Elsevier

American Heart Journal

Volume 188, June 2017, Pages 136-146
American Heart Journal

Clinical Investigation
Diastolic dysfunction revisited: A new, feasible, and unambiguous echocardiographic classification predicts major cardiovascular events

https://doi.org/10.1016/j.ahj.2017.03.013Get rights and content

Background

Echocardiographic classification of DDF has been widely discussed. The aim of this study was to investigate the independent prognostic value of established echocardiographic measures in a community-based population and create a new classification of DDF.

Methods

Within the Copenhagen City Heart Study, a prospective, community-based study, 1851 participants were examined by echocardiography including Tissue Doppler Imaging (TDI) in 2001 to 2003 and followed with regard to MACE (median, 10.9 years).

Results

We found that persons with impaired myocardial relaxation as defined by low peak early diastolic mitral annular velocity e' by TDI had higher incidence of clinical and echocardiographic markers of cardiac dysfunction and increased risk of MACE. Among persons with impaired relaxation, only echocardiographic indices of increased filling pressures such as LAVi  34 mL/m2 (HR 1.97 (1.13-3.45, P = .017), E/e′ ≥ 17 (HR 1.89 (1.34-2.65), P < .001), and E/A > 2 (HR 5.24 (1.91-14.42), P = .001) provided additional and independent prognostic information on MACE. Based on these findings, we created a new classification of DDF where all grades were significant predictors of MACE independently of age, sex, and cardiac clinical risk markers (Mild DDF: HR 1.99 (1.23-3.21), P = .005; Moderate DDF: HR 3.11 (1.81-5.34), P < .001; Severe DDF: HR 4.20 (1.81-9.73), P < .001). Increasing severity of DDF was linearly associated with increasing plasma proBNP concentrations.

Conclusions

In the general population, the presence of echocardiographic markers of elevated filling pressures in persons with impaired relaxation increased the risk of MACE significantly. Based on this, we present a new, feasible, and unambiguous classification of DDF capable of accurate risk prediction in the community.

Section snippets

Study population

This study was performed as a substudy of the 4th Copenhagen City Heart Study,4., 27. a longitudinal cohort study of cardiovascular disease and risk factors. This study includes 2221 randomly selected men and women (age 20-93 years) who underwent echocardiographic examination including both conventional echocardiography and color TDI with measurement of septal and lateral peak early diastolic mitral annular velocities (e′). Whether a participant underwent echocardiography was completely

Population characteristics

The study population (n = 1851) was divided into groups with normal or impaired relaxation according to average septal and lateral e′ (Table I). Since myocardial relaxation is known to be impaired with increasing age, our finding of the group of persons with impaired relaxation being older than the group with normal relaxation was expected. The group of persons with impaired relaxation was also more likely to be diagnosed with hypertension, diabetes, and ischemic heart disease and had higher

Discussion

In this large community study, we found that impaired myocardial relaxation according to e′ was associated with a higher incidence of cardiovascular risk factors, cardiac dysfunction by echocardiography, and increased risk of cardiovascular events independently of age. In the subgroup of persons with impaired relaxation, several conventional echocardiographic measures of DDF were predictors of MACE, however, only LAVi  34 mL/m2, E/A > 2, and elevated filling pressures according to E/e′ remained

Conclusions

In the general population, we found that impaired myocardial relaxation according to e′ was associated with cardiovascular risk factors and increased risk of MACE. Furthermore, by contrast to persons with normal relaxation, the combination of impaired relaxation and echocardiographic markers of elevated filling pressures increased the risk of MACE significantly. Based on these findings, we present a new classification of DDF capable of accurately identifying persons at risk of MACE in the

Role of the funder/sponsor

The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript.

Author contributions

Dr Dyrby Johansen and Dr Mogelvang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Dyrby Johansen, Skov Jensen, Mogelvang.

Acquisition of data: Biering-Sorensen, Mogelvang.

Analysis and interpretation of data: Dyrby Johansen, Mogelvang.

Drafting of the manuscript: Dyrby Johansen, Mogelvang.

Critical revision of the manuscript for important intellectual content: Dyrby Johansen,

Conflicts of interest

None declared.

Acknowledgements and funding

This work was supported by grants from the Lundbeck Foundation, the Novo Nordisk Foundation, and the Danish Heart Foundation (07-10-R60-A1698-B132-22413).

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