Jaromir Bobek

Usefulness of New Diastolic Strain and Strain Rate Indexes for the Estimation of Left Ventricular Filling Pressure

Tissue Doppler indexes of left ventricular (LV) filling pressure are prone to angulation errors and tethering and are less reliable in patients with preserved LV ejection fraction and indeterminate early peak transmitral diastolic flow (E)/mitral early diastolic velocity (Ea) (8 <E/Ea <15). Two-dimensional echocardiographic global longitudinal diastolic strain (Ds) and strain rate (DSr) were measured during peak mitral filling, and combined with E, derived new noninvasive indexes of LV filling pressure (E/Ds and E/10DSr). These indexes were compared with simultaneously invasively measured LV preatrial (pre-A) contraction pressure and E/Ea. Fifty patients were studied. Mean age was 55.9 +/- 9.9 years, 22 (43%) were women, and mean LV ejection fraction was 49.3 +/- 18.0%. Ds (R = 0.48, p <0.001) and DSr (R = 0.43, p = 0.002) correlated with invasively measured -dP/dt. Correlations between E/Ds and E/10DSr with LV pre-A pressure were R = 0.81 (p <0.001) and R = 0.80 (p <0.001) compared with R = 0.63 (p <0.001) between E/Ea and LV pre-A pressure, respectively. E/Ds > or =8 had higher sensitivity and specificity (95% and 94%, respectively; area under the curve = 0.96, p <0.0001) than E/Ea > or =15 (sensitivity 81%, specificity 75%; area under the curve = 0.85, p <0.0001) for the prediction of LV pre-A pressure > or =15 mm Hg (p = 0.01 for comparison). In patients with LV ejection fraction > or =50% and 8 <E/Ea <15, E/Ds and E/DSr were more accurate than E/Ea for determination of LV pre-A pressure. In conclusion, a novel ratio 2-dimensional echocardiographic diastolic strain ratio (E/Ds) was a better predictor of LV filling pressure than E/Ea. In patients with LV ejection fraction > or =50% or indeterminate E/Ea, both E/Ds and E/10DSr (a ratio based on global DSR) were better predictors of LV filling pressure than E/Ea.

Assessment of Left Ventricular Systolic Function Using Echocardiography in Patients With Preserved Ejection Fraction and Elevated Diastolic Pressures

There is controversy regarding the nature of systolic function in patients with elevated filling pressure and preserved left ventricular (LV) ejection fraction. In this study, tissue Doppler variables and 2-dimensional echocardiographic systolic strain (SS) and systolic strain rate (SSr) were measured in patients who underwent cardiac catheterization to determine correlations with invasively measured LV end-diastolic pressure (LVEDP), dP/dt, and LV mass. Forty patients were studied. Their mean age was 55.9+/-9.9 years, and their mean LV ejection fraction was 59.8+/-5.2%. Tissue Doppler systolic annular velocity (5.4+/-1.1 vs 6.4+/-1.0 cm/s, p=0.04), SS (13.4+/-3.7% vs 18.8+/-2.3%, p <0.001), and SSr (0.73+/-0.17 vs 0.98+/-0.14 s(-1), p <0.001) were significantly lower in patients with LVEDP >20 mm Hg compared with those with LVEDP <20 mm Hg. Tissue Doppler systolic velocity, SSr, and SS were correlated with LV mass (R=0.58, R=0.57, and R=0.52, respectively, all p values <0.001) and with LVEDP (R=0.49, p=0.002; R=0.79, p<0.001; and R=0.70, p<0.001, respectively). However, dP/dt was not significantly different between patients with LVEDP >20 mm Hg and those with LVEDP <20 mm Hg (1,387+/-520 vs 1,495+/-594 mm Hg/s, respectively, p=0.55) and was not correlated with LV mass (R=0.18, p=0.25). The optimum cut-off values for LVEDP >20 mm Hg were SSr <0.85 s(-1) (area under the curve 0.88, p<0.001, positive predictive value 89%, negative predictive value 86%) and SS<16% (area under the curve 0.84, p=0.002, positive predictive value 88%, negative predictive value 79%). In conclusion, as opposed to invasively measured dP/dt, tissue Doppler systolic velocity and 2-dimensional echocardiographic SS and SSr are significantly depressed in patients with preserved LV ejection fraction and LVEDP >20 mm Hg, suggesting that systolic abnormalities are present in at least some of these patients. These differences are likely because invasively measured dP/dt and these echocardiographic variables measure different systolic properties in patients with preserved LV ejection fraction.

Comparison of Higher Clopidogrel Loading and Maintenance Dose to Standard Dose on Platelet Function and Outcomes After Percutaneous Coronary Intervention Using Drug-Eluting Stents

Adequate antiplatelet therapy is paramount for good clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). The purpose of this study was to determine whether a high-dose regimen of clopidogrel in patients undergoing PCI is superior to standard dosing. A total of 119 patients undergoing PCI were blindly randomized in 2:1 fashion to receive clopidogrel loading 600 mg on the table immediately before PCI and 75 mg 2 times/day for 1 month (high-dose group) versus standard dosing (300 mg loading and 75 mg/day; low-dose group). Platelet aggregation was measured using light transmission aggregometry at baseline, 4 hours, and 30 days. The composite of cardiovascular death, myocardial infarction, and target vessel revascularization was studied at 30 days in addition to major and minor bleeding. Baseline characteristics and baseline platelet aggregation were similar in the 2 groups. Percent inhibitions of platelet activity were 41% and 27% in the high-dose group versus 19% and 10% in the low-dose group at 4 hours and 30 days (p = 0.046 and 0.047, respectively). Composite clinical end points were 10.3% in the high-dose group and 23.8% in the low-dose group (p = 0.04). No difference was noted in major or minor bleeding. In conclusion, a higher loading and maintenance dose of clopidogrel in patients undergoing PCI results in superior platelet inhibition and decreased cardiovascular events without increasing bleeding complications.

