Ventricular Activation Time as a Marker for Diastolic Dysfunction

Ventricular Activation Time as a Marker for Diastolic Dysfunction

Tissue inhibitor of metalloproteinase-1 (TIMP-1) is associated with increased fibrosis of the extracellular matrix (ECM). Myocardial stiffness is a feature of diastolic dysfunction. We assessed circulating TIMP-1 as a marker of diastolic dysfunction in patients with type 2 diabetes mellitus (DM) and hypertension, who were compared with healthy controls. We recruited 54 patients (43 males; mean age 68 +/- 5 years) with treated type 2 DM (i.e. controlled glycaemia, hypertension, hyperlipidaemia), 35 (30 males; 69 +/- 8 years) treated nondiabetic hypertensives, and 31 healthy controls (18 males; 66 +/- 5 years). Circulating TIMP-1 was measured by ELISA. Using transthoracic echocardiography, the early (E) diastolic mitral inflow velocity was measured with pulse wave Doppler, and the early mitral annular velocity (e'), a recognized index of diastolic relaxation, was measured with tissue Doppler. The E/A ratio was also calculated and isovolumic relaxation time measured. Mean e' levels differed significantly between controls, diabetics and hypertensives (P < 0.0001). Circulating TIMP-1 was significantly different between patients and controls (P = 0.006), but there was no statistically significant difference between the DM and hypertension group. In both groups, only e' was negatively correlated with TIMP-1 levels, with a stronger correlation among the hypertensive patients (Spearman r = -0.544, P = 0.001) when compared with the diabetic group (r = -0.341, P = 0.011). Diastolic relaxation is impaired in diabetes and hypertensive patients. The relationship between TIMP-1 and e' may reflect increased myocardial fibrosis and consequent diastolic dysfunction, which may be more prominent in hypertension.

Serial changes of L wave according to heart rates in a heart failure patient with persistent atrial fibrillation

BNP is a marker of systolic left ventricular dysfunction (LVSD) and heart failure. To assess BNP for the detection of diastolic dysfunction in the general population, we examined 1678 subjects within an age- and sex-stratified survey (MONICA Augsburg). BNP was measured using a commercially available RIA (Shionogi). BNP increased in subjects with diastolic dysfunction (mean 20.3+/-4.7 pg/ml vs. control 9.6+/-0.5 pg/ml, p<0.001), but to a lesser extent than in subjects with LV hypertrophy (LVH, mean 37.3+/-49.1 pg/ml, p<0.001 vs. control) or LVSD (mean 76.2+/-23.2 pg/ml, p<0.001 vs. control). Individuals with sole diastolic abnormality displayed BNP concentrations at the control level (mean 9.7+/-1.7 pg/ml). In univariate analysis, age, BMI, systolic blood pressure, left atrial size, LV mass index, diastolic dysfunction and EF displayed a significant correlation with BNP (p<0.001). However, LV mass index displaced diastolic dysfunction as a significant predictor of BNP in multivariate analysis. Upon ROC analysis, sensitivity and specificity for the detection of diastolic dysfunction by BNP were only 61% and 55%, respectively. Nevertheless, a normal BNP test virtually excluded the presence of diastolic dysfunction and concomitant LVH (NPV 99.9%). Increased BNP concentrations in subjects with diastolic dysfunction are strongly related to LVH. Population-wide screening for diastolic dysfunction with BNP cannot be recommended although a normal BNP test usually excludes diastolic dysfunction and LV hypertrophy.

