Role of echocardiography in diagnosis and risk stratification in heart failure with left ventricular systolic dysfunction

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.     

Cross sectional study of contribution of clinical assessment and simple cardiac investigations to diagnosis of left ventricular systolic dysfunction in patients admitted with acute dyspnoea.

OBJECTIVE: To assess the comparative contribution of clinical assessment, electrocardiography, and chest radiography to the diagnosis of left ventricular systolic dysfunction in patients admitted to a general medical ward with acute dyspnoea. DESIGN: Prospective cross sectional study. SETTING: Acute medical admissions ward of a teaching hospital. SUBJECTS: 71 randomly selected patients admitted with acute dyspnoea. MAIN OUTCOME MEASURES: Sensitivity and specificity of each investigation and logistic regression analysis of each variable in identifying left ventricular systolic dysfunction. RESULTS: Clinical assessment in this cohort of patients with severe dyspnoea was generally sensitive (sensitivity 81%). Patients were divided into three groups on the basis of clinical assessment. In the first group (37 patients) the diagnosis of systolic dysfunction was clear, in the second (22) it was in doubt, and in the third (12) it was unlikely. The sensitivity of clinical assessment in identifying left ventricular systolic dysfunction was 81% and the specificity was 47%. The specificity of diagnosis was improved by electrocardiography (69%) and chest radiography (92%). Logistic regression analysis showed that isolated pulmonary crepitations were a comparatively poor predictor of left ventricular systolic dysfunction chi 2 = 10.215, P = 0.0014) but that a full clinical examination had reasonable predictive value (chi 2 = 24.82, P < 0.00001). The combination of clinical assessment and chest radiography improved the accuracy of diagnosis (chi 2 = 28.08, P < 0.00001), as did the combination of clinical assessment and electrocardiography (chi 2 = 32.41, P < 0.00001). CONCLUSION: Clinical assessment in patients admitted with acute dyspnoea is comparatively accurate. Patients with abnormal results on chest radiography, electrocardiography, and clinical examination have a high likelihood of having left ventricular systolic dysfunction. Echocardiography contributes little more to the diagnosis in these patients and may be more efficiently directed towards patients in whom the diagnosis is still in doubt after clinical assessment, chest radiography, and electrocardiography.     

Paced QRS morphology predicts incident left ventricular systolic dysfunction and atrial fibrillation

Background

The prognostic significance of paced QRS complex morphology on surface ECG remains unclear. This study aimed to assess long-term outcomes associated with variations in the paced QRS complex.

Serum interleukin-6 and C-reactive protein are markedly elevated in acute decompensated heart failure patients with left ventricular systolic dysfunction

Cytokines play important roles in heart failure (HF). We examined whether cytokine levels are different in acute decompensated heart failure (ADHF) patients between with left ventricular systolic dysfunction (LVSDF) and with preserved LV ejection function (PLVEF). We studied 81 HF patients who were admitted to our hospital with acute decompensation. They were divided into two groups: LVSDF (LVEF) < 45% and PLVEF (LVEF ? 45%). Serum interleukin-6 (IL-6), highly sensitive C-reactive protein (hsCRP), tumor necrosis factor alpha (TNF-α), and IL-18 and plasma brain natriuretic peptide (BNP) were measured on admission and at discharge. On admission, IL-6 and hsCRP were higher in LVSDF than in PLVEF. IL-6 and hsCRP decreased after treatment in LVSDF, but not in PLVEF, while plasma BNP levels decreased in both HF with treatment. There was no difference in TNF-α or in IL-18 level between LVSDF and PLVEF, and they did not change after treatment in either group. In conclusion, cytokine profiles were different in ADHF between those with LVSDF and PLVEF. Activation of IL-6–hsCRP pathway may play a specific role in ADHF with LVSDF.     

Prevalence of left ventricular systolic dysfunction and heart failure in high risk patients: community based epidemiological study

ObjectivesTo determine the prevalence of left ventricular systolic dysfunction, and of heart failure due to different causes, in patients with risk factors for these conditions.DesignEpidemiological study, including detailed clinical assessment, electrocardiography, and echocardiography.Setting16 English general practices, representative for socioeconomic status and practice type.Participants1062 patients (66% response rate) with previous myocardial infarction, angina, hypertension, or diabetes.ResultsDefinite systolic dysfunction (ejection fraction <40%) was found in 54/244 (22.1%, 95% confidence interval 17.1% to 27.9%) patients with previous myocardial infarction, 26/321 (8.1%, 5.4% to 11.6%) with angina, 7/388 (1.8%, 0.7% to 3.7%) with hypertension, and 12/208 (5.8%, 3.0% to 9.9%) with diabetes. In each group, approximately half of these patients had symptoms of dyspnoea, and therefore had heart failure. Overall rates of heart failure, defined as symptoms of dyspnoea plus objective evidence of cardiac dysfunction (systolic dysfunction, atrial fibrillation, or clinically significant valve disease) were 16.0% (11.6% to 21.2%) in patients with previous myocardial infarction, 8.4% (5.6% to 12.0%) in those with angina, 2.8% (1.4% to 5.0%) in those with hypertension, and 7.7% (4.5% to 12.2%) in those with diabetes.ConclusionMany people with ischaemic heart disease or diabetes have systolic dysfunction or heart failure. The data support the need for trials of targeted echocardiographic screening, in view of the major benefits of modern treatment. In contrast, patients with uncomplicated hypertension have similar rates to the general population.