New, Simple Echocardiographic Indexes for the Estimation of Filling Pressure in Patients with Cardiac Disease and Preserved Left Ventricular Ejection Fraction

Background: There are few data on echocardiographic indexes incorporating peak mitral inflow velocity (E), left atrial volume index (LAVi), and pulmonary artery pressure (PAP) for estimation of left ventricular (LV) filling pressure in patients with preserved LV ejection fraction (EF ≥ 50%). Methods: Patients underwent echocardiography ≤20 minutes of cardiac catheterization. Echocardiographic variables were compared to invasively measured LV end‐diastolic pressure (LVEDP). Results: Of the 122 patients, 67 (55%) were women, the mean age was 55 ± 9 years, the mean left ventricular ejection fraction (LVEF) was 61 ± 6%, 107 (88%) were hypertensive, and 79 (65%) had significant coronary artery disease at catheterization. E/Ea correlated with LVEDP (R = 0.68, P < 0.0001), compared to PAP (R = 0.53, P < 0.001), peak E velocity (R = 0.48, P < 0.001), and LAVi (R = 0.48, P < 0.001). E/Ea > 12 had 75% sensitivity and 78% specificity for LVEDP ≥ 20 mmHg (area under curve (AUC) = 0.79, P < 0.0001), compared with (PAP + LAVi)/2 > 30 (sensitivity = 72%, specificity = 80%, AUC = 0.84, P < 0.001) and (E + LAVi)/2 > 57 (sensitivity = 73% and specificity = 81%, AUC = 0.82, P < 0.001) (P = NS). E <60 cm/sec had 94% negative, and E>90 cm/sec had 96% positive, predictive value for LVEDP ≥ 20 mmHg. (E + LAVi)/2 added incrementally to E/Ea when E/Ea was in the gray zone. Conclusions: New, simple echocardiographic equations, (E + LAVi)/2 and (PAP + LAVi)/2, have comparable accuracy to E/Ea for LVEDP estimation in patients with cardiac disease and preserved LVEF, and (E + LAVi)/2 added incrementally to E/Ea alone when E/Ea was in the gray zone. Peak E velocity alone had high negative and positive predictive value for elevated LVEDP in this population. These simple echocardiographic variables could be used—in isolation or with E/Ea—in patients with cardiac disease and preserved LVEF for the diagnosis of diastolic heart failure. Echocardiography 2010;27:946‐953)

Correlation of Tissue Doppler and Two-Dimensional Speckle Myocardial Velocities and Comparison of Derived Ratios with Invasively Measured Left Ventricular Filling Pressures

BACKGROUND There are a paucity of data comparing spectral and color tissue Doppler (TD) with non-Doppler, speckle-based myocardial velocities, and it is unknown how early transmitral diastolic velocity/mitral annular velocity (E/Ea) calculated using speckle velocities compares with TD-derived E/Ea. METHODS We measured systolic (Sa), Ea, and late diastolic (Aa) myocardial velocities using these 3 methods and compared calculated E/Ea with invasively measured left ventricular (LV) hemodynamics. Consecutive patients referred for cardiac catheterization were imaged, and LV pre-A contraction pressure was measured by retrograde aortic cardiac catheterization. RESULTS Fifty patients (22 women, 44%) were studied with a mean age of 54 +/- 10 years and a mean LV ejection fraction of 48% +/- 19%. Speckle and color TD Sa, Ea, and Aa were significantly lower than spectral TD velocities, resulting in higher E/Ea values compared with spectral TD E/Ea. Spectral TD E/Ea (R = 0.65, P < .001), color TD E/Ea (R = 0.69, P < .001), and speckle E/Ea (R = 0.76, P < .001) all correlated with LV pre-A pressure. Different cutoff values were needed for spectral TD, color TD, and speckle E/Ea to predict LV pre-A pressure >or= 15 mm Hg; spectral E/Ea > 14 (area under the curve [AUC] = 0.87, P < .001, sensitivity = 83%, specificity = 77%), color E/Ea > 16 (AUC = 0.89, P < .0001, sensitivity = 79%, specificity = 81%), and speckle E/Ea > 18 (AUC = 0.87, P < .0001, sensitivity = 88%, specificity = 74%; P = not significant for comparisons between the groups). CONCLUSION Spectral TD, color TD, and speckle imaging measure different velocities, and consequently different cutoff values are needed for E/Ea to predict invasively measured LV filling pressure.

IMPACT OF GENDER ON DOOR TO BALLOON TIME IN STEMI

Delay in door to balloon time (DTBT) is generally associated with worse morbidity and mortality. Women have longer DTBT compared to men. This study aimed to assess system and clinical factors associated with this disparity in care. A cohort of STEMI patients presenting to a large tertiary hospital