Background: The QRS pattern on the electrocardiogram (ECG) has an expected progressively increasing amplitude of the R waves in the anterior leads. Poor R wave progression (low R wave amplitude of &lt; 3 mm in V3) is commonly reported, however its clinical significance is unknown. It may be related to underlying cardiac pathology, body habitus, metabolic abnormalities or ECG lead placement errors. Studying the prevalence and significance of these findings in different genders and races will also shed some light on their clinical utility and applicability. Our objective is to assess the epidemiology and clinical significance of “Poor or Abnormal R-Wave Progression” as reported on routine ECGs. Methods: A database of ECGs performed at the University of South Alabama Medical Center ECG database (Intellispace and/or Cerner) was downloaded and compiled into searchable PDF format. ECGs were searched for patients with “Abnormal or Poor R Wave Progression”. Available clinical data on patients with these ECG findings were analyzed and reported as absolute numbers and percentages. Results: The total number of ECG with “Poor R-Wave Progression” were 318. Out of these, 209 (66%) were females and 109 (34%) males; 209 (66%) were black, 105 (33%) were white and 4 (1%) other races. There were 143 (45%) black females, 65 (20%) white females, 66 (21%) black males and 40 (13%) white males. There were 234 (74%) patients &lt; 60 years of age while 85 (26%) were 60 years of age or older. There were 233 (73%) with hypertension. Only 198 (62%) had echocardiograms, with an average ejection fraction (EF) of 52%. Out of these 49 ((25%) had mild to moderate decrease in EF ( &gt; 30 - 50%) while 28 (14%) had severely decreased EF of 30% or less. There were 81 (41%) with wall motion abnormalities concerning for coronary disease, while 95 (48%) had diastolic dysfunction. Discussion: Poor R-wave progression is a commonly reported finding on ECG. It is more prevalent in females, which may be due to improper lead placement or chest size. However, its higher prevalence in blacks may be indicative of higher incidence of heart failure, coronary disease and hypertension. It is more frequent in younger patients who may be more obese, but also carry multiple risk factors for cardiac disease. Poor R wave progression showed strong correlation with any degree of heart failure and with wall motion abnormalities on echocardiogram concerning for coronary disease. Therefore this finding should trigger a diagnostic cascade with echocardiography and/or stress testing, depending on the clinical scenario, in order to identify potentially serious underlying cardiac pathology which may be amenable to therapy.

Hyperdynamic left ventricle on radionuclide myocardial perfusion imaging (RNMPI): A marker of diastolic dysfunction in patients presenting with dyspnea on exertion

Objective: Obesity is a serious condition associated with increased blood volume and left ventricular hypertrophy, with diastolic dysfunction being particularly prominent during childhood. In adulthood, systolic dysfunction is more commonly observed. The aim of this study is to examine the relationship between body mass index (BMI), waist/hip ratio, and the structural changes in the heart, as well as systolic and diastolic functions, in obese adolescents. Methods: The study included 80 obese and 60 normal-weight adolescents aged between 12-18 years. The body mass index (BMI) of all participants was calculated, and their systolic and diastolic blood pressures were measured. Lipid profile and insulin resistance assessments were conducted for the obese adolescents, and waist/hip ratio was calculated. M-mode echocardiography, pulsed Doppler, and tissue Doppler echocardiography were performed on all subjects to evaluate cardiac functions. Results: The results showed that systolic and diastolic blood pressure were higher in obese adolescents compared to the control group. Left ventricular mass index (LVMI), epicardial adipose tissue (EAT), and carotid intima-media thickness (CIMT) were also found to be higher in the obese group. Additionally, a significant decrease was detected in markers of diastolic dysfunction. No systolic dysfunction was observed; however, the left ventricular Tei index (LVTEI), which reflects both systolic and diastolic dysfunction, was significantly higher in the obese group. Conclusion: This study demonstrates that cardiac dysfunction can be detected in obese adolescents before symptoms appear, providing an opportunity for early intervention

Clinical significance of diastolic dysfunction on outcomes of pulmonary valve replacement for pulmonary insufficiency

