Combined cardiopulmonary exercise stress echocardiography test: New test for assessment of diastolic dysfunction in patients with hypertension Ivana Nedeljkovic, M Ostojic, V Giga, V Stojanov, J Stepanovic, A Djordjevic Dikic, B Beleslin, M Nikolic, M Petrovic, D Popovic University of Belgrade, School of Medicine Department of Cardiology, Clinical Center of Serbia, Belgrade
Development of diatolic dysfunction/failure in pts with hypertension Pressure overload Hypertrophy Impaired relaxation Impaired relaxation and increased stiffnes Increased stiffnes Impaired early filling Normal exercise tolerance Diastolic impairment Increased filling pressure Increased pulmonary pressure at exercise Decreased exercise tolerance Diastolic dysfunction Increased LVEDP and LA dimension AF and desreased CO Poor exercise tolerance and signs of HF Diastolic heart failure
Background Diastolic dysfunction/failure are a common consequence of long-lasting hypertension. Thus, detection of this impairment in early stage represents great challenge for prevention of development of DHF
Background Recent papers showed good correlation between resting ECHO and CPET parameters in patients with DD/failure However, the main clinical symptom of DD is exertional dyspnea as a consequence of decreased exercise tolerance even in pts with normal resting ECHO
Background This limitation of resting ECHO has been overcome by the use of diastolic stress echo We proposed combination of diastolic stress ECHO and CPET
Methods: Study population 46 pts (27 male, mean age 56±14 years), 41% Column1 59% Male Female Inclusion criteria: history of essential hypertension exertional dyspnea normal baseline echo (normal SF and DF function) Absence of myocardial ischemia during CPET
Methods : Test protocol Cardiopulmonary exercise testing- Schiller CS 200 Supine bicycle ergometer Incremental ramp protocol 15 Watt/min 2D echo at rest and continuously during CPET Pulse and TDI Doppler imaging at rest and at the top of exercise
Methods : Echocardiographic analysis Baseline echo examination: - LV dimensions - LV systolic function - LV diastolic function (E/A, Dt, E/E ) ECHO measurements at maximal CPET - E/A, Dt, E/E
Methods : Transmitral flow normal DT = 160 220 ms
Methods : Mitral annular TDI Normal E/E` < 8
Patients with hypertension and exertional dyspnea LV EF > 50% E/E at rest < 8 Max Exercise E/E < 8 Normal Max Exercise E/E > 8 Dysfunction
Methods: Study population Diastolic dysfunction detected in 19/46 pts (41%) 59% (27/46) Column1 41% (19/46) DD+ DD- Variable Patients with DD n=19 Patients without DD n=27 Male gender (%) 59 41 <0.0001 Age (years) 64±9 47±11 <0.0001 p
CPET duration and workload in pts with and withot exercise induced DD WL (Watt) Time (min) 15,0 10,0 5,0 P=0.001 p=0.032 12±1.6 9.1±2 9.0±1.7 7.5±1.7 DD+ DD- 0,0 Time to VAT Test duration 150 P=0.007 100 50 90±32 120±20 DD+ DD- 0 Max WL
Max SBP and DBP in pts with and without exercise induced DD mmhg 200,0 150,0 p=ns 178±27 183±32 P=ns 100,0 50,0 94±7 98±10 DD+ DD- 0,0 SBP DBP
Baseline ECHO characteristics of pts with and without exercise induced DD 6,0 cm 4,0 2,0 DD+ DDns ns 5.1±0.4 4.9±0.4 3.2±0.2 3.0±0.2 0,0 rest LV EDD rest LV ESD % 68 67 66 65 64 63 62 ns 64±23 67±33 DD+ DD- rest EF LK
Mitral E wave Dt before and at maximal CPET in pts with and without stress induced DD Dt (s) p=0.024 N=46 pts 250 200 p=0.001 ns P=0.004 150 186 224 212 DD+ 100 163 DD- 50 0 rest Dt max Dt
E/E before and at maximal CPET in pts with and without stress induced DD E/E 12 P<0.0001 N=46 pts 10 8 6 p=ns ns 10.4±1.2 P<0.0001 DD+ 4 5.6±0.9 5.1±0.8 5.6±0.9 DD- 2 0 rest E/E' max E/E'
Peak VO2 and VAT (VO2) in pts with and without stress induced DD VO2 (ml/kg/min) N=46 pts 25 20 15 10 5 p<0.0001 P=0.0002 20±3 19±3 14±5 14±4 DD+ DD- 0 PeakVO2 VAT (VO2)
Peak O2 pulse in pts with and without stress induced DD O2p (ml/beat) N=46 pts 25 20 P=0.042 15 12±3 DD+ 10 5 10±2 DD- 0 O2 pulse
VE/VCO2 slope in pts with and without stress induced DD N=46 pts 40 35 30 36±3 p<0.0001 25 20 15 10 5 0 24±2 VE/VCO2 slope DD+ DD-
Relationship between E/E and VE/VCO2 slope r=0.89; p<0.0001
Multivariate logistic regression analysis: CPET predictors of DD 95%CI Variable p RR Lower limit Upper limit VE/VCO2 slope 0.001 1.59 1.15 2.19 VE/VCO2 slope ventilation to carbon dioxide output;
ROC curve with cut off value for VE/VCO2 slope best predictive for diastolic dysfunctin Cutoff for VE/VCO2 slope: 33.5 Sn 90.9%, Sp 95.7% AUC: 0.99 (95%CI : 0.96-1)
Conclusion Echocardiography adds more information to CPET in detection of stress induced DD CPET parameters showed significant correlation with stress induced ECHO changes VE/VCO2 slope was independant predictor of stress induced DD, with specific cutoff value of 33.5 Thus, combined CPET stress ECHO test is very useful and simple clinical tool for early detection of DD in pts with hypertension and normal LVEF