Gardin Julius M, Leifer Eric S, Fleg Jerome L, Whellan David, Kokkinos Peter, Leblanc Marie-Helene, Wolfel Eugene, Kitzman Dalane W
St. John Hospital and Medical Center, Detroit, MI; Hackensack University Medical Center, Hackensack, NJ 07601, USA.
Am Heart J. 2009 Oct;158(4 Suppl):S45-52. doi: 10.1016/j.ahj.2009.07.015.
Patients with systolic heart failure often have concomitant left ventricular (LV) diastolic dysfunction. Although in animal models diastolic dysfunction is associated with worsening exercise capacity and prognosis, information regarding these relationships in patients with established systolic heart failure (HF) is sparse.
HF-ACTION was a large, multicenter National Institutes of Health-funded trial of exercise training in systolic HF (LV ejection fraction [LVEF] < or = 35%) and included detailed Doppler-echocardiographic (echo) and cardiopulmonary exercise testing at baseline. We tested the hypothesis that echo measures of LV diastolic function predict key cardiopulmonary exercise outcomes, including aerobic exercise capacity (peak exercise oxygen consumption, VO(2)), distance in the 6-minute walk test (6MWD), and ventilatory efficiency (VE/VCO(2) slope) in patients with systolic HF.
Overall, 2,331 patients (28% women, median age 59 years, median LVEF 25%) were enrolled. There were significant bivariate correlations between echo diastolic function variables and peak VO(2) (inverse) and VE/VCO(2) slope (direct) that were strongest for ratio of early diastolic peak transmitral (MV) to myocardial tissue velocity (E/E'), peak MV early-to-late diastolic velocity ratio (E/A), and left atrial dimension (range of absolute r = 0.16-0.28). Both MV E/A and E/E' were more strongly related to all 3 exercise variables than was LVEF. The relationships of E/A and E/E' with 6MWD were weaker than with peak VO(2) or VE/VCO(2) slope. A multivariable model with peak VO(2) as the dependent variable, which included MV E/A and 9 demographic predictors including age, sex, race, body mass index, and New York Heart Association class, explained 40% of the variation in peak VO(2), with MV E/A explaining 6% of the variation. Including LVEF in the model explained less than an additional 1% of the variance in peak VO(2). In a multivariable model for VE/VCO(2) slope, MV E/A was the strongest independent echo predictor, explaining 10% of the variance. The relationship of LV diastolic function variables with 6MWD was weaker than with peak VO(2) or VE/VCO(2) slope.
In patients with systolic HF, LV early diastolic function is a modest independent predictor of aerobic exercise capacity and appears to be a better predictor than LVEF.
收缩性心力衰竭患者常伴有左心室（LV）舒张功能障碍。虽然在动物模型中舒张功能障碍与运动能力恶化和预后不良相关，但关于已确诊收缩性心力衰竭（HF）患者中这些关系的信息却很稀少。
HF-ACTION是一项由美国国立卫生研究院资助的大型多中心试验，旨在研究收缩性HF（左心室射血分数[LVEF]≤35%）患者的运动训练，并在基线时进行详细的多普勒超声心动图（回声）和心肺运动测试。我们检验了以下假设：左心室舒张功能的回声测量可预测收缩性HF患者的关键心肺运动结果，包括有氧运动能力（峰值运动耗氧量，VO₂）、6分钟步行试验（6MWD）中的距离以及通气效率（VE/VCO₂斜率）。
总体而言，共纳入2331例患者（28%为女性，中位年龄59岁，中位LVEF 25%）。回声舒张功能变量与峰值VO₂（呈负相关）和VE/VCO₂斜率（呈正相关）之间存在显著的双变量相关性，其中舒张早期二尖瓣峰值血流速度（MV）与心肌组织速度之比（E/E'）、MV舒张早期与晚期血流速度之比（E/A）以及左心房大小的相关性最强（绝对r值范围为0.16 - 0.28）。MV E/A和E/E'与所有3个运动变量的相关性均比LVEF更强。E/A和E/E'与6MWD的关系比与峰值VO₂或VE/VCO₂斜率的关系弱。以峰值VO₂为因变量的多变量模型，包括MV E/A和9个人口统计学预测因素，如年龄、性别、种族、体重指数和纽约心脏协会分级，解释了峰值VO₂变异的40%，其中MV E/A解释了6%的变异。将LVEF纳入该模型后，峰值VO₂的变异增加不到1%。在VE/VCO₂斜率的多变量模型中，MV E/A是最强的独立回声预测因素，解释了10% 的变异。左心室舒张功能变量与6MWD的关系比与峰值VO₂或VE/VCO₂斜率的关系弱。
在收缩性HF患者中，左心室舒张早期功能是有氧运动能力的适度独立预测因素，且似乎比LVEF是更好的预测因素。
