Download Correlation of the Tei Index With Left Ventricular Dilatation - J

Correlation of the Tei Index With Left Ventricular
Dilatation and Mortality in Patients With Acute
Myocardial Infarction
Isil
¸ UZUNHASAN,1 MD, Khalid BADER,1 MD, Bans¸ OKÇUN,1 MD,
MUTLU,1 MD
Ali Can HATEMI,1 MD, and Hasim
¸
SUMMARY
The Tei index is an echocardiographic index of combined systolic and diastolic function, calculated as isovolumetric relaxation time plus isovolumetric contraction time
divided by ejection time. The aim of this study was to define the correlation of the Tei
index with left ventricular dilatation and mortality in patients with acute myocardial infarction (AMI).
A total of 77 patients (58 men, 19 women) with a mean age of 53 ± 12 years, who
had presented with an AMI in our clinic between June 2001 and February 2002 were compared with a control group of 88 healthy subjects (63 men, 25 women) with a mean age
of 55 ± 6 years. Echocardiographic evaluation was carried out within 24 hours and the
third month of AMI, using a 3.5 MHz probe with pulse wave Doppler recordings by the
adult cardiac mode of an Acuson C 256 echocardiograph.
There were statistically significant differences between the 2 groups in all echocardiographic parameters, except mitral A wave. Thirteen patients died during the follow-up
period of 3 months. The Tei index was significantly higher in the patients who died compared with those who survived (0.70 ± 0.10 versus 0.61 ± 0.10; P < 0.001). The patients
who had heart failure after AMI had a mean Tei index value of 0.76 ± 0.27, whereas the
patients who did not have heart failure after AMI had a significantly lower Tei index
value of 0.60 ± 0.32 (P < 0.05). Patients were divided into 2 groups according to their
Tei index. Patients with a > 0.60 Tei index had significantly higher end-systolic and enddiastolic volumes compared to patients with a < 0.60 Tei index (P < 0.001 for both) in
the acute phase of AMI. Within 3 months, patients with a Tei index < 0.60 had a significant reduction in end-diastolic volumes (P < 0.01), whereas the end-diastolic volumes did
not change significantly in patients with an index > 0.60 (P = 0.19).
The Tei index is an important indicator of left ventricular dysfunction and death after
AMI. A greater Tei index at the onset of AMI is associated with a higher incidence of
subsequent cardiac death, CHF, and progressive LV remodeling. (Int Heart J 2006; 47:
331-342)
Key words: Tei index, Acute myocardial infarction, Mortality, Left ventricular dysfunction
From the 1 Department of Cardiology, Medical Faculty, Istanbul University, Istanbul, Turkey.
Address for correspondence: Uzunhasan Isil,
¸ MD, Department of Cardiology, Medical Faculty, Istanbul University, Ataköy
9. Klslm B-6 Blok Daire 58 Baklrköy, Istanbul, Turkey.
Received for publication November 14, 2005.
Revised and accepted February 16, 2006.
331
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MYOCARDIAL remodeling after acute myocardial infarction (AMI) is a process of progressive left ventricular (LV) dilation that contributes to the development of cardiac failure and late mortality.1) AMI results in both left ventricular
systolic and diastolic dysfunction, which have independent prognostic value.2,3)
Doppler echocardiography is a rapid, feasible, and simple noninvasive
method of assessing the prognostic factors in AMI. Clinical data demonstrate that
Doppler echocardiography provides important information about left ventricular
diastolic function and early dilatation after infarction in AMI patients.1,4,5)
In recent years, some researchers have been working on a new diagnostic
method besides EF. This new method, known as the Tei method or myocardial
performance index (MPI), was first defined by Chuwa TEI and is still at the stage
of research.6) This index is used to evaluate both the systolic and diastolic functions of the ventricle.7) In this study, we evaluated the predictive value of this new
index on the clinical parameters of mortality, CHF, and left ventricular dilatation
in patients with acute myocardial infarction.
