Download Assessment of diastolic dysfunction and heart failure with integrated

1. INTRODUCTION
Assessment of diastolic dysfunction and heart
failure with integrated Doppler echocardiography
Heart failure is a new epidemy of the developed countries, which manifests
mainly in diastolic heart failure in the elderly. The asymptomatic diastolic
dysfunction has also a considerable prevalence and prognostic significance. The
staging of diastolic dysfunction based on integrated Doppler echocardiographic
Ph.D Thesis
Mónika Dénes MD
Semmelweis University
Doctoral School of Basic Medicine
examination.
Diastolic dysfunction and diastolic heart failure
In population based studies the prevalence of heart failure is 2-3%, but in the
elderly it can reach the 20%, out of whom approximately 50% have diastolic
heart failure with a similar prognosis (DHF). Similar studies have shown that the
prevalence of asymptomatic diastolic dysfunction (DD) is 28% in the
population, out of who 7% have diastolic dysfunction with elevated left
ventricular filling pressure (moderate and severe DD). These rates are doubled
in the elderly. Both moderate and severe diastolic dysfunctions have an
important prognostic role.
According to the new European guideline on diastolic heart failure the
Supervisor:
Mária Lengyel MD, Ph.D, D.Sc
Official Reviewers:
Attila Cziráki MD, Ph.D
András Zsáry MD, Ph.D
Head of Comprehensive Exam Committee:
Mátyás Keltai MD, Ph.D, D.Sc
Members of Comprehensive Exam Committee:
confirmation of elevated left ventricular filling pressure (invasive hemodynamic
measurements, biomarker test, echocardiography) is a new criterion besides the
signs or symptoms of heart failure and the preserved ejection fraction (>50%).
The role of echocardiography in the assessment of diastolic dysfunction
Mitral inflow pattern
Traditionally, diastolic function is evaluated by the mitral inflow pattern (early
Lívia Jánoskuti MD, Ph.D
and late diastolic velocities, their ratio [E/A], deceleration time [DT]). The
Júlia Radó MD, holder of Candidate
diastolic dysfunction has three stages regarding to the inflow pattern: (1) mild
Budapest
2010
DD: the left ventricular relaxation is impaired with normal left ventricular enddiastolic pressure; (2) moderate DD: the impaired relaxation is combined with
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moderate elevation in left ventricular filling pressure, which results a seemingly
2. AIMS
normal inflow pattern (“pseudonormalization”); (3) severe DD: highly elevated
left ventricular filling pressure, causing a restrictive inflow pattern.
The two main aims of the thesis were to address the controversial issues in the
The method has several drawbacks: in moderate DD the inflow pattern is
literature related to diastolic function and heart failure by both (1)
“normal” even though the left ventricular filling pressure is elevated; in atrial
methodological and (2) clinical approach.
fibrillation the inflow pattern cannot be used.
Pulmonary venous flow
Methodological aims:
The assessment of the pulmonary venous flow is one solution to differentiate
1.
between normal and pseudonormal mitral inflow pattern. In healthy, age over 50
years subjects the ratio of the systolic (S) and diastolic (D) velocity is greater
Are tissue Doppler velocities and E/Ea ratio different by different
echocardiography systems?
2.
Which method is more reliable in the assessment of elevated left
than 1. In the presence of elevated left ventricular filling pressure this ratio is
ventricular filling pressure: tissue Doppler imaging or pulmonary venous
less than 1 (S/D <1).
flow pattern in elderly patients with preserved ejection fraction and
The method is obtainable in 75% of the patients; and unreliable in atrial
seemingly normal mitral inflow pattern?
fibrillation.
3.
Tissue Doppler imaging
To assess the normal diastolic tissue Doppler echocardiographic values
of the left and the right ventricle in healthy subjects.
Tissue Doppler imaging is a tool to obtain the motion of the myocardium both in
4.
systole and diastole. The global systolic and diastolic function can be evaluated,
To evaluate the effect of age on both standard and novel
echocardiographic parameters.
when mitral annular velocities are assessed. The early myocardial velocity (Ea)
Clinical aims:
is decreased in all stages of diastolic dysfunction, and the E/Ea ratio increases
5.
To assess the differences in systolic myocardial function in patients with
when the left ventricular filling pressure is elevated.
preserved ejection fraction and either diastolic dysfunction or diastolic
The method is independent of hemodynamics, and the only method to evaluate
heart failure.
filling pressure in case of atrial fibrillation.
