EXPEDITED REVIEW
Diastolic Stress Echocardiography: Hemodynamic Validation and Clinical Significance of Estimation of Ventricular Filling Pressure With Exercise
Malcolm I. Burgess, MD, MRCP*,
Carly Jenkins, BSc,
James E. Sharman, PhD and
Thomas H. Marwick, MD, PhD, FACC
Department of Medicine, University of Queensland, Princess Alexandra Hospital, Brisbane, Australia.
Manuscript received December 23, 2005;
revised manuscript received February 27, 2006,
accepted February 28, 2006.
* Reprint requests and correspondence: Dr. Malcolm Burgess, University of Queensland Department of Medicine, Level 4, Princess Alexandra Hospital, Ipswich Road, Brisbane QLD 4102, Australia. (Email: mburgess{at}soms.uq.edu.au).
OBJECTIVES: Our study attempted to validate a Doppler index of diastolic filling (E/E’) during exercise with simultaneously measured left ventricular diastolic pressure (LVDP), investigate its association with exercise capacity, and understand which patients to select for testing.
BACKGROUND: The ratio of early diastolic transmitral velocity to early diastolic tissue velocity approximates LVDP at rest, but there is limited validation of exercise E/E’ with invasive hemodynamic measurement, and its clinical implications are unclear.
METHODS: The ratio of early diastolic transmitral velocity to early diastolic tissue velocity was measured at rest and during supine cycle ergometry in 37 patients undergoing left heart catheterization. In addition to correlation between invasive and estimated LVDP, the accuracy of different cutoffs for identification of elevated LVDP (>15 mm Hg) was determined at both rest and exercise. Doppler index of diastolic filling was also measured at rest and immediately after maximal treadmill exercise in 166 patients to investigate the association between exercise E/E’ and exercise capacity (<8 metabolic equivalents [METs]).
RESULTS: In patients undergoing invasive measurement, nine (24%) had elevation of LVDP only during exercise. There was a good correlation between E/E’ and LVDP at rest (r = 0.67) and during exercise (r = 0.59), and the regressions at rest and exercise corresponded closely. Receiver-operator curve analysis indicated that a cutoff value of 13 for exercise E/E’ identified patients with an elevated LVDP during exercise. A post-exercise E/E’ >13 was highly specific (90%) for reduced exercise capacity, and even after classification of resting E/E’, exercise E/E’ permitted classification of patients with exercise capacity <8 METs or  8 METs.
CONCLUSIONS: The ratio of early diastolic transmitral velocity to early diastolic tissue velocity correlates with invasively measured LVDP during exercise. It can be used to reliably identify patients with elevated LVDP during exercise and reduced exercise capacity.
|
Abbreviations and Acronyms
| | A velocity = late diastolic transmitral velocity | | E velocity = early diastolic transmitral velocity | | E’ = early diastolic tissue velocity | | E/E’ = ratio of early diastolic transmitral velocity to early diastolic tissue velocity | | LV = left ventricle/ventricular | | LVDP = left ventricular diastolic pressure | | MET = metabolic equivalent | | ROC = receiver-operator characteristic |
|
This article has been cited by other articles:
|
|
|
|
 
C. Tschope and W. J. Paulus
Doppler Echocardiography Yields Dubious Estimates of Left Ventricular Diastolic Pressures
Circulation,
September 1, 2009;
120(9):
810 - 820.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. H. Marwick
The deconvolution of diastole.
J. Am. Coll. Cardiol.,
June 30, 2009;
54(1):
47 - 48.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Rustad, B. H. Amundsen, S. A. Slordahl, and A. Stoylen
Upright bicycle exercise echocardiography in patients with myocardial infarction shows lack of diastolic, but not systolic, reserve: a tissue Doppler study
Eur J Echocardiogr,
June 1, 2009;
10(4):
503 - 508.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. T. Maeder and D. M. Kaye
Heart failure with normal left ventricular ejection fraction.
