Current clinical applications of spectral tissue Doppler echocardiography (E/E' ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function

Abstract

Congestive heart failure with preserved left ventricular systolic function has emerged as a growing epidemic medical syndrome in developed countries, which is characterized by high morbidity and mortality rates. Rapid and accurate diagnosis of this condition is essential for optimizing the therapeutic management. The diagnosis of congestive heart failure is challenging in patients presenting without obvious left ventricular systolic dysfunction and additional diagnostic information is most commonly required in this setting. Comprehensive Doppler echocardiography is the single most useful diagnostic test recommended by the ESC and ACC/AHA guidelines for assessing left ventricular ejection fraction and cardiac abnormalities in patients with suspected congestive heart failure, and non-invasively determined basal or exercise-induced pulmonary capillary hypertension is likely to become a hallmark of congestive heart failure in symptomatic patients with preserved left ventricular systolic function. The present review will focus on the current clinical applications of spectral tissue Doppler echocardiography used as a reliable noninvasive surrogate for left ventricular diastolic pressures at rest as well as during exercise in the diagnosis of heart failure with preserved left ventricular systolic function. Chronic congestive heart failure, a disease of exercise, and acute heart failure syndromes are characterized by specific pathophysiologic and diagnostic issues, and these two clinical presentations will be discussed separately.

Figure 1

Example of bedside measurement of spectral Doppler velocities (cm/s) in the apical 4-chamber view in a 82 years-old woman hospitalized for new-onset congestive heart failure with preserved left ventricular systolic function related to longstanding hypertension. At presentation, the score of Boston criteria was 10 and B-type natriuretic peptide concentration 460 pg/ml. Bedside Doppler echocardiography performed before unloading therapy showed a left ventricular ejection fraction of 67% (upper part); peak E mitral velocity between the tips of mitral leaflets was 101 cm/s, spectral tissue Doppler peak early diastolic E' velocities at the septal (middle part) and lateral corner of mitral annulus (lower part) were 6 and 9 cm/s, respectively. The patient experienced a complete relief of symptoms and signs of pulmonary congestion under unloading therapy. Invasive left ventricular end-diastolic pressure recorded after clinical stabilization was 14 mm Hg.

Figure 2

Proposition for a simplified diagnostic algorithm regarding the contribution of tissue Doppler echocardiography to the diagnosis of chronic heart failure with preserved left ventricular systolic function (stage C of the ACC/AHA classification) in patients presenting with exertional dyspnea, after excluding overt myocardial ischemia, significant valvular disease and arrhythmias; adapted from the references [9,67,76-78,88]. E: peak E mitral velocity; E': spectral tissue Doppler peak early diastolic velocity at the septal side of mitral annulus; LV: left ventricular. The use of a cut-off value of 13 would reinforce the positive predictive value but would lack the negative predictive value.

Figure 3

Proposition for a simplified diagnostic algorithm in the emergency diagnosis of acute congestive heart failure on admission, before tailored therapy, in patients presenting with acute dyspnea; adapted from references [5,89,91,94,98-102]. AF: atrial fibrillation; BNP: B-type natriuretic peptide; E: peak E mitral velocity; E': peak early diastolic velocity by spectral tissue Doppler at the septal side of mitral annulus; HF: heart failure; LVEF: left ventricular ejection fraction; SR: sinus rhythm. The clinical judgment of heart failure is based on the presence of prior history of heart failure and/or radiographic pulmonary edema. *: evidence of a restrictive mitral filling pattern reinforces the likelihood of acute congestive HF.