METHODS
We prospectively studied 77 consecutive patients (58 men, 19 women; mean
age, 53.7 years) with a diagnosis of transmural first MI referred to the intensive
care unit of Istanbul University Institution of Cardiology between June 2001 and
February 2002. AMI was diagnosed on the basis of a combination of typical anginal pain of at least 30 minutes in duration, diagnostic serial electrocardiographic
changes consisting of new pathological Q waves with or without ST and T wave
changes and a typical rise and fall in the concentration of serum total creatine
kinase or creatine kinase MB. Exclusion criteria included the presence of atrial
fibrillation, a permanent pacemaker, dementia, aortic stenosis, inappropriate
Doppler recordings, and chronic obstructive lung disease. Normal values of time
intervals in the Doppler indexes were assessed in 88 healthy volunteers (63 men,
25 women; mean age, 55.8 years) with no history of cardiovascular diseases and
normal results on electrocardiography and 2-dimensional and Doppler echocardiography. The mean age of the control group was 55.8 ± 6.9 years. All patients
with AMI were given standard aspirin, β-blockers, nitrates, ACE inhibitors, and
thrombolytic treatment.
The protocol was approved by the regional scientific ethical committee, and
all enrolled patients gave written, informed consent.
Echocardiography was performed within 24 hours of arrival at the coronary
care unit using an Acuson C256 echocardiography system with a 3.5-MHz transducer, and repeated after 90 days in all surviving patients.
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TEI INDEX IN ACUTE MYOCARDIAL INFARCTION
333
Figure 1. Measurement of Tei index.
Mitral inflow was recorded with the transducer in the apical 4-chamber
view. The pulsed wave Doppler beam was aligned as perpendicular as possible to
the plane of the mitral annulus. The Doppler sample volume was placed between
the tips of the mitral leaflets during diastole. The LV outflow velocity curve was
recorded from the apical long-axis view with the Doppler sample volume positioned just below the aortic valve. Time intervals for calculating the myocardial
performance index (Tei index) were measured from mitral inflow and LV outflow
recordings, as illustrated in Figure 1. Three consecutive beats were measured and
averaged for each Doppler variable.
Left ventricular ejection fraction (EF) was estimated by the Simpson
method using apical 4-chamber views of left ventricular end-systolic volume
(LVESV) and left ventricular end-diastolic volume (LVEDV) values.
The echocardiographic parameters of the subgroups of AMI patients who
died and survived, and patients who had clinical heart failure with those who had
not were compared.
Patients also were divided into 2 groups according to their Tei index value
(< or > 0.60) and compared by echocardiographic and critical analysis.
Statistical analysis: The data were analyzed statistically by Epi-Info 2000 software program using the Student t-test, paired t-test, Mann-Whitney U test, chi-
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UZUNHASAN, ET AL
square, Fisher exact chi-square test, and/or Pearson correlation analysis test.
The level of statistical significance was defined as a P value less than 0.05.
RESULTS
A total of 77 AMI patients (58 males, 19 females; mean age, 53.7 ± 12.0
years) and 88 healthy subjects (63 males, 25 females; mean age, 55.8 ± 6.9 years)
Table I. Distribution of Patients and Healthy Control Group According to
Sociodemographic Variables and Risk Factors
Male
Age (years)
Height (cm)
Weight (kg)
BMI (kg/m2)
Family history of AMI
Hypertension
Diabetes mellitus
Smoking
Anterior MI
Inferior MI
Q-Wave MI
Patients with AMI
(n = 77)
Healthy control
group (n = 88)
58 (75.3%)
53.7 ± 12.0
167.0 ± 7.3
75.3 ± 10.4
27.0 ± 3.5
12 (15.6%)
36 (46.8%)
25 (32.5%)
53 (68.8%)
41 (53.2%)
27 (35.0%)
68 (88.3%)
30 (34.1%)
55.8 ± 6.9
164.2 ± 8.5
67.9 ± 11.1
25.2 ± 3.8
3 (3.4%)
28 (31.8%)
-
P
0.001
0.18
0.02
0.001
0.001
0.007
0.001
0.001
0.001
Values are given as n (%) or mean ± standard deviation.
BMI indicates body mass index; AMI, acute myocardial infarction; and
MI, myocardial infarction.
Table II. Echocardiographic Parameters of Patients and Healthy Control Group
Echocardiographic parameter
LVDD (cm)
LVSD (cm)
LVEDV (cm3)
LVESV (cm3)
EF (%)
Mitral E wave (cm/sec)
Mitral A wave (cm/sec)
Deceleration time for E wave (msec)
IRT (msec)
ICT (msec)
ET (msec)
Tei index
Patients with AMI
(n = 77)
Healthy control
group (n = 88)
P
5.1 ± 0.5
3.5 ± 0.7
123.0 ± 23.7
69.1 ± 23.0
44.1 ± 9.0
0.6 ± 0.2
0.6 ± 0.1
162.5 ± 0.4
78.4 ± 9.9
76.1 ± 16.6
252.6 ± 35.5
0.63 ± 0.1
4.7 ± 0.4
2.8 ± 0.5
101.3 ± 22.4
35.9 ± 11.0
69.2 ± 6.9
0.9 ± 0.2
0.7 ± 0.4
196.1 ± 32.2
83.4 ± 9.9
43.9 ± 11.0
326.1 ± 21.0
0.39 ± 0.03
0.001
0.001
0.001
0.001
0.001
0.001
0.589
0.001
0.002
0.001
0.001
0.001
Values are given as mean ± standard deviation.
