Incremental prognostic and diagnostic value of exercise echocardiography in patients with indeterminate or abnormal diastolic function

Background Exercise echocardiography (ExE) may assess LV systolic and diastolic function (DF). We aimed to assess the diagnostic and prognostic value of diastolic parameters at exercise (ratio of early LV inflow velocity to early tissue Doppler septal annulus velocity [E/e'] and systolic pulmonary artery pressure [sPAP]) in patients with indeterminate or abnormal resting DF referred for a clinically indicated ExE. Methods Data from 299 patients (72±9 years, 50% women) with LV-DF evaluated according to EACVI-Guidelines 2016, and LVEF ≥50 were extracted from our database. LV systolic and DF and mitral regurgitation (MR) were evaluated at rest. At peak exercise we assessed regional/global LV systolic function, MR, E/e', and sPAP. Abnormal ExE was defined as ischemia or fixed wall motion abnormalities, elevated E/e'values as >15 at rest and at exercise. Considered events were overall mortality, myocardial infarction, admission for unstable angina or cardiac failure, revascularization, pulmonary thromboembolism, and stroke. Results Abnormal resting DF was present in 221 patients (29%), indeterminate in 78 (10%). Exercise E/e' >15 was found in 37% of patients with abnormal DF, and in 21% with indeterminate DF; exercise E/e >15 plus sPAP>51 mmHg in 13% with abnormal DF, and in 9% with indeterminate DF. Based on exercise E/e' >15 (n=16), change from altered relaxation to restrictive pattern with exercise (n=8), or maintenance of a restrictive pattern for >65 years (n=4), indeterminate DF was reclassified to abnormal DF in 28/78 patients (36%). Among the other 50 patients with indeterminate DF and exercise E/e' ≤15, sPAP>51 mmHg was found in 21, having these subjects altered relaxation at rest and at exercise (n=19) or atrial fibrillation (n=2). Abnormal ExE was seen in 18% of patients with indeterminate resting DF, in 30% with abnormal resting DF, and in 40% with raised exercise E/e'. During median follow-up of 1 year (25th-75th percentiles 0.4–1.7) there were 53 events including 12 deaths, 6 myocardial infarctions, and 18 cardiac failures. Independent predictors were history of coronary disease (HR=2.50, 95% CI=1.31–4.75, p=0.005), ACEI/ARAII (HR=0.43, 95% CI=0.23–0.81, p=0.008), positive clinical or exercise ECG testing (HR=2.42, 95% CI=1.33–4.40, p=0.004), peak LVEF (HR=0.94, 95% CI=0.92–0.96, p<0.001), significant exercise MR (HR=3.96, 95% CI=1.58–9.97, p=0.004) and peak E/e'(HR= 1.06, 95% CI=1.02–1.10, p=0.004). Annualized event rates were 59% in patients with (+) ExE plus raised exercise E/e', 24% in those with (+) ExE and normal exercise E/e', 14% in (−) ExE and raised exercise E/e', and 5.4% with both variables normal (Figure). Conclusions ExE reclassified 21 to 36% of patients with indeterminate DF to abnormal DF, and was able to detect non-cardiac exercise-induced pulmonary hypertension. E/e'at postexercise further predicted outcome on top of ExE results in patients with indeterminate or abnormal resting DF. FUNDunding Acknowledgement Type of funding sources: None.

Additive prognostic value of exercise echocardiography in symptomatic patients with normal or abnormal left ventricular diastolic function