6.
To assess the prevalence of the different types of heart failure, and the
Left atrial size
prevalence of the stages of diastolic dysfunction in elderly, hospitalized
The association between the grades of diastolic dysfunction and left atrial size is
patients with suspected heart failure.
well established. The enlarged left atrium, in sinus rhythm and in the absence of
7.
To assess the prevalence of the stages of diastolic dysfunction in
mitral valve disease, reflects a permanently elevated left ventricular filling
asymptomatic, elderly, hypertensive patients, and the role of tissue
pressure, namely chronic diastolic dysfunction.
Doppler echocardiography in the assessment of elevated left ventricular
filling pressure in case of pseudonormal mitral inflow pattern.
8.
3
Comparison of the prognosis of systolic and diastolic heart failure.
4
Stages of diastolic dysfunction
3. METHODS
Diastolic dysfunction was classified into three stages:
Patients
- Mild DD: E/A <1, DT≥ 240 ms, no evidence of elevated filling pressure.
The studies were performed between 2004 and 2008. A total of 1350 subjects
- Moderate DD: normal mitral inflow pattern (E/A >1 and DT 160-240 ms)
with E/Ea ≥7 and/or S/D ≤1.
were enrolled (age: 19 – 95 years), 563 males and 787 females.
277 subjects participated in methodological studies (age: 12 – 92 years; 107
males and 170 females); and 1073 patients were enrolled into clinical studies
- Severe DD: DT ≤150 ms, and/or evidence of elevated filing pressure.
In atrial fibrillation only E/Ea ratio was assessed.
(age: 43 – 95 years; 456 males and 617 females).
Types of heart failure
Echocardiography
Systolic heart failure (SHF) was defined as signs (pleural effusion, dilated vena
Measurements were performed on a Sonos 2000 echocardiography system,
cava inferior) or symptoms (NYHA functional class II-IV) of heart failure and
using standard techniques and views. The tissue Doppler velocities were
impaired ejection fraction. Diastolic heart failure (DHF) was defined as signs or
compared with a Philips iE33 system during the same examination.
symptoms of heart failure, preserved ejection fraction (>50%) with moderate or
Left ventricular end-diastolic (Dd) and end-systolic (Ds) diameters, thickness of
severe diastolic dysfunction. Heart failure with preserved ejection fraction
the inerventricular septum (IVS) and the posterior wall (PW) were measured by
(HFPEF) was defined as signs or symptoms of heart failure with preserved
M-mode echocardiography. The ejection fraction was calculated by the
ejection fraction, but without the evidence of elevated filling pressure.
Quinones method. 2D-echocardiography was used to assess the left (LA) and
right
atrial
(RA)
longitudinal
diameters.
With
pulsed-wave
Doppler
4. RESULTS
echocardiography early (E) and late (A) diastolic mitral inflow velocities and
deceleration time was measured, as well as the systolic (S) and diastolic (D)
velocities of the pulmonary venous flow. At the lateral mitral and tricuspid
4.1. Comparison of tissue Doppler velocities by different types of
annulus systolic (lSa) early (lEa, rEa) and late (lAa, rAa) diastolic myocardial
echocardiography systems
velocities were assessed by pulsed-wave tissue Doppler imaging. E/A, E/Ea,
Differences between TDI velocities
Ea/Aa and S/D ratios were calculated. The pulmonary artery systolic pressure
We studied 31 consecutive patients, age between 24 and (12 males and 19
(PASP) was obtained from the peak velocity of the tricuspid regurgitant jet. The
females; mean age: 65.2 ± 17.2 years). Ea, Aa and Sa velocities were higher
following formulas were used: to calculate the relative wall thickness:
when measured by the Sonos system (Ea: 13.2 ± 4.1 cm/s vs 8.3 ± 3.6 cm/s; Aa:
RWT=(IVS+PW)/Dd (concentric remodelling: RWT>0.42); to calculate left
14.8 ± 3.8 cm/s vs 9.3 ± 2.3 cm/s; Sa: 15.2 ± 3.6 cm/s vs 8.4 ± 2.0 cm/s;
ventricular stiffness: LVS=E/Ea/Dd; to calculate left ventricular mass: LVM=
p<0.0001 all), but the Ea/Aa ratio did not differ (0.92 ± 0.39 vs 0.91 ± 0.49;
3
3
l,04x[(IVS + Dd + PW) - Dd ].
p=0.93).