What is already known on this topic

The prognosis and symptoms of patients with left ventricular systolic dysfunction and heart failure can be greatly improved by modern treatmentsMany patients with heart failure do not have an assessment of left ventricular function, resulting in undertreatment of the condition

What this study adds

Patients with a history of ischaemic heart disease (especially those with previous myocardial infarction) or diabetes commonly have left ventricular systolic dysfunctionThese patients would be candidates for a targeted echocardiographic screening programmeIn contrast, the yield from screening patients with uncomplicated hypertension would be low     

Prediction of prognosis in patients with left ventricular dysfunction using three-dimensional strain echocardiography and cardiac magnetic resonance imaging

Netherlands Heart Journal - We evaluated three-dimensional speckle tracking echocardiography (3DSTE) strain and cardiac magnetic resonance (CMR) with delayed contrast enhancement (DCE) for the...     

Beneficial effects of carvedilol as a concomitant therapy to angiotensin-converting enzyme inhibitor in patients with ischemic left ventricular systolic dysfunction

Studies are scant on the effects of short-term carvedilol treatment as an adjuvant to angiotensin-converting enzyme (ACE) inhibitor in patients with left ventricular (LV) systolic dysfunction. The objective of this study was to find the effects of short-term treatment of carvedilol on patients with ischemic LV systolic dysfunction (defined as LV ejection fraction (LVEF) 相似文献   

Echocardiographic and cardiac single photon emission computed tomography predictors of left ventricle reverse remodeling after surgical revascularization in patients with ischemic cardiomyopathy and left ventricle systolic dysfunction

Background: The extent of scar or viable hypocontractile myocardial tissue determines postinfarction left ventricle remodeling. The aim of this pilot study was to evaluate the revascularization effect in a group of patients with ischemic cardiomyopathy and LV systolic dysfunction indicated for surgical revascularization, based on evidence for multivessel disease on coronarography and viable myocardium (CMR, SPECT). Aims: To evaluate the revascularization effect in patients with ischemic LV systolic dysfunction and to find preoperative predictors of revascularization effect. Methods: 33 patients (64+/-11 years) with baseline LVEF 34.9+/-9.3 % were included in the study. After a follow-up of 10.7+/-1.2 months, ECHO and SPECT were performed again. The whole group of patients was divided according to revascularization effect (postoperative increase LVEF > 5 % and postoperative decrease LVESV > 5 % compared with baseline) into revascularization responders (R, n = 22) and nonresponders (NR, n = 11). Results: At baseline there was no difference between the subgroups in LVEF (R = 35.7+/-11.0 % vs. NR = 34.3+/-8.2 %), EDV (R = 183.6+/-43.2 vs. NR = 180.2+/-80.5 ml), ESV (R = 118.5+/-40.4 vs. NR = 119.7+/-55.2 ml). The responders showed in a revascularization effect subanalysis differences in the values of LVEF (+9.8+/-8.1 %, p < 0.009), reduction of EDV (-39.9+/-50.9 ml, p = 0.05) and ESV (-35.4+/-42.6 ml, p = 0,002) compared with baseline. The only preoperative parameters predicting LV reverse remodeling were the T(E-Em) (R = -10.6+/-44.1 vs. NR = 29.7+/-43.7 ms, p = 0.037) and the size of fixed perfusion defect (FPD) (R = 11.9+/-13.5 vs. NR = 22.9+/-15.3 % of LV, p = 0.044). Conclusions: Patients with ischemic LV systolic dysfunction with a preoperatively determined myocardial viability develop LV reverse remodeling. The only preoperative parameters predicting LV reverse remodeling were echocardiographic T(E-Em) and FPD on SPECT.     