Background Exercise echocardiography (ExE) may assess left ventricular (LV) systolic and diastolic function. We aimed to assess the value of diastolic parameters at exercise (early LV inflow velocity to early tissue Doppler annulus velocity [E/e']) in patients with normal or abnormal resting diastolic function (DF) referred for a clinically indicated ExE. Methods LV systolic and DF according to EACVI Guidelines-2016, and mitral regurgitation (MR) were evaluated at rest in 773 patients (age 67±12 years) with preserved LVEF (≥50). At peak exercise we assessed regional/global LV systolic function, MR and E/e'. Abnormal ExE was defined as ischemia or fixed wall motion abnormalities and raised E/e'values as >15 at rest and at exercise (e' at the septal level). Patients were grouped as complaining or not of dyspnea. Events were overall mortality, myocardial infarction, admission for unstable angina or cardiac failure, coronary revascularization, pulmonary thromboembolism, and stroke. Results Abnormal resting DF was present in 221 patients (29%), indeterminate in 78 (10%). Percentages were similar among the 431 patients with dyspnea (27%/11%) and the 342 without (31%/ 9%), as they were E/e values >15 at rest and at exercise (16% and 18% with dyspnea; 16% and 21% without). Exercise E/e' >15 was found in 37% of patients with abnormal DF, 21% with undeterminate DF, and 6% with normal DF (p<0.001). Patients with abnormal resting DF had more frequently abnormal ExE (30%) in comparison with indeterminate (18%) or normal DF (17%, p<0.001). Patients with abnormal ExE had more frequently abnormal resting DF than patients with normal ExE (42% vs 25%, p<0.001) and similar indeterminate DF (9% vs 10%). Also, they had raised E/e' values at rest in 29% and at exercise in 25%, in comparison with normal ExE (16% at rest, 13% at exercise, both p<0.001). During median follow-up of 0.9 years (25–75th percentiles 0.4–1.7) there were 109 events. Independent predictors were age (HR=1.03, 95% CI=1.01–1.06, p=0.001), male gender (HR=2.00, 95% CI=1.31–3.07, p=0.001), history of coronary disease (HR=1.63; 95% CI=1.05–2.51, p=0.03), positive clinical or exercise ECG testing (HR=1.92, 95% CI=1.31–2.81, p=0.001), peak exercise LVEF (HR=0.93, 95% CI=0.91–0.94, p<0.001), and exercise E/e'(HR= 1.05, 95% CI=1.01–1.08, p=0.009). Neither resting E/e' values nor resting abnormal DF by EACVI Guidelines-2016 were independent predictors. Annualized event-rates were 38% in patients with (+) ExE plus (+) exercise E/e', 21% in those with (+) ExE and (−) exercise E/e', 11.5% in (−) ExE and (+) exercise E/e', and 3.7% with both variables normal (Figure). Conclusions Diastolic dysfunction results at rest and at exercise were similar between patients with or without dyspnea referred for ExE, but they were associated to abnormal ExE. Exercise E/e' reclassified 21% of patients with indeterminate DF and further predicted outcome on top of ExE results. FUNDunding Acknowledgement Type of funding sources: None.

Role of Exercise Echocardiography to Predict Coronary Artery Disease

Background: Coronary artery disease (CAD) is predicted to be the most common cause of death globally. Early detection of coronary artery disease and adequate management can reduce CAD related morbidity and mortality. Various non-invasive procedures have been developed to diagnose CAD. Stress echocardiography, myocardial perfusion (SPECT) and cardiac MRI are accepted as useful tools for evaluation of inducible myocardial ischaemia in intermediate risk group patient documented by pre test probability. Among them exercise echocardiography is a remarkable physiological, safe, feasible and cost effective. Objective: To see the role of exercise echocardiography to predict CAD. Materials and methods: This cross sectional study was conducted in University Cardiac Center (UCC), BSMMU. This study include the patients who are appointed for exercise tolerance test (ETT). Echocardiographic wall motion study was recorded at rest and after peak exercise and analyzed to diagnosis the regional wall motion abnormality. Specific CAD was confirmed by coronary angiogram. Results: A total of 40 patients were included in the study from the patients who are appointed for ETT. Patients diagnosed as CAD has the mean age of 50.6 ± 9.7 years and majority of the patients were male (72.5%). Sensitivity, specificity, positive predictive value and negative predictive value of exercise echocardiography were 85.5%, 76.9%, 88.5% and 71.4% respectively in predicting coronary artery disease by exercise echocardiography. The predominant risk factors was hypertension (40.0%) followed by diabetes mellitus, smoking, dyslipidaemia and family H/O CAD were significantly associated with the development of CAD in the study subjects. Conclusion: Treadmill exercise stress echocardiography demonstrates high significance for diagnosis of CAD. University Heart Journal Vol. 17, No. 2, Jul 2021; 114-117

