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Left ventricular asynchrony and raised filling pressure predict limited exercise performance assessed by 6 minute walk test
Service of Cardiology, Internal Medicine Clinic, University Clinical Centre of Kosova, Prishtina, Kosovo.
Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Medicin. (Heart centre)
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2011 (Engelska)Ingår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 146, nr 3, s. 385-389Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Six minute walking test (6-MWT) may serve as a reproducible test for assessing exercise capacity in heart failure (HF) patients and can be clinically predicted. We aimed in this study to ascertain if global markers of ventricular asynchrony can predict 6MWT distance in a group of patients with HF and left ventricular (LV) ejection fraction (EF) <45%.

METHODS AND RESULTS: This study included 77 consecutive patients (60+/-12 years) with stable HF. LV end-diastolic and end-systolic dimensions, shortening fraction (SF), EF, myocardial velocities, t-IVT, and Tei index were measured, as well as 6-MWT distance. Patients with limited exercise performance (</=300 m) had lower SF (p=0.02) and EF (p=0.017), longer t-IVT (p=0.001), higher Tei index (p=0.002) and higher E/E' ratio (p<0.001) compared with good performance patients. In multivariate analysis, only E/E' ratio [0.800 (0.665-0.961), p=0.017], and t-IVT [0.769 (0.619-0.955), p=0.018] independently predicted poor exercise performance.

CONCLUSIONS: In heart failure patients, the higher the filling pressures and the more asynchronous the left ventricle, the poorer is the patient's exercise capacity. These findings highlight specific LV functional disturbances that should be targeted for better optimization of medical and/or electrical therapy.

Ort, förlag, år, upplaga, sidor
2011. Vol. 146, nr 3, s. 385-389
Nyckelord [en]
Six-minute walk test, doppler echocardiography, restrictive filling, left ventricular asynchrony
Nationell ämneskategori
Kardiologi
Identifikatorer
URN: urn:nbn:se:umu:diva-30994DOI: 10.1016/j.ijcard.2009.07.018ISI: 000286460500022PubMedID: 19699003Scopus ID: 2-s2.0-79151479036OAI: oai:DiVA.org:umu-30994DiVA, id: diva2:290287
Tillgänglig från: 2010-01-26 Skapad: 2010-01-26 Senast uppdaterad: 2023-03-24Bibliografiskt granskad
Ingår i avhandling
1. The clinical value of total isovolumic time
Öppna denna publikation i ny flik eller fönster >>The clinical value of total isovolumic time
2014 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

The objective of this thesis is to evaluate the use of Doppler echocardiography markers ofglobal dyssynchrony [total isovolumic time (t-IVT)] in the following 6 studies: 1) Its prognostic role in predicting cardiac events in patients undergoing CABG surgery,compared with conventional global systolic and diastolic measurements. 2) Its additional value in predicting six minute walk test (6-MWT) in patients with leftventricular (LV) ejection fraction (EF) <45%. 3) Its prognostic value in comparison with other clinical, biochemical and echocardiographicvariables in patients with chronic systolic heart failure (HF). 4) The relationship between 6-MWT and cardiac function measurements in a consecutivegroup of patients, irrespective of EF and to identify predictors of exercise capacity. 5) To investigate the effect of age on LV t-IVT and Tei index compared with conventionalsystolic and diastolic parameters. 6) To assess potential additional value of markers of global LV dyssynchrony in predictingcardiac resynchronization therapy (CRT) response in HF patients.

Study I

Methods: This study included 74 patients before routine CABG who were followed up for18±12 months. Results: At follow-up, 29 patients were hospitalized for a cardiac event or died. LV-ESD wasgreater (P=0.003), fractional shortening (FS) lower (p<0.001), E:A ratio and Tei index higher(all P<0.001), and t-IVT longer (P<0.001) in patients with events. Low FS [0.66 (0.50–0.87),P<0.001], high E:A ratio [l4.13 (1.17–14.60), P=0.028], large LV-ESD [0.19 (0.05–0.84),P=0.029], and long t-IVT [1.37 (1.02–1.84), P=0.035] predicted events and deaths. Conclusion: Despite satisfactory surgical revascularization, long t-IVT and systolicdysfunction suggest persistent ventricular dyssynchrony that contributes to post-CABGcardiac events.

Study II

Methods: We studied 77 patients (60±12 year, and 33.3% females) with stable HF using 6-MWT.iii Results: E’ wave (r=0.61, p<0.001), E/e’ ratio (r=-0.49, p<0.001), t-IVT (r=-0.44, p<0.001),Tei index (r=-0.43, p<0.001) and NYHA class (r=-0.53, p<0.001) had the highest correlationwith the 6-MWT distance. In multivariate analysis, only E/e’ ratio [0.800 (0.665-0.961),p=0.017], and t-IVT [0.769 (0.619-0.955), p=0.018] independently predicted poor 6-MWTperformance (<300m). Conclusions: In HF, the higher the filling pressures and the more dyssynchronous the LV, thepoorer is the patient’s exercise capacity.

