Estimation of Left Ventricular Filling Pressure with Exercise by Doppler Echocardiography in Patients with Normal Systolic Function: A Simultaneous Echocardiographic–Cardiac Catheterization Study

doi:10.1016/j.echo.2006.10.005

Journal of the American Society of Echocardiography

Volume 20, Issue 5, May 2007, Pages 477-479

https://doi.org/10.1016/j.echo.2006.10.005 Get rights and content

Background

Doppler echocardiography is now used to evaluate left ventricular filling pressures in patients at rest. However, the clinical use of Doppler echocardiography in the determination of filling pressures with exercise has been less well studied.

Objective

The aim of this prospective study was to confirm the validity of an accepted Doppler parameter (ratio of transmitral E velocity to Doppler tissue annular e’ velocity [E/e’]) as a measure of filling pressure in patients with normal systolic function during rest and exercise.

Methods

Twelve patients who presented with symptoms of dyspnea and ejection fraction greater than 50% underwent an exercise right heart catheterization during a symptom-limited bicycle exercise test. Simultaneous Doppler assessment of transmitral flow and tissue Doppler annulus motion was recorded.

Results

The transmitral E velocity increased from 0.88 ± 0.2 to 1.29 ± 0.4 cm/s whereas the mitral annular e’ velocity increased from 0.08 ± 0.02 to 0.11 ± 0.06 with exercise. The E/e’ ratio increased from 11.7 ± 0.5 to 14.4 ± 0.6. Pulmonary artery wedge pressure (PAWP) increased from 14 ± 4 to 23 ± 10 mm Hg at peak exercise. The sensitivity of an E/e’ of 15 or less as a predictor for a normal PAWP during exercise was 89%. Conversely, in all cases where the E/e’ was greater than 15, the PAWP was elevated during exercise.

Conclusion

Noninvasively obtained Doppler of mitral and mitral annulus velocities provides a reliable estimation of PAWP not only at baseline, but also with exercise. Specifically, an E/e’ ratio of greater than 15 during exercise is associated with a significantly elevated PAWP of greater than 20 mm Hg.

Section snippets

Methods

From May 2002 through June 2004, 12 patients with ejection fraction greater than 50% and exertional dyspnea (New York Heart Association class II-III) were prospectively recruited. The inclusion criteria were: (1) age 40 years or older; (2) clinically indicated right heart catheterization; and (3) LV ejection fraction greater than 50%. The exclusion criteria were: (1) more than moderate valvular heart disease or a mitral prosthesis; (2) chronic obstructive lung disease (forced expiratory volume

Results

The clinical, echocardiographic, and catheterization parameters are summarized in Table. The transmitral E velocity increased from 0.88 ± 0.2 to 1.29 ± 0.4 cm/s whereas the mitral annular e’ velocity increased from 0.08 ± 0.02 to 0.11 ± 0.06 with exercise. The E/e’ ratio increased from 11.7 ± 0.5 to 14.4 ± 0.6. The PAWP increased from 14 ± 4 to 23 ± 10 mm Hg at peak exercise.

The noninvasively derived E/e’ versus PAWP for all patients at baseline and peak exercise measurements is shown in Figure.

Discussion

Patients with normal systolic function and hypertension or LV hypertrophy may have limiting symptoms of dyspnea with exertion as a result of diastolic dysfunction.7, 8, 9 Their diastolic filling can be compensated in the baseline state, without rest symptoms. However, during exercise, they are unable to increase cardiac output without an abnormal elevation in left atrial pressure because of the inability of the LV to enhance its diastolic filling. Invasive catheterization studies have

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Cited by (106)

