Cardiology Department, Wroclaw Medical University, Wroclaw, Poland; Cardiovascular Imaging Research Group, Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Cardiovascular Imaging Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia.
Cardiology Department, Wroclaw Medical University, Wroclaw, Poland.
JACC Cardiovasc Imaging. 2019 May;12(5):771-780. doi: 10.1016/j.jcmg.2017.10.008. Epub 2018 Feb 14.
This study sought to establish the diagnostic and prognostic value of a strategy for prediction of abnormal diastolic response to exercise (AbnDR) using clinical, biochemical, and resting echocardiographic markers in dyspneic patients with mild diastolic dysfunction.
An AbnDR (increase in left ventricular filling pressure) may indicate heart failure with preserved ejection fraction as the cause of symptoms in dyspneic patients, despite a nonelevated noncardiac at rest. However, exercise testing may be inconclusive in patients with noncardiac limitations to physical activity.
In 171 dyspneic patients (64 ± 8 years) with suspected heart failure with preserved ejection fraction but resting peak early diastolic mitral inflow velocity/peak early diastolic mitral annular velocity ratio (E/e') <14, a complete echocardiogram (including assessment of myocardial deformation and rotational mechanics) and blood assays for biomarkers were performed. Echocardiography following maximal exercise was undertaken to assess AbnDR (exertional E/e' >14). Patients were followed over 26.2 ± 4.6 months for endpoints of cardiovascular hospitalization and death.
AbnDR was present in 103 subjects (60%). Independent correlates of AbnDR were resting E/e' (odds ratio [OR]: 8.23; 95% confidence interval [CI]: 3.54 to 9.16; p < 0.001), left ventricular untwisting rate (OR: 0.60; 95% CI: 0.42 to 0.86; p = 0.006), and galectin-3-a marker of fibrosis (OR: 1.80; 95% CI: 1.21 to 2.67; p = 0.004). The use of resting E/e' >11.3 and galectin-3 <1.17 ng/ml to select patients for further diagnostic processing would have allowed exercise testing to be avoided in 65% of subjects, at the cost of misclassification of 13%. The composite outcome of cardiovascular hospitalization or death occurred in 47 patients (27.5%). The predictive value of an AbnDR response and the combined strategy (resting echocardiography and galectin-3 or exercise testing in case of an inconclusive first step) showed similar event prediction (36 vs. 34; p = 0.95).
The implementation of a 2-step algorithm (echocardiographic evaluation of resting E/e' followed by the assessment of galectin-3) may improve the diagnosis and prognostic assessment of individuals with suspected heart failure with preserved ejection fraction who are unable to perform a diagnostic exercise test.
本研究旨在通过临床、生化和静息超声心动图标志物，确定一种预测运动时舒张功能异常反应（AbnDR）的策略，用于诊断和评估舒张功能轻度障碍的呼吸困难患者的舒张功能异常。
AbnDR（左心室充盈压增加）可能提示心力衰竭伴射血分数保留（HFpEF）是呼吸困难患者的症状原因，尽管静息时非心脏的非心脏因素不升高。然而，运动试验在有非心脏运动能力限制的患者中可能不明确。
在 171 名疑似 HFpEF 但静息时二尖瓣早期充盈速度/二尖瓣早期环速度峰值比（E/e'）<14 的呼吸困难患者（64±8 岁）中，进行完整的超声心动图（包括评估心肌变形和旋转力学）和血液生物标志物检测。进行最大运动后的超声心动图检查以评估 AbnDR（运动时 E/e' >14）。对患者进行了 26.2±4.6 个月的心血管住院和死亡终点随访。
103 名（60%）患者出现 AbnDR。AbnDR 的独立相关因素为静息 E/e'（比值比[OR]：8.23；95%置信区间[CI]：3.54 至 9.16；p<0.001）、左心室解旋率（OR：0.60；95%CI：0.42 至 0.86；p=0.006）和半乳糖凝集素-3（纤维化标志物）（OR：1.80；95%CI：1.21 至 2.67；p=0.004）。使用静息 E/e' >11.3 和半乳糖凝集素-3<1.17ng/ml 来选择进一步诊断处理的患者，将使 65%的患者避免运动试验，但其代价是 13%的错误分类。心血管住院或死亡的复合结局发生在 47 名患者（27.5%）中。AbnDR 反应和联合策略（静息超声心动图和 galectin-3，或在第一步不确定时进行运动试验）的预测价值显示出相似的事件预测（36 对 34；p=0.95）。
两步算法（静息状态下评估 E/e'，然后评估半乳糖凝集素-3）的实施可能会改善无法进行诊断性运动试验的疑似 HFpEF 患者的诊断和预后评估。
