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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 12 had 75% sensitivity and 78% specificity for LVEDP ≥ 20 mmHg (area under curve (AUC) = 0.79, P 30 (sensitivity = 72%, specificity = 80%, AUC = 0.84, P 57 (sensitivity = 73% and specificity = 81%, AUC = 0.82, P 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)

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.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.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 pressureor= 15 mm Hg; spectral E/Ea14 (area under the curve [AUC] = 0.87, P.001, sensitivity = 83%, specificity = 77%), color E/Ea16 (AUC = 0.89, P.0001, sensitivity = 79%, specificity = 81%), and speckle E/Ea18 (AUC = 0.87, P.0001, sensitivity = 88%, specificity = 74%; P = not significant for comparisons between the groups).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.

The effect of hydrolyzed casein (HC) on the expression of three mucin genes (Muc2, Muc3, and Muc4) in the rat intestine was investigated using quantitative real-time polymerase chain reaction. After a 10 day acclimatization period, rats received for 8 days the test diets containing either HC or a synthetic amino acid (SAA) mixture as the sole source of nitrogen or a protein-free (PF) diet (n = 12 per treatment). The addition of HC or the SAA mixture to the diet significantly improved average daily gain, average daily food intake, and gain:feed ratio as compared with the PF diet. Terminal ileal endogenous N flow was significantly higher for the HC-fed rats in comparison with either the SAA or the PF rats (p < or = 0.001). HC supported a significant increase of Muc3 mRNA (277 and 229% of that for diets PF and SAA, respectively; p < or = 0.05) in the small intestinal tissue and Muc4 mRNA (325 and 265% of that for diets PF and SAA, respectively; p < or = 0.05) in the colon. In conclusion, HC enhances ileal endogenous N flow and up-regulates in vivo the expression of some individual mucin genes.

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) (8E/Ea15). 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, p0.001) 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 (p0.001) and R = 0.80 (p0.001) compared with R = 0.63 (p0.001) between E/Ea and LV pre-A pressure, respectively. E/Dsor =8 had higher sensitivity and specificity (95% and 94%, respectively; area under the curve = 0.96, p0.0001) than E/Eaor =15 (sensitivity 81%, specificity 75%; area under the curve = 0.85, p0.0001) for the prediction of LV pre-A pressureor =15 mm Hg (p = 0.01 for comparison). In patients with LV ejection fractionor =50% and 8E/Ea15, 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 fractionor =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.

It is unknown whether right ventricular (RV) tissue Doppler (TD) predicts outcome in patients with left ventricular (LV) heart failure (HF) independently of contemporary echocardiographic Doppler variables of LV diastolic function. Comprehensive echocardiographic Doppler examination was performed before discharge in 107 patients hospitalized with LV HF. The primary end point was cardiac death or rehospitalization for HF. Follow-up was complete for 100 of 107 patients a mean of 527 days after hospital discharge. There were no significant differences in baseline clinical variables (mean age 58 ± 12 years, 46% women, 77% hypertensive, 48% diabetic, 41% current smokers, and 23% known coronary artery disease) in prediction of the primary end point. Compared with patients without an event, patients with an event had a larger left atrial volume index (42 ± 16 vs 33 ± 13 ml/m 2 , p = 0.001), lower LV ejection fraction (35 ± 19% vs 46 ± 22%, p = 0.01), higher mitral peak early diastolic flow velocity/TD early diastolic velocity (19 ± 7 vs 14 ± 7, p = 0.001), lower RV fractional area change (39 ± 11% vs 43 ± 10%, p = 0.04), and lower RV TD systolic velocity (8 ± 2 vs 10 ± 3 cm/s, p = 0.005). On Cox proportional hazards multivariate analysis, left atrial volume index (p = 0.01), mitral peak early diastolic flow velocity/TD early diastolic velocity (p = 0.03), and RV TD systolic velocity (p = 0.04) were independent predictors of outcome. Even when contemporary echocardiographic Doppler measures of LV diastolic function are considered, RV TD systolic velocity is an independent predictor of cardiac death or rehospitalization for HF in patients hospitalized with HF and appears to be superior to conventional 2-dimensional parameters of RV function.

The authors utilized rapid right atrial pacing and handgrip exercise to provoke myocardial ischemia in 20 participants (age >65 years) who, for reasons of disability, were not candidates for exercise and pharmacologic stress testing. Echocardiographic left ventricular ejection fraction and left ventricular wall motions were obtained during pacing at baseline and at maximal pacing rates and were compared with coronary angiography. Using the failure of left ventricular ejection fraction to increase with pacing as an indicator of myocardial ischemia, the test yielded a sensitivity of 75%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 71%. When a pacing-induced decrease of wall-motion index was taken as an ischemia indicator, the sensitivity was 63%, specificity 100%, positive predictive value 100%, and negative predictive value 80%. Rapid atrial pacing echocardiography is a safe test. It may be considered in a select group of elderly patients as an alternative to exercise or pharmacologic tests before resorting to coronary angiography.

