European Heart Journal Advance Access originally published online on September 4, 2007
European Heart Journal 2007 28(21):2686-2687; doi:10.1093/eurheartj/ehm380
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How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology: reply
Department of Physiology
VU University Medical Center
Van der Boechorststraat 7
Amsterdam
The Netherlands
University of Erlangen
Erlangen
Germany
Rikshospitalet
Oslo
Norway
University of Wales College of Medicine
Cardiff
UK
E-mail address: wj.paulus{at}vumc.nl
The authors appreciated Dr Kindermann's interest in our consensus document on ‘How to diagnose diastolic heart failure ?’1 and understand his concern on the use of averaged tissue Doppler (TD) lateral and septal mitral annular lengthening velocities to calculate the E/E' ratio (E/E'ave). The consensus document considers an E/E'ave > 15, derived from real-time pulsed TD, diagnostic evidence for diastolic LV dysfunction and requires additional noninvasive investigations for the diagnosis of diastolic LV dysfunction if the E/E'ave is encompassed in between 8 and 15. These cut-off values were indeed first proposed by Ommen et al.,2 who preferred the septal mitral annular lengthening velocity for the calculation of the E/E' ratio (E/E'sept). In patients with LV ejection fraction (EF) < 50% and elevated mean LV filling pressures (16.9 ± 6.4 mmHg), this study however observed equally strong correlations between mean LV filling pressures and E/E'sept (r = 0.60) or E/E'ave (r = 0.60). Only in patients with LVEF > 50% was the correlation between mean LV filling pressures and E/E'sept (r = 0.47) slightly better than E/E'ave (r = 0.45). These patients however had normal mean LV filling pressures (11.4 ± 5.6 mmHg). The better correlation observed in this group can therefore not be extrapolated to patients with heart failure and normal LV ejection fraction (HFNEF). A similar study3 correlating mean pulmonary capillary wedge pressure (PCWP) with E/E'ave also revealed E/E'ave > 15 to be the optimal cut-off value to predict elevated PCWP. These investigators preferred the use of E/E'ave following a prior study,4 in which they had compared E/E' ratios using lateral, septal, anterior, inferior, average of two, average of three, and average of four mitral annular lengthening velocities. In this study, the use of averaged lateral and septal mitral annular lengthening velocities yielded the best correlation with PCWP even in the presence of segmental LV dysfunction. Recently, the E/E' ratio using the lateral mitral annular lengthening velocity (E/E'lat) and E/E'sept was correlated in HFNEF patients with a conductance catheter derived LV stiffness modulus.5 In this study, only E/E'lat correlated with the LV stiffness modulus (r = 0.53; P < 0.001). Moreover, only E/E'lat discriminated HFNEF patients from age-matched controls possibly because of aspecific ageing-induced elevation of E/E'sept.6
In conclusion, the consensus document prefers E/E'ave over E/E'sept because both predict LV filling pressures equally well in patients with heart failure,2 because use of E/E'ave also reveals a value of 15 to be the optimal cut-off for detection of high LV filling pressures,3 and because E/E'sept fails to discriminate between HFNEF patients and controls.5 It is evident that the recommendations of the consensus document will have to be prospectively tested in clinical practice and adjusted accordingly. A critical comparison between E/E'ave, E/E'sept, and E/E'lat could be a valuable adjunct of such prospective testing.
References
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- Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation (2000) 102:1788–1794.
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- Srivastava PM, Burrell LM, Calafiore C. Lateral vs medial mitral annular tissue Doppler in the echocardiographic assessment of diastolic function and filling pressures: which should we use? Eur J Echocardiogr (2005) 6:97–106.
[Abstract/Free Full Text]
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