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Correlations between the two echocardiography systems
4.2. Tissue Doppler imaging or pulmonary venous flow to assess left
Sonos 2000 and Philips iE33 had a good correlation in Ea (r=0.84; p<0.0001)
ventricular filling pressure in elderly patients with preserved ejection
and in Ea/Aa (r=0.85; p<0.0001), and a weaker but statistically still significant
fraction?
correlation in Aa (r=0.43; p=0.02). No association was found in Sa (r=0.27;
To evaluate the cut-off value of E/Ea ratio we assessed 35 normal subjects. Due
p=0.17) between the two echo systems.
to the mean ± 2 standard deviation the E/Ea ≥7 was defined as abnormal. Based
on data from the literature left ventricular filling pressure was considered
Agreement between Sonos 2000 and Philips iE33 echo system
elevated if the ratio of the pulmonary venous S/D was less than 1 at the age over
Although there was a good correlation in Ea between the two echo systems,
50 years.
Bland-Altman analysis demonstrated a mean difference of 4.95 cm/s with broad
From the 75 elderly patients with preserved ejection fraction (mean age: 68.8 ±
limits of agreement (0.64 cm/s to 9.25 cm/s). A similar overestimation by Sonos
9.2
2000 was found in Aa (mean difference: 5.52 cm/s, limits of agreement of -1.39
(“pseudonormalization”) tissue Doppler imaging, per se, confirmed elevated left
cm/s to 12.39 cm/s), and in Sa velocities (mean difference: 6.73 cm/s, limits of
ventricular filling pressure in 16 patients (21%); pulmonary venous flow, per se,
agreement of -0.37 cm/s to 13.83 cm/s). Although a negligible difference was
in 33 patients (44%), and both methods in 26 patients (35%).
years)
and
with
seemingly
normal
mitral
inflow
pattern
found in Ea/Aa ratio (mean difference: 0.005), the limits of agreement (-0.51 to
0.52) were still unacceptable for clinical practice.
4.3. The normal values of the left and the right ventricular diastolic
function by tissue Doppler
Estimation of left ventricular filling pressure by the two echocardiography
Tissue Doppler echocardiographic values
systems
We assessed 70 normal subjects (22 males; mean age: 49.9 ± 17.1 years). There
E/Ea ratio, which is an established indicator of elevated left ventricular filling
was no difference between the Ea velocities of the left and the right ventricle
pressure, was significantly higher when obtained by the Philips system
(16,8 ± 4,63 cm/s vs 16.9 ± 4.23 cm/s), but the right ventricular late diastolic
compared to the Sonos 2000 machine (9.56±3.82 vs 5.49±1.54, p<0.0001),
myocardial velocities were higher (19.9 ± 3.52 vs 16.6 ± 3.88 cm/s; p <0.001),
although they had a good correlation (r=0.67; p<0.0001).
and the Ea/Aa ratios were lower (0.88 ± 0.30 vs 1.07 ± 0.39; p <0.001).
The accuracy of E/Ea ratio obtained by the Sonos system was tested by the ROC
The heart rate had no effect on any of the tissue Doppler velocities.
analysis. E/Ea ratio >10 assessed by the Philips iE33 system was used as a
reference indicator of elevated left ventricular diastolic pressure based on data
Correlation between the two ventricle
from the literature. An E/Ea ratio >5.6 by the Sonos system showed the optimal
There was a strong correlation between the two ventricle in Ea velocities
sensitivity (75%) and specificity (79%). Using a ratio of 4.8 resulted in a higher
(r=0.63, p <0.001) and in the Ea/Aa ratios (r=0.57, p <0.001). The association
sensitivity (92%) but a lower specificity (63%), whereas a ratio of 6.3 resulted in
between the late diastolic myocardial velocities were weaker, but still significant
a higher specificity (84%) but a lower sensitivity (67%).
(r=0.38, p <0.01).
