Clinical Investigation
Diastolic Function
Differential Clinical Implications of Current Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography

https://doi.org/10.1016/j.echo.2018.08.011Get rights and content

Highlights

  • Classification of diastolic function by echocardiography is controversial.

  • The 2009 recommendations overestimated the prevalence of grade I DD in our population.

  • The 2016 recommendations better classified patients according to clinical outcomes.

  • Indeterminate LVDF seems to have intermediate outcomes between normal and grade I DD.

Background

Classification of left ventricular diastolic function (LVDF) by echocardiography is controversial. The aim of this study was to evaluate the impact of the last 2016 recommendations for LVDF evaluation on brain natriuretic peptide (BNP) levels, proportion of final heart failure (HF) diagnosis, and cardiovascular outcomes.

Methods

Outpatients with first consultation at a one-stop HF clinic (2009–2014) were screened. The initial visit included echocardiography with LVDF evaluation and determination of BNP level. HF diagnosis was confirmed or ruled out at the end of the visit. Cardiovascular events during follow-up were recorded. LVDF classification was originally performed with the 2009 recommendations and reevaluated using the 2016 recommendations.

Results

A total of 157 patients (mean age 73.24 ± 10.3 years; 70.1% women) were included. Originally (2009 recommendations), most of the patients were classified with grade I diastolic dysfunction (DD; 67.5%). After the reanalysis using the 2016 recommendations, 49% were reclassified with normal LVDF. These subjects showed lower BNP levels (40.8 pg/mL) and a lower proportion of HF diagnosis (9.6%). Another part of the initial grade I DD group (31.1%) was reclassified with indeterminate LVDF; they had intermediate BNP levels, proportion of HF, and rate of cardiovascular events. Lower reclassification rates were observed in the other groups of DD. Kaplan-Meier survival curves showed significantly better prognostic stratification after the reclassification (P = .539 vs P = .003).

Conclusions

Current recommendations for the evaluation of LVDF by echocardiography resulted in more accurate classification of patients, according to their BNP levels, HF diagnosis, and cardiovascular outcomes, especially for those patients previously classified with grade I DD.

Section snippets

Patients

We evaluated a cohort of consecutive outpatients with suspected new onset of HF and first consultation in our one-stop clinic between 2009 and 2014. The patients belonged to a cohort that was prospectively enrolled and followed to study characteristics and outcomes of outpatients with new onset of HF in our area.9, 10 A clinical evaluation, electrocardiography, blood test analysis with BNP determination (ADVIA Centaur; Siemens Healthcare Diagnostics, Tarrytown, NY; cutoff value 37 pg/mL), and a

Results

Two hundred fourteen consecutive patients evaluated in our one-stop clinic between 2009 and 2014 were screened. Fifty-seven patients were excluded because of the presence of atrial fibrillation, pacemaker, or severe mitral valve disease. Ultimately, 157 patients were included in the study cohort. Seventy-six patients (48.4%) were diagnosed with HF (71.1% [n = 54] with HF with preserved ejection fraction and 28.9% [n = 22] with HF with reduced ejection fraction). Table 1 summarizes baseline

Discussion

The main finding of our study is that after LVDF reclassification with the new recommendations,4 most of the patients initially classified with grade I DD were reassigned to other groups, mainly to normal diastolic function (49%). These patients showed lower BNP levels (40.8 pg/mL) and a lower proportion of final diagnosis of HF (9.6%), suggesting a better classification with the use of the 2016 recommendations. An important proportion of patients initially classified as having grade DD (31.1%)

Conclusion

The 2016 guideline update for the evaluation of LVDF using echocardiography resulted in a more accurate classification of patients from diagnostic and prognostic perspectives, especially those patients previously classified as having grade I LV DD. Reclassification of patients adds a clinically relevant association with surrogates and outcomes related to HF, such as BNP levels and cardiovascular outcomes.

Acknowledgments

The authors acknowledge the CERCA Programme/Generalitat de Catalunya.

References (16)

There are more references available in the full text version of this article.

Cited by (64)

View all citing articles on Scopus

Conflicts of Interest: None.

View full text