Study III

Methods: We studied 107 systolic HF patients; age 68±12 year, 25% females and measuredplasma NT-pro-BNP. Results: Over a follow-up period of 3718 months, t-IVT ≥12.3 sec/min, mean E/Em ratio≥10, log NT-pro-BNP levels ≥2.47 pg/ml and LV EF ≤32.5% predicted clinical events. Theaddition of t-IVT and NT-pro-BNP to conventional clinical and echocardiographic variablessignificantly improved the χ2 for the prediction of outcome from 33.1 to 38.0, (p<0.001). Conclusions: Prolonged t-IVT adds to the prognostic stratification of patients with systolicHF.

Study IV

Methods: We studied 147 HF patients (61±11 year, 50.3% male) with 6-MWT.Results: The 6-MWT correlated with t-IVT (r=-0.49, p<0.001) and Tei index (r=-0.43,p<0.001) but not with any of the other clinical or echocardiographic parameters. Group Ipatients (<300m) had lower Hb (p=0.02), lower EF (p=0.003), larger left atrium (p=0.02),thicker septum (p=0.02), lower A wave (p=0.01) and lateral wall a’ (p=0.047), longerisovolumic relaxation time (r=0.003) and longer t-IVT (p= 0.03), compared with Group II(>300m). Only t-IVT ratio [1.257 (1.071-1.476), p=0.005], LV EF [0.947 (0.903-0.993),p=0.02], and E/A ratio [0.553 (0.315-0.972), p=0.04] independently predicted poor 6-MWTperformance. Conclusion: In HF, the limited 6-MWT is related mostly to severity of global LVdyssynchrony, more than EF or raised filling pressures.

Study V

Methods: We studied 47 healthy individuals (age 62±12 year, 24 female), arbitrarilyclassified into: M (middle age), S (seniors), and E (elderly). Results: Age strongly correlated with t-IVT (r=0.8, p<0.001) and with Tei index (r=0.7,p<0.001), E/A ratio (r=-0.6, p<0.001), but not with global or segmental systolic function measurements or QRS duration. The normal upper limit of the t-IVT (95% CI) for the three groups was 8.3 s/min, 10.5 s/min and 14.5 s/min, respectively, being shorter in the S compared with the E group (p=0.001). T-IVT correlated with A wave (r=0.66, p<0.001), E/Aratio (r=-0.56, p<0.001), septal e’ (r=-0.49, p=0.001) and septal a’ (r=0.4, p=0.006), but notwith QRS. Conclusions: In normals, age is associated with exaggerated LV global dyssynchrony anddiastolic function disturbances, but systolic function remains unaffected.

Study VI

Methods: We studied 103 HF patients (67±12 year, 82.5% male) recruited for CRTtreatment. Results: Prolonged t-IVT [0.878 (0.802-0.962), p=0.005], long QRS duration [0.978 (0.960-0.996), p=0.02] and high tricuspid regurgitation pressure drop (TRPD) [1.047 (1.001-1.096),p=0.046] independently predicted response to CRT. A t-IVT ≥11.6 s/min was 67% sensitiveand 62% specific (AUC 0.69, p=0.001) in predicting CRT response. Respective values for aQRS ≥ 151ms were 66% and 62% (AUC 0.65, p=0.01). Combining the two variables had asensitivity of 67% but higher specificity of 88% in predicting CRT response. In atrialfibrillation (AF) patients, only prolonged t-IVT ≥11 s/min [0.690 (0.509-0.937), p=0.03]independently predicted CRT response with a sensitivity of 69% and specificity of 79% (AUC0.78, p=0.015). Conclusion: Combining prolonged t-IVT and broad QRS had higher specificity in predictingresponse to CRT, with the former the sole predictor of response in AF patients.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå universitet, 2014. s. 89
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 1656
Nyckelord
Heart failure, cardiac resynchronization therapy, predictors, echocardiography, total isovolumic time, six-minute walk test, left ventricular dyssynchrony
Nationell ämneskategori
Kardiologi
Identifikatorer
urn:nbn:se:umu:diva-88994 (URN)978-91-7601-086-0 (ISBN)
Disputation
2014-06-10, Room D, Unod T9, Norrlands universitetssjukhus, Umea, 09:00 (Engelska)
Opponent
Handledare
Tillgänglig från: 2014-05-20 Skapad: 2014-05-19 Senast uppdaterad: 2018-06-07Bibliografiskt granskad

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