LVDD indicates left ventricular diastolic diameter; LVSD, left ventricular systolic
diameter; LVEDV, left ventricular end-diastolic volume; LVESV, left ventricular endsystolic volume; EF, ejection fraction; IRT, isovolumetric relaxation time; ICT, isovolumetric contraction time; and ET, ejection time.
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TEI INDEX IN ACUTE MYOCARDIAL INFARCTION
were included in the study. The distribution of subjects in the study groups
according to sociodemographic variables and risk factors for AMI is presented in
Table I. The frequencies of risk factors for AMI regarding age, gender, history of
diabetes mellitus, history of hypertension, serum cholesterol, and smoking status
were found to be significantly higher in the patient group, as expected.
The echocardiographic parameters of ejection fraction (EF), deceleration
time for E wave, isovolumetric relaxation time (IRT), and ejection time (ET)
were significantly lower and isovolumetric contraction time (ICT) was significantly longer in the patient group compared with the healthy group of individuals
(P < 0.001) (Table II). The Tei index was also significantly higher in the patient
group (0.63 ± 0.10 versus 0.39 ± 0.03) compared with the healthy control group
(P < 0.001) (Table II).
During the 3 month follow-up period of the 77 patients with AMI, 13
Table III. Echocardiographic Parameters of Surviving Versus Dead Patients
Tei index
IRT (ms)
ICT (ms)
ET (ms)
EF (%)
LVEDV (cm3)
LVESV (cm3)
Age
Mitral E wave/Mitral A wave
DT for E wave (ms)
DT for A wave (ms)
Surviving patients
Dead patients
P
0.61 ± 0.1
79.2 ± 9.6
73.3 ± 14.8
258.9 ± 33.6
46.5 ± 7.3
119.0 ± 17.8
63.6 ± 14.7
51.5 ± 11.3
0.9 ± 0.3
132.2 ± 28.4
54.7 ± 12.5
0.7 ± 0.1
74.5 ± 10.6
90.2 ± 18.6
221.6 ± 28.2
32.3 ± 7.6
142.9 ± 36.9
95.7 ± 36.0
64.4 ± 9.9
0.7 ± 0.3
168.7 ± 30.2
58.0 ± 10.2
0.001
0.10
0.001
0.001
0.001
0.004
0.001
0.001
0.02
0.001
0.10
Values are given as mean ± standard deviation.
IRT indicates isovolumetric relaxation time; ICT, isovolumetric contraction
time; ET, ejection time; EF, ejection fraction; LVEDV, left ventricular enddiastolic volume; LVESV, left ventricular end-systolic volume; and DT, deceleration time.
Table IV. Left Ventricular End-diastolic and End-systolic Volume for Patients
With a Tei Index > 0.60 and < 0.60 Taken in the Acute Phase of MI and 3 Months
Later
Tei index > 0.60
(n = 27)
Tei index < 0.60
(n = 37)
LVEDV (cm )
LVESV (cm3)
LVEDV (cm3)
LVESV (cm3)
3
Initial
3 months later
P
122.7 ± 21.5
70.7 ± 16.3
116.3 ± 14.3
58.5 ± 11.0
161.5 ± 16.6
92.3 ± 17.0
113.0 ± 20.9
53.3 ± 15.2
0.001
0.001
0.19
0.01
Values are given as mean ± standard deviation.
LVEDV indicates left ventricular end-diastolic volume and LVESV, left ventricular end-systolic volume.
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(16.6%) patients died due to sudden cardiac death, 22 (28.5%) patients developed
CHF (Killip V > II or NYHA > grade II), 2 patients developed reinfarction, and
34 patients underwent revascularization procedures.
When the echocardiographic parameters of survival versus death and CHF
positive versus negative patients were compared, a high Tei index, short ejection
time, low EF, increased age (not for heart failure), and increased left ventricular
diastolic and systolic diameter were defined as risk factors for mortality and CHF
(Tables III, IV).