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Correlation with atrial size
There was no difference in age, heart rate and male gender between group 2. and
The left atrial size neither had correlation with the early, nor the late diastolic
3. but the control group was significantly younger compared to group 1. (58.0 ±
myocardial velocities and nor the Ea/Aa ratio. In contrast, the right ventricular
16.7 years vs 70.7 ± 11.0 years; p <0.05) and to group 3. (58.0 ± 16.7 years vs
Ea and Ea/Aa had strong correlation with the right atrial size (Ea: r= -0.49, p
78.5 ± 8.2 years; p <0.001). Regarding to the definitions of the groups the mitral
<0.001; Ea/Aa: r= -0.46, p <0.001), but the late diastolic velocity had no
E, deceleration time and E/Ea ratio did not differ. There was no difference in
association with right atrial size (r= 0.14).
mitral A and myocardial Aa velocities, in the Ea/Aa ratio, an in the pulmonary
venous flow velocities.
4.4. Associations between age and left ventricular diastolic function
Significant age-dependency was found within the 66 normal subjects (22 males;
Radial and longitudinal systolic function
mean age: 49.3 ± 17.4 years) in terms of both the right (r= 0.48, p <0.001), and
The ejection fraction, which represents the radial systolic function, did not differ
the left atrial size (r= 0.30, p <0.02). The relative wall thickness showed a slight
between the groups (group 1: 67.2 ± 6.2%; group 2: 65.6 ± 7.4%; group 3: 76.5
increase with age (r= 0.36, p <0.005). While the early mitral E velocity
± 17.3%).
decreased with age (r= 0.58, p <0.001), the late diastolic A velocity had a
The systolic tissue Doppler velocity (Sa) was significantly lower in group 2 and
significant increase (r= 0.67, p <0.001). The strongest correlation was found
3 compared to the control group (16.9 ± 3.3 cm/s vs 15.3 ± 4.1 cm/s, p <0.05; vs
with the E/A ratio (r= -0.78, p <0.001). The deceleration time did not change
13.9 ± 3.1 cm/s, p <0.005) and to group 1 (17.1 ± 2.6 cm/s vs 15.3 ± 4.1 cm/s, p
with age (r= 0.20).
<0.05; vs 13.9 ± 3.1 cm/s, p <0.01). The Sa velocity in group 1 did not differ
The early myocardial Ea velocity (r= -0.77, p <0.001) and the Ea/Aa ratio (r= -
from the control group.
0.67, p <0.001) decreased with age, while the late diastolic Aa velocity did not
change. A slight elevation of the E/Ea ratio (r=0.27, p <0.05), and of the left
Longitudinal systolic dysfunction
ventricular stiffness (r=0.26, p <0.05)was found with age
Longitudinal systolic dysfunction (Sa <15 cm/s) was less frequent in group 1
(2/23 [8%]) than in group 2 (14/30 [47%]; p <0.05) or in group 3 (8/13 [61%]; p
4.5. Longitudinal systolic function in diastolic dysfunction and in diastolic
=0.001)
heart failure
In the 69 patients with diastolic dysfunction, there was no correlation between
The 69 consecutive patients (26 males; mean age: 70.6 ± 14.9 years) with
Sa and age, heart rate, ejection fraction, Ea velocity, Ea/Aa ratio, and pulmonary
preserved ejection fraction were divided into three groups: 1. group (mild
venous flow velocities. Significant correlation was found between Sa and mitral
diastolic dysfunction): 26 patients; 2. group (asymptomatic moderate/severe
E velocity (r= 0.25, p=0.04), mitral A (r= 0.36; p=0.006), E/A ratio (r= -0.39;
DD): 30 patients; 3. group (diastolic heart failure): 13 patients. Forty-four
p=0.002), myocardial Aa velocity (r= 0.47; p <0.001) and E/Ea ratio (r= -0.40; p
normal subjects formed the control group. Based on their data, longitudinal
<0.001).
systolic function was considered normal if Sa >15 cm/s.
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4.6. The prevalence of diastolic dysfunction and heart failure in elderly,
The early mitral E velocity was the highest in group 3 (106.9 ± 17.8 cm/s vs
hospitalized patients with preserved ejection fraction and suspected heart
group 1: 66.4 ± 19.6 cm/s; vs group 2: 86.9 ± 27.6 cm/s; vs group 4: 83.7±24.0
failure
cm/s, p<0.001 for all). Both in group 2 and 3 the early myocardial Ea velocity
Prevalence of heart failure
was lower compared to group 1 and 4 (group 2: 11.7 ± 2.6 cm/s vs group 1: 16.6
140 consecutive, age over 60 years, hospitalized patients with suspected heat
± 4.1 cm/s, vs group 4: 17.1 ± 2.3 cm/s; group 3: 14.0 ± 2.4 cm/s vs group 1:
failure were enrolled into the study (57 males, 83 females; mean age: 75.9 ± 9
16.6 ± 4.1 cm/s, vs group 4: 17.1 ± 2.3 cm/s, p<0.001 for all).
