Peteiro Jesús, Pazos Pablo, Bouzas Alberto, Piñon Pablo, Estevez Roi, Castro-Beiras Alfonso
Unit of Echocardiography and Department of Cardiology, Juan Canalejo Hospital, University of A Coruña, A Coruña, Spain.
J Am Soc Echocardiogr. 2008 Feb;21(2):178-84. doi: 10.1016/j.echo.2007.06.009. Epub 2007 Jul 20.
We hypothesize that the change in the left ventricular (LV) diastolic pattern (DP) may be measured with high reproducibility and correlates with exercise echocardiography (EE) better than the ratio of early LV inflow velocity to early diastolic annulus velocity (E/e' index).
The E/e' index has been related to LV filling pressures but has not been compared with DP.
We selected 179 consecutive patients who were referred for EE. Early (E) and late (A) LV inflow velocities by conventional pulsed Doppler, and septal annulus e' velocity by pulsed Doppler myocardial imaging were measured at rest (R) and post-exercise (PE).
Four LV-DPs were found: abnormal relaxation (AR) at R and PE (E < A) in 110 patients; AR at PE (E > A at R; E < A at PE) in 22 patients; restrictive pattern (RP) at R and PE (E > A) in 18 patients; and RP at PE (E < A at R; E > A at PE) in 29 patients. The more accurate PE cutoff E/e' values to predict abnormal EE, ischemic response, poor functional capacity (< 8 Mets in men; < 6 Mets in women), and lack of increase in left ventricular ejection fraction (LVEF) were 12, 12, 11, and 11 (areas under the curve were 0.53, 0.53, 0.63, and 0.57, respectively). Corresponding areas under the curve for an RP at R + PE or only at PE were 0.57, 0.55, 0.54, and 0.56 (P = not significant). The sensitivity of an RP at R + PE or only at PE was lower and the specificity was higher than those of the different E/e' cutoff values for predicting abnormal EE, functional capacity, ischemic response, and lack of increase in LVEF. Achieved Mets were lower in patients with an RP at R + PE or only at PE irrespectively of the E/e' values, whereas achieved Mets in patients with AR at R + PE or only at PE were lower if the E/e' was > or = 11 (8.2 +/- 2.9 vs. 9.8 +/- 3.1, P = .01). Interobserver and intraobserver concordance were 95% (kappa = 0.86) and 100% (kappa = 1.0) for an RP, and 86% (kappa = 0.73) and 92% (kappa = 0.78) for a PE-E/e' value of > or = 11.
E/e' does not allow further stratification in patients with exercise RP. We propose both measurement of E/e' and determination of the LV-DP (a quickly assessable variable) for the assessment of diastolic function during EE. However, when an RP persists or develops with exercise, further assessment may not be more informative.
我们假设左心室（LV）舒张模式（DP）的变化能够以高重复性进行测量，并且与运动超声心动图（EE）的相关性优于左心室早期流入速度与早期舒张期瓣环速度之比（E/e'指数）。
E/e'指数与左心室充盈压相关，但尚未与DP进行比较。
我们连续选取了179例因EE前来就诊的患者。通过传统脉冲多普勒测量静息（R）和运动后（PE）时的左心室早期（E）和晚期（A）流入速度，以及通过脉冲多普勒心肌成像测量间隔瓣环e'速度。
发现四种左心室DP：110例患者在R和PE时为异常松弛（AR）（E < A）；22例患者在PE时为AR（R时E > A；PE时E < A）；18例患者在R和PE时为限制性模式（RP）（E > A）；29例患者在PE时为RP（R时E < A；PE时E > A）。预测异常EE、缺血反应、功能能力差（男性< 8代谢当量；女性< 6代谢当量）以及左心室射血分数（LVEF）无增加的更准确的PE截断E/e'值分别为12、12、11和11（曲线下面积分别为0.53、0.53、0.63和0.57）。R + PE时或仅PE时RP的相应曲线下面积分别为0.57、0.55、0.54和0.56（P = 无显著性差异）。R + PE时或仅PE时RP预测异常EE、功能能力、缺血反应和LVEF无增加的敏感性低于不同E/e'截断值，而特异性高于不同E/e'截断值。无论E/e'值如何，R + PE时或仅PE时为RP的患者所达到的代谢当量较低，而R + PE时或仅PE时为AR且E/e'≥11的患者所达到的代谢当量较低（8.2±2.9对9.8±3.1，P = 0.01）。观察者间和观察者内一致性对于RP分别为95%（kappa = 0.86）和100%（kappa = 1.0），对于PE-E/e'值≥11分别为86%（kappa = 0.73）和92%（kappa = 0.78）。
E/e'不能对运动性RP患者进行进一步分层。我们建议在评估EE期间舒张功能时，同时测量E/e'并确定左心室DP（一个可快速评估的变量）。然而，当RP在运动时持续存在或出现时，进一步评估可能并无更多信息价值。