Figure 2. Comparison of the mortality rates in patients with a Tei index > 0.60 and < 0.60.
Figure 3. Comparison of the incidence of heart failure in patients with a Tei index > 0.60
and < 0.60.
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TEI INDEX IN ACUTE MYOCARDIAL INFARCTION
337
Figure 4. Comparison of incidences of Tei index > 0.60 and < 0.60 in patients with inferior
and anterior MI.
The mortality and heart failure rate in patients with a Tei index > 0.60 and <
0.60 were compared. In the high Tei index (> 0.60) group, 12 patients died
(30.8%) and 19 developed heart failure (48.7%), while in the low Tei index (<
0.60) group only one patient died (2.6%) and 3 (7.9%) developed heart failure (P
= 0.001 for both) (Figures 2 and 3).
When anterior and inferior infarctions were compared regarding the Tei
index values, in patients with anterior infarction, the ratio of patients with a Tei
index > 0.60 was higher (63.4%) than patients with inferior infarctions (29.7%)
(P = 0.001) (Figure 4).
For patients with a Tei index > 0.60, both LVEDV and LVESV increased
significantly at the end of 3 months. On the other hand, for patients with a Tei
index < 0.60, LVESV decreased significantly and LVEDV did not change.
DISCUSSION
In this study, we evaluated the correlations between MPI, also called the Tei
index, with left ventricular dilatation, CHF, and cardiac mortality rates following
AMI. We concluded from the results that the echocardiographic parameters of
patients with AMI were significantly different from those of the healthy group of
individuals. The Tei index was also significantly higher in the patient group compared with the healthy control group. A high Tei index (> 0.60), short ejection
time, low EF, increased age, and increased left ventricular diastolic and systolic
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May 2006
diameter were defined as risk factors for mortality and CHF.
We first compared the echocardiographic parameters of patients who
recently had AMI and parameters of a healthy group in this study. As expected,
the EF, deceleration time for E wave, IRT, and ET were found to be significantly
lower whereas ICT was significantly longer in patients with myocardial infarction compared with healthy individuals. In accordance with these results, the Tei
index and both systolic and diastolic left ventricular diameters were higher in
patients with myocardial infarction compared with the healthy control group.
AMI is characterized by loss of contractile tissue and changes of ventricular
geometry.8,9) The life expectancy of the AMI patient greatly depends on protection of the remaining contractile elements, and the maintenance of the optimum
function of these elements. Ischemia changes the myocardial activity periods of
isovolumetric contraction and relaxation. Due to ischemic cascade, ICT and IRT
increase, and when clinical heart failure becomes apparent, the ET decreases.10)
Previously EF was used to evaluate the patients' condition in these cases. However, this traditional risk stratification of AMI patients is focused only on systolic
function, in which numerous studies have demonstrated that EF or other parameters are powerful guides to choosing therapy and predicting the risk of future
events.2,11,12) Because systolic and diastolic dysfunctions frequently coexist, a
combined measure of left ventricular chamber performance may be more reflective of overall cardiac dysfunction than systolic or diastolic measures alone. A
more complete study of ventricular function would be useful to further understand the disease development after AMI. Tei, et al studied the ability of a new
Doppler index of combined systolic and diastolic function (Tei index: sum of IRT
and ICT divided by ET) to separate patients with normal ventricular function
from patients with heart failure nearly a decade ago.6) They showed that the separation of patients with dilated cardiomyopathy from normal individuals, by use
of the Tei index, was superior to other available indexes. Other studies have
described the prognostic value of the Tei index after AMI.13,14)
The Tei index has been shown to be a powerful independent predictor of
death from all causes in a large population with a recent AMI. Adverse outcome
is infrequently seen among patients with preserved global ventricular function
(Tei index < 0.46).15)
Furthermore, the Tei index has the advantages of being less affected by age,
heart rate, and preload than conventional Doppler measurements,16-18) and the
index has an excellent reproducibility.6,13,19,20)
The Tei index is found to be very reliable and has a predictor role not only
in MI, but also in other cardiac pathologies such as dilated cardiomyopathy, primary pulmonary hypertension, cardiac amyloidosis, and aortic stenosis as
well.21-23)
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TEI INDEX IN ACUTE MYOCARDIAL INFARCTION
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Thirteen of 77 in our patient group died and 22 had CHF. The mean value of
the Tei index was significantly higher when we compared the Tei index of dead
patients with surviving ones and patients who have CHF with patients who do not
have CHF. This finding suggests that the Tei index may be used as a predictor of
mortality and CHF. In accordance with our findings, it was previously shown that
the one year life expectancy of AMI patients is higher (89%) in patients who had
smaller Tei index values. Unfortunately, the life expectancy of patients with a
high Tei index was only 37%.13) After 3 months of follow-up we found that the
Tei index of 12 of the 13 patients who died was higher than 0.60. The mortality
risk for patients with a lower Tei index was only 2.6%, while it was 30.8% for the
higher group.
