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Acta Medica Mediterranea, 2016, 32: 1985
THE VALUE OF RIGHT VENTRICULAR SYSTOLIC AND DIASTOLIC PARAMETERS TO PREDICT
LONG-TERM OUTCOME AND ALSO HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH
HEART FAILURE
NAHID SALEHI*, MOHAMMAD-REZA SAIDI*, ALIREZA RAI*, HOSNA HOSSEYNI*, PARISA JANJANI*,**, HOOMAN TADBIRI***
*
Departmentof Cardiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran - **Student of PhD
Psychology, faculty of social sciences, Razi university, Kermanshah, Iran- ***IranUniversity of MedicalSciences, Tehran, Iran
Abstract
Background: Along with left ventricular dysfunction as a powerful prognostic marker in patients with heart failure, right ventricular dysfunction has been shown to be a powerful determinant for early and late mortality and morbidity. There is still uncertain
the best echocardiography parameters for predicting clinical outcome in patients with heart failure. The present study assessed the
value of right ventricular systolic and diastolic parameters to predict long-term outcome and also health-related quality of life (QOL)
in patients with heart failure.
Methods: One hundred and forty patients diagnosed as congestive heart failure with left ventricular ejection fraction less than
35% were included into the study. Systolic and diastolic functional status was assessed using tissue Doppler echocardiography and
QOL was also assessed using the SF-36 questionnaire. The patients were followed-up by telephone to determine one-year survival
and rate of re-hospitalization.
Results: The tricuspid annular plane systolic excursion (TAPSE) and right ventricular tissue Doppler imaging systolic velocity
(STDI) were positively and E/Ea ratio were adversely associated with higher QOL score. Using the multivariate linear regression
model, among baseline variables and echocardiography parameters, the level of QOL could predicted by higher STDI (beta = 0.811,
standard error = 0.369, p = 0.030) and lower E/Ea ratio (beta = -0.626, standard error = 0.242, p = 0.011). Also, using the ROC
curve analysis, the systolic parameters of TAPSE and STDI, as well as E/Ea diastolic function index could predict patients’ QOL
level. One-year survival rate was estimated 99.3% and also one-year readmission-free survival rate was also 70.0%. Using the Cox
proportional hazard modeling, none of the baseline demographic, clinical, and echocardiography parameters could predict longterm readmission in heart failure patients.
Conclusion: QOL level in heart failure patients can be predicted by right ventricular systolic parameters of TAPSE and STDI
as well as E/Ea diastolic parameter assessed by tissue Doppler imaging. However, both right ventricular systolic and diastolic parameters may not be helpful to predict the rate of readmission in patients with heart failure.
Keywords: Coronary, Artery, Bypass, Coronary, Artery, Cardiac, Electrophysiology.
Received April 30, 2016; Accepted July 02, 2016
Introduction
Right ventricular function assessed by measuring right ventricular ejection fraction is frequently
determined by some dynamic factors including
right ventricular muscles contraction as well as preload and after load of right ventricle(1). Furthermore,
the right ventricle functional status can be even
affected by function of the left ventricle because of
sharing interventricular septum between the two
ventricles and also due to raised total pulmonary
resistant following left ventricular end diastolic
pressure(2). Along with low left ventricular ejection
fraction as a powerful prognostic marker in patients
with acute myocardial infarction or those who suffer heart failure, right ventricular dysfunction has
been shown to be a powerful determinant for early
and late mortality and morbidity in these patients(3).
In this regard, it has been well shown a shortened
survival in heart failure patients with preserved left
ventricular function but with considerably reduced
right ventricular function(4).
1986
In recent decade, assessing right ventricle by
some techniques such as radionuclide ventriculography and tissue Doppler imaging has been
obtained more details of right ventricular systolic
and diastolic dysfunction(5). In total, there is still
uncertain the best echocardiographic parameters
and their optimal cutoff values for predicting clinical outcome in patients with heart failure. Hence,
the present study aimed to assess the value of right
ventricular systolic and diastolic parameters to predict long-term outcome and health-related quality
of life in patients with heart failure.
Nahid Salehi, Mohammad-Reza Saidi et Al
Study population
The research protocol of this cohort study was
approved by the research and ethics committees at
Kermanshah University of Medical Sciences.
Overall, 140 patients diagnosed as congestive heart
failure with left ventricular ejection fraction less
than 35% were included into the study. The individuals with the history of chronic pulmonary lung disease, or those with underlying nonfunctional valvular heart disease or candidate for coronary revascularization were not eligible toparticipate in the
study. Baseline characteristics including demographics and history of cardiovascular risk factors
were collected by reviewing the hospital files and
those patients with incorrect information were also
excluded from the study.
lus point of tricuspid valve and right ventricle lateral wall motion velocity during systole was measured and categorized as normal right ventricular
systolic function (> 11 cm/msec) and impaired right
ventricular systolic function (>11 cm/msec). For
measuring RVFA, right ventricle was traced in diastole and then in systole and the ratio of these two
tracing was determined and then categorized as normal (> 45%) and impaired (< 45%).