years). There was no heart failure in 42% of the cases (group 1: 59 patients;
The E/Ea and the S/D ratios did not differ between group 2. and 3. (E/Ea: : 7.9 ±
atrial fibrillation in 13 patients). Systolic heart failure was confirmed in 24% of
2.9 vs 7.8 ± 1.8; p=0.97; S/D: 0.73 ± 0.5 vs 0.7 ± 0.2; p=0.64).
the cases (group 2: 33 patients; atrial fibrillation in 13 patients), diastolic heart
failure in 22% (group 3: 31 patients; atrial fibrillation in 8 patients). 12% of the
Distribution of diastolic dysfunction in sinus rhythm
patients had heart failure with preserved ejection fraction (group 4: 17 patients;
Ten percent of the 97 elderly, hospitalized patients in sinus rhythm had normal
atrial fibrillation in 9 patients).
diastolic function, 52% had mild DD, 18% had moderate DD and 20% had
severe DD. Six patients had normal diastolic function in group 1, 2-2 patients in
Clinical characteristics
group 2 and 4. As expected from the study design there was no normal diastolic
There was no difference in age between the groups. The female gender was the
function in group 3, and moderate or severe dysfunction in group 1 and 4.
most prevalent in group 3 (79% vs group 2: 42%, p<0.01; vs group 4: 41%,
Mild DD was similarly frequent in group 1 and 4 (87% vs 75%, chi-square:
p<0.02); ischemic heart disease in group 2 (57% vs group 3: 6%, p<0.001; vs
0.77; p=0.38). Moderate DD was more frequent in group 3 than in group 2 (57%
group 4: 18%, p<0.01). Atrial fibrillation was more frequent in group 4
vs 25%, chi-square: 4.37, p<0.05), but there was no difference in the prevalence
compared to group 1 and group 3 (53% vs group 1: 22%, p=0.01; vs group 3:
of severe DD (43% vs 45%, chi-square: 0.01, p=0.92).
26%, p=0.06), as well as pleural effusion (76% vs group 1: 2%, p<0.001; vs
group 3: 23%, p<0.005), and lower NYHA functional stage (2.0 ± 1.0 vs group 2:
4.7. Assessment of diastolic dysfunction in elderly, asymptomatic,
2.9 ± 0.9, p<0.005; vs group 3: 2.6 ± 1.1, p<0.05).
hypertensive patients
Comparison of the groups
Echocardiographic parameters
From the 663 patients 322 patients (118 males; mean age: 70.8 ± 9.1 years)
Compared to group 1 the PASP was higher and the left atrium was enlarged in
fulfilled the inclusion criteria: age ≥50 years; preserved ejection fraction (EF
the three heart failure groups (PASP: 32.7 ± 17.3 mmHg vs group 2: 46.7 ± 22.8
≥45%), sinus rhythm, normal renal function, no signs of heart failure. There was
mmHg, p<0.001; vs group 3: 46.3 ± 22.2 mmHg, p<0.001; vs group 4: 43.6 ±
no DD in 63 cases (19.5%). Mild DD was found in 150 cases (46.5%), moderate
25.5 mmHg, p<0.01. LA: 50.2 ± 8.5 mm vs. group 2: 59.6 ± 8.4 mm, p<0.001;
DD in 86 cases (27%) and severe DD in 23 cases (7%). There was no difference
vs group 3: 54.4 ± 5.6 mm vs group 4: 55.7 ± 9.0 mm, p<0.05 for both).
in age between the groups, but women were significantly, but clinically
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negligibly older than men (71,6±9,2 yrs vs 69,5±8,7 yrs; p=0.046). The ejection
with left ventricular mass (r=0.16; p=0.008), and with E/A ratio (r= -0.16;
fraction, the thickness of the septum and the posterior wall and the left
p=0.008). Ea velocity showed a mild decline with age (r= -0,16; p=0.008). No
ventricular mass did not differ between the groups. In relative wall thickness the
correlation was found between TDI parameters and either wall thicknesses or
difference was negligible. Left ventricular hypertrophy was present in 91% of no
relative wall thickness or left ventricular mass.
