Pulmonary artery pressure and diastolic dysfunction in normal left ventricular systolic function

doi:10.1016/j.ijcard.2007.06.003

International Journal of Cardiology

Volume 127, Issue 2, 4 July 2008, Pages 174-178

https://doi.org/10.1016/j.ijcard.2007.06.003 Get rights and content

Abstract

Background

Pulmonary arterial hypertension is a well-established sequel of LV systolic dysfunction; however its association with diastolic dysfunction in subjects with normal LV systolic function has not been thoroughly studied. The aim of this study was to evaluate the correlation between diastolic dysfunction and pulmonary arterial hypertension in patients with normal left ventricular (LV) wall motion.

Methods

We analyzed retrospectively 477 consecutive echocardiographic studies that were performed in the Meir Medical Center echocardiography laboratory in subjects with normal LV systolic function and correlated the state of diastolic function (normal, impaired relaxation, pseudo normal and restrictive pattern) to the magnitude of pulmonary artery pressure (PAP) assessed by echocardiography. None of the subjects that were studied had any other established causes of pulmonary hypertension.

Results

Mean PAP for subjects with normal diastolic function (n = 110) was 31.1 ± 6 mm Hg; for grade 1 diastolic dysfunction (impaired relaxation ) (n = 256) 35.6 ± 10.2 mm Hg; for grade 2 (pseudo normal) (n = 102) 38.9=10.6 mm Hg and for grade 3 (restrictive pattern) (n = 9) the pressure was 55.1 ±11.4 mm Hg (p < 0.001 by one-way ANOVA, the differences were between each 2 groups of diastolic dysfunction).

Conclusions

LV diastolic dysfunction is associated with an increase in PAP in subjects with normal systolic function. PAP is significantly increased for each step-up in diastolic dysfunction grade.

Introduction

Diastolic heart failure is caused by the inability to produce an adequate cardiac output at normal left ventricular (LV) filling pressure despite the presence of normal ventricular systolic function [1]. A normal forward cardiac output in these patients can only be maintained by a compensatory elevation of left ventricular filling pressure [2]. This state is associated with a marked increase in morbidity [3] and all-cause mortality [4]. With the aid of echocardiography, based on the pattern of diastolic left ventricular filling velocities, diastolic failure can be subgrouped into 3 major stages: 1. impaired relaxation, in which myocardial stiffness is evident but left atrial pressure is not yet elevated, 2. pseudo normal filling pattern; in which there is already a modest increase in left atrial pressure, and 3. restrictive pattern; where left atrial pressure is markedly elevated [2]. It has been shown that progression in the degree of diastolic dysfunction is associated with worsening of the prognosis of heart failure patients [4], [5]. Pulmonary hypertension complicating left ventricular systolic dysfunction is also associated with an increased incidence of mortality [6]. Several studies have demonstrated an association between abnormal mitral inflow patterns consistent with diastolic dysfunction and increased pulmonary artery pressure (PAP) in subjects with concomitant LV dysfunction [7], [8], [9]. Enriquez-Sarano et al. have demonstrated that pulmonary hypertension is not independently related to the degree of LV systolic dysfunction but is strongly associated with diastolic dysfunction in patients with LV systolic dysfunction [10]. In their study, a restrictive mitral inflow pattern was found to be the major marker of pulmonary hypertension. Moller et al. have recently shown that the degree of diastolic dysfunction is an independent predictor of pulmonary hypertension in a population of patients with acute myocardial infarction [11]. However, this association has never been studied systematically in patients with normal systolic function.

Therefore we performed a retrospective analysis of Doppler echocardiographic studies of subjects with normal LV wall motion, to assess the correlation of the degree of diastolic dysfunction with the magnitude of PAP. Patients with other co-morbidities that could have affected PAP by mechanisms other than LV diastolic dysfunction were excluded. We hypothesized that 1. PAP is higher in patients with pure diastolic dysfunction compared to cases with both normal systolic and diastolic function. 2. The magnitude of PAP is positively correlated to the degree of diastolic dysfunction.

Section snippets

Methods

The study was approved by the Institutional Review Board.

Results

Four hundred and seventy seven patients were enrolled in the study of whom 298 (62.5%) were in-hospital patients and 179 (37.5%) out patients. Their mean age was 64.7 ± 17.1 years and 211 (44.2%) of them were males. Patients were divided into 4 groups based on their diastolic dysfunction stage. One hundred and ten patients were graded as having normal diastolic function (grade 0), 256 as grade 1 diastolic dysfunction, 102 as grade 2 and 9 had grade 3 dysfunction. Their baseline characteristics

Discussion

In this study, we have demonstrated that PAP is positively correlated with the degree of diastolic dysfunction in patients with normal LV systolic function. For any increment in diastolic dysfunction grade, a statistically significant increase in pulmonary artery systolic pressure was observed. All patients analyzed in the study had normal LV systolic function and none showed any other cardiac pathology (i.e. mitral stenosis or regurgitation, congenital heart disease or systemic disorder) that

Conclusions

Pure left ventricular diastolic dysfunction is associated with an increase in PAP. There is a significant increase in PAP for any increase in the diastolic dysfunction stage. We suggest that diastolic dysfunction should be included in the differential diagnosis of pulmonary hypertension and therefore diastolic function should be carefully examined when evaluating a patient with this disorder.