Also, for assessment of right ventricular diastolic dysfunction, Doppler imaging was used to
assess E/A ratio of tricuspid inflow velocity (E/A)
and tissue Doppler imaging for E/Ea ratio of tricuspid (E/Ea). According to these two parameters,
right ventricular diastolic function was categorized
as normal (E/A > 1.5, E/Ea< 8), mild functional
impairment (E/A < 1, E/Ea< 8), moderate functional impairment (E/A 1 -1.5, E/Ea< 7), and severe
functional impairment (E/A > 2, E/Ea> 15).
Systolic pulmonary artery pressure (SPAP) was
measured by Doppler echocardiography and pulmonary hypertension (PHTN) was categorized as
mild (SPAP 40-45 mmHg), moderate (SPAP 46–60
mmHg) or severe (SPAP >60 mmHg). The healthrelated quality of life (QOL) was measured using
the SF-36 questionnaire that its total score rated as
a 0 to 100-point scale, with a higher score on these
questionnaires indicating a better QOL.One year
after initial assessment, all patients were followedup by telephone to determine one-year survival and
rate of re-hospitalization.
Study measurement
All participants were initially assessed by
echocardiography using a Vivid 4 system and right
ventricular systolic function was determined by
measuring echocardiography parameters of the tricuspid annular plane systolic excursion (TAPSE),
right ventricular tissue Doppler imaging systolic
velocity (STDI), and right ventricular fractional
area (RVFA). To assess TAPSE value, M-mode cursor was placed through the lateral aspect of the tricuspid annulus in real time using the apical four
chamber view and then right ventricular base-toapex shortening during systole was measured. In
this regard, severity of right ventricular systolic
dysfunction was graded as normal (TAPSE > 2.4
cm), mild (2.0 to 2.4 cm), moderate (1.6 to 2.0 cm)
and severe (< 1.6 cm) according to the American
Society of Echocardiography guidelines(6).
For assessing STDI, tissue Doppler was placed
through the lateral wall of right ventricle on annu-
Statistical analysis
Results were presented as mean ± standard
deviation (SD) for quantitative variables and were
summarized by frequency (percentage) for categorical variables. Continuous variables were compared
using t test Non-parametric Mann-Whitney test
whenever the data did not appear to have normal distribution or when the assumption of equal variances
was violated across the study groups. Categorical
variables were, on the other hand, compared using
chi-square test. Correlation between quantitative
variables was tested by the Pearson’s correlation test.
Main echocardiography and clinical determinants of
QOL was determined using the multivariate linear
regression modeling. The value of each echocardiography parameters for predicting long-term survival
and hospitalization rate was examined using the
Cox-proportional hazard analysis. Also, the ROC
curve analysis was used to assess the value of
echocardiography parameters to predict long-term
Methods
The value of right ventricular systolic and diastolic parameters to predict long-term...
mortality and re-hospitalizations. The one-year survival rate and admission-free survival rate were also
assessed using the Kaplan-Mayer survival curve. For
the statistical analysis, the statistical software SPSS
version 21.0 for windows (SPSS Inc., Chicago, IL)
was used. P values of 0.05 or less were considered
statistically significant.
Results
Of 140 included patients, 67 had right ventricular failure as the case and 73 had normal right ventricular functional status as the control. the patients in the
case group was significantly younger than those in
control group with the mean age 56.80 ± 4.64 years
and 60.46 ± 6.22 years respectively (p < 0.001).
Regarding gender distribution, 32.8% in case group
and 46.6% in control group was male with no significant difference (p = 0.097). With respect to prevalence of cardiovascular risk factors, 65.7% in case
group and 74.0% in control group were diabetic (p =
0.284), 25.4% in case group and 32.9% in control
group were hypertensive (p = 0.330), 42.4% in case
group and 17.8% in control group had history of
hyperlipidemia (p = 0.001), and also 16.7% in case
group and 32.9% in control group were smoker (p =
0.028). In this regard, the prevalence rate of hyperlipidemia was higher in patients with right ventricular
failure, while current smoking was more frequent in
those patients with normal right ventricular function.
According to grading right ventricular functional status based on TAPSE value in the case group,
10.4% had mild right ventricular systolic dysfunction, 82.1% had right ventricular systolic dysfunction, and 7.5% had severe right ventricular systolic
dysfunction. Also, according to the definition of right
ventricular diastolic function status according to the
values of E/A and E/Ea ratios, in the case group with
right ventricular failure, 65.7% had mild diastolic
dysfunction, 26.9% had moderate diastolic dysfunction, and 7.4% had severe diastolic dysfunction;
while in control group, normal diastolic function was
revealed in 45.2%, whereas mild and moderate diastolic dysfunction was also found in 53.4% and 1.4%,
respectively. Comparing echocardiography parameters of right ventricular systolic and diastolic function lower mean TAPSE as well as lower mean
RVFA and STDI parameters in the patients with right
ventricular dysfunction than in normal right ventricular function group, while no difference in the mean
right ventricular diastolic functional parameters
including E/A ratioand E/Ea ratio between the two
1987
groups. The average PAP in the group with diastolic
dysfunction was 22.57 ± 4.63 mmHg and in those
with normal diastolic function was 21.53 ± 9.76
mmHg with no inter-group difference (p = 0.432).