DD group, 87% of mild DD group, 81% of moderate DD group and 75% of
severe DD group (not significant), while concentric remodeling was found in
Tissue Doppler echocardiography in case of „normal” mitral inflow pattern
78%, 84%, 76% and 78%, respectively (not significant). The left atrial diameter
We examined the proportion of elevated filling pressure in case of normal mitral
(46.9±7.9 mm) was smaller in the mild DD group than in the moderate DD
inflow pattern. Onehundred-fourtynine patients had normal mitral inflow
group (vs 53.9±7.0 mm, p<0.001), or in the severe DD group (vs 53.9±6.9 mm,
pattern, out of them 86 patients (58%) had elevated filling pressure as assessed
p<0.001).
by E/Ea or S/D ratios, thus, theses inflow patterns were “pseudonormalized.”
Diastolic function
The E/A ratio was the smallest in the mild DD group (0.68±0.17), it was
4.8. The prognosis of systolic and diastolic heart failure
followed by the no DD group (1.3±0.3), and the moderate DD group (1.7±0.6),
We enrolled 157 consecutive patients with heart failure (70 males; mean age:
and at last the severe DD group (1.9±0.6; p<0.001 for all). Early diastolic Ea
73.0 ± 11.4 years). We assessed the three-month and the long-term survivals
velocity was decreased in the mild and the moderate DD group compared to the
(median follow-up: 352 days).
no DD group (12.2±2.4 cm/s vs 14.8±2.3 cm/s, p<0.001; 13.3±2.6 cm/s vs
Systolic heart failure was found in 84 cases, diastolic hear failure in 73 cases.
14.8±2.3 cm/s; p<0.005). The new parameter for the assessment of left
There was no difference in age between the two groups (73.3 ± 11.6 years vs
ventricular stiffness, the E/Ea/Dd ratio was the highest in the moderate DD
72.7 ±11.2 years). The female gender and hypertension was more prevalent in
group (0.15±0.05 vs mild DD: 0.10±0.03, p<0.01).
diastolic heat failure (females: 67% vs 45%, p <0.01; hypertension: 84% vs
Correlations of echocardiographic variables
65%, p <0.01). Ischemic heart disease was more frequent in patients with
In the entire study population the ratio of early to late mitral velocity (E/A)
systolic heart failure (37% vs 4%, p <0.001) and they had more severe NYHA
directly correlated with left atrial dimension (r=0.38; p<0.001), and inversely
functional stage.
with deceleration time (r= -0.50; p<0.001), and with S/D ratio (r= -0.47;
p<0.001). E/A ratio had a weaker, but still significant correlation with Ea
Survival
velocity (r=0.25; p<0.001), with E/Ea ratio (r=0.27; p<0.001), with left
Patients with diastolic heart failure had a less frequent all-cause mortality rate
ventricular stiffness (r=0.17; p<0.02), and with pulmonary artery systolic
both at 3-month (7/73 [9.5%] vs 18/84 [21%], p <0.05) and at long-term follow
pressure (r=0.27; p<0.001). Relative wall thickness was in direct correlation
up (16/73 [22%] vs 36/84 [43%], p <0.005), and had a better long-term
with left ventricular stiffness (r=0.25; p=0.002) but there were weak correlations
cardiovascular mortality (7/73 [9.5%] vs 25/84 [30%], p <0.01). During the
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three-month follow-up 5 patients with systolic heart failure were rehospitalized
5. CONCLUSIONS
for heart failure, in contrast to no rehospitalization in the diastolic heart failure
group (5/84 [6%] vs 0/73 [0%], p <0.05), but this difference disappeared at
1.
We were first to described, that tissue Doppler velocities are different by
long-term follow-up (17/84 [20%] vs 10/73 [13%], p=0.09). The event-free
different types of echocardiography systems and they are not comparable,
survival was more favorable in diastolic heart failure both at three-month 11/73
therefore we suggest using the same type of echocardiography system at
[15%] vs 28/84 [33%], p <0.01) and at the long-term follow-up (39/73 [53%] vs
patient follow-up.
61/84 [73%], p <0.01).
2.
Elevated left ventricular filling pressure can be confirmed only with
integrated Doppler echocardiography.