The objective: to evaluate changes in transmitral blood flow indices asmarkers of myocardial diastolic function using Doppler echocardiography with an increase in the severity of chronic heart failure (CHF).Materials and methods. 84 patients with CHF II-III FC were examined. Evaluation of left ventricular (LV) diastolic function was carried out by the Doppler-echocardiography method in pulsed mode on a Toshiba SSH-160A apparatus (Japan) using a 3.5 MHz transducer based on transmitral diastolic blood flow.Results. The analysis showed that if in patients with CHF II FC,LV myocardial hypertrophy dominates in the pathogenesis, then in patients with CHF III FC there is systolic dysfunction. The main pathogenetic factor in the increase in the severity of CHF from II to III FC is diastolic dysfunction.Conclusion. In patients with CHF II FC in an intact left atrium, impaired transmitral diastolic blood flow occurs in the «slow relaxation» mode. Patients with CHF II FC against the background of an increased size of the left atrium, especially in the presence of post-infarction cardiosclerosis and arrhythmias, are diagnosed with a «pseudonormal» type of transmitral blood flow. The majority of patients with CHF III FC are diagnosed with a «restrictive» type of transmitral blood flow.

Changes in Uric Acid Levels and Allopurinol Use in Chronic Heart Failure: Association With Improved Survival

&#x0D; &#x0D; &#x0D; &#x0D; Background. The pathophysiology of gestational diabetes, which is related to abnormal gluocose tolerance and hyperinsulinaemia, renders standard fetal monitoring models ineffective, insufficient and inappropriate, as these models revolve around detecting and prognosticating on placenta-mediated disease rather than increased metabolic rates due to hyperinsulinaemia, functional hypoxia and ischaemic trophoblastic thresholds. To improve perinatal morbidity and mortality in gestational diabetes, there is therefore a need to introduce new prognostic parameters and scoring systems.&#x0D; Objectives. A proposed risk scoring system has been developed, based on our previous studies, to risk-categorise patients with gestational diabetes in terms of fetal outcome in view of the fact that the pathophysiology of gestational diabetes is not recognised by standard monitoring models, which revolve around placental insufficiency rather than metabolic anomalies.Methods. Patients with diabetes from four case-control studies were combined to form a total sample of 159 cases for validation of the risk scoring system. Univariate logistic regression analysis was used to assess the effect of individual risk factors with proposed cut-offs on adverse pregnancy outcome. The diagnostic accuracy of the total summative score was assessed by computing the area under the receiver operating characteristic (ROC) curve.&#x0D; Results. Four potential parameters were identified to risk-categorise fetuses in a pregnancy complicated by gestational diabetes, i.e. the myocardial performance index (MPI), the E/A ratio (early diastolic filling/late diastolic filling, a marker of diastolic dysfunction), increasing fetal weight (macrosomia), and an increased amniotic fluid index. The total score, obtained by summation of the composite scores for these parameters, ranged from 0 to 11. The total score performed as an excellent predictor of adverse outcome, evidenced by an ROC area under the curve of 0.94. A cut-point of 6 on the score confers a sensitivity of 84.2% and specificity of 90.2% for predicting adverse outcome.&#x0D; Conclusion. To our knowledge, this is the first gestational diabetes scoring system proposed to predict an adverse outcome.&#x0D; &#x0D; &#x0D; &#x0D;

