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Comparison of the Diastolic Stress Test With a Combined Resting Echocardiography and Biomarker Approach to Patients With Exertional Dyspnea: Diagnostic and Prognostic Implications.
JACC Cardiovasc Imaging. 2019 05; 12(5):771-780.JC

Abstract

OBJECTIVES

This study sought to establish the diagnostic and prognostic value of a strategy for prediction of abnormal diastolic response to exercise (AbnDR) using clinical, biochemical, and resting echocardiographic markers in dyspneic patients with mild diastolic dysfunction.

BACKGROUND

An AbnDR (increase in left ventricular filling pressure) may indicate heart failure with preserved ejection fraction as the cause of symptoms in dyspneic patients, despite a nonelevated noncardiac at rest. However, exercise testing may be inconclusive in patients with noncardiac limitations to physical activity.

METHODS

In 171 dyspneic patients (64 ± 8 years) with suspected heart failure with preserved ejection fraction but resting peak early diastolic mitral inflow velocity/peak early diastolic mitral annular velocity ratio (E/e') <14, a complete echocardiogram (including assessment of myocardial deformation and rotational mechanics) and blood assays for biomarkers were performed. Echocardiography following maximal exercise was undertaken to assess AbnDR (exertional E/e' >14). Patients were followed over 26.2 ± 4.6 months for endpoints of cardiovascular hospitalization and death.

RESULTS

AbnDR was present in 103 subjects (60%). Independent correlates of AbnDR were resting E/e' (odds ratio [OR]: 8.23; 95% confidence interval [CI]: 3.54 to 9.16; p < 0.001), left ventricular untwisting rate (OR: 0.60; 95% CI: 0.42 to 0.86; p = 0.006), and galectin-3-a marker of fibrosis (OR: 1.80; 95% CI: 1.21 to 2.67; p = 0.004). The use of resting E/e' >11.3 and galectin-3 <1.17 ng/ml to select patients for further diagnostic processing would have allowed exercise testing to be avoided in 65% of subjects, at the cost of misclassification of 13%. The composite outcome of cardiovascular hospitalization or death occurred in 47 patients (27.5%). The predictive value of an AbnDR response and the combined strategy (resting echocardiography and galectin-3 or exercise testing in case of an inconclusive first step) showed similar event prediction (36 vs. 34; p = 0.95).

CONCLUSIONS

The implementation of a 2-step algorithm (echocardiographic evaluation of resting E/e' followed by the assessment of galectin-3) may improve the diagnosis and prognostic assessment of individuals with suspected heart failure with preserved ejection fraction who are unable to perform a diagnostic exercise test.

Authors+Show Affiliations

Cardiology Department, Wroclaw Medical University, Wroclaw, Poland; Cardiovascular Imaging Research Group, Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Cardiovascular Imaging Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia.Cardiology Department, Wroclaw Medical University, Wroclaw, Poland; Cardiovascular Imaging Research Group, Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Cardiovascular Imaging Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia.Cardiology Department, Wroclaw Medical University, Wroclaw, Poland.Cardiovascular Imaging Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia. Electronic address: tom.marwick@baker.edu.au.

Pub Type(s)

Comparative Study
Journal Article
Research Support, Non-U.S. Gov't
Validation Study