Assessment of right ventricular function during exercise echocardiography in adult patients with tetralogy of Fallot

Funding Acknowledgements Type of funding sources: None. Introduction The evaluation of right ventricular (RV) function in patients with tetralogy of Fallot (TF) is important as it could impact outcome. Further exhaustive assessments with exercise might offer added information. We aimed to evaluate different parameters of RV function and their changes during exercise echocardiography (ExE) in patients with TF, and to correlate them with functional capacity Methods Treadmill ExE was performed in 31 consecutive patients with corrected TF (mean age 36 ± 11, 22 male), all of them asymptomatic. Left ventricular function was studied at peak exercise, whereas RV function parameters were acquired during the immediate post-exercise period (<1.5 min), along with mitral, tricuspid and pulmonary regurgitation (PR), transtricuspid and transpulmonary systolic gradients, and LV-E/e´ values. RV function was assessed by tricuspid annulus plane systolic excursion (TAPSE), S wave velocity in the RV lateral annulus, and RV area change. A blunted functional capacity (BFC) was considered in case of achieving <100% of the predicted metabolic equivalents (METs) during ExE, according to age and gender. Results Only 1 patient had symptoms during ExE (dyspnea). Achieved METs were 13 ± 3.5 and 10 patients (32%) had BFC. LV ejection fraction (%) changed with exercise from 58 ± 10 to 63 ± 9 (p = 0.05) and E/e´ from 11 ± 4 to 10 ± 3 (p = 0.04). TAPSE did not change (19 ± 5 at rest; 21 ± 7 at exercise; p = NS), neither RV area change (41 ± 11 cm2 at rest; 39 ± 12 cm2 at exercise; p = NS), whereas TDI-S increased from 10.5 ± 2.8 to 13.8 ± 3.1 cm2/s (p < 0.001), and systolic pulmonary pressure from 20 ± 8 to 27 ± 12 mmHg (p = 0.001). Patients with BFC had more frequently significant PR at rest (60% vs 14%; p = 0.015), lower peak systolic blood pressure (152 ± 30 vs 176 ± 24 mmHg, p = 0.02) and higher exercise E/e´ (12.6 ± 2.7 vs 8.9 ± 3.0; p = 0.003), without differ in other parameters. Δ-TDI-S correlated with achieved METs and with the percent achieved of predicted METs (r = 0.46; p = 0.01, y r = 0.47; p = 0.008, respectively). In conclusion, TDI-S assessment at the tricuspid annulus is a useful parameter for assessing RV function during exercise in subjects with TF. Abstract Figure.

Sex difference in pulmonary hypertension in the evaluation by exercise echocardiography

Male patients with pulmonary hypertension have poor survival than their female counterparts. Poor right ventricular function in men may be one of the major determinants of poor prognosis. This study aimed to investigate the difference in hemodynamics during exercise between men and women by exercise echocardiography. Consecutive patients with pulmonary hypertension who underwent right heart catheterization were enrolled, and survival was analyzed. In patients who underwent exercise echocardiography, the change in tricuspid regurgitation pressure gradient during exercise was calculated at multiple stages (low-, moderate-, and high-load exercise), and the mortality was also recorded. In a total of 93 patients, although there were no differences in pulmonary artery pressure and vascular resistance between sexes, male patients showed poor survival. In patients with exercise echocardiography, change in tricuspid regurgitation pressure gradient at low-load (25 W) exercise was significantly lower in men, although that at maximum-load exercise was not different between men and women. In the Kaplan–Meier analysis, in a median follow-up duration of 1760 days, male patients and those with lower change in tricuspid regurgitation pressure gradient at low-load exercise showed poorer survival ( P = 0.002 and 0.026, respectively). In the Cox proportional hazards analysis, the change in tricuspid regurgitation pressure gradient at low-load exercise was independently associated with poor survival after adjustment for age and sex. In conclusion, a lower change in tricuspid regurgitation pressure gradient at low-load exercise was observed in male patients and was a prognostic marker, which may be associated, at least in part, with poorer prognosis in male patients with pulmonary hypertension.