 45%; p < 0.0001) asynchrony. Systolic and diastolic asynchrony were both present in 41% patients, but one-third had isolated diastolic asynchrony. Although diastolic delays increased with QRS duration, 42% patients with narrow QRS presented with diastolic asynchrony. Conversely, 27% patients with large QRS had no diastolic asynchrony. Forty-two patients underwent CRT. Incidence of systolic intraventricular asynchrony decreased from 71% to 33% after CRT (p < 0.0001), but diastolic asynchrony decreased only from 81% to 55% (p < 0.0002). Cardiac resynchronization therapy induced new diastolic asynchrony in eight patients. CONCLUSIONS: Diastolic asynchrony is weakly correlated with QRS duration, is more frequent than systolic asynchrony, and may be observed alone. Diastolic asynchrony is less improved by CRT than systolic. Persistent diastolic asynchrony may explain some cases of lack of improvement after CRT despite good systolic resynchronization.

Comparative accuracy of color M-mode and tissue Doppler echocardiography in the emergency diagnosis of congestive heart failure in chronic hypertensive patients with normal left ventricular ejection fraction.

The accuracy of the tissue Doppler E/Ea and color M-mode Doppler E/Vp indexes in diagnosing congestive heart failure (HF) was investigated in 20 chronic hypertensive patients with acute dyspnea and normal left ventricular ejection fractions who met Vasan's criteria for definite diastolic HF, compared with 20 gender- and age-matched hypertensive patients with noncardiac cause of acute dyspnea. The E/Ea ratio appeared to be more reproducible (variability 4% to 9% vs 6 to 14%) and more precise (sensitivity 77.8%, specificity 100%, and accuracy 89.5% for the optimal cutoff of 11 vs sensitivity 73.7%, specificity 75%, and accuracy 74.3% for the optimal cutoff of 1.5) than the E/Vp ratio in this clinical setting.

Accuracy of tissue Doppler echocardiography in the emergency diagnosis of decompensated heart failure with preserved left ventricular systolic function: comparison with B-type natriuretic peptide measurement.

BACKGROUND: Tissue Doppler echocardiography provides a reliable noninvasive estimation of left ventricular (LV) filling pressures irrespective of LV ejection fraction. However, the diagnostic accuracy of E/Ea ratio has not been adequately determined in patients with suspected heart failure (HF) with preserved LV systolic function in the acute care setting. OBJECTIVE: To investigate the accuracy of E/Ea ratio in the emergency diagnosis of decompensated HF with preserved LV systolic function. METHODS: Seventy patients with a LV ejection fraction >or=45%, 32 with decompensated HF (77 +/- 12 years of age), and 38 with noncardiac cause of acute dyspnea (74 +/- 12) were enrolled. B-type natriuretic peptide (BNP) was measured on admission; lateral, septal and average E/Ea ratios were calculated within 24 hours. RESULTS: Using receiver-operating characteristic curves to evaluate diagnostic performance, BNP (AUC of 0.875, P < 0.0001) and E/Ea ratios (AUC of 0.90-0.92, P < 0.0001) provided similar accuracy for predicting decompensated HF. Optimal cutoffs were 146 pg/ml for BNP (sensitivity and specificity of 90.6% and 76.3%), 9.8 for lateral E/Ea (83.3% and 88.9%), 12.7 for septal E/Ea (76.7% and 91.4%), and 11.5 for average E/Ea ratio (80% and 94.3%). On multivariate logistic regression analysis, average E/Ea ratio yielded independent additional information to a model based on the clinical judgment and BNP level according to the standard cutoff of 100 pg/ml. CONCLUSIONS: Tissue Doppler echocardiography is accurate for predicting decompensated HF with preserved LV systolic function and may be used as a diagnostic complement to inconclusive BNP level in this setting.

B-type natriuretic peptide and tissue Doppler study findings in elderly patients hospitalized for acute diastolic heart failure.

The imbalance of Starling's forces was investigated in 25 elderly patients hospitalized for acute diastolic heart failure. Tissue Doppler evidence of elevated left ventricular filling pressures was present on admission in 17 patients with high B-type natriuretic peptide (BNP) levels. Serum proteins concentrations and colloid osmotic pressure, related to malnutrition and severe sepsis, were significantly less in the 8 patients without tissue Doppler evidence of elevated filling pressures, and a high level of BNP was consistent with paroxysmal elevation in filling pressures in this setting.

Hypoalbuminemia in elderly patients with acute diastolic heart failure.

OBJECTIVES: This study evaluated the relative contribution of serum colloid osmotic pressure (COP) lowering and pulmonary artery wedge pressure (PAWP) elevation in the pathogenesis of pulmonary edema in patients with systolic or isolated diastolic heart failure (DHF). BACKGROUND: The role of hypoalbuminemia and the resulting low COP have been shown in some patients with acute systolic heart failure (SHF). Colloid osmotic pressure and PAWP were determined in 100 patients with acute heart failure (HF) (56 with DHF and 44 with SHF; mean age, 78 +/- 12 years), in 35 patients with acute dyspnea from pulmonary origin, and in 15 normal controls. Pulmonary artery wedge pressure was estimated using transthoracic Doppler echocardiography. RESULTS: Colloid osmotic pressure was significantly lower in the DHF group (20.5 +/- 5 mm Hg) than in the SHF group (24.2 +/- 3.7 mm Hg, p < 0.001), pulmonary disease group (25.1 +/- 4.2 mm Hg, p < 0.001), or normal control group (24.7 +/- 3 mm Hg). Low COP resulted from hypoalbuminemia due to age, malnutrition, and sepsis. Pulmonary artery wedge pressure was significantly higher in patients with SHF (26 +/- 6.3 mm Hg) than in the patients with DHF (20.3 +/- 7 mm Hg, p < 0.001) and was significantly higher in the patients with DHF than in the patients with pulmonary disease (13 +/- 4.2 mm Hg, p < 0.001). The COP-PAWP gradient was similar in patients with SHF (-1.6 +/- 7.1 mm Hg) and patients with DHF (0.7 +/- 6 mm Hg). CONCLUSIONS: Frequent hypoalbuminemia resulting in low COP facilitates the onset of pulmonary edema in patients with DHF who usually have lower PAWP than patients with SHF.

Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression: An Echocardiographic Case Report.

A 69-year-old woman presented with chest pain and electrocardiographic evidence of subacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a posttraumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.