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Pathophysiology and Echocardiographic Diagnosis of Left Ventricular Diastolic Dysfunction
2019, Journal of the American Society of Echocardiography
Echocardiography is the primary imaging modality used for the clinical evaluation of left ventricular (LV) diastolic function. Using two-dimensional together with transmitral, mitral annular, and pulmonary venous Doppler data, conclusions may be drawn regarding the relaxation and compliance properties of the ventricle that can be used for estimating LV filling pressure. Echocardiographic estimation of LV filling pressure has been shown to be especially useful for evaluating patients with dyspnea of unknown etiology as well as those with heart failure with preserved ejection fraction. Moreover, echocardiographic estimation of LV filling pressure can be used for clinical decision making on day-to-day basis. This article discusses the pathophysiology of diastolic dysfunction and provides a comprehensive review of its echocardiographic evaluation.
Galectin-3 Levels Are Elevated and Predictive of Mortality in Pulmonary Hypertension
2017, Heart Lung and Circulation
Galectin-3, a novel binding-lectin involved in inflammation and fibrosis, is elevated in heart failure and is independently predictive of mortality in this condition. We sought to evaluate galectin-3 levels and its prognostic value in patients with pulmonary hypertension (PH), a known inflammatory state, in the setting of pulmonary arterial hypertension (PAH) and in heart failure with preserved ejection fraction-associated PH (HFpEF-PH).
We measured galectin-3 levels in 76 patients with PH; 37 patients with PAH and 39 patients with HFpEF-PH. Baseline characteristics, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were assessed. Univariate and multivariate analyses were used to assess the prognostic value of galectin-3.
Median (IQR) galectin-3 (ng/mL) for the entire cohort was 24.65 (IQR = 10.39, 32.90); 22.33 (IQR = 18.94, 27.30) and 28.94 (IQR = 21.67, 39.85) in the PAH and HFpEF-PH, respectively (p = 0.07). After evaluation of the galectin-3 levels by tertile, mortality rates were 16% (4/25), 34.6% (9/26), and 48% (12/25) in tertiles 1-3, respectively, and Kaplan-Meier analysis revealed a significant increase in mortality across increasing galectin-3 tertiles (log-rank p = 0.014). On Cox regression analysis, galectin-3 was a strong predictor of mortality on both univariate HR = 2.09 per tertile (95% CI = 1.21, 3.62 per tertile; p-trend = 0.008) and multivariate analysis HR = 2.19 per tertile (95% CI = 1.06, 4.54; p-trend = 0.035) after adjusting for age, sex, race, glomerular filtration rate (eGFR), NT-proBNP, medications, and aetiology of PH (PAH vs. HFpEF-PH).
Galectin-3 is a strong, independent prognostic marker in PH, regardless of aetiology. Larger studies should further evaluate the role of galectin-3 as a prognostic biomarker and possible therapeutic target in PH.
Independent predictors of developing pulmonary hypertension in heart failure with reduced versus preserved ejection fraction
2017, Journal of the Saudi Heart Association
Citation Excerpt :
Nevertheless, these parameters were not independent predictors of PH in HFrEF patients in our study; this was partly in agreement with Enriquez-Sarano et al. [15], who found that DT and the effective regurgitant orifice area of mitral regurgitation but not EF or end systolic volume were independent predictors of PH in LV dysfunction. An association between the severity of LV diastolic dysfunction and increasing PASP has been shown previously [16]. However, there was no significant difference between the two subgroups in the current study with regard to diastolic function grading.
To investigate the different clinical and echocardiographic predictors of evolving PH in patients with heart failure with and without reduced ejection fraction.
The study included 153 heart failure patients with reduced ejection fraction (HFrEF) (n = 89) and preserved ejection fraction (HFpEF) (n = 64) both of which were subdivided into 2 subgroups according to the presence of PH. All patients were subjected to detailed clinical assessment and full transthoracic echocardiogram. There were significant differences between the 2 HFrEF subgroups regarding systolic BP, presence of diabetes, dyslipidemia, diuretics usage, all LV parameters, LAD, LAV and LAV indexed to BSA, E/A ratio, DT and severity of TR. Using multivariate analysis, the presence of diabetes (P = 0.04), diuretics usage (P = 0.04), LAV (P = 0.007) and TR grade (P < 0.001) were significant independent predictors for the development of PH among HFrEF patients. There were significant differences between the 2 HFpEF subgroups regarding presence of hypertension, diuretics usage, LAD, LAA, TR severity. Using multivariate analysis, only diuretics usage (P = 0.02) and TR grade (P < 0.0001) were significant independent predictors for the development of PH among HFpEF patients.
Neither the decrease in EF among HFrEF patients nor the DD grade in HFpEF patients act as independent predictor for evolving PH. Common independent predictors for evolving PH in both HFrEF and HFpEF patients are TR grade and use of diuretics. Other independent predictors in HFrEF and not HFpEF patients are the presence of diabetes and increased LAV.
