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Transmitral Early Filling Velocity to Early Diastolic Strain Ratio vs. Mortality
Study Questions:
Does the ratio of early mitral inflow velocity to global diastolic strain rate (E/e’sr) predict cardiovascular events in a general population?
Methods:
The Copenhagen City Heart Study is a longitudinal cohort study (12,600 citizens invited to participate; 6,238 participated; 3,654 underwent echocardiography) that included 2,154 participants who underwent echocardiography that included color tissue Doppler imaging (TDI) and two-dimensional speckle tracking analysis for global longitudinal strain (GLS). After excluding subjects with heart failure (HF), atrial fibrillation, and inadequate images, 1,238 subjects remained for analysis. The primary endpoint was the composite of incident HF, acute myocardial infarction, or cardiovascular death determined using International Classification of Disease Codes 10th revision (ICD-10) coding from the Danish National Board of Health National Patient Registry.
Results:
The mean age of the study group was 56.9 ± 16.2 years, and 42.2% were male. During a median follow-up interval of 11.0 (interquartile range, 9.9-11.2) years, 140 (11.3%) participants reached the composite endpoint. A higher E/e’sr was significantly associated with increased age; male sex; smoking; higher body mass index, cholesterol levels, systolic and diastolic blood pressure, left ventricular (LV) mass index, and left atrial diameter; and lower LV ejection fraction (LVEF) and GLS; however, other measures of LV diastolic function (E/A ratio, E/e’) were not included because of collinearity with E/e’sr. In univariable regression analysis, E/e’sr was associated with adverse outcome (hazard ratio [HR], 1.17 per 10 cm increase; 95% confidence interval [CI], 1.13-1.21; p < 0.001). After multivariable adjustment for clinical and echocardiographic variables, E/e’sr remained an independent predictor of the composite endpoint (HR, 1.08; 95% CI, 1.02-1.13; p = 0.003), whereas E/e’ was not (HR, 1.03 per 1-unit increase; 95% CI, 0.99-1.06; p = 0.11). GLS modified the relationship between E/e’sr and outcome (p for interaction = 0.015). After multivariable adjustment, E/e’sr was a stronger predictor of outcomes among participants with above-median GLS (GLS ≥18%; HR, 1.28 per 10 cm increase; 95% CI, 1.06-1.54; p = 0.011) compared to participants with below-average GLS (GLS <18%; HR, 1.08; 95% CI, 1.02-1.14; p = 0.012). Compared to the SCORE risk chart for cardiovascular morbidity risk stratification (incorporating age, gender, cholesterol, smoking, and systolic blood pressure), E/e’sr provided incremental prognostic information (Harrell’s C-index, 0.839 [0.810.87] vs. 0.844 [0.82-0.87]; p = 0.045).
Conclusions:
In a general population, E/e’sr provided independent and incremental prognostic information regarding cardiovascular morbidity and mortality, and E/e’sr was a stronger predictor of cardiac events compared to E/e’.
Perspective:
Transmitral E/e’ is a measure of LV filling pressure used to assess impaired LV diastolic function, and has been associated with major adverse events. The measurements of global diastolic strain rate (e’sr) and the ratio of early mitral inflow velocity to global e’sr (E/e’sr) also reflect elevated LV filling pressure, with potential advantages of better representing the diastolic performance of all myocardial segments; E/e’sr also is influenced by comorbid conditions such as diabetes and hypertension. This study suggests that echo/Doppler measurement of E/e’sr might provide incremental prognostic value in predicting morbid and mortal cardiovascular events in a general population. Limitations include: 1) the study was based on a relatively small subsample of a community study (1,238 subjects [20%] with adequate images and neither HF nor atrial fibrillation out of 6,238 enrolled), 2) the study population was almost exclusively Caucasian, 3) e’ was measured using color Doppler TDI rather than (clinically employed) pulsed-wave TDI, and 4) outcomes were determined by an administrative database. Confirmation of findings in larger and more diverse populations would be of interest.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiovascular Care Team, Dyslipidemia, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Nonstatins, Acute Heart Failure, Echocardiography/Ultrasound, Hypertension, Smoking
Keywords: Acute Coronary Syndrome, Atrial Fibrillation, Blood Pressure, Body Mass Index, Cardiac Imaging Techniques, Cholesterol, Diabetes Mellitus, Diastole, Diagnostic Imaging, Echocardiography, Echocardiography, Doppler, Color, Heart Failure, Hypertension, Myocardial Infarction, Smoking, Stroke Volume, Systole, Secondary Prevention
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