3.
Our investigation is the first in the literature to establish a strong correlation
between the diastolic function of the left and the right ventricle.
4.
We demonstrated out that left ventricular filling pressure is elevated both in
systolic and diastolic heart failure, hence the diagnosis of heart failure can
not be established without comprehensive echocardiographic examination.
5.
We were among the first in the literature to show that only moderate-tosevere diastolic dysfunction and diastolic heart failure is related to
longitudinal myocardial systolic dysfunction.
6.
Patients with heart failure and preserved ejection fraction but without
elevated filling pressure commonly have atrial fibrillation.
7.
One-third of asymptomatic, hypertensive patients with preserved ejection
fraction have elevated left ventricular filling pressure, which can be a
predictor of diastolic heart failure, and can play an important role in its
prevention.
8.
We were first to assess the prognosis of systolic and diastolic heart failure
based on strict criteria. Although patients with diastolic heart failure had a
better prognosis than patients with systolic heart failure, the event-free
survival is still unfavorable.
A detailed analysis of diastolic function in health and disease provided new
findings to better understand of diastolic dysfunction and heart failure.
15
16
Citable abstracts
6. PUBLICATIONS
Lengyel M, Dénes M, Zorándi Á. Correlation of normal right ventricular
Publications related to the thesis
diastolic function by Doppler tissue imaging. Eur J Echocardiogr 2004; Suppl 1:
Dénes M, Lengyel M. A jobb kamra diasztolés funkciójának normálértékei
S180.
szöveti Doppler-echocardiographiás vizsgálat alapján. Cardiologia Hungarica
Dénes M, Lengyel M. A jobb kamra diasztolés funkciójának normál értékei
2006; 36 (1): 6-10.
szöveti Doppler-echocardiographiás vizsgálattal. Cardiologia Hungarica 2005;
Dénes M, Lengyel M. Szívelégtelenség és diasztolés diszfunkció idős,
35 (Suppl A): A11.
hospitalizált betegekben. Cardiologia Hungarica 2008; 38 (1):12-18.
Lengyel M, Dénes M, Zorándi Á. Szöveti Doppler echocardiographia értéke
Dénes M, Kiss I, Lengyel M. Diastolés diszfunkció idős, hypertoniás
pitvarfibrillatiós szívelégtelenségben. Cardiologia Hungarica 2005; 35 (Suppl
betegekben. Hypertonia és Nephrologia 2008;12 (6): 212-218.
A):A12.
Dénes M, Kiss I, Lengyel M. Assessment of diastolic dysfunction in elderly
Lengyel M, Dénes M, Zorándi Á. Pulmonary venous flow pattern is unreliable
hypertensive patients using integrated Doppler echocardiography. Blood Press
in atrial fibrillation to indicate heart failure. Eur J Echocardiogr 2005; Suppl 1:
2009;18:135-141. (IF: 1,625)
S31.
Dénes M, Farkas K, Erdei T, Lengyel M. Comparison of tissue Doppler
Dénes M, Lengyel M. Classification of diastolic dysfunction in elderly patients
velocities obtained by different types of echocardiography machines. Are they
with heart failure. Eur Heart J 2006; 27(Abstract Suppl): 199.
compatible? Echocardiogr 2010; közlésre elfogadva (IF: 1,429)
Dénes M, Lengyel M, Zorándi Á. Szívelégtelenség elemzése standard és szöveti
Doppler-echocardiográfiával idős, kórházi betegeken. Cardiologia Hungarica
Other publications
2006; 36 (Suppl A): A63.
Lengyel M, Farsang C, Dénes M, Kiss T. Az antikoaguláns terápia minősége
Lengyel M, Dénes M, Á Zorándi. The value of tissue Doppler echocardiography
nonvalvuláris
in heart failure with atrial fibrillation. Eur J Echocardiogr 2006; 7 (Suppl 1):
pitvarfibrillációban
egy
hazai
mintán.
Orvosi
Hetilap,
2004;145(10):517-20.
S100.