Diastolic dysfunction in the critically ill patient
2016, Medicina Intensiva
Citation Excerpt :
Peak velocity of tricuspid regurgitation measured by continuous Doppler: During development of diastolic dysfunction, the left ventricular impaired relaxation can be transmitted to right chambers, resulting in a pulmonary arterial hypertension. Pulmonary arterial pressure significantly increased for each step-up in diastolic dysfunction grade.24 Peak velocity of tricuspid regurgitation more than 2.8 m/s is associated to diastolic dysfunction and elevated left atrial pressure, once primary lung diseases have been ruled out.21
Left ventricular diastolic dysfunction is a common finding in critically ill patients. It is characterized by a progressive deterioration of the relaxation and the compliance of the left ventricle. Two-dimensional and Doppler echocardiography is a cornerstone in its diagnosis.
Acute pulmonary edema associated with hypertensive crisis is the most frequent presentation of diastolic dysfunction critically ill patients. Myocardial ischemia, sepsis and weaning failure from mechanical ventilation also may be associated with diastolic dysfunction.
The treatment is based on the reduction of pulmonary congestion and left ventricular filling pressures. Some studies have found a prognostic role of diastolic dysfunction in some diseases such as sepsis.
The present review aims to analyze thoroughly the echocardiographic diagnosis and the most frequent scenarios in critically ill patients in whom diastolic dysfunction plays a key role.
La disfunción diastólica del ventrículo izquierdo es un hallazgo frecuente en pacientes críticos. Se caracteriza por una alteración progresiva de la relajación y la complianza del ventrículo izquierdo. La ecocardiografía bidimensional y doppler juega un papel primordial en su diagnóstico.
El edema agudo de pulmón asociado a una crisis hipertensiva es la presentación más frecuente de la disfunción diastólica en pacientes críticos. La isquemia miocárdica, la sepsis y el fracaso del destete de la ventilación mecánica también pueden asociarse a la disfunción diastólica.
El tratamiento se basa en la reducción de la congestión pulmonar y en disminuir las presiones de llenado del ventrículo izquierdo. Algunos estudios han hallado un papel pronóstico de la disfunción diastólica en algunas afecciones como la sepsis.
La presente revisión procura analizar en profundidad el diagnóstico ecocardiográfico y las enfermedades del paciente crítico en las que la disfunción diastólica juega un papel clave.
Left Ventricular Diastolic Function
2016, Practice of Clinical Echocardiography
Outcomes in world health organization group II pulmonary hypertension: Mortality and readmission trends with systolic and preserved ejection fraction-induced pulmonary hypertension
2014, Journal of Cardiac Failure
Citation Excerpt :
In patients with WHOII-PH, there appears to be a strong independent association with diastolic dysfunction.27 Furthermore, increases in PASP correlate with an increased grade of diastolic dysfunction.28 In a retrospective study, Leung et al13 demonstrated that, similar to HFpEF,16,29 patients with HFpEF-PH are older and have multiple comorbid medical conditions.
Heart failure with preserved ejection fraction (HFpEF) has been increasingly recognized as a leading cause of pulmonary hypertension (HFpEF-PH). It remains unknown how HFpEF-PH fares in relation to systolic HF (reduced ejection fraction)–induced PH (HFrEF-PH). Therefore, we sought to determine the long-term morbidity and mortality of HFpEF-PH and HFrEF-PH.
We studied all patients over a 6-year period with symptomatic HF and severe PH (PASP ≥65 mm Hg) in The Bronx, New York. We classified patients as having either preserved (≥50%) or reduced (≤35%) left ventricular ejection fraction. Trends in mortality and HF readmission rates were defined in 650 patients (HFrEF-PH: n = 277; HFpEF-PH: n = 373). HFpEF-PH patients were older and more often female and white. HFrEF-PH patients were more often black, had ischemic cardiomyopathy, and were on typical HF drug regimens. Patients with HFpEF-PH had a significantly increased all-cause 5-year mortality (52% vs 42%; P = .024). HFpEF-PH was a significant predictor of mortality (adjusted hazard ratio 1.70; P = .012). Patients with HFrEF-PH had more HF readmissions (≥1) than patients with HFpEF-PH (28.6% vs 15%; P = .003), especially within the 1st year (9.1% vs 1.7%; P = .005).
Patients with HFrEF-PH and HFpEF-PH have a significantly elevated long-term mortality, with HFpEF-PH having a higher 5-year mortality rate. These findings testify to the overall poor prognosis of World Health Organization Group II PH, especially HFpEF-PH.

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^☆: No conflict of interest to disclose. The expenses of this study were covered by personal resources. No outside sponsorship was obtained.

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Pulmonary artery pressure and diastolic dysfunction in normal left ventricular systolic function☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

Am J Cardiol

Lancet

Lancet

Defining diastolic dysfunction

Circulation