Background Obesity is a growing global health problem that confers higher risks of atrial arrhythmias and sudden cardiac death. Despite this, the proarrhythmic substrate in obesity and its reversibility with weight loss has not been studied in-depth. Purpose To characterise the proarrhythmic substrate in obese patients, and its reversibility with bariatric surgery, using electrocardiographic imaging (ECGi). Methods ECGi was performed in 16 obese patients pre-bariatric surgery (PreSurg; mean age 43±12 years, 13 female) and 16 age- and sex-matched non-obese (lean) individuals (42±11 years). 12 of the 16 obese patients also underwent ECGi after bariatric surgery (PostSurg). Over 2000 atrial and ventricular epicardial electrograms were computed using high density body surface mapping (256-lead ECG) and heart-torso geometries from cardiac magnetic resonance imaging, by solving the inverse problem of electrocardiography. Local atrial and ventricular epicardial activation times (AT) were calculated as the steepest downslope of their respective activation complexes, and local ventricular repolarisation times (RT) as the steepest upslope of the T-wave. Atrial activation gradients (ATG) and ventricular repolarisation gradients (RTG) were calculated as the maximum difference within 10 mm radius divided by the corresponding distance. Results Body mass index was greater in PreSurg vs lean (46.7±5.5 vs 22.8±2.6 kg/m2, p&amp;lt;0.0001) and decreased with surgery (PostSurg 36.8±6.5 kg/m2, p&amp;lt;0.0001). Epicardial adipose tissue (EAT) was greater in PreSurg vs lean (83±56 vs 28±13 ml, p&amp;lt;0.0001) and decreased post-surgery (PostSurg 69±45 ml, p=0.0010). Total atrial AT was prolonged in PreSurg vs lean (62±15 vs 46±12 ms, p=0.0028), which persisted post-surgery (PostSurg 67±15 ms, p=0.86). Atrial ATG were also greater in PreSurg vs lean (26±11 vs 14±8 ms, p=0.0007) and did not change with weight loss (PostSurg 25±12, p=0.44). Ventricular RTG were greater in PreSurg vs lean (26±11 vs 15±7 ms/mm, p=0.0024) and decreased with weight loss (PostSurg 19±8, p=0.0009). Ventricular RTG were similar between PostSurg and lean (p=0.20). EAT from lean and PreSurg individuals correlated with atrial ATG (r=0.36, p=0.044) and ventricular RTG (r=0.54, p=0.0014). Ventricular AT were similar between lean (31±6 ms), PreSurg (34±5 ms) and PostSurg (35±9 ms); all p&amp;gt;0.05. Conclusion Steep ventricular repolarisation gradients and prolonged atrial activation contribute to the proarrhythmic substrate in obesity. Ventricular repolarisation gradients correlate with epicardial adiposity and both regress post-bariatric surgery. By contrast, atrial activation remains prolonged after weight loss. These results provide mechanistic insights into obesity-related arrhythmic risks and their reversibility with weight loss following bariatric surgery. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): British Heart FoundationNational Institute for Health Research (NIHR) Imperial Biomedical Research Centre (BRC).

HomeCirculationVol. 132, No. 1ECG Response: July 7, 2015 Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBECG Response: July 7, 2015 Originally published7 Jul 2015https://doi.org/10.1161/CIRCULATIONAHA.115.017606Circulation. 2015;132:68–69ECG Challenge: A 76-year-old man with a history of hypertension for which he is taking lisinopril, metoprolol, and diltiazem presents to his primary care physician for a routine physical examination. He reports fatigue and occasional lightheadedness. His physical examination is unremarkable except for a slow pulse, which prompts an ECG.Download figureDownload PowerPointThe rhythm is regular at a rate of 40 bpm. The QRS complexes have a normal duration (0.12 s). There is an RSR′ morphology in leads V1 (←) and a terminal S wave in leads I and V5 through V6 (↑). This is a morphology of a right bundle-branch block. The axis is normal between 0° and +90° (positive QRS complex after accounting for the terminal S wave that reflects delayed right ventricular activation and a positive QRS complex in lead aVF). There is low QRS complex voltage in the precordial leads, defined as a QRS complex amplitude <10 mm in each lead. The QT/QTc intervals are normal (520/425 ms and 500/410 ms when the prolonged QRS complex duration is considered). There are P waves seen (+), but there is no relationship between the P waves and QRS complexes (ie, there is atrioventricular dissociation). There are 2 causes for atrioventricular dissociation, including complete heart block in which the atrial rate is faster than the rate of the QRS complex and an accelerated lower pacemaker in which the atrial rate is slower than the rate of the QRS complexes. In this case, the atrial rate is faster (90 bpm) than the ventricular rate (40 bpm). Hence, there is complete heart block and the escape rhythm is junctional. The first 6 P waves have a constant PP interval (└┘) and a rate of 90 bpm. However, the 7th through 9th P waves have a longer PP interval (↔). It is also noted that QRS complexes 4 to 6 have a negative deflection following them (^). These are retrograde P waves that reset the sinus node, accounting for the longer PP interval. In ≈20% to 30% of antegrade complete heart block, there may be retrograde or ventriculoatrial conduction. This may be attributable to:the fact that antegrade and retrograde atrioventricular nodal conduction properties are different;the presence of dual atrioventricular nodal pathways;a concealed bypass tract that generally only conducts in a retrograde direction.Please go to the journal’s blog, OpenHeart, for more ECG Challenges: http://goo.gl/tQPNFp. Challenges are posted on Tuesdays and Responses on Wednesdays.FootnotesCorrespondence to Philip J. Podrid, MD, West Roxbury VA Hospital, Section of Cardiology, 1400 VFW Pkwy, West Roxbury, MA 02132. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetails July 7, 2015Vol 132, Issue 1 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.017606PMID: 26149428 Originally publishedJuly 7, 2015 PDF download Advertisement