Moreover, in patients with a higher Tei index the incidence of CHF was
higher than the patients with low Tei index values.14) We classified our patient
group according to Tei indexes below 0.60 or above 0.60. Nearly half of the Tei
index > 0.60 group developed CHF, but only 7.9% of the Tei < 0.60 group developed CHF, in accordance with other studies,14) which also supports the suggestion
that the Tei index might be useful for predicting morbidity rates in AMI. The Tei
index has been shown to be significantly different between CHF and healthy
groups too, and the authors suggested that the Tei index might be useful for evaluating cardiac dysfunction.15)
Based on these findings, it would not be wrong to suggest that the Tei index
is an important predictor of mortality and CHF risk after AMI.
It was previously shown that the Tei index is negatively correlated with EF,
but positively correlated with the prognosis.24) Our findings also support this, as
the mean EF of the patients who died was significantly lower than the EF of the
surviving patients. On the other hand, the Tei index was higher in the patients
who died compared with those who survived.
Ventricular remodeling or dilatation is an alteration in the shape, mass, and
volume of the left ventricle, a process which develops in response to myocardial
injury and/or changes in the preload and afterload. Ventricular remodeling is a
defective adaptation process. The extent of ventricular remodeling is a very
strong indicator of mortality and morbidity in patients with cardiac failure or MI.
Ventricular remodeling is positively correlated with the infarct size,25) and it
develops in several days.25,26) On the other hand, progressive left ventricular dilatation may continue for months or years.25,27) The continuous expansion in the left
ventricle after AMI is a negative prognostic sign.28) LVESV is known to be a very
strong predictor of life expectancy, morbidity and mortality after AMI, coronary
artery disease, and ischemic cardiomyopathy.2,11,29-31)
In this study, left ventricle volumes were measured within 24 hours and 3
months after AMI. Initial left ventricle volumes were significantly higher than the
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May 2006
healthy control group, and they were still high in the 3rd month measurements as
well.
We also showed that the left ventricle volumes of patients who died were
significantly higher than the left ventricle volumes of the surviving patients,
which is in agreement with previous findings. Left ventricle volumes were all
high in patients who developed cardiac failure.
In AMI patients, short E deceleration time,32) age, anterior MI, initial left
ventricle volumes, volume of the infarct, left ventricular end-diastolic pressure,
and mitral valve failure are strong predictors of possible left ventricular dilatation.33)
We also evaluated if the Tei index may be a predictor of ventricular remodeling, and found that patients with a high Tei index were more prone to develop
ventricular dilatation in this study. We suggest that the initial Tei index may be a
strong indicator of ventricular dilatation risk in AMI patients. Thus, the prognostic value of the Tei index is very important as it will help to identify patients with
high risk of ventricular remodeling sooner and the undertaking of precautions to
prevent progressive remodeling.
In this study, we also showed that the patients with anterior AMI had a
higher Tei index than the patients with inferior AMI in accordance with previous
studies.15,34) The loss of contractile function in anterior infarcts is more extensive
compared with inferior infarcts. Thus, myocardial damage of equal size affects
EF to a greater degree in the anterior than in the inferior wall.35) This could partly
explain the additional prognostic value of the Tei index.
In this study, we have showed that the Tei index, ICT, ET, EF, LVESV and
LVEDV, mitral valve E/A proportion, and E deceleration time are the echocardiographic parameters that are the most important indicators of the mortality due to
AMI.
Since both systolic and diastolic functions are impaired to various degrees in
AMI, the Tei index may be an attractive alternative to the standard methods since
it is a unique product of systolic and diastolic function. As the index is not
affected by ventricular geometry and can measure both systolic and diastolic
functions, it is a more sensitive and specific method.
In conclusion, the Tei index, which reflects global ventricular systolic and
diastolic function, provides powerful and independent prognostic information
about mortality and ventricular remodeling following AMI.
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