There are few data on adding left atrial volume index (LAVi) or pulmonary artery systolic pressure (PAP) to the ratio of early mitral inflow to mitral annular velocity (E/e') for the estimation of left ventricular (LV) filling pressure in patients with preserved LV ejection fractions (LVEFs) (50%).Patients underwent echocardiography within 20 minutes of cardiac catheterization. Echocardiographic variables were compared with invasively measured LV preatrial contraction pressure (pre-A).Of the 122 patients studied (mean age, 55 +/- 9 years; mean LVEF, 61 +/- 6%), 67 (55%) were women, 108 (88%) had hypertension, and 79 (65%) had significant coronary artery disease at catheterization. E/e' was significantly correlated with pre-A (R = 0.63, P.0001) compared with LAVi (R = 0.49, P.001) and PAP (R = 0.48, P.001). E/e'13 had sensitivity of 70% and specificity of 93% (area under the curve [AUC], 0.82; P.0001), LAVi31 mL/m2 had sensitivity of 78% and specificity of 76% (AUC, 0.80, P.001), and PAP28 mm Hg had sensitivity of 80% and specificity of 64% for pre-A15 mm Hg (AUC, 0.77, P.001). Adding LAVi31 mL/m2 for E/e' = 8 to 13 significantly increased the accuracy of E/e'13 alone (sensitivity, 87%; specificity, 88%; AUC, 0.89; P = .01 for comparison). However, adding PAP28 mm Hg for E/e' = 8 to 13 did not significantly increase the accuracy of E/e'13 alone (AUC, 0.82; sensitivity, 82%; specificity, 72%; P = NS for comparison).In patients with preserved LVEFs, adding LAVi31 mL/m2 to E/e' (when E/e' was in the gray zone, but not when E/e' was13) significantly increased the accuracy of E/e' alone for the estimation of LV filling pressure. These data support the notion of using several, rather than any single, Doppler echocardiographic parameter for the accurate assessment of LV diastolic function.

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%, p0.001), and SSr (0.73+/-0.17 vs 0.98+/-0.14 s(-1), p0.001) were significantly lower in patients with LVEDP20 mm Hg compared with those with LVEDP20 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 values0.001) and with LVEDP (R=0.49, p=0.002; R=0.79, p0.001; and R=0.70, p0.001, respectively). However, dP/dt was not significantly different between patients with LVEDP20 mm Hg and those with LVEDP20 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 LVEDP20 mm Hg were SSr0.85 s(-1) (area under the curve 0.88, p0.001, positive predictive value 89%, negative predictive value 86%) and SS16% (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 LVEDP20 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.

Noninvasive left ventricular (LV) pressure estimation in obese patients has not been well described. Simultaneous B-type natriuretic peptide (BNP) and echocardiographic Doppler examinations were performed in patients with dyspnea undergoing cardiac catheterization. Patients were divided into body mass index (BMI)35 (markedly obese), 31 to 35 (obese), andor =30 kg/m2 (nonobese). BNP levels and mitral early diastolic/tissue Doppler annular velocity (E/Ea) were compared with invasively measured LV end-diastolic and pre-atrial (pre-A) pressures. Seventy-two patients were studied. Except for BMI, LV mass index, and LV diastolic dimension, there were no significant differences in baseline, echocardiographic Doppler, or hemodynamic characteristics among the groups. However, BNP was significantly lower in markedly obese compared with obese and nonobese patients (116 +/- 187 vs 241 +/- 674 and 277 +/- 352 pg/ml, respectively; p = 0.03). BNP did not correlate with LV pre-A pressure in markedly obese patients (R = 0.13, p = 0.47), whereas BNP significantly correlated with this variable in the obese (R = 0.64) and nonobese (R = 0.58) groups. Mitral E/Ea significantly correlated with LV pre-A and LV end-diastolic pressures in all BMI groups. In markedly obese patients with dyspnea, BNP did not correlate with invasively measured LV filling pressure, whereas this correlated in obese and nonobese patients. However, mitral E/Ea significantly correlated with LV filling pressures in all BMI groups. In conclusion, BNP is not recommended for LV filling pressure estimation in ambulatory patients with dyspnea with BMI35 kg/m2.