A 23-year-old asymptomatic male patient was admitted for invasive evaluation of pre-excitation on the surface ECG persisting during exercise testing. The electrophysiological study, performed under sedation with midazolam, revealed a midseptal accessory pathway (AP) with retrograde conduction and a 1:1 conduction during atrial pacing up to a cycle length of 240 ms. No tachycardia could be induced during pacing of the atrium and ventricle. We opted for ablation of the AP due to the malignant anterograde characteristics. Two seconds after the delivery of the first application of radiofrequency energy, the delta wave disappeared and normal atrioventricular conduction was restored. Energy application was continued for an additional 58 seconds. One day after the procedure, a control ECG revealed recurrence of the pre-excitation pattern. A second invasive evaluation was, therefore, scheduled 1 week after the initial electrophysiological study. Surprisingly, the surface ECG was normalized at that time, with AH and HV intervals within normal …

Background: Hypertension is a major cardiovascular risk factor that leads to left ventricular diastolic dysfunction through myocardial hypertrophy and fibrosis. Although echocardiography is the standard tool for assessing diastolic dysfunction, its limited availability restricts widespread use. ECG-derived markers such as T Wave Peak–T Wave End interval (T-Peak-T-End, Ventricular Activation Time (VAT), P-Wave Terminal Force in Lead V1 (P-TFV1), and P-wave Dispersion (PWD) may provide a simple, cost-effective alternative for early detection of diastolic dysfunction in hypertensive patients. Objectives: To evaluate ECG-derived markers as predictors of left ventricular diastolic dysfunction in hypertensive patients using echocardiography as reference. Methods and Materials: This hospital-based cross-sectional study was conducted in the Cardiology Department of Mymensingh Medical College Hospital from July 2021 to June 2022. Ninety-two hypertensive patients were enrolled. ECG parameters including T-Peak–T-End, VAT, P-TFV1, and PWD were recorded and compared with echocardiographic assessment of diastolic function. Data were analyzed using SPSS version 25 with appropriate statistical tests. Result: Among 92 hypertensive patients (mean age 55.2 ± 9.8 years), 65.2% were aged ≥50 years and 58.7% were male. Diastolic dysfunction was present in 58 patients (63%), predominantly Grade I (39.1%). Prolonged T-Peak-T-End interval, increased VAT, abnormal PTFV1, and increased PWD were observed in 47.8%, 41.3%, 43.5%, and 50% respectively, with diastolic dysfunction present in over 78% of patients with abnormal ECG markers. Conclusion: ECG-derived markers are significantly associated with diastolic dysfunction in hypertension and may serve as simple, effective screening tools alongside echocardiography.