Prognostic Significance of Elevated Left Ventricular Filling Pressures with Exercise: Insights from a Cohort of 14,338 Patients
2024, Journal of the American Society of Echocardiography
Exercise echocardiography can assess for cardiovascular causes of dyspnea other than coronary artery disease. However, the prevalence and prognostic significance of elevated left ventricular (LV) filling pressures with exercise is understudied.
We evaluated 14,338 patients referred for maximal symptom-limited treadmill echocardiography. In addition to assessment of LV regional wall motion abnormalities (RWMAs), we measured patients’ early diastolic mitral inflow (E), septal mitral annulus relaxation (e’), and peak tricuspid regurgitation velocity before and immediately after exercise.
Over a mean follow-up of 3.3 ± 3.4 years, patients with E/e’ ≥15 with exercise (n = 1,323; 9.2%) had lower exercise capacity (7.3 ± 2.1 vs 9.1 ± 2.4 metabolic equivalents, P < .0001) and were more likely to have resting or inducible RWMAs (38% vs 18%, P < .0001). Approximately 6% (n = 837) had elevated LV filling pressures without RWMAs. Patients with a poststress E/e’ ≥15 had a 2.71-fold increased mortality rate (2.28-3.21, P < .0001) compared with those with poststress E/e’ ≤ 8. Those with an E/e’ of 9 to 14, while at lower risk than the E/e’ ≥15 cohort (hazard ratio [HR] = 0.58 [0.48-0.69]; P < .0001), had higher risk than if E/e’ ≤8 (HR = 1.56 [1.37-1.78], P < .0001). On multivariable analysis, adjusting for age, sex, exercise capacity, LV ejection fraction, and presence of pulmonary hypertension with stress, patients with E/e’ ≥15 had a 1.39-fold (95% CI, 1.18-1.65, P < .0001) increased risk of all-cause mortality compared with patients without elevated LV filling pressures. Compared with patients with E/e’ ≤ 15 after exercise, patients with E/e’ ≤15 at rest but elevated after exercise had a higher risk of cardiovascular death (HR = 8.99 [4.7-17.3], P < .0001).
Patients with elevated LV filling pressures are at increased risk of death, irrespective of myocardial ischemia or LV systolic dysfunction. These findings support the routine incorporation of LV filling pressure assessment, both before and immediately following stress, into the evaluation of patients referred for exercise echocardiography.
Utility of E/e′ Ratio During Low-Level Exercise to Diagnose Heart Failure With Preserved Ejection Fraction
2023, JACC: Cardiovascular Imaging
E/e′ ratio during exercise is the key parameter in identifying elevated pulmonary capillary wedge pressure (PCWP), and thus heart failure with preserved ejection fraction (HFpEF). However, its diagnostic value is limited when mitral inflow or tissue velocities are fused during elevated heart rate.
The authors hypothesized that E/e‘ ratio during low-level (20 W) exercise (E/e′_20W) can help diagnose HFpEF.
Ergometric exercise stress echocardiography was performed in 215 dyspneic patients with an EF ≥50%. The authors determined the feasibility of E/e′ ratio at each stage (frequency of patients who had measurable E/e′ without E-A fusion among 215 participants) and examined whether E/e′_20W could predict normal E/e′ ratio during peak exercise (E/e′_peak ≤15). The authors also evaluated whether E/e′_20W could predict normal PCWP during exercise (PCWP <25 mm Hg) in a subset of participants (n = 45) who underwent exercise right heart catheterization.
The feasibility of the E/e′ ratio decreased from 100% at rest to 96.3% during 20-W exercise and 74.9% during peak exercise caused by E-A fusion. In patients with E/e′_peak >15, there was an increase in E/e′ ratio from rest to 20-W exercise (11.2 ± 2.1 to 16.3 ± 3.5; P < 0.0001), but it did not change significantly from 20-W exercise to peak exercise (P = 0.12). E/e′_20W predicted E/e′_peak ≤15 (AUC: 0.91; P < 0.0001) with the cutoff value of ≤12.4 showing high specificity (94%) and positive predictive value (98%). During 20-W exercise, 93% of the HFpEF patients developed PCWP ≥25 mm Hg. E/e′_20W predicted normal PCWP during exercise (AUC: 0.77; P = 0.01) with the cutoff value of ≤12.4 showing high specificity (83%).
E/e′ ratio during low-level exercise is highly feasible and predicts normal E/e′ ratio or PCWP during peak exercise with high specificity. These data suggest that E/e′_20W could be used as an alternative to the peak exercise value to rule out HFpEF in patients with dyspnea.
Current clinical applications of spectral tissue Doppler echocardiography (E/e’ ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved ejection fraction. Revisited 15 years later
2021, Annales de Cardiologie et d'Angeiologie
It is currently well established that more than half of heart failure patients have preserved ejection fraction. The diagnosis of heart failure with preserved ejection fraction is complex in clinical practice despite ESC recommendations issued in 2019. In this context, the demonstration of increased left ventricular filling pressures at rest or during exercise allows a definite diagnosis of heart failure with preserved ejection fraction in patients with signs and/or symptoms compatible with the diagnosis and a preserved ejection fraction. The spectral tissue Doppler-derived E/e’ ratio by transthoracic Doppler echocardiography has been validated in the noninvasive assessment of left ventricular diastolic pressures at rest and during exercise. Several studies report the validity of E/e’ in the diagnosis of heart failure with preserved ejection fraction in patients with both isolated exertional and acute dyspnea, as well as in risk stratification. In light of the current literature, E/e’ deserves to be included on every transthoracic Doppler echocardiography report in patients with suspected heart failure with preserved ejection fraction. This updated review provides an overview of the diagnostic relevance of E/e’ in patients in its two modes of clinical presentation, isolated exertional dyspnea and the decompensated congestive form.