Assessing QOL in the two groups with and without
diastolic dysfunction using the SF-36 tool showed
lower level of QOL in the former group with mean
total QOL score 45.55 ± 3.27 and 46.55 ± 2.60,
respectively (p = 0.047). Regarding association
between right ventricular systolic and diastolic function parameters, direct association was revealed
between the different parameters indicating right
ventricular systolic functional status including
TAPSE, RVFA, and STDI. Also, direct association
was found between the two parameters indicating
right ventricular diastolic function status including
E/A ratio and E/Ea ratio, while no association was
found between the right ventricular systolic and diastolic function parameters.
With respect to the relationship between
echocardiography indices and QOL total score,
TAPSE and STDI were positively and E/Ea were
adversely associated with higher QOL score. using
the multivariate linear regression model, among
baseline variables and echocardiography parameters,
the level of QOL could predicted by higher STDI
(beta = 0.811, standard error = 0.369, p = 0.030) and
lower E/Ea ratio (beta = -0.626, standard error =
0.242, p = 0.011). This model also showed that male
gender was an indicator for poorer QOL (beta = 1.183, standard error = 0.544, p = 0.031).
Also, using the ROC curve analysis, the systolic parameters of TAPSE and STDI, as well as
E/Ea diastolic function index could predict patients’
QOL level. One-year mortality rate in our study was
0.7% (death was occurred in a patient with normal
right ventricular function), while readmission was
reported in 30% of survived patients (34.3% in the
group with right ventricular dysfunction and 26.0%
in those with normal right ventricular function, p =
0.284). In this regard, one-year survival rate was estimated 99.3% and also one-year readmission-free survival rate was also 70.0%.
Using the Cox proportional hazard modeling,
none of the baseline demographic, clinical, and
echocardiography parameters could predict longterm readmission in heart failure patients.
According to the ROC curve analysis; none of
the systolic and diastolic right ventricular function
parameters could predict readmission within one
year after discharge.
1988
Discussion
In patients with heart failure, deterioration of
right ventricular dysfunction can predispose
patients to poorer early and long-term outcome
through inducing malignant ventricular arrhythmias
and progression of ischemic or dilated cardiomyopathy. This mechanism may explain higher rate of
mortality and morbidity as well as poor long-term
survival. In the present study we suggested that
right ventricular dysfunction assessed by echocardiography parameters not only can predict adverse
clinical outcome, but also can predict low QOL
level in heart failure patients. In this context, we
aimed to first assess both systolic and diastolic
echocardiography functional parameters and then to
examine the value of these parameters to predict
one-year clinical outcome and also the level of
QOL in the patients.
The present study had some important points.
First, in parallel to previous observations, different
systolic parameters were simultaneously changed
by deteriorating heart failure and this changing
process can also occurred in diastolic functional
indices, however more interestingly, we could not
show association between systolic and diastolic
echocardiography parameters indicating independently changes in these indicators. On the other
hand, deterioration of right ventricular diastolic
dysfunction may be occurred with preserved right
ventricular diastolic function and vice versa.
Another important finding was that systolic and
diastolic echocardiography functional parameters
could effectively predict poorer QOL that was also
confirmed in multivariable regression models with
the presence of baseline variables.
On the other hand, the deterioration of both
systolic and diastolic dysfunction can result in
lower QOL level in heart failure patients. The QOL
in patients with cardiovascular disease consists of
different physical, psychological, and social components. It seems that because of the close association between patients’ functional capacity and heart
failure status, lowering the level of physical function component of QOL and echocardiography
functional parameters of right ventricle can be
explained. There is two important points regarding
association between right ventricular functional status and QOL level.
First, our findings can successfully show that
the measurement of STDI parameter as an indicator
for right ventricular systolic function provide com-
Nahid Salehi, Mohammad-Reza Saidi et Al
plementary information with a high power to predict poor QOL level probably because of potential
effects of right ventricular systolic dysfunction on
physical function capacity. Another point is that the
parameters assessed by tissue Doppler imaging can
more successfully predict long-term adverse events
and poorer QOL level than parameters assessed by
two-dimensional echocardiography.
In fact, the presence of high SPAP may not be
able to predict poor outcome in heart failure, but
may augment the role of right ventricular dysfunction to predict poor clinical outcome in heart failure
patients. In summary, among different echocardiography parameters of right ventricular function,
STDI (as an indicator for systolic function) and
E/Ea ratio (as an indicator for diastolic function)
can predict quality of life in patients with heart failure. In this regard, long-term readmission may not
be predicted by echocardiography right ventricular
functional parameters. Also, elevated SPAP alone
may not be able to predict poor prognosis in heart
failure patients, but may augment the role of systolic or even diastolic function parameters to predict poor outcome.
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Corresponding author
HOOMAN TADBIRI
Iran University of Medical Sciences, Tehran
Email: [email protected]
(Iran)
1989