Emmanuel Roux

Current clinical applications of spectral tissue Doppler echocardiography (E/E' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function

Congestive heart failure with preserved left ventricular systolic function has emerged as a growing epidemic medical syndrome in developed countries, which is characterized by high morbidity and mortality rates. Rapid and accurate diagnosis of this condition is essential for optimizing the therapeutic management. The diagnosis of congestive heart failure is challenging in patients presenting without obvious left ventricular systolic dysfunction and additional diagnostic information is most commonly required in this setting. Comprehensive Doppler echocardiography is the single most useful diagnostic test recommended by the ESC and ACC/AHA guidelines for assessing left ventricular ejection fraction and cardiac abnormalities in patients with suspected congestive heart failure, and non-invasively determined basal or exercise-induced pulmonary capillary hypertension is likely to become a hallmark of congestive heart failure in symptomatic patients with preserved left ventricular systolic function. The present review will focus on the current clinical applications of spectral tissue Doppler echocardiography used as a reliable noninvasive surrogate for left ventricular diastolic pressures at rest as well as during exercise in the diagnosis of heart failure with preserved left ventricular systolic function. Chronic congestive heart failure, a disease of exercise, and acute heart failure syndromes are characterized by specific pathophysiologic and diagnostic issues, and these two clinical presentations will be discussed separately.

Usefulness of serum albumin and serum total cholesterol in the prediction of hospital death in older patients with severe, acute heart failure

BACKGROUND Acute heart failure (HF) carries high hospital mortality rates in older patients; a multimarker strategy may help identify patients at high risk. AIMS To investigate prospectively the prognostic relevance of serum albumin and serum total cholesterol (TC) in older patients with severe, acute HF. METHODS Usual prognostic variables were collected on admission in 207 consecutive patients aged>70 years with severe, acute HF. Serum albumin and serum TC were obtained soon after clinical improvement. RESULTS Hospital mortality rate was 19%. Patients who died were similar to patients who survived in terms of age, sex, heart rate, serum haemoglobin and left ventricular ejection fraction. Patients who died had higher concentrations of B-type natriuretic peptide (BNP), blood urea nitrogen, serum creatinine, C-reactive protein and serum troponin I, lower systolic blood pressure, and lower concentrations of serum albumin and serum TC than patients who survived (P<0.01 for all). Serum albumin was the best independent predictor of hospital death (odds ratio 0.82 [0.74-0.90], P<0.001), with blood urea nitrogen (P=0.02) and log (BNP) (P=0.02). A simple risk score based on serum albumin (<3g/dL; 2 points), BNP (>840pg/mL; 1 point) and blood urea nitrogen (>15.3mmol/L; 1 point) discriminated patients without (score 0 to 1, hospital death 4%) from patients with (score 2 to 4, hospital death 35%, P<0.001) a high risk of death. CONCLUSION Hypoalbuminaemia offers powerful additional prognostic information to usual prognostic variables in older patients with severe, acute HF, and deserves further attention in multimarker strategies.

Accuracy of tissue Doppler echocardiography in the emergency diagnosis of decompensated heart failure with preserved left ventricular systolic function: comparison with B-type natriuretic peptide measurement.

Background: Tissue Doppler echocardiography provides a reliable noninvasive estimation of left ventricular (LV) filling pressures irrespective of LV ejection fraction. However, the diagnostic accuracy of E/Ea ratio has not been adequately determined in patients with suspected heart failure (HF) with preserved LV systolic function in the acute care setting. Objective: To investigate the accuracy of E/Ea ratio in the emergency diagnosis of decompensated HF with preserved LV systolic function. Methods: Seventy patients with a LV ejection fraction ≥45%, 32 with decompensated HF (77 ± 12 years of age), and 38 with noncardiac cause of acute dyspnea (74 ± 12) were enrolled. B‐type natriuretic peptide (BNP) was measured on admission; lateral, septal and average E/Ea ratios were calculated within 24 hours. Results: Using receiver‐operating characteristic curves to evaluate diagnostic performance, BNP (AUC of 0.875, P < 0.0001) and E/Ea ratios (AUC of 0.90–0.92, P < 0.0001) provided similar accuracy for predicting decompensated HF. Optimal cutoffs were 146 pg/ml for BNP (sensitivity and specificity of 90.6% and 76.3%), 9.8 for lateral E/Ea (83.3% and 88.9%), 12.7 for septal E/Ea (76.7% and 91.4%), and 11.5 for average E/Ea ratio (80% and 94.3%). On multivariate logistic regression analysis, average E/Ea ratio yielded independent additional information to a model based on the clinical judgment and BNP level according to the standard cutoff of 100 pg/ml. Conclusions: Tissue Doppler echocardiography is accurate for predicting decompensated HF with preserved LV systolic function and may be used as a diagnostic complement to inconclusive BNP level in this setting.