Noninvasive radiodiagnosis of left ventricular diastolic dysfunction in hypertensive patients

To define the informative value of Doppler studies in the early diagnosis of left ventricular (LV) diastolic dysfunction in patients with hypertensive disease (HD), the authors examined 74 patients with grade 1-2 HD, including 65 men and 9 women aged 43 to 63 years. All the patients underwent echocardiography (echoCG), Doppler echoCG (DechoCG), tissue DechoCG (TDechoCG), and treadmill. According to the echoCG LV mass index (LVMI), all the patients were divided into 2 groups: 1) 33 patients with increased LVMI and 2) 41 with normal LVMI. A control group consisted of 20 apparently healthy patients. Groups 1 and 2 showed a preponderance of patients with concentric LV hypertrophy (CLVH) and those with concentric LV remodeling, respectively. In accordance with DechoCG, the signs of primary LV diastolic dysfunction ((E/A = 0.8+/-0.1; IVRT = 103+/-15) were found only in Group 1 patients. TDechoCG displayed the signs of primary LV diastolic dysfunction in both groups (e' or =10 ratio, suggests elevated LV filling pressure as an early stage of diastolic dysfunction.     

Myocardial material mechanics: characteristic variation of the circumferential and longitudinal systolic moduli in left ventricular dysfunction

Active systolic moduli for the circumferential (E theta) and longitudinal (E phi) axes of the left ventricle were determined along with circumferential and longitudinal contractile filament stress (sigma theta and sigma phi) and circumferential and longitudinal fiber strain (epsilon theta and epsilon phi). These material property parameters were determined at four points during cardiac systole. Thirty-nine patients comprising five clinical groups were evaluated using pressure and volume data acquired from single-plane cineangiography. The results indicate that the active moduli exponentially decrease during cardiac systole. Characteristic variations from normal differentiated the various pathological groups. With compensated volume overload, E theta was significantly reduced during the latter half of systole (p less than 0.25). With decompensated volume overload, both E theta and E phi were not significantly different from the normal group throughout cardiac systole. With compensated pressure overload, both E theta and E phi were significantly lower than the normal group at end-systole (p less than 0.005; p less than 0.005). With congestive cardiomyopathy, both E theta and E phi were significantly greater during the latter half of systole compared to the normal group (p less than 0.05 and p less than or equal to 0.025).     

Sympathetic nervous dysregulation in the absence of systolic left ventricular dysfunction in a rat model of insulin resistance with hyperglycemia

Background

Diabetes mellitus is strongly associated with cardiovascular dysfunction, derived in part from impairment of sympathetic nervous system signaling. Glucose, insulin, and non-esterified fatty acids are potent stimulants of sympathetic activity and norepinephrine (NE) release. We hypothesized that sustained hyperglycemia in the high fat diet-fed streptozotocin (STZ) rat model of sustained hyperglycemia with insulin resistance would exhibit progressive sympathetic nervous dysfunction in parallel with deteriorating myocardial systolic and/or diastolic function.

Methods

Cardiac sympathetic nervous integrity was investigated in vivo via biodistribution of the positron emission tomography radiotracer and NE analogue [¹¹C]meta-hydroxyephedrine ([¹¹C]HED). Cardiac systolic and diastolic function was evaluated by echocardiography. Plasma and cardiac NE levels and NE reuptake transporter (NET) expression were evaluated as correlative measurements.

Results

The animal model displays insulin resistance, sustained hyperglycemia, and progressive hypoinsulinemia. After 8 weeks of persistent hyperglycemia, there was a significant 13-25% reduction in [¹¹C]HED retention in myocardium of STZ-treated hyperglycemic but not euglycemic rats as compared to controls. There was a parallel 17% reduction in immunoblot density for NE reuptake transporter, a 1.2 fold and 2.5 fold elevation of cardiac and plasma NE respectively, and no change in sympathetic nerve density. No change in ejection fraction or fractional area change was detected by echocardiography. Reduced heart rate, prolonged mitral valve deceleration time, and elevated transmitral early to atrial flow velocity ratio measured by pulse-wave Doppler in hyperglycemic rats suggest diastolic impairment of the left ventricle.

Conclusions

Taken together, these data suggest that sustained hyperglycemia is associated with elevated myocardial NE content and dysregulation of sympathetic nervous system signaling in the absence of systolic impairment.     

3-D MRI assessment of regional left ventricular systolic wall stress in patients with reperfused MI

The goal of this study was to assess the regional variations of end-systolic wall stress in patients with reperfused Q wave acute myocardial infarction (AMI), with the use of a three-dimensional (3-D) approach. Fifteen normal volunteers and fifty patients with reperfused AMI underwent cardiac MRI that used a short-axis fast-gradient-echo sequence. The end-systolic wall stress was calculated with the use of the Grossman formula with the radius and the wall thickness defined with a 3-D approach using the tridimensional curvature. The mean wall stress was significantly increased at each level of the short-axis plane only in patients with anterior AMI. When calculated at a regional level in patients with anterior AMI, wall stress significantly increased in anterior sector as well as normal sector. In patients with inferior AMI, wall stress significantly increased only in inferior and lateral sectors. In conclusion, the quantification of regional wall stress by cardiac MRI is better with the 3D approach than other methods for precise evaluation in patients with AMI. Despite early reperfusion, the wall stress remained high in patients with anterior AMI.