Language

eng

PubMed ID

29454783

Citation

Kosmala, Wojciech, et al. "Comparison of the Diastolic Stress Test With a Combined Resting Echocardiography and Biomarker Approach to Patients With Exertional Dyspnea: Diagnostic and Prognostic Implications." JACC. Cardiovascular Imaging, vol. 12, no. 5, 2019, pp. 771-780.
Kosmala W, Przewlocka-Kosmala M, Rojek A, et al. Comparison of the Diastolic Stress Test With a Combined Resting Echocardiography and Biomarker Approach to Patients With Exertional Dyspnea: Diagnostic and Prognostic Implications. JACC Cardiovasc Imaging. 2019;12(5):771-780.
Kosmala, W., Przewlocka-Kosmala, M., Rojek, A., & Marwick, T. H. (2019). Comparison of the Diastolic Stress Test With a Combined Resting Echocardiography and Biomarker Approach to Patients With Exertional Dyspnea: Diagnostic and Prognostic Implications. JACC. Cardiovascular Imaging, 12(5), 771-780. https://doi.org/10.1016/j.jcmg.2017.10.008
Kosmala W, et al. Comparison of the Diastolic Stress Test With a Combined Resting Echocardiography and Biomarker Approach to Patients With Exertional Dyspnea: Diagnostic and Prognostic Implications. JACC Cardiovasc Imaging. 2019;12(5):771-780. PubMed PMID: 29454783.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Comparison of the Diastolic Stress Test With a Combined Resting Echocardiography and Biomarker Approach to Patients With Exertional Dyspnea: Diagnostic and Prognostic Implications. AU - Kosmala,Wojciech, AU - Przewlocka-Kosmala,Monika, AU - Rojek,Aleksandra, AU - Marwick,Thomas H, Y1 - 2018/02/14/ PY - 2017/07/13/received PY - 2017/09/18/revised PY - 2017/10/03/accepted PY - 2018/2/20/pubmed PY - 2020/3/19/medline PY - 2018/2/19/entrez KW - E/e′ ratio KW - diastole KW - exercise testing KW - galectin-3 KW - untwisting rate SP - 771 EP - 780 JF - JACC. Cardiovascular imaging JO - JACC Cardiovasc Imaging VL - 12 IS - 5 N2 - OBJECTIVES: This study sought to establish the diagnostic and prognostic value of a strategy for prediction of abnormal diastolic response to exercise (AbnDR) using clinical, biochemical, and resting echocardiographic markers in dyspneic patients with mild diastolic dysfunction. BACKGROUND: An AbnDR (increase in left ventricular filling pressure) may indicate heart failure with preserved ejection fraction as the cause of symptoms in dyspneic patients, despite a nonelevated noncardiac at rest. However, exercise testing may be inconclusive in patients with noncardiac limitations to physical activity. METHODS: In 171 dyspneic patients (64 ± 8 years) with suspected heart failure with preserved ejection fraction but resting peak early diastolic mitral inflow velocity/peak early diastolic mitral annular velocity ratio (E/e') <14, a complete echocardiogram (including assessment of myocardial deformation and rotational mechanics) and blood assays for biomarkers were performed. Echocardiography following maximal exercise was undertaken to assess AbnDR (exertional E/e' >14). Patients were followed over 26.2 ± 4.6 months for endpoints of cardiovascular hospitalization and death. RESULTS: AbnDR was present in 103 subjects (60%). Independent correlates of AbnDR were resting E/e' (odds ratio [OR]: 8.23; 95% confidence interval [CI]: 3.54 to 9.16; p < 0.001), left ventricular untwisting rate (OR: 0.60; 95% CI: 0.42 to 0.86; p = 0.006), and galectin-3-a marker of fibrosis (OR: 1.80; 95% CI: 1.21 to 2.67; p = 0.004). The use of resting E/e' >11.3 and galectin-3 <1.17 ng/ml to select patients for further diagnostic processing would have allowed exercise testing to be avoided in 65% of subjects, at the cost of misclassification of 13%. The composite outcome of cardiovascular hospitalization or death occurred in 47 patients (27.5%). The predictive value of an AbnDR response and the combined strategy (resting echocardiography and galectin-3 or exercise testing in case of an inconclusive first step) showed similar event prediction (36 vs. 34; p = 0.95). CONCLUSIONS: The implementation of a 2-step algorithm (echocardiographic evaluation of resting E/e' followed by the assessment of galectin-3) may improve the diagnosis and prognostic assessment of individuals with suspected heart failure with preserved ejection fraction who are unable to perform a diagnostic exercise test. SN - 1876-7591 UR - https://www.unboundmedicine.com/medline/citation/29454783/Comparison_of_the_Diastolic_Stress_Test With_a_Combined_Resting_Echocardiography_and_Biomarker_Approach_to_Patients_With_Exertional_Dyspnea:_Diagnostic_and_Prognostic_Implications_ DB - PRIME DP - Unbound Medicine ER -