Download End-systolic pressure-volume relation and ventricular

End-systolic pressure-volume relation and
ventricular-arterial coupling predict cardiac
events in patients with negative stress
echocardiography
T. Bombardini1, R. Sicari1, Q. Ciampi2, S. Gherardi3,
L. Pratali1, E. Picano1
(1) Institute of Clinical Physiology of CNR, Pisa, Italy
(2) Fatebenefratelli Hospital, Division of Cardiology, Benevento, Italy
(3) M. Bufalini Hospital, Department of Cardiology, Cesena, Italy
no conflict of interest
Background I
Cardiac hemodynamics is in the domain of invasive
cardiology, but echocardiography allows a simple and
accurate assessment of Stroke Volume (SV) allowing
to derive a set of hemodynamic measures usually
difficult or impossible to obtain with resting echo
Background II
• A maximal negative stress echo
identifies a low risk subset for coronary
events
• However, the potentially prognostically
relevant information on cardiovascular
hemodynamics for heart failure-related
events is unsettled
Aim
• To assess the prognostic value of
stress-induced variation in
cardiovascular hemodynamics in
patients with negative stress
echocardiography
Methods
• We enrolled 929 patients (618 males; mean age
63 ± 12 years)
• Ejection fraction 48 ±17%
• Wall Motion Score Index = 1.48 ± 0.63
• Ischemic dilated cardiomyopathy, n = 109;
dilated cardiomyopathy, n = 222; valvular, n =
90, known or suspected coronary artery disease,
n = 508
• With negative (exercise 238, dipyridamole 501,
dobutamine 190) stress echocardiography result
Methods
• Cardiovascular hemodynamics were assessed
during stress:
• End-systolic pressure/volume ratio (ESPVR)
• Ventricular arterial coupling (VAC) indexed by the
ratio of the ESPVR to arterial elastance (Ea, ratio
of end-systolic pressure by stroke volume)
• Cardiac output (CO, stroke volume x heart rate)
calculated at baseline and at peak stress
• Changes form rest to peak stress (Δ values) were
tested as predictors of main outcome measures:
combined death and heart failure hospitalization
Results
• During a median follow-up of 16
months (interquartile range 6-32), 52
deaths and 94 hospitalization occurred
Results
Receiver-operating characteristic curves show the
predictor performance of hemodynamic changes
during stress (Δ ESPVR, Δ VAC, Δ Ea and Δ CO) in
the EX, DIP and DOB subsets (Figure, Panel A, B, C)
Conclusion
• Patients with negative stress
echocardiography may experience an
adverse outcome, which can be
identified by ΔESPVR and ΔVAC
RT3D echo with raw data of left ventricular
end-diastolic and end-systolic volumes
Derived assessment of left ventricular
elastance (contractility index)
Peak systolic pressure =
cuff sphygmomanometer
(r=.92)
Slutsky R et al. Peak systolic blood
pressure/end-systolic volume ratio:
assessment at rest and during exercise Am J
Cardiol, 1980 46: 813
LV elastance = SP/ESVIndex
Suga H, Sagawa K, Shoukas AA.
Load independence of the instantaneous pressure-volume
ratio of the canine left ventricle and effects of epinephrine
and heart rate on the ratio. Circ Res, 1973 Mar;32:314
Ventricular elastance in the echo lab:
simplify for success
Systolic Blood Pressure + 1/ End - Systolic volume
Contractility
 SP
+
 ESV
=   Contractility
 SP
+
= ESV
=
 Contractility
+
/= ESV
=
 Contractility
=/  SP
Arterial elastance= systolic
pressure /stroke volume
Ventricular-arterial coupling
Ventricular arterial coupling is indexed by
the ratio of left ventricular systolic
elastance index/arterial elastance:
VA coupling =
LV Systolic elastance
-----------------------arterial elastance