J. Am. Coll. Cardiol.,
March 17, 2009;
53(11):
905 - 918.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Wang and S. F. Nagueh
Current Perspectives on Cardiac Function in Patients With Diastolic Heart Failure
Circulation,
March 3, 2009;
119(8):
1146 - 1157.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. La Gerche, A. J. Taylor, and D. L. Prior
Athlete's Heart: The Potential for Multimodality Imaging to Address the Critical Remaining Questions.
J. Am. Coll. Cardiol. Img.,
March 1, 2009;
2(3):
350 - 363.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J-W Ha, D Choi, S Park, E-Y Choi, C-Y Shim, J-M Kim, J-A Ahn, S-W Lee, J K Oh, and N Chung
Left ventricular diastolic functional reserve during exercise in patients with impaired myocardial relaxation at rest
Heart,
March 1, 2009;
95(5):
399 - 404.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. F. Nagueh, C. P. Appleton, T. C. Gillebert, P. N. Marino, J. K. Oh, O. A. Smiseth, A. D. Waggoner, F. A. Flachskampf, P. A. Pellikka, and A. Evangelisa
Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography
Eur J Echocardiogr,
March 1, 2009;
10(2):
165 - 193.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Grewal, R. B. McCully, G. C. Kane, C. Lam, and P. A. Pellikka
Left Ventricular Function and Exercise Capacity
JAMA,
January 21, 2009;
301(3):
286 - 294.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G Wynn and M Burgess
Exercise echocardiography
Heart,
January 1, 2009;
95(1):
83 - 83.
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. A. Flachskampf, J.-U. Voigt, and W. G. Daniel
CHAPTER 4 Cardiac Ultrasound
ESC Textbook of Cardiovascular Medicine,
January 1, 2009;
2(1):
med-9780199566990-chapter - med-9780199566990-chapter.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N R Van de Veire, J De Sutter, J J Bax, and J R T C Roelandt
Technological advances in tissue Doppler imaging echocardiography
Heart,
August 1, 2008;
94(8):
1065 - 1074.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. H. Marwick and M. Schwaiger
The Future of Cardiovascular Imaging in the Diagnosis and Management of Heart Failure, Part 1: Tasks and Tools
Circ Cardiovasc Imaging,
July 1, 2008;
1(1):
58 - 69.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. J. Lester, A. J. Tajik, R. A. Nishimura, J. K. Oh, B. K. Khandheria, and J. B. Seward
Unlocking the Mysteries of Diastolic Function Deciphering the Rosetta Stone 10 Years Later.
J. Am. Coll. Cardiol.,
February 19, 2008;
51(7):
679 - 689.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Pierard
Echocardiographic Monitoring Throughout Exercise: Better Than the Post-Treadmill Approach?
J. Am. Coll. Cardiol.,
November 6, 2007;
50(19):
1864 - 1866.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. M. Bernheim, S. Kiencke, M. Fischler, L. Dorschner, J. Debrunner, H. Mairbaurl, M. Maggiorini, and H. P. Brunner-La Rocca
Acute Changes in Pulmonary Artery Pressures Due to Exercise and Exposure to High Altitude Do Not Cause Left Ventricular Diastolic Dysfunction
Chest,
August 1, 2007;
132(2):
380 - 387.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Tumminello, P. Lancellotti, M. Lempereur, V. D'Orio, and L. A. Pierard
Determinants of pulmonary artery hypertension at rest and during exercise in patients with heart failure
Eur. Heart J.,
March 1, 2007;
28(5):
569 - 574.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. E. Sanderson
Systolic and Diastolic Ventricular Dyssynchrony in Systolic and Diastolic Heart Failure
J. Am. Coll. Cardiol.,
January 2, 2007;
49(1):
106 - 108.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J.K. Oh
Echocardiography in heart failure: Beyond diagnosis
Eur J Echocardiogr,
January 1, 2007;
8(1):
4 - 14.
[Full Text]
[PDF]
|
|
|
|