Accuracy of Tissue Doppler Echocardiography in the Diagnosis of New-Onset Congestive Heart Failure in Patients with Levels of B-Type Natriuretic Peptide in the Midrange and Normal Left Ventricular Ejection Fraction

Background: Based on the hypothesis that it reflects left ventricular (LV) diastolic pressures, B‐type natriuretic peptide (BNP) is largely utilized as first‐line diagnostic complement in the emergency diagnosis of congestive heart failure (HF). The incremental diagnostic value of tissue Doppler echocardiography, a reliable noninvasive estimate of LV filling pressures, has been reported in patients with preserved LV ejection fraction and discrepancy between BNP levels and the clinical judgment, however, its clinical validity in such patients in the presence of BNP concentrations in the midrange, which may reflect intermediate, nondiagnostic levels of LV filling pressures, is unknown. Methods: 34 patients without history of HF, presenting with acute dyspnea at rest, BNP levels of 100–400 pg/ml and normal LV ejection fraction were prospectively enrolled (17 with congestive HF and 17 with noncardiac cause). Tissue Doppler echocardiography was performed within 3 hours after admission. Results: unlike BNP (P = 0.78), Boston criteria (P = 0.0129), radiographic pulmonary edema (P = 0.0036) and average E/Ea ratio (P = 0.0032) were predictive of congestive HF by logistic regression analysis. In this clinical setting, radiographic pulmonary edema had a positive predictive value of 80% in the diagnosis of congestive HF. In patients without evidence of radiographic pulmonary edema, average E/Ea > 10 was a powerful predictor of congestive HF (area under the ROC curve of 0.886, P < 0.001, sensitivity 100% and specificity 78.6%). Conclusion: by better reflecting LV filling pressures, bedside tissue Doppler echocardiography accurately differentiates congestive HF from noncardiac cause in dyspneic patients with intermediate, nondiagnostic BNP levels and normal LV ejection fraction.

Usefulness of basal B-type natriuretic peptide levels for the diagnosis of diastolic heart failure in young patients: An echocardiographic-catheterization study

The aim of the present study was to address the diagnostic relevance of B-type natriuretic peptide (BNP) for the diagnosis of diastolic heart failure (DHF) in young patients presenting with chronic, isolated dyspnea. We prospectively included 26 consecutive patients with a left ventricular ejection fraction >50% referred for catheterism. DHF was authenticated in 15 patients with an invasive left ventricular end-diastolic pressure >16 mmHg. By logistic regression analysis, BNP was predictive of DHF (p=0.03). A cut-off value of 31 pg/ml was 67% sensitive and 73% specific for the diagnosis (area under the ROC curve of 0.76 [0.55-0.9], p=0.007).

Identification and quantification of prosthetic mitral regurgitation by flow convergence method using transthoracic approach

The present case report illustrates the clinical applicability of the proximal isovelocity surface area (PISA) method in identifying, locating and assessing paravalvular prosthetic mitral regurgitation by transthoracic echocardiography.

Angiographic coronary artery disease associated with hypertensive heart failure and normal ejection fraction. Insights from a prospective monocenter study

The prevalence of underlying coronary artery disease (CAD) was examined in 23 consecutive hypertensive patients presenting with acute onset of heart failure and normal ejection fraction (HFnlEF) without clinical, electrocardiographic and biochemical evidence of myocardial ischemia. By coronary angiography, 2 patients had 1-vessel disease, 5 patients had 2-vessels disease and 1 patient had 3-vessels disease. 26% of patients was classified as having ischemic heart disease. Underlying CAD is not an uncommon finding in hypertensive HFnlEF and must be checked with the aim to enhance the therapeutic management.