Lengyel M, Dénes M, Kiss T, Zorándi Á. Gyors INR-teszt krónikus
Lengyel M, Dénes M, Zorándi Á. Tissue Doppler imaging in heart failure with
anticoagulans kezelés során. Háziorv Továbbképző Szle 2005; 10: 862-65.
preserved systolic function. Eur J Echocardiogr 2006; 7 (Suppl 1): S107
Nagy A, Dénes M, Lengyel M. Predictors of the outcome of thrombolytic
Lengyel M, Dénes M, Zorándi Á. Tissue Doppler imaging in heart failure: sinus
therapy in prosthetic mitral valve thrombosis. A study of 62 cases. J Heart Valve
rhythm vs atrial fibrillation. Eur J Echocardiogr 2006; 7 (Suppl 1): S100.
Dis 2009; 18: 268-275. (IF: 1,112)
Lengyel M, Dénes M, Zorándi Á. Pszeudonormalizáció és szívelégtelenség.
Cardiologia Hungarica 2006; 36 (Suppl A):A71.
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Dénes M, Lengyel M. Prevalence of the stages of isolated diastolic dysfunction
Erdei T, Dénes M, Temesvári A, Lengyel M. A bal pitvari volumen, funkció és
in hypertension. An integrated Doppler echocardiographic study. Eur J
a bal kamrai diasztolés funkció összefüggéseinek vizsgálata echocardiográfiával
Echocardiography 2007; 8 (Suppl 1): S110.
paroxizmális pitvarfibrilláló betegekben. Cardiologia Hungarica 2009; 39
Dénes M, Lengyel M. Normal aging and diastolic function. Eur J
(Suppl A): A15.
Echocardiography 2007; 8 (Suppl 1): S49.
Dénes M, Lengyel M. Does pure diastolic dysfunction exist? Eur Heart J 2009;
Dénes M, Lengyel M. Tissue Doppler imaging or pulmonary venous flow
30 (Abstract supplement): 838.
velocities to assess elevated left ventricular filling pressure? Eur J
Dénes M, Farkas K, Erdei T, Lengyel M. Comparing tissue Doppler velocities
Echocardiography 2007; 8 (Suppl 1): S50.
by different types of echocardiography systems. Eur J Echocardiography 2009;
Dénes M, Lengyel M. Izolált diasztolés diszfunkció stádiumainak megoszlása
10 (Suppl 2): S109.
idős, hipertóniás betegekben integrált Doppler-echocardiográfiai vizsgálat
Dénes M, Lengyel M. The prognosis in diastolic heart failure is better than in
alapján. Cardiologia Hungarica 2007; 37 (Suppl A): A8.
systolic heart failure in the elderly. Eur J Echocardiography 2009; 10 (Suppl 2):
Lengyel M, Dénes M, Kiss I. Left ventricular diastolic dysfunction and
S22.
hypervolaemia in patients on hemodialysis using integrated Doppler
Dénes M, Kiss I, Kiss T, Lengyel M. Bedside assessment of NT-proBNP and its
echocardiography. Eur J Echocardiography 2007; 8 (Suppl 1): S50.
association with echocardiographic parameters in patients with chronic kidney
Lengyel M, Dénes M. The role of integrated Doppler echocardiography in
disease. Eur J Echocardiography 2009; 10 (Suppl 2): S97
isolated,
Nagy A, Dénes M, Lengyel M. Thrombolysis as first line treatment in prosthetic
asymptomatic,
significant
diastolic
dysfunction.
Eur
J
Echocardiography 2007; 8 (Suppl 1): S51.
mitral valve thrombosis. Eur Heart J 2009; 30 (Abstract Supplement): 407.
Lengyel M, Dénes M. Integrált Doppler-echocardiográfia jelentősége izolált,
aszimptomatikus,
jelentős
fokú
diasztolés
diszfunkció
kimutatásában.
Cardiologia Hungarica 2007; 37 (Suppl A): A10.
Dénes M, Lengyel M. Létezik-e izolált diasztolés diszfunkció? Cardiologia
Hungarica 2008;38 (Suppl B): B5.
Dénes M, Kiss I, Lengyel M. Izolált diasztolés diszfunkció és hypervolaemia
hemodializált betegekben. Hypertonia és Nephrologia 2008; 12 (S5): 235
Lengyel M, Dénes M. Új paraméter a bal kamrai szisztolés funkció
értékeléséhez. Cardiologia Hungarica 2008;38 ( Suppl B): B6.
Dénes M, Kiss I, Lengyel M. Izolált diasztolés diszfunkció és hypervolaemia
hemodializált betegekben. Cardiologia Hungarica 2009; 39 (Suppl A): A15.
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