Il est actuellement bien établi que plus de la moitié des patients souffrant d’insuffisance cardiaque ont une fraction d’éjection préservée. Le diagnostic de l’insuffisance cardiaque à fraction d’éjection préservée est complexe en pratique clinique malgré des recommandations de l’ESC publiées en 2019. Dans ce contexte, la mise en évidence d’une élévation des pressions de remplissage ventriculaires gauches au repos ou à l’effort permet un diagnostic sûr de l’insuffisance cardiaque à fraction d’éjection préservée chez les patients avec signes et/ou symptômes compatibles avec le diagnostic et une fraction d’éjection préservée. Le rapport E/e’ en Doppler tissulaire spectral a été validé dans la détermination des pressions diastoliques ventriculaires gauche au repos comme à l’effort en échocardiographie Doppler transthoracique. De nombreuses études rapportent la validité de E/e’ dans le diagnostic de l’insuffisance cardiaque à fraction d’éjection préservée chez les patients souffrant de dyspnée isolée à l’effort comme de dyspnée aiguë ainsi que dans la stratification du risque. À la lumière de la littérature actuelle, E/e’ mérite de figurer sur chaque rapport d’échocardiographie Doppler transthoracique chez les patients suspects d’insuffisance cardiaque à fraction d’éjection préservée. Cette mise au point mise à jour passe en revue la pertinence diagnostique de E/e’ chez les patients suspects d’insuffisance cardiaque à fraction d’éjection préservée tant dans sa forme chronique que dans sa forme décompensée.
Stress Testing in Heart Failure with Preserved Ejection Fraction
2021, Heart Failure Clinics
Left Atrial Strain in Evaluation of Heart Failure with Preserved Ejection Fraction
2020, Journal of the American Society of Echocardiography
Patients with heart failure with preserved ejection fraction (HFpEF) may have elevated left ventricular filling pressure with exercise (LVFP-ex), despite normal LVFP at rest. The aim of this study was to assess the diagnostic value of resting left atrial strain (LAS) in detecting elevated LVFP-ex in patients with dyspnea evaluated on exercise stress echocardiography.
Two-dimensional speckle-tracking analysis for LAS was performed in 669 consecutive patients (mean age, 64 ± 14 years; 53% men) who underwent treadmill echocardiographic evaluation and had left ventricular ejection fractions ≥ 50%. Assessment of LVFP at rest LVFP-ex was based on the 2016 American Society of Echocardiography guidelines for diastolic function assessment. An E/e′ ratio ≥ 15 after exercise is considered to indicate elevated LVFP-ex. A continuous diagnostic score of HFpEF was calculated on the basis of the European Society of Cardiology HFA-PEFF diagnostic algorithm.
LAS_reservoir was lowest in patients with elevated LVFP at rest (n = 81) and lower in those with normal resting filling pressure who developed elevated LVFP-ex (n = 108) compared with those who maintained normal LVFP-ex (29.0 ± 5.2% vs 33.1 ± 5.0% vs 39.3 ± 4.8%, P < .001). Lower LAS_reservoir was associated with worse exercise capacity as assessed by metabolic equivalents, exercise time, and functional aerobic capacity (multivariate-adjusted P values all < .05). In patients with normal or indeterminate LVFP at rest (n = 587), LAS_reservoir and preexercise HFA-PEFF score demonstrated areas under the curve of 0.82 and 0.7, respectively, for elevated LVFP-ex. There were 28% higher odds of developing elevated LVFP-ex per 1% decrease in LAS_reservoir (odds ratio, 0.78; 95% CI, 0.74–0.82). Among patients with intermediate scores (n = 461), 123 developed elevations in LVFP-ex and were classified as having HFpEF per the diagnostic algorithm. The addition of LAS_reservoir improved the diagnostic value of HFA-PEFF score for HFpEF (area under the curve increased from 0.71 to 0.80, P = .01).
LAS_reservoir has potential to identify patients with intermediate scores for HFpEF who may develop elevated LVFP-ex only and is therefore a promising alternative to aid in diagnosis when exercise testing is not feasible.
Impaired Exercise Tolerance in Heart Failure With Preserved Ejection Fraction: Quantification of Multiorgan System Reserve Capacity
2020, JACC: Heart Failure
Exercise intolerance is a principal feature of heart failure with preserved ejection fraction (HFpEF), whether or not there is evidence of congestion at rest. The degree of functional limitation observed in HFpEF is comparable to patients with advanced heart failure and reduced ejection fraction. Exercise intolerance in HFpEF is characterized by impairments in the physiological reserve capacity of multiple organ systems, but the relative cardiac and extracardiac deficits vary among individuals. Detailed measurements made during exercise are necessary to identify and rank-order the multiorgan system limitations in reserve capacity that culminate in exertional intolerance in a given person. We use a case-based approach to comprehensively review mechanisms of exercise intolerance and optimal approaches to evaluate exercise capacity in HFpEF. We also summarize recent and ongoing trials of novel devices, drugs, and behavioral interventions that aim to improve specific exercise measures such as peak oxygen uptake, 6-min walk distance, heart rate, and hemodynamic profiles in HFpEF. Evaluation during the clinically relevant physiological perturbation of exercise holds promise to improve the precision with which HFpEF is defined and therapeutically targeted.

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: Supported by a postdoctoral fellowship grant from the American Heart Association.

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Original articleEstimation of Left Ventricular Filling Pressure with Exercise by Doppler Echocardiography in Patients with Normal Systolic Function: A Simultaneous Echocardiographic–Cardiac Catheterization Study

Background

Objective

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Mayo Clin Proc

J Am Coll Cardiol

Original article
Estimation of Left Ventricular Filling Pressure with Exercise by Doppler Echocardiography in Patients with Normal Systolic Function: A Simultaneous Echocardiographic–Cardiac Catheterization Study